Unindicated preoperative testing: ASA physical status and financial implications.

STUDY OBJECTIVE: To determine if the ordering of unindicated preoperative laboratory tests is different for healthy (ASA physical status I and II) versus sicker (ASA physical status III) patients, and to examine the financial implications at our institution of unindicated preoperative testing. DESIGN: Prospective, cross-sectional study. SETTING: University hospital. PATIENTS: 383 consecutive patients scheduled for elective surgery and seen by an anesthesiologist in the Preoperative Clinic. Complete data was available for 312 patients. MEASUREMENTS AND MAIN RESULTS: Preoperative laboratory tests ordered by the surgeon were compared to those tests considered indicated by one of several anesthesiologists for ASA physical status I and II versus ASA physical status III patients. An average of 72.5% of tests ordered by surgeons were considered not indicated by the anesthesiologists. ASA physical status III patients had significantly fewer unindicated complete blood count, platelet count, prothrombin time, partial thromboplastin time, chemistry 12 profile, and chest radiography orders than did ASA physical status I and II patients. Our hospital could generate approximately $80,000 in variable and semifixed cost savings by eliminating these unindicated preoperative tests for the 5,100 patients seen in Preoperative Clinic annually (29% of the total surgical patients). CONCLUSIONS: A large percentage of preoperative tests ordered by surgeons at our institution are not indicated. Eliminating unindicated tests would cut hospital revenues in a climate where testing is fee-for-service and would save the hospital money in a managed-care or capitated system.

Penile block timing for postoperative analgesia of hypospadias repair in children.

PURPOSE: It has been well established that a dorsal penile nerve block immediately after surgery decreases postoperative pain in children undergoing hypospadias repair. However, to our knowledge the efficacy of a penile block immediately before versus immediately after surgery for postoperative pain control has not been previously studied in such children. MATERIALS AND METHODS: We evaluated 98 healthy boys 6 months to 12 years old undergoing hypospadias repair. General anesthesia was induced and maintained in a standard fashion. Patients were randomly assigned to receive a penile block with the same total dose of bupivacaine at the completion of surgery, before the incision or before and at the completion of surgery. No other analgesic was administered intraoperatively. Pain was assessed using a modified objective pain-discomfort scale at 15 minutes, and 3, 12 and 24 hours after surgery. The number of doses of acetaminophen required to control postoperative pain was also recorded. RESULTS: Pain scores were defined in a range of 0-no pain to 6-greatest pain. During recovery median pain scores in the 30, 36 and 32 boys who received a penile block after, before, and before and after surgery were 3, 1.5 and 0 at 15 minutes; 2.5, 1 and 0 at 3 hours; 3, 2 and 0 at 12 hours; and 1, 0 and 0 at 24 hours, respectively. There was no difference in acetaminophen doses required 15 minutes and 3 hours postoperatively in the 3 groups. By 12 hours after surgery the number of acetaminophen doses required for pain control was significantly lower in the before and after, and before groups than in the after group. By 24 hours boys in the before and after group required significantly fewer doses of analgesics than those in the after and before groups. There was no statistically significant difference between the after and before groups. CONCLUSIONS: Two penile blocks performed at the beginning and conclusion of hypospadias repair, respectively, provide better postoperative pain control than 1 penile block done before or after surgery (p < 0.05). These patients require less analgesic than those who receive a penile block only before or only after surgery.