Stanford Plavin MD is a board-certified anesthesiologist with Oral Surgery Anesthesia Associates in Atlanta, GA and Founder of Technical Anesthesia Strategies and Solutions. In this article Dr. Stanford Plavin explains how many anesthesiologists approach risk stratification during the patient selection and treatment process.
In the USA, annually, it is estimated that more than 20 million patients will receive general anesthesia. An anesthetic is a vital component of care allowing them to safely receive treatments and procedures vital to their overall health. This includes everything from dental work to heart surgery and everything in between.
Without anesthesia, perform these surgeries and procedures would be impossible. Without an appropriate risk assessment and anesthetic plan; Stanford Plavin explains that the most appropriate and safest anesthetic care would likely be impossible.
There are many types of anesthetics, including intravenous sedation, peripheral nerve blocks, epidurals,spinals, as well as general anesthetics requiring the use of volatile gas agents (Inhalational) Each patient requires an individualized assessment prior to their anesthetic as well as those incorporating many standardized components of care; I term the concept; “Standardization with Individualization” ®
Stanford Plavin notes that prior to patient engagement and delivery of care; exacting an appropriate clinical history is critical to overall anesthesia risk assessment and is one of the most important components of a responsible presurgical work-up.
What is Risk Assessment for Anesthesia?
Dr. Stanford Plavin reports that pinpointing the right type of medical procedure that’s medically necessary is one of the most important decisions that can be made between you and your operating physician. When an anesthetic is requested and is required, physician anesthesiologists are a key part of most peri-procedural medical decisions, especially during the provision of the anesthesia.
Prior to a surgical/medical procedure beginning, a risk assessment is undertaken; not only by the surgeon but also the anesthesia provider. This helps identify patients who may have a higher risk of perioperative morbidity or mortality. This can include assessment complications as it relates to an anesthetic as well as the surgical procedure.
Some tools rely on risk scores and models showcasing risk prediction says Stanford Plavin MD, but both are determined by analyzing the various risk factors related to a medical goal or needed outcome.
Scores are determined by looking at a wide variety of factors specific to a patient and the procedure that they are undergoing. Some factors are given more weight than others, like how a small quiz may be worth 10% of an overall grade in school, while a final exam may be worth 50%.
Stanford Plavin notes that risk prediction models generally estimate an overall risk probability for individual patients by including a patient’s unique data using multiple variables.
Evaluating Patient Risk
Several factors may make anesthesia riskier for certain patients. These include those who currently have complex medical conditions or who have them prior. Some of these current conditions may include heart disease, prior heart attack, high blood pressure, diabetes, vascular disease and those patients who have adverse reactions to anesthesia in the past. Some of these could include neurological issues such as strokes or seizures.
Patients that present with chronic kidney problems, obstructive sleep apnea, obesity, as well as certain lung conditions are at a higher risk for anesthesia complications as it relates to their surgical procedure.
A patient’s surgical and anesthetic risk has also shown to be increased if they average drinking more than two alcoholic beverages daily. Smoking is an independent risk factor as well.
A common risk score assessment is the physical status score devised by the American Society of Anesthesiology. The ASA-PS was created in 1941 to provide a metric to guide physicians as to whether a patient is healthy enough to undergo surgery and anesthesia safely.
Stanford Plavin explains that body-mass index, alcohol use, and smoking were integrated into the assessment score in 2014. The ASA physical status system is considered a good indicator of risk both during anesthesia procedures as well as postoperatively. It’s use offers mortality-risk percentages tied to certain clinical care and overall morbidity and mortality.
This classification system divides risks into scales ranging from I to VI. A healthy, normal patient is assigned an ASA I. As an example: an ASA II (mild systemic disease) represents a patient who may be obese, pregnant, may have mild lung disease, controlled diabetes, controlled high blood pressure, a smoker or socially consumes alcohol.
Stanford Plavin says the ASA III patient can and does include such conditions as end-stage kidney disease, morbid obesity, chronic alcohol dependence as well as patients who have more complex medical problems that present a more constant daily threat to their overall well-being.
An ASA IV patient is one that has medical problems that pose a constant threat to their life. These include patients who chronic medical problems such as Congestive Heart failure and Uncontrolled diabetes.
As the physical status increases, the patient conditions worsen as well. An ASA V: is a patient who is critically ill and is unlikely to survive without surgical intervention; and an ASA VI; is a patient who has been declared brain dead and can donate their organs.
Stanford Plavin on Adapting Anesthesia for At-Risk Patients
Dr. Stanford Plavin states that just as there are numerous factors which we utilize to calculate risk assessment for anesthesia, anesthesiologists may also take many different approaches to treating these patients who present with elevated risk of complications.
While several procedures require general anesthesia, there may be basic alternatives (like a spinal or local anesthetics). There are several different options available to safely manage a patient’s anesthetic care. If there is a family history of adverse reactions to anesthesia, a doctor may be more inclined to find an alternative.
Talking with an anesthesiologist about your family history, as well as detailing past medical problems and/or current medications being used, Stanford Plavin says; will enable the anesthesia provider to create a detailed and carefully crafted anesthesia plan.
An anesthetic is usually comprised of analgesia (pain relief) and many times; amnesia (Lack of recall). Throughout a surgery, a physician anesthesiologist will closely monitor how these being controlled focusing on all the bodily functions. The goal of anesthetic is to maintain the patient’s vital signs as close to normal while offsetting the pain and bodily changes associated with surgery. Having a solid foundation and understanding of at-risk patients and adapting the anesthetic plan is paramount to a successful outcome. This is especially true of the medically complex patient.
The work of the anesthesiologist doesn’t just stop once the surgical procedure has ended. According to Dr. Stanford Plavin, anesthesiologists are responsible for managing the care of the patients along with the postsurgical nursing team. We continue monitor a patient’s oxygen level, blood circulation, and breathing, level of pain control and overall well-being. As always, we answer any concerns and questions.
Many times, it’s the anesthesiologist who often gives the discharge order for a patient be able to head home with their loved one. There are occasions when patients do remain in the hospital and spend time convalescing as well. This is where an understanding of all things related to patient care provides the anesthesiologist the information needed to provide the best care not only for their patients but also for their loved ones piece of mind.