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Preanesthetic Evaluation : Inadequate or Missing Test Result
Case Synopsis 1
A 64 - year-old man with low activity tolerance, a history of hypertension, obesity, and vague episodes of epigastric discomfort is scheduled for elective open partial colectomy. No preoperative electrocardiogram is obtained. The patient subsequently sustains a perioperative myocardial infarction secondary to undiagnosed coronary artery disease.
Case Synopsis 2
A 73-year-old woman who is taking several diuretic medications is scheduled for elective hip arthroplasty. An outside provider obtained a chemistry and electrolyte panel and faxed the results to your surgeon’s office. On the day of surgery the results are not available. A discussion ensues about the need to obtain a repeat test. The test is finally found and the plasma sodium is 124 mEq/L. Surgery is postponed.
Problem Analysis
Definition
Effective preoperative test selection may be enhanced by knowing how outcomes are affected by the performance or omission of testing. The following are four important unwanted outcomes:
- 1.
Misinterpretation of test significance by providers or patients
- 2.
Adverse medical events from incorrect actions as a result of a test, or failing to act on test results
- 3.
Increased cost of care from the test, retesting, or subsequent follow-up tests or procedures
- 4.
Litigation for any reason related to the above
Simply knowing the result of a preoperative test cannot ensure a good outcome. Moreover, the accuracy and usefulness of a test depend greatly on its sensitivity and specificity, combined with the frequency of the condition in the population. In addition, considering the pretest probability of disease for that particular patient will add greatly to the utility of testing.
Recognition
Tests may not be used for clinical care if they are not performed, not reviewed, or not available. A more difficult question is whether a specific test was actually indicated, if performed. Hindsight may not be adequate to determine actual preoperative need. Only well-structured clinical studies and logical analysis can provide direction for clinicians who wish to provide evidence-based care.
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