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Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 16  |  Issue : 3  |  Page : 392-396  

The value of routine tests before pediatric eye surgery: A 10-year experience at a tertiary care hospital


1 Department of Anesthesiology, Faculty of Medicine, University of Toyama, Toyama, Japan
2 Department of Anesthesiology, Toyama Nishi General Hospital, Toyama, Japan

Date of Submission21-Jul-2022
Date of Decision09-Sep-2022
Date of Acceptance22-Sep-2022
Date of Web Publication09-Dec-2022

Correspondence Address:
Dr. Mitsuhiro Matsuo
Department of Anesthesiology, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.aer_112_22

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   Abstract 

Background: Routine tests before ophthalmologic surgery in adult patients are no longer recommended. However, there are limited data on the utility of routine preoperative tests for children. Aims: We aimed to describe the effect of routine preoperative tests on systemic perioperative complications by hospital discharge or by day 30 following eye surgery. Settings and Design: This was a single-center, observational, and descriptive study. Subjects and Methods: We examined all patients ≤ 17 years old for whom ophthalmologists consulted with anesthesiologists before eye surgery under general anesthesia in an academic teaching tertiary care hospital from January 2010 to December 2019. Results: A total of 708 pediatric patients were analyzed. The mean patient age was 8.5 ± 4.6 years. The most frequently performed procedure was strabismus surgery in 433 patients (61.2%). Following anesthetic consultations, 15 patients (2.1%) underwent surgery postponed due to abnormalities at the physical examination. Routine tests identified that the two patients (0.3%) required additional evaluations due to elevated serum creatine kinase and electrocardiographic abnormalities. However, further examinations found that these abnormalities were unremarkable. The remaining 691 patients (97.6%) underwent surgery as scheduled. Substantial intraoperative blood loss was observed only in three patients with malignant tumors or trauma. The incidence of systemic complications was 0 (0%; 95% confidence interval, 0%–0.05%). Conclusions: These data indicated that the development of systemic perioperative complications following pediatric ophthalmic surgery is rare. Preoperative tests should be requested only if they are clinically indicated or before potentially bleeding procedures, such as malignancy or trauma surgery.

Keywords: General anesthesia, ophthalmologic surgical procedures, pediatrics, postoperative complications, routine diagnostic tests


How to cite this article:
Horikawa H, Matsuo M, Yamazaki M. The value of routine tests before pediatric eye surgery: A 10-year experience at a tertiary care hospital. Anesth Essays Res 2022;16:392-6

How to cite this URL:
Horikawa H, Matsuo M, Yamazaki M. The value of routine tests before pediatric eye surgery: A 10-year experience at a tertiary care hospital. Anesth Essays Res [serial online] 2022 [cited 2023 Feb 3];16:392-6. Available from: https://www.aeronline.org/text.asp?2022/16/3/392/363124


   Introduction Top


Routine tests before a low-risk surgery in adults are no longer recommended.[1],[2] This is because screening laboratory tests, chest X-rays (CXR), and electrocardiograms (ECGs) are unlikely to predict the development of cardiovascular events after adult noncardiac surgery.[3] In addition, medical history and physical examinations are essential for assessing perioperative mortality and morbidity caused by cardiovascular events.[4] However, preoperative blood tests are still frequently performed even before low-risk surgeries in some countries, including Japan.[5]

There are anatomical and physiological differences between adults and young children such as airway anatomy and drug susceptibility. In contrast to adults, the development of airway problems and cardiac arrest due to arrhythmia are severe perioperative complications in pediatric surgery.[6] For example, cardiac arrest attributable to anesthesia develops more frequently in children than adults.[7] Even in major surgeries, such as cardiothoracic and neurosurgery, routine preoperative tests are shown to be largely unnecessary for children.[8],[9] Although ophthalmologic surgery is minimally invasive, it can be associated with arrhythmias, potentially resulting in asystole.[10] Nevertheless, the impact of routine tests before eye surgery under general anesthesia in children has not been reported. In the present study, we examined the results of routine tests before pediatric eye surgery on perioperative systemic outcomes at a tertiary care hospital.


   Subjects and Methods Top


Study design

This single-center, retrospective, and observational study was approved by the ethics committee of our hospital (No. R2020160; December 4, 2020) and conducted following the principles of the Declaration of Helsinki. The requirement for written informed consent was waived due to the retrospective nature of this study. Instead, opt-out consent documents were presented on our hospital website for patients who did not wish to participate.

Patients

Using electronic medical records, we identified all patients ≤ 17 years old for whom ophthalmologists consulted with anesthesiologists before eye surgery under general anesthesia in our hospital from January 2010 to December 2019. In our hospital, routine tests are ordered, at the same time, the ophthalmologist requests an anesthetic consultation. At the anesthetic consultation, a decision was made by attending anesthesiologists on whether or not to proceed with surgery based on the history taking, physical examination, and results of routine tests.

Routine tests

Routine preoperative tests consist of laboratory blood tests, CXR, and ECG. Laboratory blood tests included a complete blood count, total bilirubin, albumin, creatinine, creatine kinase (CK), random blood glucose, sodium, potassium, and chloride measurements. Coagulation tests were not routinely performed as routine tests before pediatric eye surgery in our hospital. Pediatric reference ranges were the same as those used for adults in our hospital. Abnormalities in CXR and ECG were assessed by the attending anesthesiologists.

Purpose

The purpose of this study was to describe the effect of routine preoperative test results on systemic perioperative complications by hospital discharge or by day 30 following eye surgery. Postoperative complications were defined as a Clavien–Dindo classification Grade III or higher.[11]

Statistical analysis

Given the observational nature of the study, the sample size was not calculated a priori. The continuous values are expressed as mean ± standard deviation. The 95% confidence interval (CI) was calculated using EZR, which is a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria).[12]


   Results Top


Over our 10-year assessment period, 714 anesthetic consultations were performed before pediatric ophthalmologic surgery under general anesthesia at our hospital. Because four patients refused surgery and two patients had their symptoms relieved without surgery, the remaining 708 cases were analyzed in the present study [Table 1].
Table 1: Characteristics of pediatric patients who underwent anesthetic consultation

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As a result of the anesthetic consultations, 15 patients (2.1%) underwent surgery postponed due to abnormalities in physical examination, which included the common cold in 14 patients and a skin rash in one patient. Two patients (0.3%) required additional evaluations due to the abnormal findings identified only by routine tests – a 15-year-old boy without a family history of muscle diseases showed transiently high serum CK levels (7324 U.L−1) on the day after exercise, whereas the other patient had a second-degree atrioventricular block, eventually diagnosed Wenckebach block by a pediatric cardiologist. The remaining 691 patients (97.6%) underwent surgery as scheduled. Eventually, all patients who were consulted by anesthesiologists proceeded to surgery with or without postpones [Table 2]. The operating time was 56 ± 37 min. Blood loss was detected only in three patients: 30 mL in a 2-year-old girl with retinoblastoma, 58 mL in a 3-year-old boy with retinoblastoma, and 50 mL in a 17-year-old male with orbital floor fractures. Blood transfusion was not administered in any cases. The incidence of systemic complications was 0 (0%; 95% CI, 0%–0.05%).
Table 2: Surgical characteristics

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Abnormalities in routine tests were divided into two categories – the first was a known abnormality based on medical history, whereas the other was an unknown abnormality that was incidentally found by routine tests. The results of the laboratory tests are summarized in [Table 3]. The most frequent abnormality was seen in serum creatinine (584 of 696 samples; 84%). All abnormal creatinine values were lower than the reference range. The next most frequent abnormal value (63%) was hemoglobin level (439 and 4 cases were lower and higher than the reference range, respectively).
Table 3: Results of routine laboratory tests before eye surgery

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CXRs were performed in all patients, with the majority showing unremarkable findings (687 patients, 97%). There were 17 known CXR abnormalities, which included 10 cardiac shape abnormalities associated with known congenital heart diseases and four nasogastric tube placements. Unknown abnormalities in CXRs were noted in four patients – three were scoliosis, and one was a pulmonary infiltrate (their anesthetic management was not affected). ECGs were performed in 703 patients (99%), although three ECGs were difficult to interpret due to motion artifacts. Known and unknown abnormalities in ECGs were found in nine and six patients, respectively. Only one case showed an ECG abnormality that required further investigation, which resulted in the diagnosis of Wenckebach block, as described above. No patients were identified with long QT syndrome or Wolff–Parkinson–White syndrome.

The number of patients with any abnormalities in the routine tests are 47 (100%; 95% CI, 0.925–1), 281 (100%; 95% CI, 0.987–1), 229 (98%; 95% CI, 0.957–0.995), and 117 (80%; 95% CI, 0.722–0.858) in 0–1, 2–6, 7–12, and 13–17 years group, respectively. Totally, 674 children (95.2%; 95% CI, 0.934–0.967) had at least one abnormal finding in routine tests before ophthalmologic surgery.


   Discussion Top


In the present study, we investigated the impact of routine preoperative tests on perioperative complications in pediatric eye surgery. Over our 10-year observation period, 708 laboratory tests, 708 CXRs, and 703 ECGs were performed as preoperative screens. Routine tests identified significant abnormalities in only two patients, which required further evaluation. However, these two abnormalities were found to be unremarkable. Regardless of the routine test results, no severe perioperative complications developed in our patients. This is the first study to focus on routine test before pediatric eye surgery. Our results support the Choosing Wisely[13] and other guidelines,[14],[15] which encourage health-care providers and professional societies to lead efforts to reduce the use of low-value care.

Cardiac arrest remains a critical complication in pediatric surgery. The frequency of cardiac arrest in low-risk patients during noncardiac surgery is very low (0.3 per 10,000), but increases with increasing patient' risk.[16],[17] For example, in a large study of 92,881 patients, most patients who experienced perioperative cardiac arrest (88%) had congenital heart disease. In the present study conducted in a tertiary hospital, the prevalence of congenital heart disease was 5% [Table 1], which is higher than the general prevalence of approximately 1%.[18],[19] Moreover, ECG abnormalities that can cause cardiac arrests, such as long QT syndrome and Wolff–Parkinson–White syndrome, can be detected by routine testing, although their prevalence is low.[14],[20] Ophthalmic surgery is associated with a risk of cardiac arrhythmias related to the Aschner reflex.[7] Nevertheless, despite our inclusion of patients with a high prevalence of congenital heart disease before eye surgery, no critical arrhythmias developed in the perioperative period. A previous study reported that routine preoperative ECG did not change decision-making, even in cardiothoracic surgery.[9] Since the development of lethal cardiac complications is rare, detailed interviews and communication with family pediatricians seem to be more important than routine tests.

Perioperative oxygen saturation quickly decreases during apnea, especially in younger or low body weight children.[21],[22] Adverse respiratory events are the leading cause of perioperative cardiac arrest.[23] The most common cause of airway obstruction is laryngospasm, followed by inadequate ventilation and difficult intubation.[24] Oropharyngeal surgery and upper respiratory infection are also associated with adverse perioperative respiratory events.[25],[26] The development of laryngospasm is related to recent upper respiratory infection, the presence of an upper airway anomaly, and environmental tobacco smoke.[27],[28] One retrospective study found no differences in perioperative complications between patients receiving a preoperative CXR or not.[29] Collectively, routine preoperative CXR seems to be unhelpful for predicting perioperative respiratory adverse events.

Massive bleeding also causes anesthesia-related cardiac arrest.[30] In the present study, hemoglobin levels were lower than the reference range in 439 patients (62%). However, intraoperative blood loss was negligible in all patients other than three patients in this study. Elevated serum CK levels are often associated with congenital muscular dystrophy and myopathy. However, CK levels alone are insufficient to include or rule out these diseases.[31],[32]

There are several limitations of this study. First, we did not investigate systemic postoperative complications defined as a Clavien–Dindo classification Grade I or II, and intraocular issues such as local infection. Second, the reference interval we used was that for adults in our hospital, whereas in children, the reference values for blood tests differ depending on age.[33] Finally, it was a single-center, retrospective study with a small sample size.


   Conclusions Top


Our results showed that the development of systemic complications following pediatric ophthalmic surgery is rare. Preoperative tests should be requested only if they are clinically indicated or before potentially bleeding procedures, such as malignancy or trauma surgery. Analytic studies are needed to elucidate the association of routine preoperative tests with postoperative complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3]



 

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