The preoperative anesthetic evaluation is a key component of anesthetic management. The American Society of Anesthesiologists establishes guidelines detailing that each patient requiring care by an anesthesia provider must be provided a detailed medical, anesthesia and drug history, a physical exam, appropriate diagnostic testing and data, assignment of an ASA physical status score, and formulation and discussion of an anesthetic plan. Taken together, this process allows for preoperative risk stratification and adequate preparation to provide safe anesthesia.
When and how the pre-anesthesia assessment occurs differs from practice to practice. One study found that an overwhelming majority of patients preferred to complete their preoperative evaluation via telephone. This obviously does not allow for a physical examination, which would need to be done on the day of surgery. While this modality (along with its even less rigorous cousin, completing the entire pre-anesthetic assessment upon meeting the patient immediately before surgery) may serve well to provide pertinent negatives in healthy individuals, the question remains what to do about concerning positive findings. There is rarely time to schedule a stress test for a patient admitting for occasional exertional chest pain the evening prior to or on the day of surgery, a complication which often necessitates cancellation of their procedure for workup and medical optimization. Other potential pitfalls include lack of preparation for a patient with a concerning airway examination, leaving the anesthesia provider to scramble at the last minute to locate equipment or additional personnel to safely manage the patient’s airway. One study attempted to have patients self-administer an airway questionnaire but found poor correlation with an airway assessment by an anesthesiologist.
The value of an in-person visit to a dedicated pre-anesthesia assessment clinic rests in both expertise and time. The patient is able to be evaluated by a provider skilled at least in providing preoperative assessments (one model entails nurse practitioners who are trained to evaluate patients and discuss any unexpected findings with a supervising anesthesiologist) and is allowed enough time before the scheduled surgical date to identify any modifiable risk factors, confer with specialists, optimize regimens, and answer questions. Arguments that such clinic visits are costly and inconvenient are countered by positive results borne out in studies: well-designed pre-anesthesia clinics decrease surgical cancellations, reduce costs due to unnecessary tests, and are even associated with lower in-hospital mortality for patients admitted after surgery.
For ambulatory surgery in healthy patient populations, it may not be cost-effective or high-yield to send every patient to a pre-anesthesia clinic. In these cases, a phone interview should be conducted to screen for any potential red flags prior to surgery. For hospital-based surgeries and higher risk populations, an in-person pre-anesthesia evaluation is more likely to provide safer and more cost-effective anesthetic management.
References:
Blitz JD1, Kendale SM, Jain SK, Cuff GE, Kim JT, Rosenberg AD. Preoperative Evaluation Clinic Visit Is Associated with Decreased Risk of In-hospital Postoperative Mortality. Anesthesiology. 2016 Aug;125(2):280-94.
Payne E, Ragheb J, Jewell ES, Huang BP, Bailey AM, Fritsch LM, Engoren M. Are physician assistant and patient airway assessments reliable compared to anesthesiologist assessments in detecting difficult airways in general surgical patients? Perioperative Medicine20176:20
Prabhakar, A., Helander, E., Chopra, N. et al. Preoperative Assessment for Ambulatory Surgery. Curr Pain Headache Rep (2017) 21: 43.
