The postoperative anaesthetic review.
Abstract: An anaesthetic preoperative assessment for all patients is the standard of care in UK hospitals. The Royal College of Anaesthetists (RCoA) 2009 guidelines state that a postoperative visit, within 24 hours following surgery, is recommended for patients only in certain circumstances. This article critiques these guidelines and explores factors which must be taken into consideration when deciding whether or not anaesthetists should routinely visit their patients after they leave the recovery area. We discuss the physiological rationale for performing a postoperative anaesthetic visit; the identification of post-operative morbidity including provision of adequate post-operative analgesia; patient benefits; limitations of performing postoperative review, and the implications that expanding anaesthetists' responsibilities as perioperative physicians has had upon anaesthetic training and service provision. Finally, this article offers an alternative model for deciding when to perform a post-anaesthetic visit.

KEYWORDS Anaesthetic assessment / Postoperative review / Post-anaesthetic visit / Post-anaesthetic review
Article Type: Report
Subject: Anesthesiologists (Practice)
Anesthesiologists (Standards)
Medical societies (Standards)
Authors: Sultan, Pervez
Jigajinni, Suyogi
McGlennan, Alan
Butwick, Alexander
Pub Date: 04/01/2011
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: April, 2011 Source Volume: 21 Source Issue: 4
Topic: Event Code: 200 Management dynamics; 350 Product standards, safety, & recalls
Product: Product Code: 8622000 Medical Associations NAICS Code: 81392 Professional Organizations SIC Code: 8621 Professional organizations
Organization: Organization: American Society of Anesthesiologists
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 272168011
Full Text: In the UK, the expected standard of care afforded to all preoperative patients includes a preoperative assessment by a qualified anaesthetist. This has been heralded as the best way to gather important information about the patient and an opportune moment to obtain the patient's treatment consent. Equally, one can argue that a postoperative visit is also necessary to complete the anaesthetist's care. The Royal College of Anaesthetists (RCoA) 2009 guidelines exist to guide staff in improving the quality of service for patients. However, the guidelines do not necessarily indicate that a postoperative visit should become the norm. In fact, they state that a postoperative visit, within 24 hours following surgery, is recommended only for patients in these circumstances:

(1) Those graded as American Society of Anesthesiologists (ASA) Physical Status 3, 4 or 5.

(2) Those receiving epidural analgesia in a general ward.

(3) Those discharged from recovery with invasive monitoring in situ.

(4) Those for whom a request is made by other medical, nursing or other clinical colleagues.

(5) Those for whom there is any other appropriate need.

Anecdotal information exists that anaesthetists do indeed regularly carry out postoperative visits for patients, exceeding these recommendations; however, we lack evidence as to the nature of an anaesthetist's involvement or what type of service will ensure the patient is safely and effectively cared for from preoperative assessment to discharge from the hospital. This article critiques the RCoA guidelines, discusses the factors involved in deciding whether to perform a postoperative anaesthetic review, and finally offers an alternative model for deciding when to perform such a visit.

Current guidelines about the postoperative anaesthetic visit

RCoA 2009 guidelines specify the indications that the anaesthetist should consider when deciding whether to visit a postoperative patient. However, it is not known whether such a visit improves postoperative patient management and patient outcomes prior to hospital discharge. From the guidelines mentioned above, the following four statements are critiqued in this article:

1 Those graded as ASA Physical Status 3, 4, or 5.

2 Those for whom there is any other appropriate need.

3 Those discharged from recovery with invasive monitoring in situ.

4 Postoperative visit within 24 hours of their operation.

1. Those graded as ASA Physical Status 3, 4 or 5

Although Rogers et al (2005) showed that the ASA classification system can predict postoperative outcome, this system was not designed to predict who would require a postoperative anaesthetic visit. Nor does ASA status account for important perioperative factors such as mode of anaesthesia, type and duration of surgery, intraoperative adverse events, and potential airway compromise, all of which the anaesthetist must consider when determining the need for a post-anaesthetic visit. Moreover, different anaesthetists often assign different ASA grades to the same patient (Little 1995). Consequently, although ASA grading is a useful predictor of morbidity, it should not be used in isolation to decide whether patients require postoperative review.

2. Those for whom there is any other appropriate need

The phrase 'any other appropriate need' is open to interpretation. For example, clinicians may disagree as to whether an ASA 2 patient undergoing uncomplicated major bowel or urological surgery should be visited postoperatively by the anaesthetic team. Current guidelines could be revised to specify clinical indications that necessitate a postoperative anaesthetic visit, rather than relying on the individual anaesthetist's discretion.

3. Those discharged from recovery with invasive monitoring in situ

The RCoA guidelines (2009) suggest that patients should be seen postoperatively if invasive monitoring is in-situ. Presently, institutions vary as to whether such patients are actually reviewed postoperatively by trained anaesthetists or by intensive care specialists.

4. Postoperative visit within 24 hours of their operation

The RCoA guidelines (2009) recommend that the postoperative anaesthetic visit ought to be performed within 24 hours of surgery. This recommendation is supported by studies which encourage the implementation of intraoperative (Wakeling et al 2005) and immediate postoperative (Pearse et al 2005) goal-directed therapy, to optimise oxygen delivery and improve postoperative outcomes (Lees et al 2009). However, postoperative medical complications are not confined to the first 24 hours following surgery. Moreover, it is unclear whether this recommendation applies to low-, medium- or high-risk surgical patients and whether repeated anaesthetic visits after the first postoperative day can reduce morbidity.

Physiological reasons for performing postoperative visits

In general, mandatory postoperative review can be justified for physiological reasons, as major changes in adrenergic activity, plasma catecholamine concentrations, pulmonary function, body temperature, fluid balance, perception of pain, and sleep disturbance occur postoperatively (Estafanous 1990). These fluctuations can lead to physiological imbalance, particularly between myocardial oxygen supply and demand, thus increasing the risk of developing myocardial ischaemia.

Identification of postoperative morbidity

Anaesthetists have become increasingly recognised as perioperative experts that staff can turn to for advice in managing patients with early signs of critical illness; they are also experts for guiding each patient's postoperative plan (such as recommending acceptable parameters for the postoperative assessment of vital signs).

In 1998 Lee et al performed an observational study with 34 cases and 126 controls and reported the incidence of major postoperative complications within 48 hours of surgery as 0.2%. The study defined major complications as abnormal physiological variables (respiratory rate <5 or >36/min, pulse rate <40 or >140 beats/min, systolic BP <90mmHg and decreased level of consciousness) or specific conditions (repeated or prolonged seizures, threatened airway, respiratory or cardiac arrest). With such a low prevalence, an anaesthetist is unlikely to discover a critically ill patient by performing a single, routine visit during the postoperative period.

This study also demonstrated that high-risk patients, including ASA 4+ patients and those requiring surgery out-of-hours, are at greatest risk of major postoperative morbidity. Patients with major medical complications following surgery (Table 1) are likely to be the ones who could best benefit from a postoperative anaesthetic visit.

In addition to the primary team, hospital outreach teams, whose purpose is ensuring timely and appropriate management of deteriorating patients on general hospital wards, may also assess at-risk surgical patients. These teams respond to the need for a more equitable, hospital-wide approach to managing 'at risk' patients (NCEPOD 2005). An outreach team's early postoperative medical intervention (DH 2000, ICS 2002) could avert an ICU admission.

Anaesthetists and intensivists, along with hospital rapid-response teams, are integral to organising and implementing such services. As perioperative physicians, anaesthetists conducting post-anaesthesia reviews may identify postoperative problems that require further laboratory tests, clinical investigations, or subspecialty referral. It is unclear if post-anaesthesia reviews can identify patients at risk of developing critical illness in the postoperative period and reduce the need for ICU admission. At the very least, their reviews complement routine ward reviews by members of the surgical and nursing team.

Postoperative analgesia

A postoperative anaesthetic review can help to ensure good analgesia for the patient. A systematic review by Dolin and Cashman (2005) reported 'maximum acceptable prevalence' for postoperative, analgesia-related side effects (Table 2). Adequate provision of postoperative analgesia is an important factor in decreasing postoperative pulmonary (Canet & Mazo 2010) and cardiac complications (Ralley 1996). The RCoA states that failure of analgesia postoperatively should be detected within two hours (Counsell 2006), and that no patient should be returned to the ward in uncontrolled pain, defined as a pain score of 4 or more on a visual analogue scale (American Pain Society Quality of Care Committee 1995).

A nationwide survey performed in the US revealed that approximately 80% of patients experienced acute pain after surgery. Of these patients, 86% had moderate, severe, or extreme pain (Apfelbaum et al 2003). In a review by Dolin et al in 2002, the reported mean prevalence of moderate to severe pain was 29.7%, and severe pain was 10.9% following major surgery. These studies suggest that the desired standards of care outlined in the 1997 UK Audit Commission (Audit Commission 1997) might be unachievable with intramuscular opioids, patient-controlled analgesia and epidural analgesia. The RCoA and the Pain Society recommend providing resources to ensure continuous coverage for acute pain management at all times (RCoA and Pain Society 2003). Who better to ensure the patient is receiving adequate analgesia than the anaesthetist during the postoperative visit? Similarly, if a pain review is required postoperatively, this practically presents an excellent opportunity for a post-anaesthetic visit to be incorporated into the patient assessment.

Patient benefits from post-anaesthetic review

Nightingale et al (1992) showed that, based on a numerical scoring system, 82% of

patients highly valued the preoperative anaesthetic visit. In contrast, Zvara et al (1996) compared patients receiving one, two or three postoperative anaesthetic visits and found that increased postoperative contact with the anaesthetist was not associated with patients' improved satisfaction with anaesthesia services.

Despite these patient perceptions, a postanaesthetic visit affords the anaesthetist the opportunity to impart potentially lifesaving information regarding difficulties encountered during anaesthesia such as a difficult airway, anaphlaxis, suxamethonium apnoea or malignant hyperthermia. Careful explanation can be provided including a description of anaesthetic events, requirement for further investigations and implications for future anaesthesia or surgery. Organising further testing to diagnose specific allergens, providing a Medic Alert bracelet, or simply providing a hand written letter warning future physicians of such complications, are examples in which future anaesthesia management can be improved from information conveyed during a postanaesthesia visit.

Limitations and considerations associated with the post-anaesthetic visit

Although the frequency of post surgery anaesthetic review is unknown, we do know that increasing demand may limit the time, personnel and resources necessary for all patients to receive them. Ideally, the anaesthetist who gave the anaesthetic should make the post-anaesthetic visit, to maintain continuity of care and reduce errors. However, in reality, the primary anaesthetist may be unavailable because of other clinical responsibilities and time pressures, changing patterns of junior and senior doctors' schedules, shift-based systems, and changes to consultant contracts.

Ways to address these limitations include:

* formulation of contingency plans by individual anaesthtic departments to ensure that appropriately experienced anaesthetists are available to review postoperative patients

* prioritisation of need for review and consideration of the duration, timing and frequency of anaesthesia assessment

* consideration of the seniority of anaesthetist performing the visit

* provision of training for anaesthetic trainees in postoperative anaesthetic assessment.

Mandatory postoperative anaesthetic reviews: A training issue

The post-anaesthetic visit can be used to assess the quality of anaesthetic care, patient satisfaction, and the incidence of anaesthetic-related adverse events (such as post-dural puncture headache, peripheral neuropathy, and postoperative nausea and vomiting). It allows the trainee time to reflect on their own practice and can ultimately help to improve the standard of care for future patient management. However, anaesthetists may not be able to routinely assess their patients postoperatively due to either work rules or time constraints. If postoperative anaesthetic reviews or 'rounds' became mandatory, then further resources would need to be provided to cover the additional workload, particularly since the European Working Time Directive of a 48-hour week has already impacted staffing rotas (MorrisStiff et al 2005). An increased anaesthetic workload would potentially reduce time for training opportunities in the operating theatre. Trainees would need to consider breaching their contracted working hours to find the time to assess patients postoperatively, or rotas would need to incorporate time for these visits.

Alternative criteria for whether to perform post-anaesthetic review

Anaesthetists are trained to manage postoperative patients with critical illness and major organ dysfunction. To optimise acute, postoperative care, anaesthetists individualise their patient strategies for postoperative analgesia, emesis prophylaxis, and fluid management. Although it may not be feasible for anaesthetists to see every post-surgical patient on the ward, new scoring systems and policies can help to determine who should be seen peri- and post-operatively.

For example, anaesthetists can score patients with the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) model, a validated scoring system which is used extensively to predict postoperative mortality and morbidity (Richards et al 2010). Regardless of the system used to decide which patients require a postoperative visit, the decision to perform such review should be based on a systematic approach such as that outlined in Table 3.

Conclusion

Anaesthetic care does not end after the patient leaves the recovery room. Instead, the patient needs increased attention and resources in the postoperative period. A compromise must be sought between spending adequate time being trained in theatre and providing continuity of care to patients postoperatively. Furthermore, postoperative anaesthetic visits provide valuable clinical data related to health outcomes research, particularly postanaesthetic patient outcomes and auditing of clinical information. As perioperative physicians, anaesthetists bear increasing responsibility for patient care beyond the recovery room. Systems should ensure that anaesthetists' skills are used to optimise patient care following surgery and to provide advice to nursing and surgical colleagues.

No competing interests declared

References

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Correspondence address: Pervez Sultan, University College London Hospital, 230 Euston Road, London, NW12BU. Email: p.sultan@doctors.org.uk

About the authors

Pervez Sultan MBChB, FRCA

SpR Anaesthetics, University College London Hospital, London

Suyogi Jigajinni MBChB, BSc, FRCA SpR Anaesthetics, Royal London Hospital, London

Alan McGlennan BSC, MBBS, FRCA Consultant Anaesthetist, Royal Free Hospital, London

Alexander Butwick MBBS, FRCA Associate Professor Anesthesiology, Stanford University School of Medicine, California, USA
Table 1 Prevalence of major medical complications following surgery

Co-morbidity            Postoperative prevalence

Acute kidney injury     1% general surgery cases
                        (Kheterpal et al 2009)
Myocardial infarction   3.9% with or at risk of cardiac disease
                        (Devereaux et al 2005)
Cognitive dysfunction   26-41% (Moller et al 1998, Monk et al 2008)
Deep vein thrombosis    42-57% post total hip arthroplasty
                        (Geerts et al 2008)
Pulmonary embolism      0.9-28% post total hip arthroplasty
                        (Geerts 2008)

Table 2 Maximum acceptable prevalence of side-effects associated with
postoperative analgesia.

Side-effect              Maximum acceptable prevalence (%)

Nausea                                  25
Vomiting                                20
Minor sedation                          24
Excessive sedation                       3
Pruritus                                15
Urine retention                         23
(with catheterisation)

Table 3 Alternative criteria for post-anaesthetic review

Factor                When to perform review

ASA grade             Patient has ASA status >3
Anaesthesia           Anaesthesia-related complication exists, e.g.
                      adverse drug reaction, pneumothorax after
                      central line insertion

Surgery               All cardio-thoracic; major urological,
                      vascular, neurological, orthopaedic, general
                      or gynaecological surgery

Medical/nursing       Physicians, surgeons, or senior nursing staff
referral              request the review

Investigations        Review relevant postoperative investigations,
                      e.g. chest xray following central venous
                      catheter placement

Cardiovascular        Pre-existing, major, cardiac morbidity;
                      perioperative cardiovascular adverse event

Respiratory           Pre-existing, major, respiratory morbidity;
                      perioperative respiratory complication
                      requiring respiratory support postoperatively

Renal                 Chronic renal failure; acute renal failure
                      during the perioperative period

Metabolic             Clinically significant, acid-base disturbance

Neurology             Pre-existing or postoperative major
                      neurological deficit

Analgesia             Neuraxial block or difficulties with pain
                      management by primary care team

Invasive monitoring   Invasive monitoring in situ

Airway                Major head and neck/maxillofacial surgery;
                      evidence of perioperative upper airway
                      compromise

Fluid management      Perioperative transfusion or blood loss > 1.5l
                      intraoperatively; complicated fluid balance
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