Conference Lectures
A preoperative anesthesia clinic do we need??
Dr.S.Rangalakshmi MD
Professor,Anesthesia andHead Critical Care, Rajarajeswari Medical College and Hospital, Bangalore, Karnataka
Preanaesthesia evaluation is the process of clinical assessment by an anaesthetist, which precedes the delivery of anaesthesia care for surgery and non-surgical procedures.Preanaesthetic clinic (PAC) is a specialty clinic where patients are evaluated before surgery to establish a database upon which risk assessment and perioperative management decisions can be made. It includes an interview and examination of the patient, a review of previous medical, surgical and anaesthesia problems, a detailed account of current medication use, and provisions for obtaining and reviewing preoperative tests.. The goals of a preoperative evaluation are to reduce patient risk and morbidity associated with surgery and coexisting diseases, promote efficiency and reduce costs, as well as to prepare the patient medically and psychologically for surgery and anesthesia. They have been developed to improve the preoperative experience of the patients by coordinating surgical, anaesthesia, nursing and laboratory care. These clinics can also help in developing practice guidelines, and decreasing the number of consultations, laboratory tests and surgical cancellations.
- Preanaesthetic evaluation through review of the medical records, history, examination and relevant ancillary testing, followed by risk optimisation through appropriate interventions and consultations.
- Discussion of the risks and benefits of anaesthetic options and pain management strategies.
- Alleviation of anxiety through counselling.
- Patient and family education on topics such as fasting, medications to continue on the day of surgery, special nursing care requirements, anticipated duration of hospital stay, transportation issues and contingency for undercurrent illness.
- Validation of consent and documentation of advanced medical directives (if any).
- Reduction of day-of-surgery delay or no-show via telephone calls made on the day before surgery.
Changing Concepts in Preoperative Evaluation
Traditionally, elective surgical patients were admitted to hospital the day before surgery to undergo preanaesthetic assessment, risk optimisation and preoperative preparation. This practice is no longer a routine in many parts of the world because of its lack of cost-effectiveness. In addition, in-patient evaluation did not effectively eliminate day-of-surgery cancellations due to inadequate optimisation of co-morbidities and administrative factors.
Moreover, as the focus of health care delivery has been recently towards ambulatory care, an efficient working PAC is required.
With the advent of numerous small nursing homes other than corporate hospitals preanesthetic assessment seems to be no longer “fashionable”.Most anesthetists see the patient for the first time just before the surgery.However to be fair to the profession many have done a virtual preanestheticcheck up regarding the clinical details of the patient including the test reports and with improvements in communication have all images on their phone or tablet.Even telephonic interviews of the patient are conducted;it is only the clinical examination which is lacking .The day is not far when we can have a virtual clinical examination with the patient hooked up to monitors and the video /images can be viewed by the anesthesiologist.All this does constitute part of the preanesthetic evaluation though the patient does not attend a clinic conducted by the anesthesiologists.This is followed in our country extensively where sadly there aren’t enough medicolegal checks and less accountability though this scenario is also rapidly changing in the diametrically opposite direction.
Do we need a preanesthetic clinic?? Of course some sort of review is a must even today where ambulatory surgery is fast gaining popularity due to its cost effectiveness and time maximisation.However the evaluation is required in order to optimize the patient's health status prior to surgery, formulation of the plan of anesthesia, preparation for post operative care ,review of medications and preemptve administration of certain medications depending on the condition of the patient. Risk stratification is a very important component of the preanestheticexamination .
A computer database of the details of the preanaesthtic check-up of the patients can be made so that it can be reviewed by anybody connected to the network. Such electronic medical records allow standardisation of patient information, avoid redundancy, and provide a database for research.
Reproduced from W. A. van Klei, L. M. Peelen et al Feedback system to estimate the quality of outpatient preoperative evaluation records: an analysis of end-user satisfaction British Journal of Anaesthesia 105 (5): 620–6 (2010)
Both the above tables show that the anesthesiologists feedback on the inadequate/improper preanesthetic evaluation which has affected the anesthetic management and outcome.
Having established the need for some kind of preoperative consult by the anesthesiologist are we over doing it??An Updated Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation was published in March 2012.The task force reviewed the earlier recommendation in 2002 and suggested certain changes.The task force stated that the preanesthetic evaluation depends on the severity of the disease and the invasiveness of the surgical procedure. In this Advisory,a routine test is defined as a test ordered in the absence of a specific clinical indication or purpose. Global designations such as “preop status” or “surgical screening” are not considered as specific clinical indications or purposes. An indicated test is defined as a test that is ordered for a specific clinical indication or purpose.
Although literature strongly suggests that preanaesthesia consultations at OPE clinics allow time for optimization of a patient’s physical condition, reduce late operating theatre cancellations, and facilitate same day admissions, a benchmark for the effectiveness of an OPE clinic is not yet available. Literature is also conflicting and differences might exist between individual anaesthesiologists about information needs and the level of detail they would like to have in the PER, that is, how critical they are.The following are broad guidelines :
Preanesthesia History and Physical Examination
Theassessmentofanestheticrisksassociatedwiththepatient’s medical conditions, therapies, alternative treatments, surgical andotherprocedures,andofoptionsforanesthetictechniques is an essential component of basic anesthetic practice.
An assessment of readily accessible, pertinent medical records with consultations, when appropriate,should be performed as part of the preanesthetic evaluation before the day of surgery for procedures with high surgical invasiveness
For procedures with low surgical invasiveness, the review and assessment of medical records may be done on or before the day of surgery by anesthesia staff.
For patients with low severity of disease and undergoing procedures with high surgical invasiveness, the interview and physical exam should also be performed before the day of surgery. For patients with low severity of disease undergoing procedures with medium or low surgical invasiveness, the initial interview and physical exam may be performed on or before the day of surgery.
At a minimum, a focused preanesthetic physical examination should include an assessment of the airway, lungs, and heart, with documentation of vital signs.
Selection and Timing of Preoperative Tests
Preoperative tests should not be ordered routinely. The tests may be ordered, required, or performed on a selective basis for purposes of guiding or optimizing perioperative management
There is insufficient evidence to identify explicit decision parameters or rules for ordering preoperative tests on the basis of specific clinical characteristics.
Electrocardiogram Important clinical characteristics may include cardiocirculatory disease, respiratory disease, and type or invasiveness of surgery. The Task Force recognizes that ECG abnormalities may be higher in older patients and in patients with multiple cardiac risk factors. An ECG may be indicated for patients with known cardiovascular risk factors or for patients with risk factors identified in the course of a preanesthesia evaluation. Age alone may not be an indication for ECG.
For preanesthesiacardiac evaluation other than ECG ,anesthesiologists should balance the risks and costs of these evaluations against their benefits. Clinical characteristics to consider include cardiovascular risk factors and type of surgery.
Preanesthesia Chest RadiographsClinical characteristics to consider include smoking, recentupper respiratory infection, COPD, and cardiac disease.Extremes of age, smoking, stable COPD, stable cardiac disease, or resolved recent upper respiratory infection should not be considered unequivocal indications for chest radiography. For other investigations such as pulmonaryfunctiontests,spirometry,pulseoximetry)toinvasiveassessmentofpulmonaryfunction(e.g.,arterialblood gas),anesthesiologistsshouldbalancetherisksandcostsofthese evaluationsagainsttheirbenefits. Clinical characteristics to consider include type and invasiveness of the surgical procedure, interval from previous evaluation, treated or symptomatic asthma, symptomatic COPD, and scoliosis with restrictive function.
Routine hemoglobin or hematocrit is not indicated. However in India where there is a high incidence of nutritional deficiencies we need to tailor these recommendations to suit our patient population.
Preanesthesiaserum chemistries (i.e., Potassium, Glucose, Sodium, Renal and Liver Function Studies) Clinical characteristics to consider before ordering preanesthesia serum chemistries include likely perioperative therapies, endocrine disorders, risk of renal and liver dysfunction, and use of certain medications or alternative therapies.
Urinalysis is not indicated except for specific procedures (e.g.,prosthesisimplantation,urologic procedures)or when urinary tract symptoms are present. Pregnancy testing may be offered to female patients of child bearing age and for whom the result would alter the patient’s management.
Test results obtained from the medical record within 6 months of surgery generally are acceptable if the patient’s medical history has not changed substantially.
Another comprehensive survey suggests that there is not a robust evidence base to support the use of routine tests in low-risk patients undergoing ASA grade 1 and grade 2 elective surgery. Beyond this, the survey results suggest that current practice has moved on and that the time of universal utilisation of pre-operative tests for all surgical patients has passed.
Yet another survey among European anesthesiologists shows a large variety in organisation and practice of preoperative evaluation throughout Europe. This practice is frequently not in accordance with guideline recommendations. The survey confirms that there is a shift towards selective testing and also that the majority of respondents support a move towards reducing preoperative testing.
Some kind of preanaesthesia assessment clinic exists in all Anaesthesia Departments of public Spanish hospitals, although there are differences in design and organisation.
In conclusion we do need some kind of preanesthetic evaluation especially in these days of ambulatory and day care surgery. Literature has shown a positive association in terms of reduced hospital stay, unnecessary cancellations and perioperative morbidity and mortality in patients taken up for anesthesia and surgery after preanesthetic evaluation.
References:
Clinical Anesthesia Paul S Barash ,Bruce F Cullen et al 6th Edition Lippincott Williams and Wilkins 2009
Mata J, Cabrera S et al A national survey on current practice of preanaesthetic assessment in elective surgery patients in Spain Rev EspAnestesiolReanim. 2012 Jun-Jul;59(6):299-305.
Amato L, Colais P, Davoli M et al Volume and health outcomes: evidence from systematic reviews and from evaluation of Italian hospital data].Epidemiol Prev. 2013 Mar-Jun;37(2-3 Suppl 2):1-100.
Gupta A, Gupta N. Setting up and functioning of a preanaesthetic clinic. Indian J Anaesth 2010;54:504-7
Van Gelder FE, de Graaff JC et al Preoperative testing in noncardiac surgery patients: a survey amongst European anaesthesiologists.Eur J Anaesthesiol. 2012 Oct;29(10):465-70
W. A. van Klei, L. M. Peelen et al Feedback system to estimate the quality of outpatient preoperative evaluation records: an analysis of end-user satisfaction British Journal of Anaesthesia 105 (5): 620–6 (2010)
Practice Advisory for Preanesthesia Evaluation An Updated Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation Anesthesiology 2012; 116:522–38