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

Latest posts by the anesthesia consultant (see all)

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.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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THE PERIOPERATIVE SURGICAL HOME HAS EXISTED FOR YEARS

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

Latest posts by the anesthesia consultant (see all)

The American Society of Anesthesiologists is supporting an expansion of the role of anesthesiologists in the delivery of perioperative care in hospitals. This proposed model is called the Perioperative Surgical Home. The American Society of Anesthesiologists defines the Perioperative Surgical Home as “a patient centered, innovative model of delivering health care during the entire patient surgical/procedural experience; from the time of the decision for surgery until the patient has recovered and returned to the care of his or her Patient Centered Medical Home or primary care provider.”

 

It’s a sound idea, and it resembles a model that’s existed for decades outside the hospital. In an outpatient surgery center the Perioperative Surgical Home concept is carried out by an anesthesiologist who is the Medical Director. I can speak to this, as I’ve been the Medical Director at a busy surgery center only minutes from Stanford University in downtown Palo Alto, for the past 12 years.

A surgery center Medical Director is responsible for:

  • All preoperative matters, including preoperative medical assessment of patients, scheduling of block times, surgical cases, anesthesia assignments, and creation of protocols,
  • All intraoperative matters, including quality issues, efficiency and turnover of cases, and the economics of running a profitable set of operating rooms, and
  • All postoperative matters, including overseeing Post Anesthesia Care Unit (PACU) nursing care, post anesthesia medical decisions, and supervision of post-discharge follow up with patients.

All medical problems including complications, hospital transfers, and patient complaints, are routed through the anesthesiologist Medical Director.

A key difference between a surgery center and a hospital is scale. A busy hospital has dozens of operating rooms, hundreds of surgeries per day, and hundreds of inpatient beds. No one Medical Director can oversee all of this every day—it takes a team. At Stanford University Medical Center the anesthesia department is known as the Department of Anesthesia, Perioperative and Pain Medicine. The word “Perioperative” is appropriate, because anesthesia practice involves medical care before, during, and after surgery. A team of anesthesiologists is uniquely qualified to oversee preoperative assessment, intraoperative management, and post-operative pain control and medical care in the hospital setting, just as the solitary Medical Director does in a surgery center setting.

A second key difference between a surgery center and a hospital is that medical care is more complex in a hospital. Patients are sicker, invasive surgeries disturb physiology to a greater degree, and patients stay overnight after surgery, often with significant pain control or intensive care requirements. Again, a team of physicians from a Department of Anesthesia, Perioperative and Pain Medicine is best suited to supervise management of these problems.

The greatest hurdle to instituting the Perioperative Surgical Home model is pre-existing economic reality. In a hospital, other departments such as surgery, internal medicine, radiology, cardiology, pulmonology, and nursing are intimately involved in the perioperative management of surgery patients. Each of these departments has staff, a budget, income, and incentives related to maintaining their current role. Surgeons intake patients through their preoperative clinics, and may regard themselves as captains of the ship for all medical care on their own patients. Internal medicine doctors are called on for preoperative medical clearance on patients, and thus compete with anesthesia preoperative clinics. The internal medicine department includes hospitalists, inpatient doctors who may be involved in the post-operative management of inpatients. Invasive radiologists perform multiple non-invasive surgical procedures. Like their surgical colleagues, they may see themselves as decision makers for all medical care on their own patients. Cardiologists manage coronary care units and intensive care units in some hospitals, and may feel threatened by anesthesiologists intent on taking over their territory. Pulmonologists manage coronary care units and intensive care units in some hospitals, and may feel threatened by anesthesiologists intent on taking over their territory. Nurses are involved in all phases of perioperative care. If the chain of command among physicians changes, nurses must be willing partners of and participants with such change.

Why has the anesthesiology leadership role of a Medical Director evolved naturally at surgery centers while the Perioperative Surgical Home idea has to be sold to hospitals? At surgery centers the competing financial incentives of surgeons, internal medicine doctors, radiologists, pulmonologists, cardiologists, and nurses are minimal. In a freestanding surgery center, surgeons want to be able to depart for their offices following procedures, and welcome the skills that anesthesiologists bring to managing any medical complications that arise. Internal medicine doctors have no significant on-site role in surgery centers, although they are helpful office consultants for the anesthesiologist/Medical Director in assembling preoperative clearance for outpatients. Radiologists have no significant on-site role at most surgery centers—if they do perform invasive radiology procedures on outpatients, they too welcome the skills that anesthesiologists bring to managing medical complications that arise. Because there are no intensive care units at a surgery center, there is no role for pulmonary or cardiology specialists. Nursing leadership at a surgery center works hand-in-hand with the Medical Director to assure optimal nursing care of all patients.

Hospital administrators anticipate penetration of the Accountable Care Organization (ACO) model for payment of medical care by insurers. In the ACO model, a medical center receives a predetermined bundled payment for each surgical procedure. The hospital and all specialties caring for that patient negotiate what percentage of that ACO payment each will receive. A Perioperative Surgical Home may or may not simplify this task. You can bet anesthesiologists see the Perioperative Surgical Home as a means to increase their piece of the pie. Ideally the Perioperative Surgical Home will be a means to streamline medical care, decrease costs, and increase profit for the hospital and all departments. Anesthesiologists are rightly concerned that if they don’t take the lead in this process, some other specialty will.

Establishing the Perioperative Surgical Home is an excellent opportunity for anesthesiologists to facilitate patient care in multiple aspects of hospital medicine. To make this dream a reality across multiple medical centers, anesthesiology leadership must demonstrate excellent public relations skills to convince administrators and chairpeople of the multiple other specialties. I expect data on outcomes improvement or cost-control to be slow and inadequate to proactively provoke this change. It will take significant lobbying, convincing, and promoting. Change will require a leap of faith for a hospital, and such change will only be accomplished by anesthesia leadership that captures the confidence of the hospital CEO and the chairs of multiple other departments.

I’m impressed by the adoption of the Perioperative Surgical Home at the University of California at Irvine. I’ve listened to Zev Kain, MD, Professor and Chairman of the Department of Anesthesia and Perioperative Medicine lecture, and I’ve met him personally. He’s the prototype of the charismatic, intelligent, and convincing physician needed to convince others that the Perioperative Surgical Home is the model of the future.(http://www.anesthesiology.uci.edu/clinical_surgicalhome.shtml)

I expect the transition to the Perioperative Surgical Home to occur more easily in university or HMO hospitals than in community hospitals. It will be easier for academic or HMO chairmen to assign new roles to salaried physicians than it will be for community hospitals to control the behavior of multiple private physicians.

Anesthesiologists were leaders in improving perioperative safety by the discovery and adoption of pulse oximetry and end-tidal carbon dioxide monitoring. Can anesthesiologists lead the way again by championing the adoption of Perioperative Surgical Home on a wide scale? Time will tell. Is the Perioperative Surgical Home an optimal way to take care of surgical patients before, during, and after surgeries? I believe it is, just as the Medical Director is a successful model of how an anesthesiologist can optimally lead an outpatient surgery center. Those lobbying for the Perioperative Surgical Home would be wise to examine the successful role of anesthesiologist Medical Directors who’ve led outpatient surgery centers for years. The stakes are high. As intraoperative care becomes safer and the role of nurse anesthesia in the United States threatens to expand, it’s imperative that physician anesthesiologists assert their expertise outside the operating room.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

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12 Important Things to Know as You Near the End of Your Anesthesia Training

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

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BLINK: WHEN AN EXPERIENCED ANESTHESIOLOGIST MEETS THEIR PATIENT

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

Latest posts by the anesthesia consultant (see all)

I urge you to use Malcolm Gladwell’s book Blink to become a better anesthesiologist. Clinical Case for Discussion:  As an anesthesia resident, how does your preoperative interview with a patient differ from that of an anesthesiologist with 20 years of experience?

Discussion:  In my second year of residency, I had the pleasure of working with Stanford anesthesia attending C. Philip Larson, M.D., a Past-Chairman of the Department and a Past Editor-In-Chief of our specialty’s leading publication, Anesthesiology.  My rotation was neuroanesthesia, and each evening prior to surgery Dr. Larson and I would make rounds on the wards to meet the surgical patients for the next day. (In the 1980’s almost all patients were hospitalized one night prior to surgery.)

I was surprised and taken aback by the experience, and I never forgot what those patient encounters were like.  Although Dr. Larson always let me do the anesthesia procedures in the operating room, he presented himself at the pre-op interview as the primary physician in charge of the anesthesia care.  When Dr. Larson entered a patient’s room, he sat down on the bed and played a role that was part Santa Claus and part all-knowing, all-loving deity.

Dr. Larson greeted the patient kindly, introduced both of us, and then launched into a comfortable dialogue about any variety of topics, none of them remotely related to the surgery or the anesthesia.  I kept waiting to hear him say, “can you walk up two flights of stairs?” or “do you ever have chest pain?”

These questions were never asked or answered at the bedside.  They’d already been asked and answered and were present in the patient’s chart.  Dr. Larson valued the preoperative interview as a time to connect with his patient, and to establish rapport and comfort between them.  After perhaps ten minutes of such banter, he would switch gears and state that we would be doing the anesthesia care the next day, that we would keep him or her asleep and safe, and give a modicum of detail about what to expect.  He did not perform any detailed physical exam.

Despite the fact that Dr. Larson was a renowned expert witness in the specialty of anesthesia, he did not recite a litany of informed consent risks.  A particular pet peeve of his was the suggestion that an informed consent discussion should include telling a patient of the risk of death.  His opinion on this issue always was, “If you tell the patient that they can die, and then you do something negligent and they do die, your informed consent protects you not one bit from the fact that you practiced below the standard of care.”

In his best-selling book, Blink, Malcolm Gladwell writes that the risk of a doctor ever being sued has very little to do with how many errors they make.  He explains that there’s an overwhelming number of patients who’ve been harmed by shoddy medical care yet never have filed a malpractice claim.  What was the common denominator of the people who do choose to sue?  According to Gladwell, they feel they were treated badly by their doctor.  That even when injured by clear negligence, most people won’t sue a doctor they like.

Dr. Bruce Halperin, a member of the Associated Anesthesiologists Medical Group in Palo Alto and a member of the Stanford clinical faculty, was renowned for his bedside manner.  In the preoperative area, I often heard Dr. Halperin telling joke after joke, and the intermittent bursts of laughter from his patients sometimes made it difficult for me to even hear the conversation with my own patient.  One of our busiest cosmetic surgeons often had Dr. Halperin telephone patients early in the consultative process to discuss anesthesia issues.  A patient later told this surgeon, “I’m not sure if I want to have the plastic surgery, but I sure do want to have the anesthesia!”

As an anesthesiologist, you have 10-15 minutes to complete your medical interview with your patient, and to get them to respect you, to have confidence in you, and yes . . . to like you.

As a resident-in-training, your preoperative interviews may be thick with questions about active medical problems, particularly cardiac, pulmonary, and neurologic questions.  You may perform a rigorous and detailed exam of the airway, lungs, and heart.  And you likely spend ample time explaining the anesthetic technique, alternatives, and risks.

You are trained to do all these things.  Twenty years from now, your interview may not be as conversational and sparse on medical questions as Dr. Larson’s was, but your technique will evolve.

Most pertinent questions have already been asked and answered in the patient’s medical records.  Tailor your interview as appropriate for the patient’s medical co-morbidities and the invasiveness of the surgery.  For a 68-year-old with diabetes and hypertension who is about to have a cholecystectomy, it will be relevant to ask them whether they can walk up two flights of stairs and whether they ever have chest pain.  For a 24-year-old with a negative history who is about to have a knee arthroscopy, a simple “Are you in excellent health?” may suffice.

What about the physical exam?  For experienced anesthesiologists, the assessment of whether the airway may be difficult can usually accomplished in seconds, with examination of the mouth opening and the neck extension.  You will listen to the lungs and the heart, but in the absence of symptoms, it is rare to uncover any information with your stethoscope that changes your anesthetic.

Patients are nervous before surgery.  They welcome both your expertise in medicine and your skills in making them relax.  Experienced anesthesiologists can explain the anesthetic plan and risks in a fashion that will gain the patient’s trust and confidence.

The only procedure most of us do while the patient is awake and unsedated is the insertion of an I.V. catheter.  This is a time when you have the luxury of talking about any topic that is calming to the patient.  Conversations about the patient’s hobbies, work, hometown, or family are all pleasant diversions to enter the realm of Dr. C. Philip Larson, and connect with the patient without talking any further about anesthesia.

In my previous career, I was an internal medicine doctor.  In medicine clinic there are dozens of questions to be asked and answered:  “Where is the pain?  How long has it been there?  What makes it better?  What makes it worse?  Does it move anywhere? . . .”  With a waiting room full of patients, there was little time to ask each patient where they had dinner last night or where their child was going to college.

In contrast, anesthesia practice can provide a wonderful opportunity to relax your patient with well-spun conversation.  My advice to you is to be as much like C. Philip Larson, M.D. as your practice allows.  Try not to be a walking, talking EPIC-checklist when it’s time to connect with your patients.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

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A PREOPERATIVE ANESTHESIA CLINIC: DO YOU NEED ONE?

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

Latest posts by the anesthesia consultant (see all)

Do you need a Preoperative Anesthesia Clinic? You’ve just graduated from your anesthesia training program.  The night before your first day in community practice, your operating room surgery list reads: 7:30 a.m. = 68-year-old male for a thyroidectomy, 11 a.m. = 42-year-old male for laparoscopic cholecystectomy, and 1 p.m. = 56-year-old female for a vaginal hysterectomy.

Who, if anyone, has done the preoperative evaluations for these patients?  How can anesthesiologists and surgeons function without a preoperative clinic and its employees to evaluate patients prior to surgery?

Discussion:  In the academic teaching setting, the Preoperative Anesthesia Clinic is useful.  University surgical patients are complex, not all residents in anesthesia and surgery are experienced in preoperative evaluation, and many patients do not have an internist or a primary care provider.

In most community practice models, a Preoperative Anesthesia Clinic is impractical.  As community anesthesiologists in private practice, we distribute guidelines to surgeon’s offices regarding the indications for preoperative lab tests, consultations, and medication management.  Surgeons or their nurse practitioners do the preoperative evaluations for healthy patients, and surgeons refer more complex patients to internists preoperatively as indicated.  When the surgeon wants an anesthesia consult (or else risk a cancellation on the day of surgery), he or she will call the attending anesthesiologist who is responsible for preoperative phone consultations.  The surgeon or the surgeon’s nurse practitioner will present the case, and the anesthesiologist will advise whether further diagnostic tests or medicine consultations are necessary prior to scheduling the surgery.

The night before the surgery, each attending anesthesiologist in our practice usually telephones their patients.  The anesthesiologist asks medical history questions that are pertinent, and answers the patient’s questions.  Patients are advised as to eating and drinking restrictions before surgery, and whether the patient should take or hold any usual oral medications in the day prior to surgery.

On the day of surgery, pertinent labs, ECG’s and consults are on the chart.  Any omissions can be supplemented, e.g. bedside ECG or fingerstick blood glucose.

This method works in community private practice of anesthesia, because all the involved M.D.’s are fully trained and they have incentive to complete the surgical cases, not to cancel them.  Key advantages of this method are  (1) Patients like it.  Patients like talking to their attending anesthesiologist the night before, instead of waiting at an anesthesia clinic to be evaluated by a third party.  (2 ) There is no expense to rent clinic space and pay clinic employees.  (3) Community private practice anesthesiologists do not want to staff a clinic, where there is no financial incentive to be there.  (4) For pediatric surgery, parents prefer to talk to the attending surgeon the night before surgery from the comfort of their own home, rather than bringing their child to the hospital twice.  (5) This system works.  In our practice, each anesthesiologist averages 5 -6 cancellations on the day of surgery, out of 600 cases per year.  Example cancellations may occur for patients who have fever the day of surgery, chest symptoms the day of surgery, or elevated blood pressure the day of surgery.  Very few patients are cancelled because of incomplete laboratory workup, as current anesthesia standards show that many preoperative lab tests are either not indicated or do not change the management of the anesthetic. American Society of Anesthesiologists (ASA) Practice Advisory for Preanesthesia Evaluation ( http://www.asahq.org/For-Members/Practice-Management/Practice-Parameters.aspx)

Instead of staffing a Preoperative Anesthesia Clinic, your preoperative homework is three telephone calls the night before surgery.  Because it is your first day at a new practice, you choose to telephone a senior member of your anesthesia group the night before surgery as well, so he or she can give you advice on what to expect from each surgeon the next day.  Time = 25 minutes.  Cost = 0.

An occasional patient may need to be evaluated prior to the day of surgery. The American Society of Anesthesiologists (ASA) Practice Advisory for Preanesthesia Evaluation ( http://www.asahq.org/For-Members/Practice-Management/Practice-Parameters.aspx) addresses the issue of the timing of preanesthesia evaluation. For cases of high surgical invasiveness, 59% of ASA members recommended that the preoperative anesthesia history and physical take place prior to the day of surgery.

For patients with a high severity of disease, 89% of ASA members recommended that that the preoperative anesthesia history and physical take place prior to the day of surgery.

In these instances, arrangements can be made for a member of the anesthesia group to meet and evaluate the patient prior to the day of surgery.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

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SHOULD YOU CANCEL SURGERY FOR A LOW POTASSIUM LEVEL OF 3.4 mEq/L?

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

Latest posts by the anesthesia consultant (see all)

Clinical Case of the Month:  You’re medical director for a busy outpatient surgery center.  An RN routinely does the preoperative screening by telephoning each patient two days prior to surgery.  The RN pages you with this question:  A 48-year-old patient scheduled for anterior cruciate ligament (ACL) reconstruction surgery takes hydrochlorothiazide for hypertension, and has not had electrolytes checked for six months.  His last labs show a low potassium = 3.4 mEq/L.  The patient is asymptomatic except for knee pain. The nurse asks you whether this patient needs to have his potassium rechecked now, before surgery.  What do you do?

Discussion: Pre-op evaluation will never be the topic of a Hollywood thriller — you’ll never see Tom Cruise or Brad Pitt rubbing their temples worrying about whether they need to recheck the electrolytes.  But for you and me, it’s a question worth discussing. How important is it to diagnose hypokalemia in this asymptomatic patient on chronic diuretic therapy?  If the K=3.0 mEq/L, will you cancel the surgery?  What about if the K=2.9 mEq/L?  Experienced anesthesiologists know standards of care for their specialty, and also develop a gut impression about which patients are prepared for surgery, and which ones are not.  Do you sense this patient is at risk for sudden death or a cardiac arrhythmia?  Let’s examine this question.

First off, why didn’t you see this patient in your pre-op clinic?  The answer is because you won’t find the Stanford model of a well-staffed Pre-Anesthesia Clinic in the private practice community.  The Pre-Anesthesia Clinic is important at Stanford because many patients suffer from significant medical comorbidities, and because of the invasive nature of many of the inpatient surgeries.  In a community practice with healthier patients and less invasive procedures, there is neither the money nor the need to physically meet and examine every patient several days prior to surgery.  Adam Smith’s economic dictum of the invisible hand pertains to clinical medicine as well — anesthesiologists are paid to give anesthetics.  Neither insurers nor Medicare will reimburse you for routine pre-operative clinic encounters with patients.

In 2002, the American Society of Anesthesia published Practice Advisory for Preanesthesia Evaluation:  A Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Their recommendations for the timing of preanesthesia evaluation differ, depending on the severity of disease and also on the surgical invasiveness.  Our patient’s surgery involves a non-severe comorbidity (well-controlled hypertension) and a non-invasive surgery (knee arthroscopy).  For patients such as this, the ASA Practice Advisory states, “preoperative assessment may be done on or before the day of surgery. “ In our community outpatient practice in Palo Alto, a surgery-center RN calls the patient two days prior to surgery to ask pertinent questions.  This telephone call helps avoid day-of-surgery surprises (e.g. patients still on aspirin, patients with undiagnosed chest pain or dyspnea).  The physical evaluation by the anesthesia attending occurs on the day of surgery.

Outpatient surgery centers rarely have the ability to do lab tests other than blood glucose measurements or a 12-lead ECG.  Tests such as the measurement of electrolyte concentrations need to be done at an outside lab, at least one day prior to surgery.  Regarding preanesthesia serum chemistries (i.e., potassium, glucose, sodium, renal and liver function studies), the ASA Practice Advisory gives no specific recommendation to check preoperative electrolytes during chronic diuretic therapy.  The recommendation on checking pre-op electrolytes states  “Clinical characteristics to consider before ordering such tests include likely perioperative therapies, endocrine disorders, risk of renal and liver dysfunction, and use of certain medications or alternative therapies.”

Might “perioperative therapies” include potassium replacement? Consider this: potassium is predominantly an intracellular ion.  Per Miller’s Anesthesia, “Only 2% of total-body potassium is stored in plasma. . . .  a 20% to 25% change in potassium levels in plasma could represent a change in total-body potassium of 1000 mEq or more if the change were chronic or as little as 10 to 20 mEq if the change were acute. . . . Chronic changes are relatively well tolerated because of the equilibration of serum and intracellular stores that takes place over time to return the resting membrane potential of excitable cells to nearly normal levels.” (Miller’s Anesthesia, 2005, pp.1105-6)

The same textbook states, “Retrospective epidemiologic studies attribute significant risk to the administration of potassium (even chronic oral administration).  In one study, 1910 of 16,048 consecutive hospitalized patients were given oral potassium supplements.  Of these 1910 patients, hyperkalemia contributed to death in 7, and the incidence of complications of potassium therapy was 1 in 250.” (Miller’s Anesthesia, 2005, p. 1107).

Given this information, what should we do?

Here’s the answer: Per Miller’s Anesthesia, p. 1107, “As a rule, all patients undergoing elective surgery should have normal serum potassium levels.  However, we do not recommend delaying surgery if the serum potassium level is above 2.8 mEq/L or below 5.9 mEq/L, if the cause of the potassium imbalance is known, and if the patient is in otherwise optimal condition.”

The same textbook points out an additional problem in ordering lab tests: “the failure to pursue an abnormality appropriately poses a greater risk of medicolegal liability than does failure to detect that abnormality. In this way, extra testing increases the medicolegal risk to physicians.” (Miller’s Anesthesia, 2005, p. 945)

Regarding the timing of lab testing, the ASA Practice Advisory on Preanesthesia Evaluation states “test results obtained from the medical record within 6 months of surgery are generally acceptable if the patient’s medical history has not changed substantially. More recent test results may be desirable when the medical history has changed, or when test results may play a role in the selection of a specific anesthetic technique (e.g., regional anesthesia in the setting of anticoagulation therapy.)”

For all the reasons stated above, you tell the RN that you won’t recheck the potassium lab value for this patient, and you won’t delay or cancel the ACL surgery.  The surgery is completed two days later, without complication.  Your two clients, the patient and the surgeon, are both happy, and you’ve practiced sound, evidence-based medicine.

For further details on the management of hypokalemia and hyperkalemia before, during, and after surgery, see the chapter I wrote entitled Disorders of Potassium Balance, in Complications in Anesthesia, 3rd Edition, 2017, edited by Lee Fleisher and Stanley Rosenbaum, Elsevier Press, Philadelphia.

 

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The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

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Learn more about Rick Novak’s fiction writing at rick novak.com by clicking on the picture below:

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