Complications can be common yet detrimental for patients undergoing major surgery [1]. Anesthesia consultations play a crucial role in the multidisciplinary management of high-risk surgical patients and mitigating potentially avoidable complications. High-risk surgical patients encompass individuals with pre-existing medical conditions, advanced age, or complex medical histories that increase the likelihood of complications during surgery and ultimately increase their risk for morbidity and mortality [2]. Conditions such as cardiovascular diseases, respiratory disorders, and diabetes can pose challenges during anesthesia and surgery, necessitating a comprehensive approach to preoperative assessment and preparation. This encompasses a wide array of patients. For example, approximately 25% of patients are either at risk for or have a history of ischemic heart disease, while 14% have a diagnosis of chronic obstructive pulmonary disease [3]. Incorporating preoperative anesthesia consultations is essential for high-risk patients as they can optimize patients’ conditions prior to surgery or indicate that surgery could cause more harm than benefit.

A preoperative anesthesia consultation is a formal consult with an anesthesiologist either days or weeks before surgery, typically in an outpatient setting. The consultation involves documenting any comorbidities, ordering diagnostic tests if needed, optimizing pre-existing medical conditions, discussing perioperative care and anesthesia, and deferring surgery if necessary. Preoperative optimization may also include medication adjustments, fluid management, and other interventions to enhance the patient’s readiness for surgery. Thus, during these consultations, important risk factors can be identified which allows anesthesiologists to tailor anesthetic plans to the specific needs of the patient. To help with risk evaluation, there are scales and risk calculators in place such as the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator [6]. Overall, studies have shown that preoperative consultations are associated with reduced patient anxiety, same-day surgery cancelations, duration of hospitalization and hospital costs [3].

Especially with the introduction of novel surgical procedures, perioperative care requires close collaboration between anesthesiologists, surgeons, and other healthcare professionals to create a unified care plan. For example, minimally invasive surgery has widened the indications for surgery in many high-risk patients, including the elderly and those with severe medical comorbidities [4]. While the invasiveness of surgery may be minimal, the impact of anesthesia on the body may be more extensive [5]. Thus, it is important in preoperative consultations and workup for the surgeon and anesthesiologist to weigh the risks and benefits from both surgery and anesthesia for high-risk patients. One study proposed the use of “high-risk conferences” to optimize multidisciplinary communication between patients, family members, physicians, nurses, and medical social workers to determine optimal treatment course and treatment outcomes [4]. These high-risk conferences demonstrated success in tailoring surgical plans to optimize outcomes and suggested the importance of institution-based systems for preoperative consultations and multidisciplinary communication.

Overall, anesthesia consultations for high-risk surgical patients are a vital aspect of perioperative care. By emphasizing the significance of risk assessment, multidisciplinary collaboration, and tailored anesthetic plans, healthcare professionals can enhance the safety and success of surgical interventions in this patient population, while navigating the evolving surgical field.

References

1. Hamilton, Mark A. MRCP, FRCA; Cecconi, Maurizio MD; Rhodes, Andrew FRCP, FRCA. A Systematic Review and Meta-Analysis on the Use of Preemptive Hemodynamic Intervention to Improve Postoperative Outcomes in Moderate and High-Risk Surgical Patients. Anesthesia & Analgesia 112(6):p 1392-1402, June 2011.

2. A. R. J. Girbes, “The high-risk surgical patient and the role of preoperative management,” The Netherlands Journal of Medicine, vol. 57, no. 3, pp. 98-105, 2000/09/01.

3. Wijeysundera DN, Austin PC, Beattie WS, Hux JE, Laupacis A. A Population-Based Study of Anesthesia Consultation Before Major Noncardiac Surgery. Arch Intern Med. 2009;169(6):595–602.

4. Koike, M., Yoshimura, M., Mio, Y. et al. The effects of a preoperative multidisciplinary conference on outcomes for high-risk patients with challenging surgical treatment options: a retrospective study. BMC Anesthesiol 21, 39 (2021).

5. Henny CP, Hofland J. Laparoscopic surgery: pitfalls due to anesthesia, positioning, and pneumoperitoneum. Surg Endosc. 2005;19:1163–71.

6. American College of Surgeons National Surgical Quality Improvement Program. ACS NSQIP Surgical Risk Calculator. https://riskcalculator.facs.org/RiskCalculator/.