By Marti Webb Slay
Anesthesiologists are now playing a bigger patient assessment role prior to surgery. “It’s becoming imperative that anesthesiologists practice more than just intraoperative anesthesia, but that they move into the preoperative space as well, especially in a tertiary referral center like UAB,” said Chris Godlewski, MD, MSHA, associate professor in the UAB Department of Anesthesiology & Perioperative Medicine. “It can be a challenge to take care of some patients, given the burden of comorbidities and the extent of surgery they may be having.
“The upshot of this is that Anesthesiologists have expanded into the perioperative surgical home concept. We now have a process in which the patient’s medical history is reviewed, and they are often seen by an anesthesia provider prior to the day of surgery. We order lab studies, initiate pathways for things like sleep apnea and postoperative nausea, collect critical information and intervene when necessary to try to ensure the patient isn’t going to get cancelled the day of surgery, and to make sure the anesthesiologist has all the necessary information. This allows the patient to proceed through the peri-operative period as safely as they can.
“To help with this process, my colleague Dr. Jeff Simmons has built a robust Preoperative Assessment, Consultation, and Treatment Clinic. It is constantly updated with the latest perioperative guidelines with the goal being the safest surgical experience possible.”
Prior to surgery, it can be helpful for the anesthesiologist to see many of the studies that historically only specialists would evaluate. “We can tailor our anesthetic plan as a result of those studies,” Godlewski said. “From an anesthesia perspective, we have to consider the entirety of the patient’s medical and surgical history. We may obtain cardiac catheterization reports, echocardiograms, and pulmonary function tests and put it all together in package. This allows us to be much more safe and effective than the traditional letter from a consulting physician stating ‘cleared for surgery.’”
Godlewski said not being evaluated by an anesthesia provider until the day of surgery can sometimes lead to delays and cancellations. “It can be a scramble to collect and review results at the last minute,” he said. “The more information we have, the more smoothly the process goes. And it allows us to take better care of the patient and customize the anesthetic. Technology and pharmacology have evolved, so rather than a one-size-fits-all approach, we can be highly specific with what we give the patient to safely address their health issues and hone in on the best possible outcomes. In a complicated patient, we have the ability to mitigate substantial risk when we are able to evaluate them prior to the day of surgery.”
There are questions which are specific to a given surgery, but there are also many questions that are important regardless of which surgery a patient is having. “There are certain things that catch our attention no matter what the surgery is,” Godlewski said. “One big factor is cardiac status. Do they have heart failure? Have they had heart attacks or stents? Are they having chest pains, shortness of breath or irregular heart rhythms? If so, have they been seeing somebody and has it been investigated enough that on the day of surgery we aren’t seeking more information?
“There are other concerns as well. Do they smoke? Have they had strokes? Blood clots? Bad heartburn or reflux? How well is their diabetes being controlled? All of these factors can have a substantial impact on the patient’s perioperative course and are considered in the anesthetic plan.”
The answers to these questions can determine not only the course of anesthesia, but also where the patient can or should have the surgery. “A patient with severe cardiovascular disease is often better served having surgery at a larger hospital because of the increased level of care that may be required,” he said. “Our specialty has become sophisticated in our ability to do this,” he said. “Having folks on the other end giving us this information in a timely fashion is critical. One of our stumbling blocks can be when the patient’s time to surgery is short. Sometimes the clinic on the other end -- who we need information from -- doesn’t get us the information quickly enough. Obtaining those test results are crucial because we can’t do anything with the information if we don’t have it. That can absolutely lead to their surgery being postponed or cancelled. It plays a bigger part than people know.”