What tests are typically done before major surgery, such as Chest X-ray (CXR), Full Blood Count (FBC), Electrocardiogram (ECG), and urine test?

Preoperative Testing Before Major Surgery

For major surgery, the essential preoperative tests depend on patient risk factors and surgical invasiveness, but intermediate- and high-risk patients undergoing major procedures should have FBC, ECG, renal function, and coagulation profile checked preoperatively. 1

Risk-Stratified Approach to Testing

Full Blood Count (FBC)

• FBC is recommended for all patients undergoing cardiovascular surgery and major procedures where significant blood loss is anticipated. 1
• Order FBC for patients with liver disease, history of anemia or recent blood loss, or hematologic disorders. 1, 2
• For major surgery (grade 3-4), FBC is indicated in ASA class 2-3 patients over 60 years with cardiovascular disease, and those with respiratory or renal disease. 1

Electrocardiogram (ECG)

• ECG is mandatory for intermediate- and high-risk patients undergoing major surgery. 1
• Specifically indicated for patients with known cardiovascular disease, structural heart disease, heart failure, cerebrovascular disease, diabetes, or renal impairment undergoing intermediate or high-risk surgery. 2
• All patients undergoing lung resection or thoracic aortic surgery require preoperative ECG. 1
• Patients undergoing low-risk surgery without cardiovascular risk factors do not require ECG. 2

Chest X-Ray (CXR)

• CXR is NOT routinely indicated for asymptomatic, otherwise healthy patients, even before major surgery. 1, 2
• Order CXR only for patients with new or unstable cardiopulmonary signs or symptoms. 2
• Consider CXR for patients at risk of postoperative pulmonary complications if results would change perioperative management. 2
• All patients being considered for lung resection surgery should have a plain chest radiograph. 1

Urine Test (Urinalysis)

• Routine urinalysis is NOT indicated for asymptomatic patients undergoing major surgery. 2
• Urinalysis is only indicated for patients undergoing urologic procedures or implantation of foreign material (prosthetic joint, heart valve). 2

Additional Essential Tests for Major Surgery

Renal Function and Electrolytes

• Electrolyte and creatinine testing is recommended for all patients with known renal conditions and those undergoing neurosurgery or cardiovascular surgery. 1, 2
• Test patients taking diuretics, ACE inhibitors, ARBs, NSAIDs, or digoxin. 2
• Required for patients with hypertension, heart failure, chronic kidney disease, complicated diabetes, or liver disease. 2

Coagulation Profile

• Intermediate- and high-risk patients undergoing major surgery should have coagulation profile (prothrombin time, platelet count) checked preoperatively. 1
• Reserve coagulation testing for patients with history of bleeding disorders, liver disease, or those taking anticoagulants. 2
• Do not order indiscriminately due to low prevalence of inherited coagulopathies. 2

Common Pitfalls to Avoid

• Do not order tests "just to be safe" or based on arbitrary protocols—only order tests that would alter perioperative care. 2
• Avoid routine testing in healthy ASA class 1 patients undergoing low-risk procedures, as abnormalities are found in only 0.8-22% of cases with management changes in only 1.1-4%. 1, 2
• The history and physical examination remain the strongest predictors of perioperative complications, not routine laboratory tests. 3

Timing Considerations

• For high surgical invasiveness or high severity of disease (ASA class 3), assessment and testing must occur prior to the day of surgery. 1, 4
• For low-risk patients undergoing low-invasiveness procedures, testing may be performed on the day of surgery. 1