Why is EKG (+blood tests) required for upper eyelid blepharoplasty under IV sedation based solely upon age with no heart issues?

Question

Medical clearance is standard form not tailored to individual: H&P, CBC, & CMP (30 d), EKG (6 mo), Cardiac Clearance if applicable. Patient age >60, no heart issues, exercise tolerance high (e.g cardio 860 calories in 65 min). All specialty societies recommend against routine ECG. One study cited in ACC/AHA guidelines found 20% false positives in asymptomatic individuals undergoing pre-op ECG. Does anyone have any insight into why pre-op testing is necessary when patient objects?

Kenneth D. Steinsapir, MD · Answer

Age is one of those elements in the history.  Having a baseline EKG is very helpful to use as a basis for comparison to determine if an abnormal EKG at the time of surgery is a new change in the EKG or something that was previously present.  Yes, there is always the risk of false positive or negative tests.  However, routine screening prior to surgery can be very helpful in advance of elective surgery.  It is hard to argue about getting a CBC prior to surgery where you have a risk of loosing blood.  You did not get a chest X-ray, which was once part of routine testing.  The History and physical is essential, and the CMP (comprehensive metabolic panel) helps identify other issues that might be present but asymptomatic.  Hope that helps.

Kathleen F. Archer, MD · Answer

Dear Bob F,
All outpatient surgery facilities I work at in Houston have a protocol in place for elective  outpatient surgical procedures regarding EKG's and lab work.  Your surgeon typically does not have a say in this unless the surgery is performed in their office.  This is performed for safety reasons for the patient.  If any abnormalities show up on lab work or EKG, evaluation prior to surgery may be required.  If you just recently had lab work and EKG from your primary care physician, those can be provided to the facility.  All surgeons have had patients who had normal vitals in the office, but had irregular heart rhythms or abnormality on their lab work at pre-registration at the facility.
In healthy patients, with authorization from their primary care physician, I will perform blepharoplasty in office, without IV or sedation, under topical anesthetic cream placement, followed 10-15 minutes later with local anesthetic.  Other than that injection, the procedure is comfortable.  Discuss this option with your surgeon.

Scott C. Lindsay, DO · Answer

Thanks for your question!  Most places do have a standard protocol for pre-admission testing which is often dictated by whomever is administering anesthesia.  I would just look at it as an extra precaution to keep you safe.  Also, ask with your specific plastic surgeon why he/she has this recommendation in place.  Good luck!

Jordan Rihani, MD · Answer

Hello Bob F and thank you for your question. I agree that nearly all recommendations are against routine EKG in the absence of other risk factors (cardiovascular disease or other anesthesia risk factors). That being said, with large numbers of patients coming through a surgery center, it is often easier to issue a standard protocol - which is likely the case. Ultimately, it is a conversation that should be had with your physician and yourself and proceed on terms with which you are both comfortable. Best of luck!

Mark L. Mazow, MD, FACS · Answer

This issue is a frequent topic of conversation between surgeons and anesthesiologists. While the current trend is away from pre op lab work and EKGs in asymptomatic patients, many Anesthesiologists prefer a baseline EKG and labs for patient safety. In my practice we individualize the need for pre op lab work and EKG based on history and age in consultation with the Anesthesiologist. I would emphasize that this is done for your safety and I would hope that you view it that way. I would discuss it with your surgeon.

William Portuese, MD · Answer

Every surgery center has different parameters on the different amount of testing performed prior to elective cosmetic surgery. Most of these tests are done for patient safety. In our practice the amount of pre-op testing is directly dependent upon the patient's medical history.

William Marshall Guy, MD · Answer

Hello Bob F,There are many standardized tests based on age for patients prior to receiving anesthesia.  This depends a lot on your individual risk factors as well as policies where you hare having surgery.  Anesthetics can sometimes affect your electrolytes.  If they start outside of normal ranges then the minimal effects they have can lead to cardiac arrhythmias.  If your EKG has basline changes this would put your at further risk of having an adverse event.  These types of tests are designed for your safety prior to receiving anesthesia.  Now, if you are having it all performed simply under local anesthesia then blood tests and other workup is not generally required.  I'd recommend you discuss your concerns with your surgeon.I hope this helps and good luck.

Matheson A. Harris, MD · Answer

Testing required by surgery centers before any procedure is at their sole discretion in most cases. It could be due to a policy set forth by the anesthesia providers or simply by the lawyers who want to protect the center from bad outcomes.  When you have a high volume of patients, many surgical centers default to checking everyone for a certain baseline amount of things to hopefully catch the few patients with serious, unseen issues that could affect their surgery or lead to complications.  It's not ideal, but it is common place.

Why is EKG (+blood tests) required for upper eyelid blepharoplasty under IV sedation based solely upon age with no heart issues?

Answers (8)

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