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KEY POINTS
Anesthesiologists function as perioperative consultants when the entire spectrum of perioperative care is examined, not solely the intraoperative period, and interventions are implemented to improve overall outcome.
Risk assessment tools are used to quantify risk and provide a common language for communication with patients and colleagues.
The medical history and physical examination are the cornerstones of preanesthetic assessment. Preoperative investigations are indicated to diagnose disease based on known risk factors or to evaluate the current state of an existing disease.
“Routine” or “screening” preoperative tests are not indicated, as they are costly and seldom provide useful information.
At-risk patients are best assessed prior to the day of surgery to allow adequate time for assessment and implementation of indicated risk reduction strategies. At-risk patients may include those with
Cardiovascular disease: hypertension, ischemic heart disease, coronary stents, valvular disease, heart failure, rhythm disturbances, cardiovascular implantable electronic devices
Respiratory disease: reactive airways disease, chronic obstructive pulmonary disease, pulmonary hypertension, upper respiratory tract infection, smokers, obstructive sleep apnea
Significant systemic disease: obesity, diabetes mellitus, renal disease, hepatic disease, anemia, neurologic disease, cancer, thromboembolic disorder
Substance abuse
Anesthesia-specific concerns
Ambulatory surgery
Consultation with other physicians should seek specific advice regarding the diagnosis and status of a patient’s condition or the creation of a clinical risk profile. “Preoperative clearance” is seldom helpful and should not be requested.
Evidence-based practice guidelines minimize cancellations or delays on the day of surgery resulting from individual practice variation. Liberalized fasting guidelines permitting consumption of clear fluids until 2-3 hours preoperatively are safe and minimize patient discomfort.
Preanesthetic assessment in clinic by an anesthesiologist prior to surgery improves patient satisfaction and alleviates anxiety; avoids medicolegal culpability resulting from inadequate assessment or unnecessary testing; and is economically beneficial by minimizing preoperative testing and avoiding case cancellations or delays.
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THE ANESTHESIOLOGIST AS PERIOPERATIVE CONSULTANT
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As the practice of medicine becomes increasingly outcomes driven and cost conscious, the role of the anesthesiologist as a perioperative consultant continues to evolve. No other specialty is more uniquely positioned or well suited to coordinate overall perioperative care than anesthesiology. The cornerstone of perioperative management is the preanesthetic assessment, a snapshot of a patient’s overall physical status that allows for risk assessment for an upcoming surgical procedure and implementation of risk reduction strategies. Whether performed weeks in advance of the procedure or immediately prior, this information-gathering session serves to detect and evaluate disease through the medical history, physical examination, and review of investigations and findings. Certain at-risk populations will benefit from intensive planning and therefore may benefit from assessment in advance of the procedure to allow for time to implement management strategies. Perioperative patient management may include consultations with other physicians, application of relevant practice guidelines, discussion of appropriate fasting recommendations, providing instructions for medications, and postoperative disposition planning. The evolving role of the anesthesiologist demands attention to the entire continuum of perioperative care, not solely the intraoperative ...