¿Deberían todos los pacientes tiener un ECG de reposo de 12 derivaciones antes de la cirugía electiva no cardiaca?
Should all patients have a resting 12-lead ECG before elective noncardiac surgery?
Sharma P, Dhungel S, Prabhakaran A.
Clev Clin J Med October 2014
http://www.ccjm.org/content/81/10/594.full.pdf+html
Valoración preoperatoria. De las pruebas de rutina a la investigación individualizada
Preoperative risk assessment--from routine tests to individualized investigation.
Böhmer AB1, Wappler F, Zwissler B.
Dtsch Arztebl Int. 2014 Jun 20;111(25):437-45; quiz 446. doi: 10.3238/arztebl.2014.0437.
Abstract
BACKGROUND:Risk assessment in adults who are about to undergo elective surgery (other than cardiac and thoracic procedures) involves history-taking, physical examination, and ancillary studies performed for individual indications. Further testing beyond the history and physical examination is often of low predictive value for perioperative complications.METHOD:
This review is based on pertinent articles that were retrieved by a selective search in the Medline and Cochrane Library databases and on the consensus-derived recommendations of the German specialty societies. RESULTS:The history and physical examination remain the central components of preoperative risk assessment. Advanced age is not, in itself, a reason for ancillary testing. Laboratory testing should be performed only if relevant organ disease is known or suspected, or to assess the potential side effects of pharmacotherapy. Electrocardiography as a screening test seems to add little relevant information, even in patients with stable heart disease. A chest X-ray should be obtained only if a disease is suspected whose detection would have clinical consequences in the perioperative period. CONCLUSION:In preoperative risk assessment, the history and physical examination are the strongest predictors of perioperative complications. Ancillary tests are indicated on an individual basis if the history and physical examination reveal that significant disease may be present.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4095591/pdf/Dtsch_Arztebl_Int-111-0437.pdf
Beneficios y daño de las pruebas preoperatorias de rutina. Efectividad comparativa
Benefits and Harms of Routine Preoperative Testing: Comparative Effectiveness [Internet].
Editors Balk EM, Earley A, Hadar N, Shah N, Trikalinos TA.
Rockville (MD): Agency for Healthcare Research and Quality (US); 2014 Jan. Report No.: 14-EHC009-EF. AHRQ Comparative Effectiveness Reviews.
Excerpt
OBJECTIVES:Preoperative testing is used to guide the action plan for patients undergoing surgical and other procedures that require anesthesia and to predict potential postoperative complications. There is uncertainty whether routine or per-protocol testing in the absence of a specific indication prevents complications and improves outcomes, or whether it causes unnecessary delays, costs, and harms due to false-positive results.DATA SOURCES:We searched MEDLINE® and Ovid Healthstar® (from inception to July 22, 2013), as well as Cochrane Central Trials Registry and Cochrane Database of Systematic Reviews.REVIEW METHODS:We included comparative and cohort studies of both adults and children undergoing surgical and other procedures requiring either anesthesia or sedation (excluding local anesthesia). We included all preoperative tests that were likely to be conducted routinely (in all patients) or on a per-protocol basis (in selected patients). For comparative studies, the comparator of interest was either no testing or ad hoc testing done at the discretion of the clinician. We also looked for studies that compared routine and per-protocol testing. The outcomes of interest were mortality, perioperative events, complications, patient satisfaction, resource utilization, and harms related to testing.RESULTS:Fifty-seven studies (14 comparative and 43 cohort) met inclusion criteria for the review. Well-conducted randomized controlled trials (RCTs) of cataract surgeries suggested that rout
i ne testing with electrocardiography, complete blood count, and/or a basic metabolic panel did not affect procedure cancellations (2 RCTs, relative risks [RRs] of 1.00 or 0.97), and there was no clinically important difference for total complications (3 RCTs, RR = 0.99; 95% confidence interval, 0.86 to 1.14). Two RCTs and six nonrandomized comparative studies of general elective surgeries in adults varied greatly in the surgeries and patients included, along with the routine or per-protocol tests used. They also mostly had high risk of bias due to lack of adjustment for patient and clinician factors, making their results unreliable. Therefore, they yielded insufficient evidence regarding the effect of routine or per-protocol testing on complications and other outcomes. There was also insufficient evidence for patients undergoing other procedures. No studies reported on quality of life, patient satisfaction, or harms related to testing. CONCLUSIONS:There is high strength of evidence that, for patients scheduled for cataract surgery, routine preoperative testing has no effect on total perioperative complications or procedure cancellation. There is insufficient evidence for all other procedures and insufficient evidence comparing routine and per-protocol testing. There is no evidence regarding quality of life or satisfaction, resource utilization, or harms of testing and no evidence regarding other factors that may affect the balance of benefits and harms. The findings of the cataract surgery studies are not reliably applicable to other patients undergoing other higher risk procedures. Except arguably for cataract surgery, numerous future adequately powered RCTs or well-conducted and analyzed observational comparative studies are needed to evaluate the benefits and harms of routine preoperative testing in specific groups of patients with different risk factors for surgical and anesthetic complications undergoing specific types of procedures and types of anesthesia.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0063242/pdf/TOC.pdf
Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org
Should all patients have a resting 12-lead ECG before elective noncardiac surgery?
Sharma P, Dhungel S, Prabhakaran A.
Clev Clin J Med October 2014
http://www.ccjm.org/content/81/10/594.full.pdf+html
Valoración preoperatoria. De las pruebas de rutina a la investigación individualizada
Preoperative risk assessment--from routine tests to individualized investigation.
Böhmer AB1, Wappler F, Zwissler B.
Dtsch Arztebl Int. 2014 Jun 20;111(25):437-45; quiz 446. doi: 10.3238/arztebl.2014.0437.
Abstract
BACKGROUND:Risk assessment in adults who are about to undergo elective surgery (other than cardiac and thoracic procedures) involves history-taking, physical examination, and ancillary studies performed for individual indications. Further testing beyond the history and physical examination is often of low predictive value for perioperative complications.METHOD:
This review is based on pertinent articles that were retrieved by a selective search in the Medline and Cochrane Library databases and on the consensus-derived recommendations of the German specialty societies. RESULTS:The history and physical examination remain the central components of preoperative risk assessment. Advanced age is not, in itself, a reason for ancillary testing. Laboratory testing should be performed only if relevant organ disease is known or suspected, or to assess the potential side effects of pharmacotherapy. Electrocardiography as a screening test seems to add little relevant information, even in patients with stable heart disease. A chest X-ray should be obtained only if a disease is suspected whose detection would have clinical consequences in the perioperative period. CONCLUSION:In preoperative risk assessment, the history and physical examination are the strongest predictors of perioperative complications. Ancillary tests are indicated on an individual basis if the history and physical examination reveal that significant disease may be present.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4095591/pdf/Dtsch_Arztebl_Int-111-0437.pdf
Beneficios y daño de las pruebas preoperatorias de rutina. Efectividad comparativa
Benefits and Harms of Routine Preoperative Testing: Comparative Effectiveness [Internet].
Editors Balk EM, Earley A, Hadar N, Shah N, Trikalinos TA.
Rockville (MD): Agency for Healthcare Research and Quality (US); 2014 Jan. Report No.: 14-EHC009-EF. AHRQ Comparative Effectiveness Reviews.
Excerpt
OBJECTIVES:Preoperative testing is used to guide the action plan for patients undergoing surgical and other procedures that require anesthesia and to predict potential postoperative complications. There is uncertainty whether routine or per-protocol testing in the absence of a specific indication prevents complications and improves outcomes, or whether it causes unnecessary delays, costs, and harms due to false-positive results.DATA SOURCES:We searched MEDLINE® and Ovid Healthstar® (from inception to July 22, 2013), as well as Cochrane Central Trials Registry and Cochrane Database of Systematic Reviews.REVIEW METHODS:We included comparative and cohort studies of both adults and children undergoing surgical and other procedures requiring either anesthesia or sedation (excluding local anesthesia). We included all preoperative tests that were likely to be conducted routinely (in all patients) or on a per-protocol basis (in selected patients). For comparative studies, the comparator of interest was either no testing or ad hoc testing done at the discretion of the clinician. We also looked for studies that compared routine and per-protocol testing. The outcomes of interest were mortality, perioperative events, complications, patient satisfaction, resource utilization, and harms related to testing.RESULTS:Fifty-seven studies (14 comparative and 43 cohort) met inclusion criteria for the review. Well-conducted randomized controlled trials (RCTs) of cataract surgeries suggested that rout
i ne testing with electrocardiography, complete blood count, and/or a basic metabolic panel did not affect procedure cancellations (2 RCTs, relative risks [RRs] of 1.00 or 0.97), and there was no clinically important difference for total complications (3 RCTs, RR = 0.99; 95% confidence interval, 0.86 to 1.14). Two RCTs and six nonrandomized comparative studies of general elective surgeries in adults varied greatly in the surgeries and patients included, along with the routine or per-protocol tests used. They also mostly had high risk of bias due to lack of adjustment for patient and clinician factors, making their results unreliable. Therefore, they yielded insufficient evidence regarding the effect of routine or per-protocol testing on complications and other outcomes. There was also insufficient evidence for patients undergoing other procedures. No studies reported on quality of life, patient satisfaction, or harms related to testing. CONCLUSIONS:There is high strength of evidence that, for patients scheduled for cataract surgery, routine preoperative testing has no effect on total perioperative complications or procedure cancellation. There is insufficient evidence for all other procedures and insufficient evidence comparing routine and per-protocol testing. There is no evidence regarding quality of life or satisfaction, resource utilization, or harms of testing and no evidence regarding other factors that may affect the balance of benefits and harms. The findings of the cataract surgery studies are not reliably applicable to other patients undergoing other higher risk procedures. Except arguably for cataract surgery, numerous future adequately powered RCTs or well-conducted and analyzed observational comparative studies are needed to evaluate the benefits and harms of routine preoperative testing in specific groups of patients with different risk factors for surgical and anesthetic complications undergoing specific types of procedures and types of anesthesia.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0063242/pdf/TOC.pdf
Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org
