INTRODUCTION: BEYOND PHARMACOLOGY AND PHYSIOLOGY
Anesthesia is an interplay between pharmacology and physiology. Medications used during anesthesia provide a specific function of a balanced anesthetic technique comprised of amnesia, analgesia, akinesia, hypnosis, and control of autonomic responses. The anesthesiologist directs this biological interaction while also playing a vital leadership role in the perioperative team. This physician leads a team of nurse anesthetists, anesthesia assistants, or residents, engages with hospital consults to develop a safe anesthetic plan, communicates risks and plans with the surgery team, and directs intraoperative and perioperative care. Most importantly, the anesthesiologist will explain the anesthesia-related risks, benefits, and alternatives with the patient with the goal of shared decision-making.
The overall goal of preoperative evaluation for anesthesiologists is threefold. One, identify modifiable risks that are amenable to optimization before surgery and create a plan of action to address or improve the comorbidity in an attempt to improve overall patient outcomes. Two, risk stratify the patient based on a thorough assessment to determine the need for additional cardiopulmonary testing, delay in the procedure, or move to an appropriate surgical location. Ideally, the first two goals are accomplished in the weeks before surgery to allow for intervention. Optimization for surgery includes patient education on the risks, benefits, and alternatives to surgery and anesthetic options. Three, develop a patient-specific anesthetic plan based on the type of surgery and comorbidities. The day of surgery anesthesia care team determines the final anesthetic plan, including drug choice and dosing sequence, level of sedation required, definitive airway management, and communication with the surgery team.
The anesthesia and surgical teams often solicit input from primary care or specialty medicine services, such as cardiology or pulmonology, to aid in preoperative risk stratification. The purpose of this consultation is to assess the opportunity for optimization of chronic medical conditions that have a direct bearing on surgical and anesthetic outcomes.
Surgical clearance is an older term that implies a degree of certainty of outcome. It does not address perioperative care, risk factor modification, or coordination of care issues, and is not focused on longitudinal health improvement and management. Clearance often leaves patients feeling as though there is “zero risk” to them from their anesthetic and surgical procedure. Writing “cleared for surgery” has no meaning to the surgery and anesthesia teams as there is no indication of the basis of the clearance. Equally less useful are the common recommendations to “avoid hypoxia, hypotension, and hypothermia,” since avoidance of these factors is fundamental to all anesthetics.
All surgical procedures carry an element of risk, where total risk is the sum of intrinsic and modifiable factors.1 Optimization focuses on the preemptive reduction of elements of modifiable risk, such as preoperative smoking cessation. Optimization purposely does not imply outcome certainty and sets the stage for coordinated perioperative care among a multitude of providers, such as ...