PREOPERATIVE ASSESSMENT AND THE ANESTHESIA CLINIC

Abstract

The shift toward outpatient surgery, including both ambulatory and AM-admission surgery, has intensified since the last issue of Anesthesiology Clinics outpatient anesthesia in 1987. Today, more than ever before, anesthesiologists are taking care of people who are not in-hospital patients before the day of surgery. This group includes not only the American Society of Anesthesiologists (ASA) physical status I or II patient who is to undergo routine outpatient surgery, but also the ASA physical status III and even IV patient who is to be admitted after not-so-routine surgery. Indeed, patient age and medical conditions, as well as surgical procedure and length, no longer necessarily determine the appropriateness of ambulatory surgery. 43 At Seattle Children's Hospital and Medical Center and at the University of Washington Medical Center approximately 60% of surgical cases are ambulatory surgical cases and another 20% are AM-admission cases. Even at these tertiary care hospitals, only about 20% of surgical cases are available in-hospital the day before surgery for preoperative anesthetic evaluation. In addition, nonsurgical needs for anesthesia care have greatly expanded and thereby further challenge the anesthesia care team. With this comprehensive shift away from inpatient surgery the anesthesia has become the venue for preoperative evaluation at many institutions. This is not a new phenomenon. In 1949, Lee 36 discussed the value of the anaesthetic out-patient clinic in the preparation of patients for surgery, and in the early 1970s Frost 22 pointed out the value of the anesthesia preadmission evaluation in improving preoperative care and shortening hospital stay. In this setting, the anesthesiologist joins surgical and nursing colleagues in initiating the process of patient evaluation and preparation for surgery. The challenge is to provide thoughtful, efficient, and cost-effective care while ensuring that surgery and anesthesia can proceed safely without delay on the day of scheduled surgery. Thus, the anesthesia assessment becomes one important component of a patient-care system that requires effective participation by multiple hospital services for the system to function well. In this article preoperative assessment of the surgical patient, both pediatric and adult, is considered in the setting of a preoperative anesthesia clinic. Many issues related to care of patients arise in the setting of the preoperative clinic, issues that become apparent considering the following two case scenarios: