Preoperative investigations: Practice guidelines from the Indian Society of Anaesthesiologists: Caveats to these guidelines

Dear Editor, We read with interest the Indian Society of Anaesthesiologists (ISA) guidelines on preoperative investigations.[1] The extensive research and painstaking efforts of the authors are laudable. The guidelines attempt uniformity and reduce the investigations to a minimum. The guidelines should help to save costs and time, reduce hassles and minimise delays in surgery. The guidelines also address an important issue regarding the validity of available investigations. However, the authors feel that by adopting the new guidelines, the maxim of ‘maximum good for maximum people’ and community healthcare takes a backseat. Therefore, recommendations need a relook. The quadruple aims of preanaesthetic assessment are assessment of overall physical status, detection of undiagnosed diseases, quantifying any preoperative risk and patient optimisation translating into a reduced hospital stay.[2] India has a sizeable population with undiagnosed diabetes (one in two diabetics)[3] and undiagnosed hypertension (one in three hypertensives).[4] Both hypertension and diabetes mellitus are labelled as ‘silent killers’ – conditions without obvious symptoms that can progress to an advanced stage before they are discovered. Any robust healthcare system should catch the silent killers early, treat them and prevent death. The ISA guidelines categorise patients as ‘cardiac/non-cardiac’ and ‘diabetic/non-diabetic’. But such categorisation is possible only once screening has been done. The majority of patients presenting at the preanaesthetic checkup (PAC) clinic are unscreened. As high as 50%–70% of patients remain undiagnosed, presenting directly with diabetic complications.[5] Would it not be appropriate that any patient who visits the healthcare facility should become aware of his status of diabetes and cardiac disease? A good PAC had been doing this till date: screening patients for unrecognised diseases.This is where, the authors feel, an anaesthesiologist has a crucial role to play and the newly formulated guidelines, although well-meaning, become counterproductive and against the felt needs of society. The present guidelines are restrictive towards investigations and detection of undiagnosed diseases. Further, it is pertinent to note that as regards predisposition to non-communicable diseases, all Indians are not same. There exists a nine-fold interstate variation in the burden of ischaemic heart disease disability-adjusted life years (DALYs) per 100,000 persons (highest Punjab, lowest Mizoram).[6] Similarly, there is a six-fold interstate variation in stroke DALYs burden (highest West Bengal, lowest Mizoram),[6] necessitating tailoring investigations according to the state burden. Let us determine the cost-effectiveness of this restrictive investigation approach [Table 1].Table 1: Summary of preoperative investigation recommendations with some caveats and against the backdrop of costAs per the guidelines, irrespective of the nature of the surgery, every patient is prescribed a complete blood count (CBC). This necessitates queuing at the sample collection facility for blood sample withdrawal. In case extra investigations (random blood sugar [RBS], electrocardiogram) are also requested, the same PAC consultation fees, the same hospital visit, the same needle prick and some additional payment (570) suffice. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.