PREANESTHESIA CLEARANCE: TWO QUESTIONS FOR PRIMARY CARE DOCTORS

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

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Many patients require preoperative clearance prior to surgery, especially patients with significant medical problems or at extremes of age. Preanesthesia evaluation reduces surgical and medical complications. What two questions for primary care doctors summarize the desired important information in preoperative surgical clearance?

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Some health care systems run preoperative anesthesia clinics, where anesthesia professionals evaluate these patients prior to surgery. Such clinics can increase operating room efficiency and decrease day-of-surgery cancellations and delays, and are especially important prior to major inpatient surgeries such as brain surgeries, chest surgeries, abdominal surgeries and major transplants. In many health care systems there are no anesthesia clinics, and primary care doctors (internal medicine specialists, family practitioners, or pediatricians) do the preoperative assessments.

The surgeon may request the clearance or an anesthesiologist may request the clearance, but it will ultimately be the anesthesiologist who must care for the heart, lungs, brain, and blood pressure during the surgery and in the recovery room after the surgery.

Let’s choose an illustrative example. A 60-year-old man is scheduled to have a laparoscopic gallbladder removal (cholecystectomy). He takes lisinopril for hypertension and metformin for diabetes. He weighs 240 pounds, has a Body Mass Index of 38, and never exercises. What do anesthesiologists want to see in the internal medicine preoperative clearance consult?

We want to know the answer to two questions:

  1. Does the patient require any additional diagnostic workup prior to the surgery?
  2. Does the patient require any additional therapeutic changes prior to the surgery?

I’m Stanford-trained and board-certified in both internal medicine and anesthesiology, so I’m uniquely qualified to discuss this topic. Let’s look at what the process of an internal medicine preoperative consult looks like.

Let’s assume the internist has not seen the patient in the past year. The patient will be seen at the internist’s office, where the internist does a history and a physical, followed by an assessment and plan. The history includes a documentation of the past medical history, a review of current symptoms, a list of medications, allergies, past surgical history and family history. The physical exam includes the height, weight, vital signs, and documentation of any abnormal findings on exam of the entire body. The internist’s assessment will include a list of medical problems and a plan for each problem. For the patient above, the problem list would include:

  1. Hypertension
  2. Type 2 diabetes
  3. Obesity
  4. Sedentary lifestyle
  5. Preoperative assessment for upcoming general anesthesia for gallstones

An assessment and plan for each medical problem would be listed as follows:

  1. BP= 140/85 today. Plan: currently adequately controlled. Continue lisinopril.
  2. Plan: Check fasting glucose and hemoglobin A1c. Continue metformin.
  3. Plan: Weight loss counseling and consult with dietician.
  4. Sedentary Lifestyle. Plan: Advised initiation of exercise program.
  5. Preoperative assessment. Plan: cleared for general anesthesia providing ECG and labs are normal.

The labs are ordered, and the results accompany the history and physical. All the lab tests are normal. The ECG is abnormal, and shows diffuse ST wave abnormalities suspicious for ischemia (inadequate blood flow to the heart muscle). At this point the primary care physician can answer the two questions above:

  1. Does the patient require any additional diagnostic workup prior to the surgery? Answer: Yes. The patient requires referral to a cardiologist for workup of the abnormal ECG, especially in context of his sedentary lifestyle and risk factors of hypertension and diabetes.
  2. Does the patient require any additional therapeutic changes prior to the surgery? Answer: Dependent on the cardiologist’s assessment.

The surgery is delayed pending the cardiologist assessment. The cardiologist sees the patient, and recommends an exercise stress echocardiographic. The test is done, and is abnormal—the patient has abnormal decreased movement of the left anterior wall of his heart with exercise. Because of this abnormality, the cardiologist recommends a cardiac catheterization. The cardiac cath is done, and the patient has a 90% narrowing of his left anterior descending coronary artery. The cardiologist places a stent across this narrowing, and the patient is discharged home.

Because of the primary care doctor’s work, the patient had the necessary diagnostic tests done (blood work, ECG, and referral to cardiology), and the patient had a necessary therapeutic intervention done (a coronary stent). The gall bladder surgery is scheduled for one month hence.

Let’s discuss what a primary care doctor’s not should NOT be. The primary care doctor should not recommend what form of anesthesia is safe, e.g. “medically cleared for spinal anesthesia,” or “medically cleared for local anesthesia plus sedation.,” or “medically cleared for regional block anesthesia.” The primary care doctor should not recommend what drugs are safe to use. The primary care doctor should not recommend where the surgery should or should not be done, e.g. in a hospital, a surgery center, or in a doctor’s office. The primary care doctor should not estimate the percentage of survival or morbidity for the scheduled procedure.

Primary care doctors are very smart and highly trained professionals, but primary care doctors don’t work in operating rooms. They don’t know which anesthetic technique to recommend, which drugs to utilize, or the different strengths and weaknesses of different anesthetizing locations. What they do know is the outpatient condition of their patient.

Anesthesiologists need the answers to #1 and #2 above. If you’re an anesthesiologist, you now know exactly what questions to ask. If you’re a patient about to undergo surgery, you now know how important the preoperative medical assessment is to your anesthesiologist.

 

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