"A Man can't make a mistake can't make anything"

Tuesday, 1 May 2012


Chapter I

I.1. Background

Once we know the importance of routine examination screnning preoperative for smooth operation and to control costs in the hospital. Therefore here I downloaded on the official website of the Ministry of Health  hopefully useful to all colleagues, especially colleagues Surgical and anesthesia. Preoperative routine examination, either on the basis of appropriate clinical indications patient or not, has become part of clinical practice for many years. The purpose of the investigation is to identify conditions unexpected that may require treatment prior to surgery or changes in the management of perioperative surgery or anesthesia; assess previously known diseases, disorders, or medical therapy alternatives that may affect perioperative anesthetic; estimate postoperative complications; as the consideration for the reference next; examination screening. (1)     

Last literature recommends not adequately about assessment of clinical benefit or harm preoperative routine examination. At the time found abnormal or positive results, the percentage of patients who changes in its management varies. (1)
Termination of the word "routine" is unclear and requires clarification. One sense of routine checks are carried out all examinations based on existing regulations, these regulations have never changed by clinicians. In the assessment of a routine examination by the unit preoperative HTA English, understanding the inspection routine is intended for healthy indiviuals, asymptomatic, with no specific clinical indication, to know the condition is not detected by clinical history and physical examination. Based on the understanding that, if a patient found to have specific clinical features with the consideration that examination may be useful, it is defined that the examination The indications are not on the basis of examination routine. (1)
On the other hand has been agreed by the consultant and member of the American Society of Anesthesiologists (ASA) that the examination should not prabedah done routinely. Pre operation examination can be done selectively for optimizing the perioperative implementation. Indication does examination should be based on information gathered from the records medical, anamnesis, physical examination, the type and level of invasive surgery planned and should note. (2)
Several studies have shown that in the absence of clinical indications, the likelihood of finding significant abnormal results on examlaboratory, electrocardiography and chest X-ray small. Abnormal results are procedure is not expected to affect operation. (3)

I.2. problems

From the clinical history and physical examination can be determined from healthy patients who appropriate for surgery, and selecting the examination pre operation necessary. The reason why the doctors still perform
prabedah is chosen well without them believing that history clinical and physical examination are not sensitive and may be a routine pre operation  can protect them from medikolegal issue. Each inspection  pre opertion  to do with good reason so as to bring benefits to patients and avoid side effects potential. The benefits include the execution time of anesthesia or the use of sources that can improve the safety and effectiveness process of anesthesia during and after surgery. Potential side effects can occur, including interventions that can cause injury, uncomfort, delays or expenses that are not comparable with benefits.


I.3. purpose

Realization of scientific studies as the basis of government recommendations to establish policies in preparation for elective pre operation so as to reduce the cost of expenses for patients who do not have the disorder.

Chapter II

II.1. The literature search strategy

Search articles through Medline, New England Journal of Medicine, British Medical Journal, Anesthesiology, Annals of Internal Medicine, Canadian Journal of Anesthesia, British Journal of Anaesthesia, and BioMedicalCenter Anesthesiology, Surgery, Pediatrics, Anaesthesia, America Journal of Surgery, Journal of Clinical Anesthesia, Academy of Emergency Medicine, Mayo Clinic Proceedings, Anesthesia and Anesthesia, Anesthesia in the last 25 years (1978-2003). Information was also obtained from the guideline include a structured by ASA, American College of Cardiology (ACC), American Heart Association (AHA), National Institute of Clinical Excellence (NICE) and the Institute for Clinical Systems Improvement (ICSI) and the results of HTA studies from several countries, among Another England in 1997 on Routine Preoperative Testing. The keywords used were preoperative evaluation, preoperative examination, preoperative assessment, preoperative testing, guidelines, routine, Electrocardiography (ECG), fasting, chest X-ray, hemostatic screening, urinalysis, pulmonary function tests, laboratory tests, elective surgery, pediatric Patients, Patients elderly.

II.2. Level of Evidence and Level Recommendations
Any literature which gained critical assessment (critical appraisal) based on the rules of evidence based medicine, then the specified level. The recommendations are set to be determined level of recommendation. Level of evidence and the recommendations are classified according to the definition of Scottish Intercollegiate Guidelines Network, originating from the U.S. Agency for Health Care Policy and Research.
Level of evidence:

Ia.  Meta-analysis of randomized controlled trials.
Ib.  At least one randomized controlled trials.
IIa.  At least one non-randomized controlled trials.
IIb.  Cohort studies and / or case-control study
IIIa. Cross-sectional study
IIIb. Case series and case reports
IV.   Consensus and expert opinion

A. Evidence included in the level he or lb.
B. Evidence included in level IIa or II b
C. Evidence included in level IIIa, IIIb or IV

II.3. Target Population

Patients who do not have the disorder (asymptomatic), which is divided into groups of children (0-18 years) and adult (> 18 years). Recommended preparation preoperative elective set based support facilities are available at type C hospital with moderate to severe levels of operations.

Chapter III
PREPARATION Preoperative elective

III.1. Are blood tests routinely performed on the edge of complete preoperative preparatory elective?

Answer: Yes (Recommendation C)
Recommendation: Examination of routine complete blood count (hemoglobin, hematocrit, leukocyte, count types, platelets) performed in children aged <5 years, while for children aged ≥ 5 years of blood tests carried out on the edge of the indication, the patient are estimated to suffer from iron deficiency anemia, patients with disease heart, kidney, or respiratory infection.
Dkk4 Baron, in a retrospective study, states that 1.1% of 1863 children have a hematocrit value of less than 30% or greater than 50%. Roy colleagues studied 2,000 patients aged 1 month-18 years scheduled to undergo minor surgery. A total of 11 patients (3 patients aged <1 year and 8 patients 1-5 years old) had Hb <10 g / dl. Twenty-seven percent of patients operation is postponed and rescheduled after iron therapy orally, whereas 73% of patients still undergo surgery without complications.
Researchers concluded that healthy patients aged ≥ 5 years minor surgery do not require routine Hb. More
Furthermore, the low incidence of anemia in children aged 1-5 years raises questions about the importance of Hb in group prabedah this age.
Hackmann dkk4 anemia reported in 0.5% of 2648 children who will undergo surgery. Only 2 of these patients experienced anemia delay surgery (one patient suffering from respiratory tract infection). Researcher
concluded three things: (1) the incidence of anemia is rare, and occurs more often at age <1 year, (2) presence of mild anemia does not alter the decision setting the day of surgery, and (3) doctors can not detect anemia of clinical consistently.


last states that in determining child's fitness for surgery, patient history and examination physically far more important than routine laboratory tests, although difficult to detect anemia clinically consistent. Inspection Hb / Ht prabedah is indicated for patients who are more vulnerable groups suffer from anemia, the age <1 year; young women who are menstruating; have a chronic illness; undergo a surgical procedure that causes blood loss many. (4)

The advantage is a complete examination of peripheral blood can detect leukopenia or leukocytosis indicating infection or a rarer still is a malignancy of blood. O'Connor and Drasner (4) report presence of abnormal white cell count in 13 (2.7%) of 486 patients, and no one surgery postponed. One patient experienced an increase leukocytes due to acute otitis media, while 12 others are unknown
and no further assessment.
Coté5 stated that in infants aged ≤ 6 months should Peripheral blood examination considering the possibility of anemia greater physiological, anesthesia and surgery so that doctors know the Hb of patients. If the child is born prematurely the Hb examination become more importantly because of the relationship between anemia with increased incidence of apnea. Besides the examination of peripheral blood considered to be beneficial in patients with iron deficiency anemia, kidney failure, heart disease and respiratory tract.
Based on the report of Health Research and Development (Research and Development) 6 in 1997, 24-35% of school-age children in Indonesia suffer from iron deficiency anemia. The main cause is the low iron input through food, and the high iron absorption inhibitors contained in food and parasite infestation. Given the current Indonesia experienced a prolonged monetary crisis is expected to figure will rise again. It is therefore necessary to routine inspection preoperative Hb in children as one attempt to detecting anemia so that operations can be performed safely.

Answer: No (Recommendation C)
Recommendation: Detailed examination of peripheral blood in patients with liver disease, history of anemia, bleeding and other blood disorders, as well as depending on the type and degree of invasive surgical procedures.
Purpose of routine inspection is to detect anemia hemoglobin preoperative who are not clinically apparent. It happened since the trust that mild to moderate anemia may increase the risk of complications general anesthesia. ASA working group in 2001 recommended hemoglobin and hematocrit that examination is not routinely indicated.
Clinical characteristics as an indication of the type examination and the degree of invasive surgical procedures, patients with liver disease, history of anemia, other. (1) bleeding and blood disorders, 2
Based on the study of the UK HTA Unit found no controlled trial to evaluate the importance of hemoglobin or blood counts. All the available scientific evidence in the form of case-series. Preoperative  routine examination showed Hb levels <10 to 10.5 g / dl at 5% patients, rarely with Hb <9 g / dl, and the only change management in the 0.1 to 2.7% of patients. Assessment of scientific evidence does not support the policy of Hb examination or routine blood counts at all patients and vice versa there is no scientific evidence that states that examination of the harm. Conventional limit of anemia is Hb <10 g / dl, when less than the value of the operation can be postponed. But there is some scientific evidence that the risk of not operating increased significantly up to a Hb 8 g / dl. In healthy individuals, Blood transfusions are usually required if Hb <7 g / dl. But not so clear whether the transfusion of red blood effect when Hb between 7 and 10 g / dl. A multi-center study recently showed no improvement in morbidity or mortality in elderly patients who received postoperative transfusion when the hemoglobin concentration between 8 and 10 g / dl. One study suggested that Hb 7 g / dl perioperative quite safe. (7-9)
The assessment report concluded that the Swedish HTA Unit hemoglobin or hematocrit routine inspection is an examination of the The most cost-effective. (1)
Another thing that may influence the decision anesthesia is high leukocytes suggests the possibility of infection is not detected clinically, or low platelets causing bleeding Perioperative excessive. On a routine inspection found the pr leukocytes was lower in 1% of patients, whereas a low platelet count as much as 1.1% of patients and rarely lead to changes in management patient. (1) 

Dzankic dkk (10) do research prospective cohort to evaluate the prevalence and predictive value of laboratory tests prabedah abnormal in patients aged ≥ 70 years who underwent surgery other than the heart. In the 544 patients, found the results of abnormal platelet as much as 0.5 to 5%, abnormal creatinine 12%, 10% abnormal hemoglobin, glucose abnormal 7%. By multivariate logistic regression, only ASA classification (> II) (OR 2.55, 95% CI 1.56 to 4.19, p <0.001) and the risk of surgery (OR 3.48, 95% CI 2.31 to 5.23, p <0.001) as significant factors of free predictors likelihood of postoperative side effects. The prevalence of the electrolyte and abnormal platelet prabedah small, as well as predictive values. Although more related, the value of hemoglobin, creatinine and glucose abnormal is also not a predictor of adverse postoperative factors.
Routine examination of hemoglobin, creatinine, glucose and electrolytes Preoperative based solely on age is not an indication to do in geriatric patients. However, selective laboratory based on medical history and physical examination, which in turn determine the patient's comorbidities and risk of surgery, an indication laboratory tests done preoperative.

III.2. Are checks carried out on a routine blood chemistry Preoperative preparatory elective?

Answer: No (Recommendation C)
Recommendation: blood chemistry tests done when there is a risk kidney disorders, liver, endocrine therapy, perioperative, and drug usealternative.
Since 1981, in Italy, pediatric patients scheduled to undergo surgery just do some minor laboratory tests such as levels Hb, urinalysis and serum creatinine phosphokinase to detect suspicious serum cholinesterase and malignant hyperthermia. The results Meneghini dkk (11) reported a total of 508 (27%) of 1884 pediatric patients have a value abnormal serum creatinine phosphokinase. Further examination was repeated at 87 patients with serum creatinine values ​​fosfokinasenya three times the normal value and found only 5 cases of abnormal results. This suggests that serum creatinine phosphokinase prabedah examination is not necessary.

Answer: No, recommendation C
Recommendation: Routine blood chemistry tests performed only on patients advanced age, endocrine abnormalities, renal and liver function abnormalities, use of certain medications or alternative treatments.
Electrolyte disorders or acid-base balance in healthy individuals is very rarely so in practice the decision to do a routine check only to detect the presence of mild to moderate hypokalemia, renal impairment or diabetes mellitus who are not clinically apparent, the allows the operation was postponed until the abnormalities have overcome.(1)
ASA working group recommends that the clinical characteristics examination is an indication of calcium, glucose, sodium, renal function and liver is the possibility of perioperative therapy, endocrine disorders, the risk of kidney and liver function abnormalities, the use of certain drugs or alternative.(2) treatment UK HTA Unit reported that there is no controlled trial of preoperative routine blood chemistries, all of them in the form of case series.
The results of abnormal levels of sodium and potassium of 1.4% on the examination Preoperative routine examination while the abnormal urea and creatinine in 2.5% and 5.2% of blood sugar. These results rarely alter the management of patients thus concluded that no facts that support the policy blood chemistries Preoperative Routine. (1)
In elderly patients, levels of blood urea nitrogen and creatinine serum is an important component of laboratory tests Preoperative. Although the glomerular filtration rate decreased with increasing age,
usually urea nitrogen levels and normal serum creatinine for age continued to have muscle mass reduce. (12, 13)

III.3. Are checks carried out on routine hemostasis preoperative preparatory elective?

Answer: No (Recommendation C)
Recommendation: Examination of hemostasis in patients with history or clinical condition leading to coagulation disorders, will undergo operations that can cause coagulation disorders (such as cardiopulmonary bypass), as required for adequate hemostasis (such as tonsillectomies), and the possibility of postoperative bleeding (such as nerve surgery).
Dkk (4) Boger reported that 21% of patients who underwent tonsillectomy has a value of APTT (Activated Partial thromboplastin Time), PT (Prothrombin Time), or abnormal bleeding time, and suggested that the examination was performed in all patients to look for possible abnormalities
koagulasi. (4)
Close dkk (4) stated that routine APTT and PT in asymptomatic patients who will undergo a tonsillectomy is not useful in predicting postoperative bleeding. Massive bleeding in tonsillectomy is usually not as a result of coagulation disorders.
Burk dkk (14) conducted a prospective study to evaluate usefulness of screening prabedah bleeding disorder in children. Research performed on a history of bleeding and laboratory tests
(Blood counts, PT, APTT, and bleeding time) 1603 children who will undergoing tonsillectomy. Reported there were 31 patients (2%) with the initial results abnormal. A total of 23 of the 31 patients had elongated APTT values. Three patients had APTT and bleeding time prolonged, one patient with PT and APTT prolonged, two patients with PT lengthwise and 2 patients with bleeding time lengthened. A total of 15 patients (0.9%) having persistent abnormalities when examined 7-10 days later (14 patients with APTT lengthwise, 1 patient with elongated APTT and bleeding time). Disease history and laboratory screening has a high specificity and high negative predictive value but has a sensitivity and predictive value low positive in identifying patients who will experience perioperative bleeding. Some children with bleeding disorders may was first detected by examination of coagulation preoperative, then replacement therapy, the delay or cancellation of surgery can reduce or prevent perioperative bleeding. The amount of false positives in laboratory tests and a history of bleeding, coupled with rare congenital or acquired coagulopathy disorder, causing the increasing doubts about the usefulness of routine screening.

Answer: No (Recommendation C)
Recommendation: Examination of hemostasis in patients who have history of coagulation disorders, or recent history that led to the coagulation disorders, or are taking anticoagulant drugs or drug could be expected to interfere with coagulation, including traditional medicine, patients who require postoperative anticoagulation, patients who had abnormal liver and kidney.
Rational: Various reasons for doing routine checks prabedah hemostasis between others to identify patients with a bleeding tendency can be overcome or reversible after surgery, for example delays operating in patients taking aspirin or other drugs that inhibit Platelet function; to identify high-risk patients suffered intraoperative or postoperative bleeding, so the technique operations need to be modified or the need to prepare for transfusion blood. (1)
ASA working group recommends clinical characteristics as considered an indication of the examination INR, PT, APTT, platelets are is selective bleeding disorders, kidney disorders, liver disorders, type and
the degree of invasive procedures operation. (2)
UK HTA Unit identified 23 studies prabedah, which all case-series form. Bleeding time (Bleeding Time / BT) of 0 to 15.6% reported abnormal on routine examination and the indication, whereas the results of a routine examination in asymptomatic people only of 3.8%. PT reported abnormal values ​​of 0 to 12.9%, while the value Abnormal APTT obtained 16.3% of patients. Examination of hemostasis only
5.3% change the management of patients, and examination results BT / CT / PT / APTT no effect on the incidence of bleeding postoperative or in other words that the positive predictive value inspection
low that this is not clinically useful. In addition it also stated intraoperative or postoperative bleeding that more contact with the surgical technique rather than a coagulation disorder minor. (1)
In the study 3242 patients with multiple flashlights, Houry dkk15 in prospectively compare the results of the screening hemostasis standard prabedah (PT, APTT, platelet count, BT) with a history and clinical data. The result states that the hemostasis screening preoperative should not be done routinely, but only in patients who have abnormal clinical data.

III.4. Is routine urine examination carried out on preparations
prabedah elective?

Answer: No (Recommendation C)
Recommendation: Routine urine examination performed on the operating involves the manipulation of urinary tract infections and patients with symptoms of the channel tract.
Routine urine examination prabedah purpose is to track and resolve urinary tract infections and kidney disease are not unexpected. O'Connor and Drasner4 reported a 36 (8%) of 453 patients who had the
abnormal examination. Of the 36 patients, 12 patients had disease previously known, 12 patients showed normal results on re-examination, and 12 other patients there was no continuation of medical records. Suspended operations at two children, one child underwent emergency surgery a week later, and another child underwent surgery after overcoming tract infection bladder. It is concluded that routine urine examination adds little information on the evaluation preoperative healthy children and because it is not necessary.
If there is a history of problems that lead to the possibility of channel urine, the urine should do. (5) Wood and Haekelmen (16) reported no association between abnormal results of urine tests preoperative with postoperative complications in the study examination of the urine 1859 children who underwent elective surgery.

Answer: No (Recommendation C)
Recommendation: Routine urine examination performed on the operating involves the manipulation of urinary tract infections and patients with symptoms of the channel tract.
Rational: One reason for requesting a rational examination of the urine is detected asymptomatic urinary tract infections that can change the management of The next patient. For some procedures, such as joint replacement is really require aseptic conditions, urinary tract infection can delay the operation, although there is scientific evidence that states that the risk infection is not affected by the presence of urine. (1) tract infection ASA working group recommends that urine tests are not indicated except for specific procedures, such as implantation of the prosthesis, urologic procedures or the urine. (2) tract symptoms HTA Unit of the UK said there was no controlled trial has published on the importance of urine. All the scientific evidence that there is a case-series. Abnormal results of routine urinalysis preoperative 1 - 34.1% of patients and only 0.1 to 2.8% change in patient management.
Which causes a change of management is finding leukocytes in urine. But there is no scientific evidence that abnormal urinalysis prabedah complications associated with perioperative and postoperative. (4)
Abnormal urine test results will only change management if found leukocytes, which may indicate an infection urinary tract. Although leukocytes are found, not all patients received treatment. The results showed a clinical response to the results abnormal is more devoted to the examination on the basis of indications than  routine examination.
Both the indication and routine inspection, discovery of protein, or erythrocyte glucose does not alter the management clinical. It is the consideration that the clinician does not consideras a routine screening examination is important for people diabetes mellitus or urine.(1) tract diseases Recommended by the Swedish HTA Unit that the indication of bacteriuria asymptomatic is essential before surgery involving the channel manipulation urine.(1)
Elderly people have difficulty in the excretion of water, sodium, calcium followed by a decreased ability to concentrate urine. Because of the decline in glomerular filtration rate, then the risk occurrence of renal failure during operation into height. (13)
One study at the Mayo Clinic reported that the examination Routine laboratory did not change the output (outcome) or anesthesia plan in patients of all ages. Laboratory tests in elderly patients indicated by history and examination physical. (12, 13)

III.5. Is routine chest X-ray examinations performed on preoperative preparatory elective?

Answer: No (Recommendation C)
Recommendation: Routine radiographic examinations prabedah not necessary.
Rational: Wood dkk16 conducted a retrospective study on the benefits of screening X-ray as a screening procedure in pediatric patients for preoperative detect abnormalities of the unknown and determine whether the patient preoperative performed radiographic complications of anesthesia and fewer postoperative compared with those not done X-ray. Of the 749 cases, found 35 patients (4.7%) with abnormal results not previously suspected. Of the 35 patients, a total of 9 patients (1.2%) tested clinically significant disorder and 3 patients (0.4%) delayed surgery. There was no difference in anesthesia procedures or postoperative complications between the two groups. Further recommended that routine chest X-ray examination in children preoperative well do not need to be continued. At the beginning of the 1983 American Academy of Pediatrics recommends not perform routine radiographic examination in preparation preoperative. (17)

Answer: No (Recommendation C)
Recommendation: radiographic examinations performed on patients aged over 60 years, patients with signs and symptoms of cardiopulmonary disease, infection Acute respiratory tract, a history of smoking.
Purpose of the implementation of routine radiographic examination preoperative are:
Management of anesthesia or medical condition immediately. The main purpose of routine chest X-ray examination in operating non-preoperative cardiopulmonary is as an input to assess fitness of patients prior to general anesthesia. Expected X-ray able to detect conditions such as heart failure or lung disease chronicles that are not detected clinically, which may be cause delays or cancellation of surgery or require modification techniques anesthesia. (1)
Prediction of postoperative complications. Another purpose of routine radiographic examination is to preoperative identify patients who may be at risk of suffering complications postoperative lung or heart so that the management of patients Postoperative may be modified based on the results, for example
by moving the patient to the intensive care (High Care Unit) . (1)
As a basic interpretation of postoperative. Some authors state the importance of chest X-ray prabedah as basic interpretation of postoperative images are accurate when the patient arises postoperative complications of lung or heart. An example is happening postoperative pulmonary embolus, a chest X-ray picture of the minimal probably can not be seen unless there is radiographic prabedah as for comparison. (1)
As screening.
WHO estimates that one third of the world's population infected with Mycobacterium tuberculosis and 3 million people die each year from TB. Each year is estimated to occur 8 to 10 million new cases of TB. In Indonesia, WHO report in 2003 based on the number of patients with pulmonary TB doubling of the population in 1998 20/100.000 be 43/100.000 population in 2001. Therefore photo thorax can be used as a TB screening pulmo. (18)

Several studies have studied large series uses X-ray preoperative and reported that a routine chest radiograph preoperative not only no benefits, but also cause many patients got a management that does not need to because of abnormalities on chest X-ray. So the routine chest radiograph prabedah useless and should be avoided, except the indications according to medical history or examination physical. (2, 3.19)
Clinical characteristics of the radiographic examination for consideration preoperative includes a history of smoking, acute respiratory infections, diseases chronic obstructive pulmonary disease (COPD) and heart disease. Possibility abnormal chest X-ray results obtained quite high in some patients, but yet there is a guide to whether the factors of age, smoking history, infection acute upper respiratory tract, stable COPD or heart disease should be stable considered an indication of the examination thoracic. (2) photo UK HTA Unit has conducted a review of inspection images Routine thoracic preoperative. Several studies that examined degree of radiographic abnormalities increase with age. It is used as a basis for recommending "X-ray preoperative routine for n years of age ". Delahunt and Turnbull report
contrary to the statement, the results were not different significantly among the elderly with younger age. McCleane suggested that the increased prevalence of radiographic abnormalities more related to the degree of ASA than with age. Of the 6 studies to evaluate the radiographic results, obtained approximately from 0 to 2.1% of patients management changes. At the end of the UK HTA Unit tithrough the results have been published stating that the X-ray preoperative should not be done routinely because there are no facts supporting radiographic prabedah can raise or lower the risk perioperative. (1)
Only 1.3% of chest X-ray examination describes the abnormalities are not found on clinical examination and only causes 0.1% change in the management of absence prabedah change the results more god. (20) preoperative CXR may be obtained upon indication of a medical condition, according to the anamnesis and examination physical, or when necessary for the management of postoperative (Figure 1) . 21

III.6. Are electrocardiographic examination (ECG) was routinely performed in preparation for elective preoperative?
Answer: No (Recommendation C)
Recommendtation: Only done on the indication, if from a clinical examination found signs of heart abnormalities.
The incidence of congenital heart disease in Indonesia is 8 per 1000 births of life. Diagnosis of congenital heart disease confirmed by anamnesis, physical examination and investigation. One of investigation is the ECG, the ECG may show abnormalities of the heart rhythm and heart indirectly.

Answer: No (Recommendation C)
Recommendation: Examination of ECG in patients with diabetes mellitus, hypertension, chest pain, congestive heart failure, history of smoking, peripheral vascular disease, and obesity, which did not have EKG results in Last 1 year regardless of age. Besides ECG was also conducted in patients with cardiovascular symptoms or signs and symptoms of periodic unstable cardiac disease (unstable), and all patients were age> 40 years.
The main purpose is to detect preoperative EKG heart condition, as a new myocardial infarction, ischemic heart disease, conduction defects or arrhythmias, that could affect anesthesia or even delay surgery;
identify the possible complications of cardiac patients, especially acute myocardial infarction after operation. (1)
All the scientific evidence in the form of case-series, and there is no scientific evidence which supports the importance of ECG prabedah to base consideration. Conversely there is no scientific evidence that routine ECG preoperative will dangerous. (1)

Clinical characteristics of patients with essential including disease cardiovascular, respiratory disease and level of invasive surgery. On patients with coronary disease, the ECG is an important examination in determine the prognosis associated with long-term morbidity and mortality. ECG (No activity) can not be identified increased perioperative risk in patients undergoing surgery risks low, but abnormal ECG is a predictor of increased risk Perioperative and long-term cardiovascular patients undergoing
moderate risk surgery and high. (2)
ASA working group study reported abnormal results on Routine EKG as much as 7 to 42.7% of cases (N = 12 studies) and change management in 9.1% of cases (N = 1 study). While EKG prabedah the indication was reported as abnormal results 4.8 to 78.8% of cases (N = 17 studies) and as much as 2-20% of cases had change management. Rabkin and Horne asked questions ie how often specific ECG changes found in patients who had earlier ECGs. Abnormal results are found in 2% of patients, although the possibility of abnormal outcomes increased with increasing of age. McCleane2 reported that the prevalence of abnormalities also increased along with worsening ASA status Although most routine checks on the basis of age may not be important, but perhaps one exception prabedah ECG and required for most elderly patients because it is often found abnormal results. The high incidence of heart disease is silent and Other diseases such as hypertension can affect EKG results. ECG results prabedah abnormal are often found in elderly patients is atrial fibrillation, an abnormal ST waves that lead to ischemic, Left and right ventricular hypertrophy, arrhythmias and blocks atrioventrikular.2, 21
Dkk2 Seymour, 21 studied 222 patients aged ≥ 65 years, and found results are abnormal EKG is not related to the onset of complications postoperative heart in men, but women may be related.
While other studies that examined 198 patients, concluded that ST-T wave abnormalities and intraventricular conduction delay associated with increased postoperative morbidity and mortality due to heart complications. Synthesized by Goldberger and O'Kinski2, (22.23) from 4 studies state the age limit did an EKG, usually between 45 and 65 years. But the age limit was chosen because it is subjective advantage in detecting abnormalities can not be demonstrated. On the other hand, ASA has been no consensus about the minimum age limit for praanestesia EKG, especially in patients without risk factors specifics. Yet agreed on an EKG is indicated for patients who known to have cardiovascular risk factors or patients with factor risks identified during the evaluation preanestesia.
In the Swedish HTA report noted, are often found changes Significant ECG according to age and, very
reasonable to put an age limit in selecting patients who should ECG examination. Age limit is a matter of assessment difficult, and ultimately many clinicians who use the 50-60 age limit years, and age> 40 years if the patient does not have a normal ECG prior as referensi.(1)

Prabedah EKG recommendation of ACC and AHA are: (22)

Class I
Episodes of chest pain or equivalent iskemikk risk patients medium and high-risk surgery was scheduled for and height.

Class II
Asymptomatic patients with diabetes mellitus.

Class IIb
1. Patients with a history of previous coronary revascularization
2. Asymptomatic male patients> 45 years of age or women> 55 years with 2 or more atherosclerotic risk factors.
3. History of hospitalization due to heart disease

Class III
As a routine examination in asymptomatic patients who low-risk surgery.

Here is a guide to recommended EKG preoperative by Vanderbilt University (Figure 2).

Murdoch dkk (24) reported 154 (13%) of 1185 patients who will underwent surgery EKG criteria predictive of disease coronary arteries. Twenty-six percent of 154 patients the results obtained abnormal as much as 26%, most patients are known to have hypertension. Only 20% of patients who have had abnormal ECG results delay the operation. No postoperative complications that occur. Concluded that an EKG had limited value in determine risk stratification in patients undergoing surgery.

III.7. Is pulmonary function tests routinely performed on properative preparatory elective?


Answer: No (Recommendation C)
Recommendation: Only done on indication.

Answer: No (Recommendation C)
Recommendation: Examination of spirometry performed in patients with a history smoking or dyspnea who will undergo surgery shortcut (bypass) coronary or upper abdomen; patients with dyspnea without cause or symptom lung will undergo head and neck surgery, orthopedic, or abdominal below, all patients undergoing lung resection and all patients aged up.
Increase in age causes a gradual reduction in the ability and some changes in lung function that can be expected. Thoracic become more rigid which leads to reduced power expansion ribs, it The increased work of breathing while strength and muscle mass reduced. Changes that result in reduced respiratory capacity maximum. Decreased ability of the lung parenchyma recoil. Respiratory tract the smaller it becomes easier to collapse and closing capacity increases with age, so the volume is cause airway closure during normal breathing. All the above changes predispose the occurrence of hypoxia and
atelectasis in patients with advanced age. (12, 13.25)
Patients with significant respiratory disease should preoperative identified during the evaluation, especially in those who would high-risk surgery, such as upper abdominal surgery. In addition to known that lung function decreased with increasing age, only there is little scientific evidence that suggests pulmonary function tests prabedah is a useful factor in predicting complications
postoperative lung. (12,13,25)
One reason for the rational examination of spirometry is to identify patients at high risk of allowing the
delay the operation. Clinicians should use a variety of strategies to reduce the risk of pulmonary complications in high risk patients through clinical evaluation and assessment of risk factors. No data are states that spirometry can identify people at risk height without having clinical symptoms of pulmonary or other risk factors possible occurrence of pulmonary complications. Spirometry may be useful for patients with COPD or asthma, if after a clinical evaluation obtained doubt whether the degree of airway obstruction have fallen optimal or not. (25)
In 1990 the American College of Physicians recommends examination of spirometry in patients with a history of smoking or dyspnea who will undergo surgery or coronary shortcut upper abdomen; patients with dyspnea without cause or symptom of lung will undergo head and neck surgery, orthopedic, or lower abdomen; all patients will undergo lung resection. Some recent studies claim that spirometry have predictive value varies. Also stated that clinical findings have more predictive value than spirometry in estimate the likelihood of pulmonary complications after surgery. But there has been no randomized clinical trial of the case this. (25)

III.8. Is fasting routinely performed in preparation preoperative elective?

Answer: Yes (Recommendation C)
Recommendation: fasting period of breast milk, formula and food solid is 4 hours in children aged <6 months, 6 hours in children aged 6-36 months and 8 hours in children aged> 36 months. Period of fasting from clear liquids is 2 hours in children aged <6 months, 3 hours in children aged 6-36 months and > 36 months.
However there are still some doubt, how to infants aged <6 months who drink breast milk, formula milk and solid foods. Doubt due to the composition of breast milk in the breast milk depends on maternal diet, the higher the fat intake of the mother the higher the milk fat content so that digestion is also slower. Usually for infants <6 months allowed to drink milk, formula milk and solid foods until 4 hours before intubation, while the allowed until 2 hours before operation is a clear fluid it. (5, 26)
According to the ASA working group, there is not enough data to evaluate relationship between intake of milk and milk formula before the procedure anesthesia with the incidence of emesis or pulmonary aspiration. Further Breastfeeding is recommended that fasting for 4 hours or more before procedures general anesthesia, regional, or sedation / analgesia, whereas for formula milk for 6 hours or more. (26)
For children> 6 months Coté5 suggest fasting milk, dairy and food solid for 6 hours, but allowed to drink clear liquids up to 3 hours before surgery. Some literature has shown that emptying of liquids clear in the stomach takes place quickly. Gastric residual volume in children who drink clear liquids until 2 hours before induction did not different or slightly different from the child who has been fasting all night. There was no difference in gastric volume between the children who fasted for 2-4 with the fasting hours> 4 hours. It is therefore not required period too much time fasting before elective surgery in pediatric patients. Case caused most institutions have changed the term child
fasting time for liquids clear. (26)
Some clinicians claim children> 3 years requires long- Longer fasting time of 8 hours of fasting milk and solid foods, 3 hours of fasting and clear liquid. This allows the child does not experience hypovolemia due to prolonged fasting. Fluid intake is more Smoking also allow a reduction in the incidence of hypoglycemia and hypotension prabedah after induction of anesthesia inhalation, although this has not studied. (5)

Answer: Yes (Recommendation C)
Recommendation: fasting period is eight hours.
ASA working group stated that no evidence was reported the relationship between fasting times, gastric volume or gastric acidity the risk of reflux / emesis or pulmonary aspiration in humans.
In the study comparing the long fasts between 2-4 hours to> 4 obtained at a smaller gastric volume in adults fasted for 2-4 hours. ASA working group recommends that fasting for 2 hours or more for adequate clear fluid before implementation of general anesthesia, regional or sedation / analgesia. The sample such clear water, fruit juice, soda, unsweetened tea and coffee. Volume fluid is not so important when compared with the type fluid. (26)
There are no adequate data concerning the period of fasting for solid food. For patients in all age categories, the working group ASA light recommend fasting from food or milk other than breast milk for 6 hours or more prior to elective surgery with general anesthesia, regional, or analgesia. They claimed that the intake of rice, fatty foods or meat may prolong gastric emptying. Both the number and types of food should be considered to determine the period of fasting the right. (26)

Chapter IV



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2. American Society of Anesthesiologists. Practice advisory for preanesthesia evaluation. Anesthesiology 2002;96:485-96.

3. Perez A, Planell J, Bacardaz, Hounie A, Franci J, Brotons C, dkk. Value of routine preoperative tests: a multicentre study in four general hospital. Br J Anaesth 1995;74:250-6.

4. Patel RI, DeWitt L, Hannallah RS. Preoperative laboratory testing in children undergoing elective surgery: analysis of current practice. Clin Anesth 1997;9:258-61.

5. Coté CJ. Preoperative preparation and premedication. Br J Anaesth 1999;83:16-28.

6. Badan Penelitian dan Pengembangan Kesehatan. Report of the policy workshop on iron deficiency anemia in Indonesia. Jakarta, Indonesia. 1-2 April 1997.

7. National Institutes of Health Consensus Development Conference Statement. Perioperative red cell transfusion. 27-29 Juni 1988.

8. Carson JL, Duff A, Berlin JA, Lawrence VA, Poses RM, Huber EC, dkk.   Perioperative   blood   transfusion   and   postoperative   mortality. 1998;279:199-205.

9. Stehling L. New concepts in transfusion therapy. International Anaestesia Research Society 1998. Review Course Lectures.h. 62-5.

10. Dzankic S, Pastor D, Gonzales C, Leung JM. The prevalence and predictive value of abnormal preoperative laboratory tests in elderly surgical patients. Anesthesia & Analgesia 2001;93(2):301-8.

11. Meneghini L, Zadra N, Zanette G. The usefulness of routine preoperative laboratory tests for one-day surgery in healthy children. Paediatr Anaesth 1998;8(1):11-5.

12. Barnett SR. Preoperative evaluation and preparation of the elderly patient. Current Anesthesiology Reports 2000;2:445-52.

13. Akrp AH, Koval KJ. Preoperative medical evaluation of the elderly patient. Archives of the American Academy of Orthopaedic Surgeons 1998;2(1):81-7.

14. Burk CD, Miller L, Handler SD, Cohen AR. Preoperative history and coagulAtion screening in children undergoing tonsillectomy. Pediatrics 1992;89(1):691-5.Burk CD, Miller L, Handler SD, Cohen AR. Preoperative history and coagulAtion screening in children undergoing tonsillectomy. Pediatrics 1992;89(1):691-5.

15. Houry S, Georgeac C, Hay JM, Fingerhut A, Boudet MJ. A prospective multicenter evaluation of preoperative hemostatic screening tests. Am J Surg 1995;170(8):19-23.

16. Wood RA, Hoekelman RA. Value of the chest X-ray as a screening test for elective surgery in children. Pediatrics 1981 Apr;67(4):447-52.

17.  American Academy of Pediatrics. Evaluation and preparation of pediatric patients undergoing anesthesia. Pediatrics 1996;98(3):502-8.

18. WHO. Global tuberculosis control: surveillance, planning, financing. WHO Report 2003.

19. Health Services Utilization and Research Commission. Selective chest radiography:  guidelines.     Didapat          dari http://www.hsurc.sk.ca/research_studies/pdf.

20. Velanovich V. The value of routine preoperative laboratory testing in predicting postoperative complications: a multivariate analysis. Surgery;109:236-43.

21. Vanderbilt University Guidelines For Preoperative Evaluation and Preparation. Didapat                                                                            dari URL:http://www.anesthesiology.mc.vanderbilt.edu/vpecguide/guidemenu.htm. 

22. American College of Cardiology and the American Heart Association, Inc. ACC/AHA guideline update on perioperative cardiovascular evaluation for noncardiac surgery. Amerika Serikat 2002.

23. Goldberger AL, O’Konski M. Utility of the routine electrocardiogram before surgery and on general hospital admission: critical review and new guidelines. Ann Intern Med 1986 Oct;105(4):552-7.

24. Murdoch CJ, Murdoch DR, McIntyre P, Hoste H, Clark C. The pre-operative ECG in day surgery: a habit? Anaesthesia 1999;54(9):907-8.

25. Smetana  GW.  Preoperative  pulmonary  evaluation.  N  Engl  J  Med 1999;340(12):937-44.

26.  American Society of Anesthesiologists. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures. Anesthesiology 1999;90(3):896-905.

27. Institute for Clinical Systems Improvement. Health care guideline: preoperative evaluation. Didapat dari URL: http://www,.icsi.org, Sox HC, Garber AM, Littenberg B. The resting electrocardiogram as a screening test: a clinical analysis. Annals Internal Medicine 1989 Sep 15;111(6):489-502.

28. Narr BJ, Warner ME, Schroeder DR. Outcomes of patients with no laboratory assessment before anesthesia and a surgical procedure. Mayo Clin Proc 1997;72(6):505-9

29. Auble TE, Taylor DM, Hsu EB, Yealy DM. Evaluation of guidelines for ordering prothrombin and partial thromboplastin times. Acad Emerg Med 2002;9(6):567-74.

30. Schein OD, Katz J, Bass EB, Tielsch JM, Lubomski LH, Feldman MA, dkk. The value of routine preoperative medical testing before cataract surgery. NEJM 2000;342(3):168-75.

31. Ramírez-Mora JC, Moyao-Garcia D, Nava-Ocampo AA. Attitudes of Mexican anesthesiologists to indicate preoperative fasting periods: a cross-sectional survey. BMC Anesthesiology 2002;2:1-6.

32. Preoperative evaluation and preparation. The center for laparoscopic obesity surgery                    1998. Didapat dari URL:http://anesthesiology.mc.vanderbilt.edu/vpecguide/guidemenu.htm

33.  British Columbia Medical Association. Guidelines & protocols advisory committee: preoperative testing 2000. Didapat dari URL: http://www.hlth.gov.bc.ac/msp/protoguides/gps/preop.pdf
King MS. Preoperative evaluation. Am Fam Physician 2000;62:387-96.

34. Association of Ottawa Anesthesiologists. Anesthesia preoperative assessment. 2000. Didapat dari URL:http://www.anesthesia.org/pau/pau_english.html 
35. The practice of anesthesiology. Dalam: Morgan GE, Mikhail MS, Murray MJ, penyunting. Clinical Anesthesiology. Edisi ketiga. New York: Lange Medical Book/McGraw-Hill; 1996. h. 5-9.

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