Fit for Anesthesia: Fit for Surgery

(Anesthesia Blind Spots & The Silo’s of Specialisms)

©G.M. Woerlee, 2005–2024


Anesthesiologists are often requested to assess whether patients are “fit for anesthesia”. All anesthesiologists know that nearly all patients can safely undergo anesthesia. However, problems can arise during the course of a surgical procedure performed under anesthesia due to the physiological stresses and consequences of surgery. So during surgical procedures performed under anesthesia, anesthesiologists may need to manage hypotension due to blood, plasma or other fluid losses, or hypotension due to heart failure or reduced cardiovascular function, manage any anuria or oliguria during surgery, as well as manage excesses of hemodynamic stress induced by surgical pain. Such surgery-induced problems can seriously impact postoperative recovery if not adequately managed. James Cottrell, a former president of the American Society of Anesthesiologists, once pithily summarized the importance of anesthesiological management of problems arising due to the effects and stresses caused by surgery.

Our job is to keep patients alive while the surgeon does things that could kill them. (New York Times, 8 January 2002)

The preoperative condition of patients undergoing surgery, together with the planned type of anesthesia of surgery determine the likelihood and severity of these perioperative problems. Furthermore, anesthetic drug choice and the types of anesthesia may influence, or even exacerbate the severity of these surgery-induced problems. So the anesthesiological assessment for fitness for anesthesia, is actually an assessment of fitness for anesthesia plus fitness for surgery—the outcome quality of many operations is determined not only by the surgical team, but also by the anesthesia team.

Can you recommend a good anesthesiologist?

It is not uncommon for a future patient, or a member of their family, to request a recommendation of a good anesthesiologist from people considered to know the qualities of the anesthesiologists working at a particular hospital. Such a request is a manifestation of an implicit understanding that the quality of anesthesiological care can significantly affect surgical outcome.

The preoperative anesthesiological assessment

The preoperative assessment is not so much to determine fitness for anesthesia, but more importantly, to determine fitness for anesthesia plus surgery. The latter means determination of conditions, comorbidities, and medicines likely to cause or exacerbate problems during anesthesia and operation. Not surprisingly, these are also the same conditions, comorbidities, and medicines likely to cause or exacerbate problems during recovery after surgery.

The ASA score usually used to express the total severity and incapacity resulting from all conditions, comorbidities, and medicines, as well as the pathology requiring surgery. The higher the preoperative ASA score, the greater the chance of peroperative and postoperative problems. However, the ASA score alone is insufficient information for planning anesthetic and surgical management—knowledge of the specific preoperative comorbidities, together with the type of surgery planned are required for planning optimal anesthesia and management of specific patients during surgery, as well as recovery after surgery.

Elephants, the anesthesia-surgery information gap & Silo’s

No one disagrees with the reality of the above. Nonetheless, there is a very large “elephant in the room”, as well as a strange information gap between anesthesiologists and surgeons.

So what is the true value of present-day preoperative anesthesiological assessments, regardless of the fact they are made according to the current state of international knowledge regarding these matters. This knowledge is all very well as a general guide, but does not reveal whether preoperative anesthesiological assessments reflect the true local situation, or are even relevant for specific surgical procedures. This, together with the absence of any systematic analyses of preoperative anesthesiological assessments in relation to postoperative outcomes reveals a huge information gap, indicating that anesthesiologists and surgeons seem to live in different worlds, or silo’s. But the situation is even worse than just existing in different silo’s …

One size does not fit all

Nearly all preoperative assessments ignore the differing consequences of different types of surgery in relation to existing pathology. True, some crude studies have revealed there is a relation between type of surgery and perioperative consequences. For example, think of the chance of postoperative pulmonary problems in relation to the surgical site, e.g. upper abdominal surgery versus hip surgery. Nonetheless, this is still quite crude, because most preoperative assessment still uses the “one size fits all” principle, implying that the risk of perioperative problems in relation to preoperative comorbidity is the same regardless of type of surgery. That this “one size fits all” principle is incorrect, is clearly demonstrated by a study showing that patients undergoing elective hip or knee arthroplasty have very much fewer postoperative problems than equivalent patients undergoing elective laparoscopic colon surgery (see table below showing unpublished results from a study performed in the Alrijne Hospital, The Netherlands, 2022).


Postoperative outcomes Elective laparoscopic
colon resection
(N = 217)
Elective total hip
replacement
(N = 452)
Postoperative mortality 1(0.46%) 0
Intensive Care Unit admission 26(12%) 1(0.66%)
Delirium 7(3.23%) 5(1.1%)
Sepsis / septicemia 8(3.7%) 1(0.22%)
Cardiac complications 13(6%) 3(0.66%)
Respiratory complications 23(10.6%) 3(0.66%)
Venous thrombosis / thromboembolism 0 0
Surgical site infection 13(6%) 0
Wound dehiscence 6(2.76%) 0
Bowel anastomosis leak 6(2.76%) 0
Ileus 9(4.15%) 0
Readmission 3(1.38%) 7(1.55%)
Results from an unpublished PANSURAS® study in the Alrijne Hospital during 2022

It is actually quite surprising that so few investigations have been performed to study the reality that a system of “one size fits all” preoperative assessment does not address the true reality and nuances of the anesthetic-surgical perioperative situation.

Added value & quality of anesthesiology departments

Anesthesiologists perform their work of preoperative assessment, and the peroperative management of patients under their care according to: knowledge from current international scientific publications, the guidelines of their anesthesiological associations, and local protocols. They sometimes even actively maintain a complication register. But do these things mean that groups of anesthesiologists, departments of anesthesiology, actually add value to the perioperative processes within any given hospital?

Slavishly adhering to local protocols, or guidelines of anesthesiological associations, does not necessarily indicate quality or added value. Scientific publications based upon studies of patients in different countries and perioperative protocols are not always relevant to the local situation. The same applies to maintaining complication registers. None of these things are measures of the quality, or added value of anesthesiologists, or departments of anesthesiology—guidelines, protocols, and complication registers are measures of conformity to current standards, but not necesarily of added value. Patients are not interested in guidelines, protocols, or complication registers. Patients just want doctors to treat and resolve their problems with the minimum of pain and complications so they can return to their normal lives—this is patient care relevant to the experience of patients (Wallace 2022).




Patient care is the “core business” of anesthesiologists, just as it is for all physicians and others involved with medical care wherever it occurs. Quality and added value for the perioperative process is actually measured in terms of postoperative outcomes such as: postoperatieve respiratory or cardiac complications, wound infections, length of stay, the necessity for intensive care admission, etc., etc.. These are metrics of quality and added value of surgical care, and because perioperative anesthesiological management does influence postoperative outcomes, these are also metrics determining the real quality and added value of good anesthesiological management (see beginning of this page, and Wallace 2022). However, these are medical and hospital problems divorced from the personal experiences of most patients. As expressed by Scott Wallace during 2022, patients have a more holistic view of the whole perioperative surgical process (Wallace 2022). For patients, added value and quality is when they undergo perioperative management and surgery with the least pain, the fewest postoperative complications, shortest hospital admission, and best surgical result—and these results are a product of all the above surgical and anesthesiological quality metrics. The process of diagnosis of a surgically correctable problem, to full recovery after surgery, can be dissected into components expressed in terms of a perioperative “Chain of Care”—individual anesthesiologists, and departments of anesthesiology also have an important facilitating role in this chain of perioperative surgical care, the final result of which is the totality of patient care and experience.

GIRFT & breaking down the silo’s …

Measurement, and action upon these metrics by anesthesiologists together with surgeons, not only breaks down the walls separating anesthesiological and surgical silo’s (Laudanski 2022, Mahajan 2021), but also enables optimization of perioperative protocols, making it possible to reduce postoperative complications. In turn, reduced postoperative complications means reduced costs and better patient care—better patient care is also good hospital management, reducing costs of care, so improving hospital profitability and reputation (Pradarelli 2017). This is effective implementation of the British National Heath Service slogan “Get It Right First Time” (GIRFT)—the aim of all physicians and persons involved directly and indirectly in patient care.


PANSURAS® is a computer program designed to facilitate improvement of perioperative anesthesia and surgical management quality within hospitals!

References

  1. Hubbard RE, Story DA, (2014), Patient frailty: the elephant in the operating room. Anaesthesia, 69(suppl. 1): 26-34. doi:10.1111/anae.12490
  2. Laudanski K, (2022), Quo Vadis Anesthesiologist? The Value Proposition of Future Anesthesiologists Lies in Preserving or Restoring Presurgical Health after Surgical Insult, Journal of Clinical Medicine, 11: 1135. https://doi.org/10.3390/jcm11041135
  3. Mahajan A, et al, (2021), Anesthesiologists’ Role in Value-based Perioperative Care and Healthcare Transformation, Anesthesiology, 134: 526-540. DOI: 10.1097/ALN.0000000000003717
  4. Pradarelli JC, Nathan H, (2017), Treating Perioperative Complications: Should Everyone Be This Expensive? JAMA Surgery, 152: 959. doi:10.1001/jamasurg.2017.1719
  5. Wallace S, (2022), Advancing the profession and avoiding the commoditization of anesthesiology, Canadian Journal of Anesthesia, 69:815-817. https://doi.org/10.1007/s12630-022-02239-8


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