03: Utility of EKG for preoperative evaluation in benign hysterectomy

Abstract

Preoperative electrocardiogram (EKG) is commonly utilized in work up for benign hysterectomy. No standard of care exists to guide gynecologists in its use to optimize patients for surgery. Our institutional guidelines, developed by consensus opinion by the anesthesia department, recommend EKG for patients who meet the following criteria: age >60 years, type 2 diabetes, renal disease, alcohol/drug use, radiation/chemotherapy in the last 3 months, or digoxin use. In the United Kingdom, the National Institute for Health and Care Excellence (NICE) guidelines recommend EKG for age > 65 years and an American Society of Anesthesia (ASA) classification of 2 or more. Our objective was to assess guideline compliance and utility of preoperative EKG for benign hysterectomy. Medical records of 182 patients who underwent EKG for preoperative evaluation for benign hysterectomy at a single institution from January 1 to December 31, 2016 were reviewed. Each EKG was evaluated for indication, compliance with institutional and NICE guidelines, effect on management, result, and association with perioperative complications. Data was analyzed with descriptive statistics. For 587 benign hysterectomies, 182 (31%) preoperative EKGs were performed. EKG was indicated in 166 (28%) patients according to institutional criteria and 177 (30%) patients per NICE criteria, with 91% institutional and 97% NICE guideline compliance. Of institutional criteria, obesity was the most common indication in 124 (68%) patients (median BMI 33 kg/m2; SD ± 6.8), followed by hypertension in 120 (66%) and hyperlipidemia in 33 patients (18%). Additional indications were: age 60 or above (20; median age 46 years; SD ± 8.6), type 2 diabetes (40), renal disease (4), and alcohol/drug use (42). No patients had radiation/chemotherapy in the last 3 months or used digoxin. EKGs indicated per NICE criteria included those for age 65 or above (8), ASA 2 (145), and ASA 3 (28). Findings were normal in 93 (51%) and abnormal in 89 (49%) of 182 EKGs. Of 17 patients with an abnormal review of systems or cardiac exam, 10 (59%) were found to have EKG abnormalities. Positive results included: 42 (47%) voltage (i.e., ventricular hypertrophy, heart blocks), 35 (39%) ischemic (i.e., S and T wave changes), 22 (24%) rate (i.e., tachycardia, bradycardia), and 12 (14%) rhythm (i.e., sinus arrhythmia, ectopic foci) abnormalities. Further work up was pursued in 16 of 89 patients (18%) with abnormal EKGs through repeated EKG (6), additional cardiac testing (7), and specialist consultation (7). Two surgical delays of 1 and 4 months occurred as a result of additional work up ordered for abnormal EKG. Two perioperative complications were noted. Surgery was aborted after post-induction ischemic EKG changes in a patient with minimal ventricular hypertrophy voltage criteria on preoperative EKG. A second patient with airway edema failed extubation, with preoperative EKG showing a non-acute inferior infarct. Despite excellent compliance with guidelines, preoperative EKG offers little clinical utility in terms of modifying perioperative risk. Preoperative EKG, regardless of result did not change management nor impact perioperative complications.