The Need for Preoperative Laboratory Tests for

Elective Surgery: A Systematic Review

Bewket Mesganaw¹

Debre Markos University

Ketema Misganaw
Ethiopian Public Health Institute
Mekuriaw Belayneh¹
Debre Markos University

Systematic Review

Keywords: preoperative laboratory tests, elective surgery, Clinical relevance, healthcare cost

Posted Date: June 4th, 2025

DOI: https://doi.org/10.21203/rs.3.rs-6587241/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License.
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Additional Declarations: No competing interests reported.

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Abstract
Background
Preoperative laboratory testing is commonly conducted before elective surgery to assess a patient's
overall health and identify potential risks. However, its necessity, clinical benefit, and economic
justification remain controversial.

Objective
To systematically review the existing literature on the need, utility, clinical relevance, and cost-
effectiveness of preoperative laboratory tests for elective surgeries.

Method
A systematic literature search was performed in databases including PubMed, Cochrane Library, and
Google Scholar for studies published between 2015 and 2024. Thirty-two studies assessing the utility,
clinical relevance, and cost-effectiveness of preoperative laboratory tests for elective surgeries were
included. Data were extracted and qualitatively synthesized.

Results
The majority of studies agree that routine testing (CBC, renal function, liver function, and coagulation
tests) for low-risk patients undergoing elective surgery is unnecessary and offering little impact on
surgical outcomes and significantly increasing healthcare costs. However, such tests remain essential in
high-risk patients and complex surgical procedures when guided by clinical assessment.

Conclusion
Routine laboratory testing for all elective surgical candidates is inefficient. A selective, indication-based
approach improves patient safety while reducing unnecessary healthcare expenditures.

Introduction
Elective surgical procedures are planned interventions that allow time for comprehensive preoperative
evaluations(1). Preoperative laboratory testing is commonly conducted before elective surgery to assess
a patient's overall health and identify potential risks(2). However, the universal application of
preoperative laboratory tests to all surgical patients—irrespective of clinical history—has raised concerns
about overutilization and cost-effectiveness(3). This systematic review aims to assess the necessity,

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clinical value, and economic impact of preoperative laboratory tests and to align findings with global
recommendations.

Methodology
Search Strategy
A comprehensive search was conducted in PubMed, Cochrane Library, and Google Scholar for relevant
studies published from January 2015 to December 2024. Search terms included combinations of:
“preoperative tests,” “laboratory testing,” “elective surgery,” “surgical outcomes,” and “clinical utility.”

Inclusion Criteria
Studies assessing preoperative laboratory testing for elective surgeries
Reviews, systematic reviews, cohort studies, cross-sectional studies, clinical audits, and cost-
effectiveness analyses
English-language articles published between 2015 and 2024

Exclusion Criteria
Studies focused solely on emergency surgeries
Non-human studies
Articles without available full-text access

Based on these criteria, initially, a total of 553 articles were identified from data bases and websites
using an electronic search. Of these articles, 75 were removed for duplication and 396 studies were
excluded after reviewing their titles and abstracts. At the screening stage, 82 articles were retrieved and
evaluated for the eligibility. Finally, 32 studies related to preoperative investigations were included in this
systematic review (Figure 1).

Data Extraction and Analysis

Information on study design, population, tested parameters (CBC, electrolytes, liver function, coagulation
profiles, etc.), main findings, and recommendations was extracted and synthesized thematically (Table
1).

Table 1. Summary of included articles

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Reference Author(s) Year Study Design Focus Main Findings
No. (Important Lab
Tests)

5 Taylor GA, et al. 2022 Cohort Study Routine Finds that routine
preoperative testing for ASA 1
testing for ASA 1 and 2 patients is not
and 2 patients necessary, but CBC
and electrolytes may
still be useful in
specific cases.

6 Siddaiah H, et 2020 Review Choosing Wisely Highlights those

al. guidelines for tests like CBC, renal
preoperative function tests, and
tests coagulation profiles
are not routinely
needed for low-risk
patients.

7 Kannaujia AK, 2020 Cross- Importance of Suggests that tests

et al. Sectional routine like CBC, renal
Study laboratory function, and liver
investigations function tests are
before elective often unnecessary
surgery unless clinically
indicated.

8 Yonekura H, et 2018 Retrospective Preoperative Recommends

al. Study blood tests omitting routine
before low-risk blood tests (CBC,
surgery in Japan electrolytes) in low-
risk surgeries,
focusing on tests
specific to patient
condition.

9 Martin SK, Cifu 2017 Review Routine Argues that CBC,

AS preoperative renal function tests,
laboratory tests and blood glucose
tests are generally
unnecessary in
healthy patients
undergoing elective
surgery.

10 Dossett LA, et 2022 Systematic Reducing Emphasizes that

al. Review unnecessary routine testing like
preoperative CBC, liver, and renal
testing function tests should
be avoided unless
clinically justified.

11 Kirkham KR, et 2016 Review Preoperative Identifies CBC, liver

al. laboratory enzymes, and renal
investigations function tests as
important in high-
risk surgeries but not

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 routinely needed in
low-risk surgeries.

12 Antwi-Kusi A, et 2019 Cross- Preoperative lab Indicates that tests

al. Sectional testing by like CBC, renal
Study surgeons function, and
coagulation studies
are frequently
ordered
unnecessarily by
surgeons.

13 Dhatariya KK, 2016 Review Preoperative Emphasizes the

Wiles MD testing need to avoid
guidelines unnecessary tests
such as CBC, liver,
and renal function
tests, focusing on
more targeted
screening.

14 Leung BC, et al. 2015 Retrospective Reducing Advocates for

Study unnecessary eliminating routine
preoperative tests like CBC and
testing in ENT renal function tests
surgery in low-risk ENT
surgeries.

15 Nieto RM, et al. 2017 Retrospective Preoperative lab Emphasizes the

Study testing in need for tests like
pediatric CBC and coagulation
cardiothoracic studies in pediatric
surgery cardiothoracic
surgery, but many
tests are not
necessary.

16 Nicholls J, et al. 2016 Retrospective Preoperative Finds that CBC and

Study investigations at renal function tests
Queen Elizabeth are commonly
Hospital ordered without
clear clinical
indications in low-
risk surgeries.

17 Alzahrani A, et 2019 Retrospective Routine Concludes that

al. Study coagulation tests routine coagulation
in children tests are
unnecessary in most
pediatric patients
undergoing elective
surgery.

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18 BENEFIT UT 2015 Review Do healthy Argues that routine
patients need lab testing, such as
routine CBC and liver
laboratory testing function tests,
before elective should be avoided
noncardiac for healthy patients
surgery? undergoing elective
surgery.

19 Vanjare H.et al 2020 Cross evaluate the Emphasizes tests

sectional impact of pre- that contribute to
study operative perioperative risk
investigations on stratification, like
resource complete blood
utilization and count (CBC) and
peri-operative electrolytes.
management in
elective surgeries

20 Vikas M, et al. 2022 Cohort Study Utility of Supports selective

preoperative testing, including
testing in ASA 1 CBC and renal
& 2 patients function tests, but
suggests omitting
routine tests in low-
risk cases.

21 Firde M, 2024 Clinical Audit Preoperative Finds that tests like

Yetneberk T investigation CBC and electrolytes
practices are overused, and
advocates for
limiting testing to
those that affect
clinical
management.

22 O'Neill F, et al. 2016 Review Routine Recommends

preoperative avoiding routine CBC
tests for elective and coagulation
surgery: tests in low-risk
summary of patients, and using
updated NICE them selectively
guidance based on risk
factors.

23 Chandra A, et 2019 Cohort Study Role of Suggests that CBC

al. preoperative and electrolytes are
investigations in not necessary for
healthy patients healthy patients,
advocating for more
selective testing
based on surgery
type.

24 TEKLEMARIAM 2022 Cross- Routine Finds that tests like

BT, et al. Sectional preoperative CBC, renal function,
Study testing in Addis and liver function
Ababa tests are commonly
overused in the
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 region,
recommending
targeted testing.

25 Kaur TS, 2020 Review Relevance of Suggests that CBC

Chatterjee BP preoperative and coagulation
laboratory testing tests are most
in elective oral important for
and maxillofacial patients undergoing
surgeries oral/maxillofacial
surgery, depending
on surgery
complexity.

26 Taylor GA, et al. 2021 Cohort Study Preoperative lab Suggests that CBC
testing before and renal function
ambulatory tests are important,
endocrine but routine testing
surgery can be reduced in
most cases.

27 Bock M, et al. 2015 Review Impact of Recommends blood

preoperative glucose and HbA1c
blood glucose testing for diabetic
and HbA1c patients or those
testing with metabolic
disorders before
surgery.

28 Danvath K, 2021 Cohort Study Usefulness of Finds that tests like

Matta S routine CBC and renal
preoperative function studies
investigations often do not alter
surgical outcomes
and should be
reduced.

29 Bock M, Fritsch 2016 Review Preoperative Focus on the

G, Hepner DL laboratory testing necessity of CBC,
renal function tests,
and coagulation
studies in higher-risk
patients.

30 Smetana GW 2015 Review Unnecessary Concludes that CBC,

preoperative renal function, and
testing liver tests are not
essential for most
elective surgeries,
except in specific
clinical contexts.

31 Lee KC, Lee IO 2021 Review Preoperative lab Focuses on CBC,

testing in elderly renal function, and
patients electrolytes as
crucial for elderly
patients undergoing
surgery, given their

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 higher risk of
complications.

32 Scarlett MD, et 2019 Review Guidelines for Advocates for more

al. preoperative selective testing,
investigations with a focus on CBC
and renal function in
high-risk patients.

33 Obasuyi BI, 2017 Review Economic burden States that routine

Antwi-Kusi A of routine tests like CBC and
preoperative lab liver function tests
testing are a financial
burden with minimal
impact on surgical
outcomes.

34 Keshavan VH, 2016 Cost- Comparison and Focuses on the cost

Swamy CM Effectiveness cost analysis of and clinical
Study preoperative relevance of tests
testing like CBC, liver
function, and
electrolytes,
suggesting more
selective use.

35 Admass BA, et 2022 Review Preoperative Suggests prioritizing

al. investigations in CBC and basic
resource-limited metabolic panels in
settings resource-limited
settings, where
comprehensive
testing is often not
feasible.

36 Koumpos A, et 2022 Cost- Cost of routine Highlights the cost

al. Effectiveness preoperative implications of
Study tests in Greece routine tests like
CBC and renal
function tests,
recommending a
more selective
approach.

Results
Characteristics of the included studies
From an initial pool of 553 articles, 32 were included after screening and eligibility assessment. These
comprised 14 reviews, 8 cohort studies, 7 cross-sectional studies, 2 retrospective studies, and 1 clinical
audit. Most studies focused on the necessity and appropriateness of routine laboratory testing in

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elective surgery candidates, particularly those categorized as American Society of Anesthesiologists
class I and II (4).

Clinical Relevance of Routine Testing

Most studies (5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18) consistently reported that routine tests such
as CBC, renal function, liver function, and coagulation studies are unnecessary for healthy patients (ASA
I and II). Selective testing based on clinical assessment provided similar or better outcomes without
increasing perioperative risk (19, 20, 21, 22, 23, 24, 25, 26, 27, 28).

High-risk patients, elderly populations, and patients undergoing major surgeries were identified as
groups who may benefit from targeted preoperative testing (29, 30, 31, 32).

Economic Impact
Several studies (33, 34, 35, 36) stressed that unnecessary routine testing significantly adds to healthcare
costs without corresponding benefits in surgical outcomes.

Discussion
The findings of this systematic review reinforce that preoperative laboratory testing should not be
uniformly applied to all surgical candidates. Testing should be personalized according to the patient's
comorbidities, surgical risk, and clinical judgment.

Despite clear and evidence-based recommendations from respected professional bodies such as the
National Institute for Health and Care Excellence (37) and the Choosing Wisely campaign (38) many
healthcare institutions and practitioners across various countries continue to demonstrate poor
adherence to guidelines that advocate for selective preoperative testing. These guidelines emphasize
that routine laboratory tests—such as complete blood counts, coagulation profiles, and metabolic panels
—should only be performed when clinically indicated based on the patient’s history, physical
examination, and the nature of the surgical procedure. However, numerous studies have reported that
unnecessary tests are still frequently ordered for low-risk patients undergoing minor or intermediate
surgeries (39). This persistent trend of over-testing not only contributes to increased healthcare costs
and resource wastage but also exposes patients to potential harm from false-positive results, delays in
surgery, and further unwarranted investigations or treatments (40).

Moreover, resource-limited settings can benefit greatly from implementing selective testing practices to
optimize limited healthcare budgets without compromising patient safety​(41).

Conclusion
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Routine preoperative laboratory testing for all elective surgery patients is unnecessary and economically
inefficient. A selective, patient-centered approach guided by clinical evaluation and surgical risk
stratification should be adopted globally.

Recommendation
Implement selective preoperative testing based on patient history, examination, and surgery-specific
risks.
Educate clinicians on evidence-based guidelines to minimize defensive or routine ordering.
Institutional policies should be updated to align with international best practices.
Further research should focus on the development of clinical prediction tools to aid decision-
making.

Declarations
Ethics Approval and Consent to Participate
Not applicable. This review is based on previously published studies.

Consent for Publication

Not applicable.

Availability of Data and Materials

All data supporting the findings of this review are included in the manuscript.

Competing Interests
The authors declare that they have no competing interests.

Funding
The authors received no external funding for this work.

Authors' Contributions

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BM conceived and designed the study, performed the literature search and data extraction, and drafted
the manuscript. KM and MB contributed to the analysis, interpretation, and critical revision. All authors
read and approved the final manuscript.

References
1. Prin M, Guglielminotti J, Mtalimanja O, Li G, Charles A. Emergency-to-elective surgery ratio: a global
indicator of access to surgical care. World Journal of Surgery. 2018;42:1971-80.
2. Siddaiah H, Patil S, Shelvan A, Ehrhardt KP, Stark CW, Ulicny K, et al. Preoperative laboratory testing:
Implications of “Choosing Wisely” guidelines. Best Practice & Research Clinical Anaesthesiology.
2020;34(2):303-14.
3. Ranasinghe P, Perera YS, Senaratne JS, Abayadeera A. Preoperative testing in elective surgery: Is it
really cost effective? Anesthesia Essays and Researches. 2011;5(1):28-32.
4. Doyle DJ, Hendrix JM, Garmon EH. American society of anesthesiologists classification. 2017.
5. Alzahrani A, Othman N, Bin-Ali T, Elfaraidi H, Al Mussaed E, Alabbas F, et al. Routine preoperative
coagulation tests in children undergoing elective surgery or invasive procedures: are they still
necessary? Clinical Medicine Insights: Blood Disorders. 2019;12:1179545X18821158.
6. Antwi-Kusi A, Addison W, Obasuyi BI, Domoyeri P. Preoperative laboratory testing by surgeons:
Implication on anaesthetic management. International Journal of Clinical Medicine. 2019;10(6):345-
52.
7. BENEFIT UTBO. Q: Do healthy patients need routine laboratory testing before elective noncardiac
surgery? Cleveland Clinic Journal of Medicine. 2015;82(10):665.
8. Dhatariya K, Wiles M. Pre‐operative testing guidelines: a NICE try but not enough. Wiley Online
Library; 2016. p. 1403-7.
9. Dossett LA, Edelman AL, Wilkinson G, Ruzycki SM. Reducing unnecessary preoperative testing. bmj.
2022;379.
10. Edwards AF, Forest DJ. Preoperative laboratory testing. Anesthesiology clinics. 2018;36(4):493-507.
11. Kannaujia AK, Gupta A, Verma S, Srivastava U, Haldar R, Jasuja S. Importance of routine laboratory
investigations before elective surgery. Discoveries. 2020;8(3):e114.
12. Leung B, Nazeer S, Smith M, McRae D. Reducing unnecessary preoperative testing in elective ENT
surgery: clinical and financial implications. Journal of perioperative practice. 2015;25(11):225-9.
13. Martin SK, Cifu AS. Routine preoperative laboratory tests for elective surgery. Jama.
2017;318(6):567-8.
14. Nicholls J, Gaskin PS, Ward J, Areti YK. Guidelines for preoperative investigations for elective
surgery at Queen Elizabeth Hospital: effects on practices, outcomes, and costs. Journal of Clinical
Anesthesia. 2016;35:176-89.
15. Nieto RM, De León LE, Diaz DT, Krauklis KA, Fraser Jr CD. Routine preoperative laboratory testing in
elective pediatric cardiothoracic surgery is largely unnecessary. The Journal of thoracic and
Page 11/14
 cardiovascular surgery. 2017;153(3):678-85.
16. Smetana GW. The conundrum of unnecessary preoperative testing. JAMA Internal Medicine.
2015;175(8):1359-61.
17. Taylor GA, Oresanya LB, Kling SM, Saxena V, Mutter O, Raman S, et al. Rethinking the routine:
Preoperative laboratory testing among American Society of Anesthesiologists class 1 and 2 patients
before low-risk ambulatory surgery in the 2017 National Surgical Quality Improvement Program
cohort. Surgery. 2022;171(2):267-74.
18. Yonekura H, Seto K, Ide K, Kawasaki Y, Tanaka S, Nahara I, et al. Preoperative blood tests conducted
before low-risk surgery in Japan: A retrospective observational study using a nationwide insurance
claims database. Anesthesia & Analgesia. 2018;126(5):1633-40.
19. Vanjare H, Duggal R, Chandra A, Deshmukh C, Panwar N. A prospective observational study to
evaluate the impact of pre-operative investigations on resource utilisation and peri-operative
management in elective surgeries. Indian J Clin Anaesth. 2020;7:502-8.
20. Vikas M, John K, Apruzzese P, Kendall MC, De Oliveira G. Utility of preoperative laboratory testing in
ASA 1 & ASA 2 patients undergoing outpatient surgery in the United States. Journal of Clinical
Anesthesia. 2022;76:110580.
21. Firde M, Yetneberk T. Preoperative investigation practices for elective surgical patients: clinical
audit. BMC anesthesiology. 2024;24(1):184.
22. O’Neill F, Carter E, Pink N, Smith I. Routine preoperative tests for elective surgery: summary of
updated NICE guidance. Bmj. 2016;354.
23. Chandra A, Thakur V, Bhasin N, Gupta D. The role of pre-operative investigations in relatively healthy
general surgical patients-a retrospective study. Anaesthesia, Pain & Intensive Care. 2019:241-4.
24. TEKLEMARIAM BT, DESALEGN M, TADESE M, GAMA M. Assessment of Routine Preoperative
Laboratory Testing Practice among Elective Surgical Patients at a Tertiary Care Institution, Addis
Ababa, Ethiopia: A Retrospective Study. Journal of Clinical & Diagnostic Research. 2022;16(4).
25. Kaur TS, Chatterjee BP. “Too much information with little meaning,” relevance of preoperative
laboratory testing in elective oral and maxillofacial surgeries: A systematic integrative review.
National Journal of Maxillofacial Surgery. 2020;11(1):3-9.
26. Taylor GA, Liu JC, Schmalbach CE, Kuo LE. Preoperative laboratory testing among low-risk patients
prior to elective ambulatory endocrine surgeries: A review of the 2015–2018 NSQIP cohorts. The
American Journal of Surgery. 2021;222(3):554-61.
27. Bock M, Johansson T, Fritsch G, Flamm M, Hansbauer B, Mann E, et al. The impact of preoperative
testing for blood glucose concentration and haemoglobin A1c on mortality, changes in management
and complications in noncardiac elective surgery: a systematic review. European Journal of
Anaesthesiology| EJA. 2015;32(3):152-9.
28. Danvath K, Matta S. Usefulness of routine preoperative investigations in patients undergoing
uncomplicated elective general surgical procedures. Journal of Datta Meghe Institute of Medical
Sciences University. 2021;16(2):290-4.
Page 12/14
29. Bock M, Fritsch G, Hepner DL. Preoperative laboratory testing. Anesthesiology clinics.
2016;34(1):43-58.
30. Kirkham KR, Wijeysundera DN, Pendrith C, Ng R, Tu JV, Boozary AS, et al. Preoperative laboratory
investigations. Anesthesiology. 2016;124(4):804-14.
31. Lee K-C, Lee I-O. Preoperative laboratory testing in elderly patients. Current Opinion in
Anesthesiology. 2021;34(4):409-14.
32. Scarlett M, Tennant I, Condell M, Deans-Minott J, Harding-Goldson H, Plummer J. Guidelines for
Appropriate Preoperative Investigations of Patients for Elective Surgery. West Indian Medical
Journal. 2019;68.
33. Obasuyi BI, Antwi-Kusi A. Routine preoperative laboratory testing: economic burden on pre-surgical
patients. Open Journal of Anesthesiology. 2017;7(01):15.
34. Keshavan VH, Swamy CM. Pre-operative laboratory testing: A prospective study on comparison and
cost analysis. Indian Journal of Anaesthesia. 2016;60(11):838-42.
35. Admass BA, Ego BY, Tawye HY, Ahmed SA. Preoperative investigations for elective surgical patients
in a resource limited setting: systematic review. Annals of Medicine and Surgery. 2022;82:104777.
36. Koumpos A, Mavroudi E, Perede M, Tsapara V, Koutsioumpa S, Galanopoulos I. 147 Management
and cost of routine preoperative tests for elective surgery in four public hospitals in Greece. BMJ
Evidence-Based Medicine. 2022;27(Suppl 1):A34-A.
37. Guttikonda N, Nileshwar A, Rao M, Sushma T. Preoperative laboratory testing-Comparison of
National Institute of Clinical Excellence guidelines with current practice-An observational study.
Journal of Anaesthesiology Clinical Pharmacology. 2019;35(2):227-30.
38. Matulis J, Liu S, Mecchella J, North F, Holmes A. Choosing wisely: a quality improvement initiative to
decrease unnecessary preoperative testing. BMJ Open Quality. 2017;6(1):bmjqir. u216281. w6691.
39. Soares DdS, Brandão RRM, Mourão MRN, Azevedo VLFd, Figueiredo AV, Trindade ES. Relevance of
routine testing in low-risk patients undergoing minor and medium surgical procedures. Revista
Brasileira De Anestesiologia. 2013;63:197-201.
40. Slawomirski L, Kelly D, de Bienassis K, Kallas K-A, Klazinga N. The economics of diagnostic safety.
OECD Publishing; 2025.
41. Al-Worafi YM. Patient Care Related Issues in the Developing Countries: Laboratory Tests and its
Interpretation. 2024.

Figures

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Figure 1

PRISMA flow diagram of article selection process

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