The postoperative anaesthetic review.
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
Medical societies (Standards)
|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|
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.
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.
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
American Pain Society Quality of Care Committee 1995 Quality improvement guidelines for the treatment of acute pain and cancer pain Journal of the American Medical Association 274 1874-1880
Apfelbaum JL, Connie C, Mehta SS, Tong GT 2003 Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged Anesthesia Analgesia 97 534 -540
Audit Commission for Local Authorities and the National Health Service in England and Wales 1997 Anaesthesia Under Examination: the efficiency and effectiveness of anaesthesia and pain relief services in England and Wales London, Audit Commission
Canet J, Mazo V 2010 Postoperative pulmonary complications Minerva Anestesiologica 76 (2) 138-143
Counsell D 2006 Efficacy of acute pain management in the postoperative period. In: Colvin J The Royal College of Anaesthetists. Raising the Standard: A compendium of audit recipes for continuous quality improvement in anaesthesia London, RCoA
Department of Health 2000 Comprehensive Critical Care. A review of adult critical care services. London, DH Available from: www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_4006585 [Accessed January 2011]
Devereaux PJ, Goldman L, Cook DJ, Gilbert K, Leslie K, Guyatt GH 2005 Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk Canadian Medical Association Journal 173 627-634
Dolin SJ, Cashman JN 2005 Tolerability of acute postoperative pain management: nausea, vomiting, sedation, pruritus, and urinary retention. Evidence from published data British Journal of Anaesthesia 95 (5) 584-591
Dolin SJ Cashman JN Bland JM 2002 Effectiveness of acute postoperative pain management: I. Evidence from published data. British Journal of Anaesthesia 89 (3) 409-423
Estafanous FG 1990 Postoperative myocardial ischemia: mechanisms on therapies. In: Siliciano D, Mangano DT Opioids in Anesthesia II Stoneham, Mass, Butterworth
Geerts WH, Bergqvist D, Pineo GF et al 2008 Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition) Chest 133 (suppl 6) 381S-453S
Intensive Care Society 2002 Guidelines for the introduction of outreach services. Standards and guidelines London, ICS Available from: www.ics.ac.uk/intensive_care_professional/ standards_and_guidelines/guidelines_for_the_introduction_of_outreach_2003 [Accessed January 2011]
Kheterpal S, Tremper KK, Heung M et al 2009 Development and validation of an acute kidney injury risk index for patients undergoing general surgery: Results from a national data set Anesthesiology 110 (3) 505-515
Lee A, Lum ME, O'Regan WJ, Hillman KM 1998 Early postoperative emergencies requiring an intensive care team intervention Anaesthesia 53 529-535
Lees N, Hamilton M, Rhodes A 2009 Clinical review: Goal-directed therapy in high risk surgical patients Critical Care 13 (5) 231
Little JP 1995 Consistency of ASA grading Anaesthesia 50 (7) 658-659
Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED 2005 Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial Critical Care 9 R687-693
Moller JT, Cluitmans P, Rasmussen LS et al 1998 Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study Lancet 351 857-861
Monk TG, Weldon BC, Garvan CW et al 2008 Predictors of cognitive dysfunction after major noncardiac surgery Anesthesiology 108 18-30
Morris-Stiff GJ, Sarasin S, Edwards P, Lewis WG, Lewi MH 2005 The European Working Time Directive: One for all and all for one? Surgery 137 (3) 293-297
National Confidential Enquiry into Patient Outcome and Death 2005 An Acute Problem? A report of the national confidential enquiry into patient outcome and death London, NCEPOD Available from: www.ncepod.org.uk/2005report/summary.pdf [Accessed January 2011]
Nightingale JJ, Lack JA, Stubbing JF, Reed J 1992 The pre-operative anaesthetic visit. Its value to the patient and the anaesthetist Anaesthesia 47 (9) 801-803
The Royal College of Anaesthetists and The Pain Society 2003 Pain Management Services: Good practice Available from: www.rcoa.ac.uk/docs/painservices.pdf [Accessed January 2011]
Ralley FE 1996 Postoperative anaesthesia care Canadian Journal of Anaesthesia 43 (8) 759-763
Richards CH, Leitch FE, Horgan PG, McMillan DC 2010 A systematic review of POSSUM and its related models as predictors of post-operative mortality and morbidity in patients undergoing surgery for colorectal cancer Journal of Gastrointestinal Surgery 14 (10) 1511-1520
Rogers S, Kenyon P, Lowe D, Grant C, Dempsey G 2005 The relation between health-related quality of life, past medical history, and American Society of Anesthesiologists' ASA grade in patients having primary operations for oral and oropharyngeal cancer British Journal of Oral and Maxillofacial Surgery 43 (2) 134-143
Royal College of Anaesthetists 2009 Postoperative care In: Guidelines on the Provision of Anaesthetic Services for Postoperative Care London, RCoA Available from: www.rcoa.ac.uk/docs/GPAS-Post.pdf [Accessed January 2011]
Wakeling HG, McFall MR, Jenkins CS et al 2005 Intraoperative oesophageal Doppler guided fluid management shorthens post-operative hospital stay after major bowel surgery British Journal of Anaesthesia 95 634-642
Zvara DA, Nelson JM, Brooker RF et al 1996 The importance of the postoperative anesthetic visit: do repeated visits improve patient satisfaction or physician recognition? Anesthesia & Analgesia 83 793-797
Correspondence address: Pervez Sultan, University College London Hospital, 230 Euston Road, London, NW12BU. Email: firstname.lastname@example.org
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
|Gale Copyright:||Copyright 2011 Gale, Cengage Learning. All rights reserved.|