Evidence-Based Preoperative Testing Protocols Save Time, Money

Can a streamlined preoperative care and testing workflow be designed for the otolaryngology–head and neck surgical practice?

Bottom Line: Evidence-based preoperative assessment protocols that reduce unnecessary testing and extraneous cost without increased perioperative morbidity and mortality should be implemented into routine otolaryngology practice.

Commentary: “This article presents an up-to-date literature review of preoperative assessment for otolaryngology patients and presents an algorithm for determination of pre-operative testing necessary per published evidence.” —Cristina Cabrera-Muffly, MD

Background: A window of opportunity exists between surgical scheduling and the operative date to prepare patients for elective surgery in hopes of identifying high-risk individuals with significant perioperative morbidity. Standard practice typically combines a history and physical examination with a broad routine testing battery, but this practice is inefficient, poorly standardized across institutions, and expensive.

Study design: Literature review.

Setting: Department of Otolaryngology–Head and Neck Surgery, Morsani College of Medicine, University of South Florida, Tampa, Fla.

Synopsis: Currently, the Surgical Risk Scale (SRS) and American Society of Anesthesiologists (ASA) risk assessment instruments are the most applicable perioperative risk stratification systems. Healthy patients undergoing low-risk surgery (ASA grade 1-2) require little to no preoperative workup. Patients able to exert ≥4 METS (1 MET is the basal oxygen consumption of a typical 40-year-old, 70-kg male) have at least moderate functional capacity and are at low risk of perioperative cardiac complications. There are no broadly accepted preoperative pulmonary assessment guidelines, but in select cases smoking cessation up to or more than six weeks prior to elective surgery may be beneficial. Key prehabilitation screening tools are serum creatinine (preexisting chronic renal failure), hemoglobin/hematocrit (preoperative anemia), electrocardiography (significant systemic medical comorbidities), and pregnancy testing. There is no evidence to support additional assessments for routine preoperative evaluation. There are special otolaryngologic circumstances that deserve consideration. Hypothyroidism has an association with adverse wound healing and pharyngocutaneous fistula development. Perioperative hyperglycemia, malnutrition, and age-related decline in physiologic reserve, or frailty, increase the risk of adverse outcomes.

Citation: Nickel C, Segarra D, Padhya T, Mifsud M. The evidence-based preoperative assessment for the otolaryngologist. Laryngoscope. 2020;130:38–44.