© Springer International Publishing Switzerland 2015
Molly Blackley Jackson, Somnath Mookherjee and Nason P. Hamlin (eds.)The Perioperative Medicine Consult Handbook10.1007/978-3-319-09366-6_55. Anesthesia Pearls
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Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
Background
The anesthesiologist fulfills several critical roles in the perioperative period apart from the actual administration of the anesthetic. The anesthesiologist functions also as a “primary care” physician for the patient’s medical conditions in the operating room. Anesthesiologists have a wide range of core medical knowledge as well as broad experience in managing coexisting disease in the operating room. They also have specialty knowledge in cardiovascular and respiratory physiology, and critical event management. Many issues of interest to the anesthesiologist in the perioperative period overlap with concerns of the medicine consultant.
Perioperative Management
A primary focus of anesthesia practice is risk management and patient safety. In the preoperative period, some examples of issues that anesthesiologists focus on include the following:
Relative risk of the surgery in question.
Current medical comorbidities and whether they have been optimized.
History or physical exam indications of any undiagnosed medical conditions that could affect anesthesia and surgery.
What anesthetic techniques are options for surgery, and which best address the medical comorbidities of the patient while providing good surgical conditions.
In what ways physical aspects of the surgery (positioning, site of incision, duration, need for muscle relaxation) affect anesthetic choices and monitoring patients.
The monitoring (including hemodynamic and neuromuscular monitoring) that is appropriate for the surgery and will mitigate risk.
Postoperative management of pain, respiratory changes, nausea, and vomiting.
Discharge issues, such as how soon the patients can be discharged, where the patient will be discharged to, and in whose company.
Pearls to Consider
Evidence-based guidelines on anesthesia and surgery are extremely helpful in most cases, but are not always completely applicable, because they fail to account for local differences in surgical practice, as well as important differences among individual surgeons. Issues that can affect whether further workup of a medical condition, or other management, is needed in the perioperative period and are often overlooked include the following:
Positioning during surgery. Some surgeries require sitting position (shoulder, breast, and some neurosurgery). Further cardiac or neurovascular workup may be indicated if the patient will undergo unusual positioning with adverse hemodynamic consequences.
Blood loss. While surgeries can be categorized into major, minor, and minimal blood loss, this is highly dependent on the surgeon, whether the surgery is a revision of a previous one, and the surgical technique. For example, blood loss during spine surgery can range from minor (1–2 unit loss not requiring transfusion) to major/disastrous (up to or exceeding a patient’s entire blood volume). Consultation with an anesthesiologist may be helpful in defining these risks for the patient, based both on the surgery and the surgeon performing it.
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