Care of the Surgical Patient
The anesthesiologist is the perioperative physician (“peri-” meaning “all-around”) who provides medical care to each patient throughout his or her surgical experience. This includes medically evaluating the patient before surgery (preoperative), consulting with the surgical team, providing pain control and supporting life functions during surgery (intraoperative), supervising care after surgery (postoperative) and medically discharging the patient from the recovery unit.
Preoperative EvaluationAnesthesiologists play a vital role in assessing a patient’s medical readiness for surgery. They are unique in their advanced knowledge of both the medical illnesses that a patient undergoing surgery may suffer, as well as the effects on the body of the specific operation to be performed. The anesthesiologist’s preoperative evaluation may be very brief (such as in the case of a surgical emergency) or very prolonged (such as in the case of a patient with multiple chronic medical problems who is to undergo an extensive operation). In all cases, however, the anesthesiologist performs a focused history and physical examination, reviews available laboratory and special test results, and assesses the need for additional testing prior to proceeding with surgery.
Intraoperative Care
It is estimated that nearly 40 million anesthetics are administered each year in this country. Anesthesiologists provide or participate in more than 90 percent of these anesthetics. In the operating room, they are responsible for the medical management and anesthetic care of the patient throughout the duration of the surgery. The anesthesiologist must carefully match the anesthetic needs of each patient to that patient’s medical condition, responses to anesthesia and the requirements of the surgery. In many surgical settings, anesthesiologists work in the “anesthesia care team” mode, medically supervising the work of nonphysician anesthetists such as nurse anesthetists and anesthesiologist assistants, who, though not physicians, have been trained in the technical administration of anesthetics. Anesthesiologists have important functions outside of operating room suites, such as evaluating patients prior to surgery or conducting postoperative visits. However, the majority of their activities, which are performed inside the operating room, are seen by few people outside of the surgical and nursing team. Even the patients themselves are often unable to remember much of their involvement with this vital specialist because much of the anesthesiologist’s critical work may be done while the patient is anesthetized! The role of the anesthesiologist in the operating room is to: 1) provide continual medical assessment of the patient; 2) monitor and control the patient’s vital life functions, including heart rate and rhythm, breathing, blood pressure, body temperature and body fluid balance; and 3) control the patient’s pain and level of consciousness to make conditions ideal for a safe and successful surgery.
The Postanesthesia Care Unit (PACU) or “Recovery Room”After surgery, patients are transferred to the Postanesthesia Care Unit, where they continue to emerge from the effects of anesthesia under the watchful eyes of the peri-anesthesia nurse with anesthesiologist consultation immediately available. Evidence of recovery – including activity level, adequacy of breathing, circulation, level of consciousness and oxygen saturation – is continuously monitored. Pain control is optimized. In most cases, the anesthesiologist decides when the patient has recovered enough to be sent home following outpatient surgery or has been stabilized sufficiently to be moved to a regular room in the medical facility or transferred to an intensive care unit.
Critical Care and Trauma MedicineAs an outgrowth of the PACU, critical care units are now found in all major medical facilities throughout the country. Because of their extensive training in clinical physiology/pharmacology and resuscitation, anesthesiologists are uniquely qualified to coordinate the care of patients in the intensive care unit. Some anesthesiologists pursue advanced fellowship training to subspecialize in critical care medicine in both adult and pediatric hospitals. In the intensive care unit, they direct the complete medical care for the sickest patients. The role of the anesthesiologist in this setting includes the provision of medical assessment and diagnosis, respiratory and cardiovascular support and infection control. Anesthesiologists also possess the medical knowledge and technical expertise to deal with many emergency and trauma situations. They provide airway management, cardiac and pulmonary resuscitation, advanced life support and pain control. As consultants, they play an active role in stabilizing and preparing the patient for emergency surgery.
Anesthesia Outside the Operating RoomAs medical technology has advanced, so has the need for anesthesiologists to become involved in caring for patients during uncomfortable or prolonged procedures in locations remote from the confines of the traditional operating suite. These procedures frequently include radiological imaging, gastrointestinal endoscopy, placement and testing of cardiac pacemakers and defibrillators, lithotripsy and electroconvulsive therapy. In most institutions, anesthesiologists are available during cardiac catheterizations and angioplasty procedures should emergency airway management or resuscitation become necessary. It would be impossible to perform many of these tests on infants and young children without the use of anesthesia or various sedation techniques provided by an anesthesiologist.
Pain MedicineBecause of their specialty training and vast experience in controlling pain during surgery, anesthesiologists are uniquely qualified to prescribe and administer drug therapies or perform special techniques for acute, chronic and cancer pain.
Acute Pain Management
In addition to relief of patients’ pain during a surgical procedure, it is equally important for the patient’s comfort and well-being to receive adequate pain relief postoperatively. Anesthesiologists are responsible for ensuring that a patient’s pain is under control before they are discharged from the PACU. An anesthesiologist may prescribe specific pain medications or perform specialized procedures to maximize patient comfort, which helps to minimize stress on the patient’s heart and blood pressure. The techniques that are best suited for each individual patient are chosen to allow for proper rest and healing.
Chronic and Cancer Pain Management Anesthesiologists are the vanguard of those who are developing new therapies for chronic pain syndromes and cancer-related pain. Anesthesiologists who specialize in the treatment of chronic pain often dedicate their practices exclusively to a multidisciplinary approach to pain medicine, working collaboratively with other medical specialists in a pain clinic.
Obstetric Anesthesia
It has become very common for anesthesiologists to provide expectant mothers with pain relief during labor and delivery. While many mothers choose to use natural childbirth techniques, the demand for epidural anesthesia for labor and delivery has increased dramatically over the last several years due to the proven safety and benefits of this resource. During childbirth, the anesthesiologist manages the care of two patients, providing effective pain relief for the mother while maintaining a high degree of safety for her unborn infant. In most cases, this involves administration of local anesthetics and/or narcotics via spinal or epidural routes. In the event of an emergency cesarean section, the anesthesiologist provides surgical anesthesia while managing the life functions of both the mother and the baby.
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