Is routine preoperative testing standard of care for surgical patients?

Routine Preoperative Testing is NOT Standard of Care

Routine preoperative testing—defined as ordering a battery of tests in the absence of specific clinical indications—is explicitly not recommended and should be abandoned in favor of selective, risk-stratified testing based on patient history, comorbidities, and physical examination findings 1.

The Evidence Against Routine Testing

An extensive systematic review concluded there is no evidence to support routine preoperative testing 1. Multiple professional societies including the American Society of Anesthesiologists, European Society of Anaesthesiology, and UK National Institute for Health Care and Excellence have all stated that routine preoperative testing is not supported by evidence 2.

The data are compelling:

• In low-risk patients (ASA class 1-2) undergoing ambulatory surgery, preoperative testing fails to reduce complications 2
• A large NSQIP study of 19,855 patients found no difference in postoperative complications between those who received preoperative testing and those who did not (2.5% vs 2.2%, p=0.30) 3
• Another NSQIP analysis of 73,596 hernia patients found that neither testing nor abnormal results were associated with postoperative outcomes 4

The Problem: Testing Continues Despite Evidence

Despite clear guidance since 2002, routine testing remains overused:

• 72% of low-risk patients still receive preoperative testing before ambulatory gynecologic surgery 3
• 54% of patients with no comorbidities and no indication for testing still receive at least one test 4
• Professional guidance has had minimal impact, with only electrocardiogram testing showing reduction after guideline publication 5

The Risk-Stratified Approach (What IS Standard of Care)

Testing should be ordered only when specific clinical indications exist 1, 6. Here's the algorithmic approach:

Electrocardiography

• Order for: Patients with signs/symptoms of active cardiovascular disease (regardless of surgery type), high-risk surgery, or intermediate-risk surgery with additional risk factors 1
• Do NOT order for: Asymptomatic patients undergoing low-risk surgery 1

Chest Radiography

• Order for: Patients at risk of postoperative pulmonary complications only if results would change perioperative management 1
• Do NOT order routinely

Laboratory Testing

Electrolytes/Creatinine:

• Order for: Patients with chronic kidney disease, liver disease, or taking medications causing electrolyte abnormalities (diuretics, digoxin, ACE inhibitors/ARBs) 1

Complete Blood Count:

• Order for: Diseases increasing anemia risk or anticipated significant blood loss 1

Glucose:

• Order for: High risk of undiagnosed diabetes 1
• HbA1c in known diabetics: Only if results would change perioperative management 1

Coagulation Studies:

• Order for: History of bleeding disorders, conditions predisposing to bleeding, or anticoagulant use 1

Urinalysis:

• Order for: Invasive urologic procedures or implantation of foreign material 1

Special Case: Cataract Surgery

Patients in their usual state of health undergoing cataract surgery require NO preoperative testing 1.

Common Pitfalls to Avoid

1. Protocol-driven testing: Ordering tests because "it's always done" rather than for medical necessity 1
2. Same-day testing: 15% of tested patients undergo testing the day of surgery, with surgery proceeding despite 62% having abnormal results 4—this suggests the tests weren't clinically necessary
3. Following up incidental abnormalities: Routine testing leads to cascade testing of often-normal results, delaying surgery and increasing costs 1

Bottom Line

The standard of care is selective, indication-based testing, not routine testing. The decision framework is: clinical history → physical examination → risk stratification → targeted testing only when results will change management. This approach improves quality, reduces costs, and does not compromise patient safety 1, 3, 4.