What are the indications for blood work, electrocardiogram (ECG), and chest X-ray preoperatively?

From the Guidelines

Preoperative bloodwork, ECG, and chest X-ray should be ordered selectively based on patient-specific factors rather than routinely for all surgical patients. The decision to perform these tests should be guided by the patient's clinical history, comorbidities, and physical examination findings, as well as the type of surgery being performed 1.

Indications for Testing

• Bloodwork (complete blood count, metabolic panel, coagulation studies) is indicated for patients with systemic diseases (diabetes, kidney disease, liver disease), those on medications affecting blood counts or coagulation, and for surgeries with significant blood loss risk 1.
• ECG is recommended for patients over 65 years, those with cardiovascular disease, diabetes, renal disease, or when undergoing intermediate to high-risk procedures, as it can help identify patients at risk of perioperative cardiac complications 1.
• Chest X-rays are appropriate for patients with active cardiopulmonary symptoms, known cardiopulmonary disease, or recent changes in respiratory status, as they can help identify patients at risk of perioperative pulmonary complications 1.

Rationale for Selective Testing

The rationale for selective testing is to identify abnormalities that might alter perioperative management while avoiding unnecessary tests that increase costs and may lead to false positives 1. Age alone is not an indication for testing; rather, the patient's overall health status, comorbidities, and the invasiveness of the planned procedure should guide the decision to order these tests.

Key Considerations

• Patients with signs or symptoms of active cardiovascular disease should be evaluated with appropriate testing, regardless of their preoperative status 1.
• Patients undergoing low-risk surgery do not require electrocardiography, unless they have underlying cardiovascular disease or other risk factors 1.
• Preoperative urinalysis is recommended for patients undergoing invasive urologic procedures and those undergoing implantation of foreign material 1.

From the Research

Indications for Preoperative Tests

The following are indications for blood work, electrocardiogram (ECG), and chest X-ray preoperatively:

• Blood work:
  • Full blood count test 2
  • Kidney function tests 2
  • Haemostasis tests 2
  • Urinalysis and urine culture 2
• Electrocardiogram (ECG):
  • Resting electrocardiogram is recommended under specific conditions 2
  • 90.4% of patients underwent ECG as recommended in the guidelines 3
• Chest X-ray:
  • Not routinely recommended 2
  • 98.5% of patients underwent chest-X-ray as recommended in the guidelines 3
  • Routine preoperative chest X-rays in elderly patients are worthwhile even without medical indication 4
  • Recommended in patients over the age of 60 years 5
  • 21.8% of chest X-rays were reported to have some abnormality in the film 6

Specific Patient Groups

• Elderly patients:
  • Routine preoperative chest X-rays are worthwhile even without medical indication 4
  • 75% of patients had medical indications for chest X-ray 4
• Patients over 60 years:
  • Recommended to have routine preoperative chest X-ray 5
  • Higher frequency of lung field abnormalities 5
• Patients with co-morbidities:
  • Good medical history and clinical examination can save many patients from unnecessary CXR 6