Subtitle: We’ve Come a Long Way From Ether
Learn how an anesthesiologist approaches perioperative medicine from how to choose the right type of anesthesia (general anesthesia vs regional anesthesia vs MAC), to preoperative risk assessment, and how to avoid anesthesia related complications. Our guest, anesthesiologist, Dr. Angela Selzer (Denver, CO) helps us explore high yield pearls regarding the practice of anesthesiology to empower the internal medicine clinician to deliver team-based, perioperative care.
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“The most important thing that we do… is creating safe surgical conditions.” ~ Dr. Selzer
Criteria number one for a patient to receive regional anesthesia is the informed consent from the patient. There are many advantages to regional anesthesia over general anesthesia, including better experience overall, less postoperative nausea and vomiting (PONV), less post-anesthetic “hangover”, faster awakening, and fewer postoperative narcotic needs. Physiologically, the risk of postop delirium or cognitive dysfunction intuitively feels like it would be lower with regional anesthesia versus general anesthesia—but there is currently no robust evidence to support this.
Contraindications to neuraxial anesthesia may include: patient refusal, insufficient anticoagulation hold times (ASRA anticoagulation guidelines 2018), underlying coagulopathy, infection at the local injection site, or certain pathologic conditions. The 2021 REGAIN trial did not show that spinal anesthesia was superior to GA for survival and recovery of ambulation after hip fracture surgery. Dr. Selzer’s interpretation of this data is that hip fracture patients are often complex and medically fragile and may have many confounders in studying their periop outcomes (BONUS–this was also reviewed for NEJM Journal Watch by Curbsider Dr. Rahul Ganatra!)
Institutional memory might be a large driving factor for what type of anesthesia is preferred for a given case. ALWAYS make it a conversation—between the anesthesiologist, surgeon, AND patient.
An anesthesiologist’s approach to preoperative assessments
Anesthesiologists take care of patients during a really critical period, and the surgeries they have can be very intense and stressful, and as much information as you can give us on that patient’s functional status, on their medical history, on whether or not those medical problems are optimized is really helpful for us take better care of the patient. Just letting us know that the patient is “cleared” is not helpful.” ~ Dr. Selzer
It’s NOT about “clearance”, and it’s not only about the stress test (or lack thereof). Functional tolerance is a key element of preoperative assessments and histories, as can be primary records from past testing. Dr. O’Glasser’s periop mantra: knowledge is empowering!
Whether or not a preop test (like an ECHO) will change management might be answered differently by an outpatient PCP, inpatient hospitalist, and anesthesiologist. Our job as non-anesthesiologists may require us to think like an anesthesiologist as much as possible, and consider how a test will inform and empower intraoperative management decisions.
Depending on the patient, especially those with significant functional limitations, certain tests can be very helpful for an anesthesiologist’s management in the operating room. For example:
“The words “pulmonary” and “hypertension” are fairly benign on their own, but when you remove the “and” and say “pulmonary hypertension”, it becomes a really big problem for anesthesiologists.” ~ Dr. Selzer
The ASA classification system was developed several decades ago to standardize periop outcomes research based on patient complexity. ASA classes 1–6 exist, plus there is an “e” (emergency) modifier.
It’s very hard to be an ASA 1 as an adult! Even social alcohol consumption earns a patient an ASA 2 status, and pregnancy = ASA 2 class. BMI > 40 is at least an ASA 3 patient. There is a lot of interpersonal variability between ASA 2 and 3, and between ASA 3 and 4 (Haynes 1995, Ranta 1997, Mak 2002)—and making those distinctions can be really challenging (though adding narrative examples as a reference improves scoring)! An ASA 3 patient has substantive functional limitations; an ASA 4 patient has a condition that is a constant threat to life. Dr. Selzer’s teaching PEARL to determine ASA 3 versus 4: would you be surprised if a patient with the same pathology died suddenly while grocery shopping? If not, and you could easily determine a likely etiology, they are very likely an ASA 4 patient.
Ambulatory surgery can be a higher risk setting for certain patients. This is another reason why an appropriately thorough preop assessment of patient comorbid conditions is important to triage location of surgery (remember, “knowledge is empowering”!) (Mathis 2013, Whippey 2013).
Anesthesia care has also expanded to the non-operating room setting (NORA). Very commonly this is GA for MRIs, but this can also be provided for any non-OR based procedure (including interventional cardiology, electrophysiology, gastroenterology, and interventional radiology).
While many NORA cases are performed without anesthesia, this may be unsafe in certain patient populations, including children, patients with neuropsychiatric conditions and patients with complex medical comorbidities. These patients may benefit from an anesthesia team dedicated to achieving a safe level of anesthesia, monitoring vital signs and assisting with ventilation during their procedure.
A patient may report a history of a complication of anesthesia when they actually had an expected periop course. Again, “knowledge is empowering”—try to get more details about what happened.
Delayed emergence due to a pseudocholinesterase deficiency is rare. “Trouble waking up” in the PACU may not be true delayed emergence—it may be on the expected continuum of post-anesthesia grogginess or a sign of something like underlying OSA. Someone with true delayed emergence might need to remain intubated and “wake up” in the ICU well after surgery is completed.
Intraoperative awareness due to rapid metabolism of agents (and waking up paralyzed and aware of surgery going on) is also exceedingly rare. If a patient says they woke up during a case, get the records to tease out if this was done with a lighter level of sedation (e.g. with or without regional anesthesia). TIDBIT: natural redheads need more anesthesia drug doses to stay asleep!
Malignant hyperthermia is also extremely rare but can be life threatening! Knowing a patient has malignant hyperthermia or even family members who had malignant hyperthermia (or an intraop death) WILL change periop management as all volatile anesthetics need to be removed from the room, machines cleaned differently, and triggering agents avoided.
MAC: monitored anesthesia care
LMA: laryngeal mask airway
GA: general anesthesia
TIVA: total intravenous anesthesia
PONV: postoperative nausea and vomiting
NORA: non-operating room anesthesia
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Listeners will develop an understanding of the types of care that anesthesiologists provide and how internal medicine clinicians can work with anesthesiologists and other members of the surgical team to provide the safest surgical space possible.
After listening to this episode listeners will…
Dr. Selzer reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Jyang E, Selzer A, O’Glasser AY, Watto MF. “#Perioperative Medicine with Anesthesiologist Dr. Angela Selzer”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list. November 11, 2022.
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