Practice Perfect 907
The Pod Periop Medical Management Series:
An Introduction

Hello to all you surgeons out there. Welcome to our new ongoing series, the Pod Periop Medical Management Series. As we all know, taking care of surgical patients is a highly complex process with many steps, and at each step, something can go wrong. Whether it’s not having the correct hardware to simply a challenging anatomy, surgery can be difficult. But in my experience, it’s not these issues that lead to surgical cases being cancelled, but rather it’s the medical issues. Whether it’s hyperkalemia in the diabetic patient, a concern for pericarditis, or a cardiac emergency, these are the issues that really plague surgeons.

It’s the medical issues that most often lead to surgical cases being cancelled.

Humans are complicated! And it takes a lot of knowledge to care for another person in a safe and effective manner during surgery. But, like all machines, the human body responds in logical ways to things that occur within it. A person doesn’t go into pulseless electrical activity because they want to. That hyperkalemia doesn’t happen on whim. We live in a mechanical universe that obeys laws of nature, and the human machine is no different. This makes it possible for us to both understand the patterns of disease that occur and employ effective means to treat them.

And, of course, for our discussion in this series, it’s all about prediction. It is key to predict what may occur during a surgery and prepare ahead. This comes via the comprehensive history and physical examination, where we begin by stratifying patients by risk factors created by their unique disease processes. The challenge for anyone out of residency is to remain current with our knowledge, as medicine changes, it seems, almost daily.

In this series, we’re going to cover a number of the most important pathologies pertinent to perioperative patient management. We will endeavor to make our discussions concise, to the point, evidence-based, and high yield.

To that end, let’s focus on one primary concept today: most physicians order too many preoperative tests.

In the past, physicians would order a battery of preoperative examinations with the intent to screen for occult disease. This would be the equivalent of a complete blood count, comprehensive metabolic panel, electrocardiogram, and a chest radiograph.

It is no longer necessary or appropriate to order a complete blood count, comprehensive metabolic panel, electrocardiogram, and a chest radiograph prior to surgery.

This is no longer necessary or appropriate. Smetana and Macpherson made a strong argument with the following statistics1:

In a healthy patient, there is a 5% probability of an abnormal test if one test is ordered. If you order a panel of 20 tests, the likelihood rises to 64%, even if the patient has no disease. False negative test results are much more common than we might at first realize. Additionally, Smetana and Macpherson relate that 30 – 60% of abnormal test results are ignored. Remember also that if you order a test, and the result is abnormal, you are obligated to either treat it (referral back to their primary care doctor or an emergency room may be indicated) or explain why no action is necessary. This sounds like unnecessary medicolegal risk.

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Final verdict: order labs and imaging studies according to the history and physical and known risk factors2.

In next week’s issue, we’ll carry this statement to the next level, discussing the modern preoperative testing paradigm. As a little teaser, I’ll tell you to stop ordering chest x-rays!

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

  1. Smetana GW and Macpherson DS. The case against routine preoperative laboratory testing. Med Clin North Am. 2003 Jan;87(1) 7-40.
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  2. Medical Management of the Surgical Patient, 3rd Ed. Merli G and Weitz H editors. Saunders Elsevier, Philadelphia, 2008.
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