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Indian J. Anaesth.

2006; 50 (2) : 148 - 149


148 INDIAN JOURNAL OF ANAESTHESIA, APRIL 2006
148
BEST EVIDENCE ANAESTHESIA REPORTS (BEARs)

IS IT NECESSARY TO ESTIMATE HAEMOGLOBIN LEVEL


ROUTINELY PRIOR TO SURGERY ?
Dr. Kotur. P. F.

BEARs are the summary of the evidences Pertinent focused answerable question: Can a
pertaining to a specific clinical dilemma encountered in 28 years old ASA I male patient be accepted for emergency
the day today anaesthetic practice. They are not the appendicectomy without preoperative Hb% estimation?
systematic reviews but rather contain the best evidence
(highest level) available to any practicing anaesthesiologist. Clinical Scenario: A 28 years old male patient
The search strategies adopted will not be discussed in of ASA class I is posted for emergency appendicectomy no
detail. Hb% estimated and surgeon is refusing to get the Hb%
estimated stating that it is unnecessary. The anaesthesiologist
Each BEAR is based on a clinical scenario and is in dilemma and wants to know what the EBM says in
ends with a clinical bottom line that indicates, in the this regard.
light of the evidences found, what one should do or how
one should respond if he/she encounters similar clinical Search strategy: Medline 1966 till present, Embase
situation again. 1988 till present ,using OVID interphase using keywords-
Preoperative, Hemoglobin estimation, anesthesia- were
Determination of Haemoglobin percentage (Hb%) searched and also the standard text and reference books
prior to any surgery has become an integral part of pre were referred for answering the above said question.
anaesthetic evaluation; the rationale being a mere belief or Opinions of senior consultants in anaesthesia and surgery
a custom inherited from our teachers than a valid scientific were also sought and integrated in to the evidence.
evidence.
Available evidence
The sole objective of an anaesthesiologist during 1) Earlier retrospective studies have documented that
the stressful period of an operation is to ensure supply of severe preoperative anaemia may be a precipitating
adequate quantity of O2 to all the vital organs. Of the four factor for perioperative morbidity and mortality; and
components viz. Hb%, SpO2, Cardiac output and Hb-O2 mortality increased as Hb% decreased. These studies
affinity, which detetrmine the quantity of O2, available for were conducted when the overall anaesthetic mortality
bodily functions, Hb% is the only component which can be and morbidity were significantly higher than present.1,2
augmented easily in the preoperative period itself for
enhancing the availability of O2 and this thinking has 2) It was however found subsequently that the severely
been the basis for preoperative Hb% estimation by the anaemic patients of renal failure tolerated anaesthesia
anaesthesiologists. and surgery well than expected.3

Recent thinking about preanaesthetic laboratory 3) Other prospective trials have documented that
testing of any organ function has been that the test performed preoperative screening of baseline Hb levels prior to
should detect unsuspected abnormalities, should help in the surgeries not involving significant blood loss does not
preparation of the patient for anaesthesia and should guide predict adverse outcome or any specific preoperative
the necessary perioperative interventions by providing the risk.4,5
baseline values. 4) Another recent prospective case study involving
The issue of accepting the patient for sugery without elderly patients (>65 years) who sustained fracture
preoperative Hb% estimation raises several issues for the hip inferred that anaemic patients had lower functional
anaesthesiologist including a feeling of guilt of accepting or status, longer hospital stay and higher mortality at
refusing the case and also fear of attracting medico legal 6-12 months after fracture.6
litigations in case of any untoward event in the perioperative 5) Another study on patients who underwent surgeries
period. but refused blood transfusion showed that the
M.D., Prof. & HOD of Anaesthesiology patient who expired had significantly lower mean
J. N. Medical College, Nehru Nagar, Belgaum - 590 010. preoperative Hb% (7.6 gm/dl) than those who survived
E-mail : profkotur@hotmail.com (11.8 gm/dl) and patients who underwent surgeries
KOTUR : BEARS : Hb% ESTIMATION AND ANAESTHESIA 149

involving low blood loss tolerated lower Hb%, with 2. Lunn JN, Elwood PC. Anaemia and surgery. Br Med J 1970;
no patients with Hb% more than 8 gm/dl expired.7 3: 71-73.
3. Consensus conference : Perioperative Red Blood Transfusion:
6) Anaesthiologists are the major prescribers and uses
JAMA 1988; 260: 2700-03.
of blood. In studies involving patients who underwent
surgeries involving major blood loss, it has been 4. Dzarkic S, Pastro D, Gonzalez C, Leung JM. The prevalence
and predictive value of abnormal preoperative laboratory.
documented that preoperative Hb% estimation not
Anesth Analg 2001; 93: 301-08.
only helps to predict the perioperative risk, and to
5. Section OD, Katiz J, Basis EB, Tilelsch J M, Lubomax L H,
calculate blood loss but also guides the transfusion
Feldman M A, Petty BG, Sterinberg EP. The value of routine
practices.8,9 preoperative medical testing before cataract surgery. Study
of medical testing for Cataract Surgery. N En J med 2000;
Bottom Line
342: 168-175.
1) Anaesthesiologists need not insist for preoperative 6. Gruson KI, Aharonoff GB, Egol KA, Zukerman JD, Koval
estimation of Hb% of a clinically normal patient if KJ. The relationship between admission Hb level and outcome
the proposed surgery does not involve major blood loss after hip fracture. J Ortho Trauma 2002; 16: 39-44.
and the patient does not have associated cardiac and 7. Carson JL, Duff A, Berkin JA, Lawrence VA, Posses RM,
pulmonary diseases. Huber EC, O’ Hara DA, Novedc H, Store BL. Perioperative
2) If the proposed surgery involves major blood loss, blood transfusión and perioperative mortality. JAMA 1998;
279: 199-205.
then preoperative estimation of Hb% is quite beneficial
to predict the outcome, calculate blood loss and to 8. Herbert PC, Wells G, Blajchmcn MA, Marshall J, Maritin C
et al. A multicentre, randomised, controlled clinical trial of
decide about intraoperative blood transfusion
transfusion requirements in critical care. N Engl J Med 1999;
References 340: 409-17.
1. Carson JL, Poses RM, Spence RK, Bonavita G. Severity of 9. Van Klei WA, Moons KG. Leyssius AT, Knape JT. A reduction
anaemia and operative mortality and morbidity Lancet 1988; in type and screen; preoperative prediction of RBC
1: 727-29. transfusions in surgery procedures as the intermediate
transfusion risks. Br J Anaesth 2001; 87: 250-57.

BOOK REVIEW
BASIC METHODS OF MEDICAL RESEARCH
A. Indrayan, Publishers : AITBS Publishers India. Cost : Rs. 225/- per copy.

Research in the field of medicine in India is a scientific study, whether it be a dissertation of a


unfortunately in a primitive stage. The quantum of postgraduate student or post doctoral research of a fellow
contribution by an Indian doctor in his/her respective or a scientific paper of an experienced physician. The
field to the scientific literature is very much negligible contents of the book are tailored to cater to the needs
incomparison to his counterpart in the developed world. of everybody including the novices in research. A very
Though late, this deficit has been realized by all of us positive point of this book is that no special background
and we see growing awareness and eagerness to do knowledge is essential to understand the concepts
research in the younger generation. described in book as each chapter covers A-Z information
in a simplified way.
I must appreciate Abhay Indrayan for his efforts
of facilitating primary medical research by providing I strongly recommend the book to all the
this comprehensive book giving basic details of research postgraduates and researchers in medicine. The book is
methodology and biomedical statistics. paradoxically priced very low : Thanks to AITBS
publishers, New Delhi.
The book is very much readable and reflects
clear concepts needed to be understood by all those who Prof. P. F. Kotur
conceive the idea, to design, plan, conduct and publish Editor

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