Anesthesiologist Intensivists and Evaluating High-risk Surgical Patients
Perioperative management of high-risk surgical patients poses many challenges. Patients may be deemed high risk based on poor baseline functional status, severe or uncontrolled co-morbidities, poor scores on risk and frailty calculators, invasiveness of the planned procedure and other qualitative and quantitative data. High-risk surgical patients may be more susceptible to complications and prolonged recovery. The scheduled surgery may be a suboptimal choice even in the setting of a “typical indication” compared to less invasive or even palliative options, which may not have been presented or considered. The risks of the surgery may outweigh the proposed benefits and may not align with the patient’s values and preferences.
How do we ensure that appropriate, high-quality decision making is being performed on our most vulnerable patients? A shift to a multidisciplinary approach to surgical decision making for high-risk patients scheduled for complex procedures ensures careful deliberation by all the stakeholders and may be the future of medicine. Of course, this transition will require a “culture shift” among our surgical colleagues and additional resources, and it has financial implications. At Roswell Park Comprehensive Cancer Center, our anesthesiologists have developed a model to evaluate high-risk surgical patients before surgery. We call it the High-Risk Committee (HRC), and we recently published our experience with 167 high-risk patients. The HRC offers a concise, multidisciplinary meeting adjacent to the operating suites. Members of the meeting include the surgeon, the director of the anesthesia preoperative clinic, anesthesiologists, an intensivist and medical consultants (i.e., staff cardiologist), as well as palliative care, ethics and risk management. The patient is presented, and alternative treatments, including non-surgical options, are discussed. The patient’s preferences for surgery are considered. Anesthetic and critical care considerations are explored. A consensus opinion of all gathered is reached to determine if the surgery is “risk-prohibitive” or cleared to proceed. Cases that are risk-prohibitive are cancelled or, in some cases, reconsidered if certain goals are met (i.e., improvement after pulmonary rehabilitation). Cases cleared to proceed do so with recommendations from the HRC to the rest of the perioperative team.
Anesthesiologist intensivists are uniquely trained to evaluate and manage high-risk surgical patients throughout the perioperative period, from the preoperative anesthesia consultation through the surgery and to the critical care units, if necessary. As an anesthesiologist intensivist, I can participate in our HRC meeting as a preoperative clinic anesthesiologist, as a consultant anesthesiologist for intraoperative matters and as a critical care specialist for evidence-based postoperative care and monitoring. Our expertise in each step of the perioperative course helps us anticipate complications, risk-stratify our patients and communicate with our colleagues as well as patients to ensure high-quality surgical care is delivered with the best possible outcomes. At the Medical College of Wisconsin, the Preoperative Anesthesia Testing (PAT) clinic and inpatient service is staffed by a combination of internists and anesthesiologists. All high-risk patients are seen by the anesthesiologist. The PAT director and associate director are anesthesia intensivists who we feel are best suited to address alternative options, plan meaningful optimization and help set expectations about the perioperative course for our patients.
Why Anesthesiologist Intensivists Should Be Involved in Preoperative ICU Goals of Care
Recently, Bennett et al. have highlighted the role of the anesthesiologist intensivist, offering leadership and clinical guidance in providing better outcomes for patients. Despite being small in number (less than 5 percent of all certified anesthesiologists), this subspecialty is familiar with not just the clinical aspects of complex surgical procedures, but also the subsequent turbulent recovery period in the ICU for such high-risk patients. It becomes important for patients, families and surgeons to involve intensivists in the goals of care discussions, which should precede operations involving high-risk and requiring postoperative ICU care. Such discussions should be led by the intensivists who, by the nature of their training and experience, would know the complexities of the kind of support needed by the particular patient. This patient-centered and personalized guidance is important and vital when informed choices are to be made by the patient and their surrogates. Expert knowledge on ECMO, ventilation, vasopressors, ultrasound, echo, dialysis, invasive central lines, antibiotics, etc., would be of use when deciding care boundaries for patients with a high chance of mortality and morbidity.
There is no one better than an ICU anesthesiologist for expertise in the ethical dilemmas encountered in the daily practice of critical care, and the tensions and conflicts that may arise from such care. Discussions on limiting life-supportive therapy are frequently required in the ICU, but these are often done too late and conducted by surgeons who may not have explained the anticipated risks to the patients and families before the surgery – and, therefore, the autonomous preferences of these patients may not be known. It seems logical to have the anesthesiologist intensivist involved in preoperative goals of care discussions with select high-risk patients and their families and surgeons where protracted ICU care would be anticipated. In an increasingly technology-driven and expensive ICU landscape, it seems remiss not to involve the important stakeholders who will be in the lead when such care and discussions are to be implemented, and when such important decisions are to be made further downstream. In addition to reduction in cancellation, cost savings and patient outcomes data, there is also the relief we give to our colleagues and patients. Anesthesiologists know that high-risk patients who have been evaluated by the perioperative care team have accurately and thoughtfully weighed the risks and benefits of alternatives. This allows the day-of-surgery discussions to focus more on reassurance, rather than ringing alarm bells, which has its own benefit.
A shift to a multidisciplinary approach to surgical decision making for high-risk patients scheduled for complex procedures ensures careful deliberation by all the stakeholders and may be the future of medicine.