In order to formulate an anesthetic plan, the anesthesiologist must consider both the patient’s medical condition and the proposed surgical procedure. Patient factors include patient preferences, previous anesthetic experiences, presenting illness, medical history, as well as the patient’s medications and allergies. During a physical examination, particular attention is paid to the patient’s airway and cardiac and respiratory systems. Each surgical procedure has its own set of anesthetic considerations that need to be balanced with the patient’s physiologic status. Procedures may be performed with local anesthesia alone, monitored anesthetic care, regional anesthesia, general anesthesia, or a combination of these choices (e.g., combined epidural and general anesthesia). It is only after considering the patient’s preferences, medical condition and the surgical procedure that a reasonable decision can be made regarding the choice of anesthetic modality best suited to the patient’s operative procedure.
Fig. 2.3 Patient flow to and from a hospital operating room.
The Scope of Anesthetic Practice:
The scope of anesthesia practice has expanded beyond our primary function in the operating room into a broad spectrum of roles both inside and outside the operating room. The uniqueness of the specialty of anesthesia is the fact that anesthesiologists provide care for all surgical specialties and at all ages of a patient’s life twenty-four hours a day.
The scope of anesthesia practice today may include work in the following areas:
Pre-admission unit
Operating room (OR)
Obstetrical suites
Post anesthetic care unit (PACU)
Intensive care units (ICU)
Surgical step down units
Acute pain service
Procedural sedation (endoscopy units,interventional radiology, surgical outpatient clinics)
Chronic pain clinic
Surgical/anesthesia care coordinator/facilitator/scheduler
Teaching
Administration
Research
Simulation centre (instructor, manager, coordinator, research)
Surgical procedures may be performed on an elective, urgent or emergent basis. Elective procedures are scheduled to permit an assessment of the patient’s fitness for the surgery prior to the surgical date (see Chapter 3 Preoperative Assessment). On occasion, time limitations do not permit a complete assessment and optimization of a patient’s condition prior to urgent or emergent surgery. Fig. 2.3 is an overview of the typical flow of a patient to and from the operating room.
Anesthesiology is a fascinating specialty where principles of applied pharmacology, physiology, and anatomy are used to provide care for patients of all ages. It has experienced exponential growth from the humble beginnings of Dr. W.G. Morton’s experience with inhalational anesthetics to our current practice. Like a painter’s brush, no two anesthesiologists have the same practice, and there are subtle nuances that continue to allow for the art as well as the science of medicine. We hope this primer serves as a useful guide during your introduction to our specialty.
References:
1 Marcucci, L. (2010). Inside Surgery. Origin of the Word “Anesthesia”.
1 Astyrakaki E, Papioannou A, Askitopoulou H. (2010). References to anesthesia, pain, and analgesia in the Hippocratic Collection. Anesth Analg 2010; 110(1):188-94.
2 Sullivan J. Surgery before anesthesia. Excerpt from the ASA Newsletter 1966;60(9):8-10.
3 Shepard DAE, Turner KE. (2004). Preserving the Heritage of Canadian Anesthesiology: A panorama of People, Ideas, Techniques and Events.
Chapter 3
Preoperative Evaluation
Raylene Sauvé MD, Gregory Bryson MD
Learning Objectives
1 To develop an understanding of the anesthetic considerations for patients undergoing surgical procedures.
2 To perform a preoperative assessment and formulate an anesthetic plan.
Key Points
1 All preoperative visits should include the following steps: problem identification, perioperative risk assessment, preoperative preparation and proposed plan and technique.
2 It is of paramount importance that anesthesiologists perform a final preanesthetic assessment in the immediate preoperative period to formulate their own “patient-specific” assessment and plan.
3 A patient’s functional capacity is a powerful predictor of postoperative complications.
4 Laboratory and other diagnostic tests should be ordered only when indicated by the patient’s medical co-morbidities or drug therapy or the nature of the proposed surgical procedure.
What is a preoperative assessment, and what is its value to the anesthesiologist?
A preoperative evaluation offers the anesthesiologist an opportunity to define the patient’s medical problems and plan an appropriate anesthetic technique. Additional pre-operative investigations, consultations, and interventions are used to ensure that the patient is in the best possible condition prior to surgery (i.e., preoperative optimization). Following the optimization process, the anesthesiologist can educate and reassure the patient about the procedure, potentially decreasing the patient’s anxiety prior to surgery.
This chapter is intended for care providers who may have little or no exposure to the specialty of anesthesia. It provides the framework to evaluate a patient’s condition, formulate an appropriate anesthetic plan, and communicate this information to colleagues. The preoperative evaluation does not replace the role of the primary care provider and is not meant to address health care issues that are not relevant to the delivery of safe and quality care in the perioperative period.
All preoperative visits should include the following essential steps:
Problem identification
Perioperative risk assessment
Preoperative preparation
Proposed plan for anesthetic techniqu
History of Presenting Illness:
Anesthesiologists must be able to anticipate, avoid, and manage perioperative complications. These complications are specific to the proposed surgery and the patient’s coexisting medical problems. This chapter describes how to use an evaluation of the patient’s