The anesthesiologist is at the center of everything when it comes to the hospital OR or the surgical center that uses a multidisciplinary approach,” said Medhat Mikhael, MD, pain management specialist, anesthesiologist, and medical director of the non-operative program of the Spine Health Center at MemorialCare Orange Coast Medical Center in Fountain Valley, California.
He likens the anesthesiologist's role as the leader of a multidisciplinary team of clinicians in the operating theater to the role of an airplane pilot who must complete several steps on a detailed checklist before taking off in order to optimize the chances of bringing the plane back down safely and landing smoothly.
“Let me explain how,” Dr. Mikhael offered. “When the surgeon is ready to begin a procedure, he or she usually doesn't need to think about whether the patient is optimal to undergo such a surgery from the standpoint of anesthesia, from the standpoint of breathing, from the standpoint of pain. But the anesthesiologist must be thinking about all of these things all of the time because it is his or her responsibility to take the patient safely from Point A to Point B after they recover from the anesthesia.”
Once an operation is deemed necessary, the anesthesiologist typically will review the medical record to make sure there's nothing about the patient's medical status or family history to be worried about, Dr. Mikhael noted. However, if the record indicates that a patient is high-risk due to a heart element, for example, an outside referral will be made to a cardiologist to clear the patient before the surgery is even scheduled in most cases.
“But when the anesthesiologist feels there is still risk, this is where the multidisciplinary approach to surgery happens,” he said. “This where the perioperative team, the nursing team, and everybody in the operating theater start directing patient care and making sure everything gets done in order to complete workups for the anesthesiologist so they can be sure this patient is optimal for the anesthesia and for the surgery.”
If the anesthesiologist still feels a patient's heart or lung problem has not been cleared adequately heading into surgery, Dr. Mikhael said the patient will again be seen by the cardiologist and typically get an electrocardiogram or electrocardiogram, or be evaluated by the pulmonologist who will work to maximize their lung function. In the meantime, the anesthesiologist will order blood work or ask the patient's primary care physician to do so.
“With all of that done, and when all of the clearances go through, all of this information goes to the preoperative nurse, who assesses it and says, ‘I get that. I've got that. Review it.’ And then the anesthesiologist can begin to build the anesthesia plan based on what he or she sees is best,” he said. “For example, when you use a lot of inhalation anesthetics it tends to depress the cardiovascular system. So when a patient has a heart condition, the anesthesiologist may choose to use a lot less of the inhalation anesthetics and use all of the other measures through I.V. to control anesthesia.”
When it comes to pain management, anesthesiologists follow an important rule, Dr. Mikhael said, which is to use a multimodal approach and preemptive analgesia. “A ‘multimodal approach’ means using different approaches that have different mechanisms of action. For example, when a patient is undergoing a total knee replacement, they will employ general anesthesia, spinal anesthesia, and place a localized catheter to block the nerve sensation in the knee. All work with different mechanisms of action and help keep the patient comfortable and stable during surgery and postoperatively without needing much narcotics.” Preemptive analgesia, he added, means giving patients medications before the incident to prevent or minimize the pain intra- and postoperatively.
But while the anesthesiologist is considered the decision-maker for a multidisciplinary team, Dr. Mikhael emphasized that they are supported in the operating theater by other physicians who can advise them on the patient's status, as well as specialty-trained nurses and other clinicians who play integral roles in maximizing the patient's condition. “From the preoperative, to the intra-operative, to the postoperative area, everyone on the multidisciplinary team must work effectively together to optimize the patient for surgery and pain control postoperatively,” he said.
One recent study described an anesthesiologist-led multidisciplinary high-risk committee model in preoperative evaluation clinic at an academic comprehensive cancer center. The group of patients in which surgery was denied by the committee had a greater risk of hypertension, dyspnea, heart failure, COPD, diabetes, renal failure, and a smoking history. Of the 107 high-risk patients selected for surgery, only one died within the first 30 days postop, which was fewer than the group denied surgery. Among all 167 high-risk patients included in the retrospective analysis, the mortality rate was below 2% in the first 30 days after surgery (J Healthc Risk Manag July 2018).
So, what advice does Dr. Mikhael offer other anesthesiologists who work in a setting that deals with high-risk patients and uses a multidisciplinary approach? Lead by example, he says, and don't be afraid to take advantage of the resources available to you, including using patient simulators to teach complex procedures to nurses and other clinicians. But always remember that it is the anesthesiologist who is responsible for navigating a smooth landing for the patient and the entire multidisciplinary team.
“Use the other specialties, the other physicians, and the nurses who are well trained to optimize every patient before anesthesia and the surgery takes place,” Dr. Mikhael said. “Also, completing CMEs and continuing education hours for nurses and for other providers is very important in order for everyone to be aware of methods and techniques we use to optimize patients and to continue to deliver care safely and effectively.”
Chuck Holt is a contributing writer.
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