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 Evaluation
Anesthesiologists 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 Medicine
As 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 Room
As 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 Medicine
Because 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.
Ambulatory and Office-Based Anesthesia
The number of operations performed in ambulatory surgical centers and doctors’ offices continues to rise. Many of the patients being treated in these facilities are from an increasingly elderly population with more complex medical problems. Patients deserve the same high standard of care in these facilities that they receive in the hospital setting. Anesthesiologists are working with federal and state legislators and agencies and collaborating with other physicians and accrediting bodies to establish safety standards for such facilities.
Operating Room Management
In addition to providing patient care, the anesthesiologist is often responsible for managing the resources of the operating suite, including the efficient use of operating rooms, supplies, equipment and personnel. Unlike most surgeons, who spend much of their time seeing patients in private offices, anesthesiologists work in the operating suite every day. Their continuous presence, along with their wide-based appreciation for the needs of surgeons and other physicians who perform procedures requiring anesthesia, uniquely qualifies anesthesiologists for leadership positions in operating room administration and management.
Basic Science and Clinical Research
Some of the most significant strides in medicine and surgery have been directly attributable to anesthesiology’s advances in patient monitoring, improved anesthetic agents and new drug therapy. Anesthesia research at the clinical and basic science levels has been completed almost exclusively by anesthesiologists or Ph.D. scientists with the goal of continually improving patient care and safety. Research is conducted in each of the subspecialties of pediatric, geriatric, obstetric, critical care, cardiovascular, neurosurgical and ambulatory anesthesia. Other areas of active study include blood transfusions and fluid therapy, infection control, difficult airway management, cardiopulmonary resuscitation, complications, new devices and methods of monitoring, pharmacology, patient safety, pain therapy and organ transplantation.
Education and Training
The education of today’s anesthesiologists has kept pace with their expanding role in offering the highest quality health care available anywhere in the world. After completing a four-year college program and four years of medical school, they enter a four-year anesthesiology residency training program. Fellowships in an anesthesia subspecialty, education or research also may be taken for an additional year. Almost 90 percent of the active members of the American Society of Anesthesiologists have been certified as diplomates of the American Board of Anesthesiology.
Educational and Legislative Activities
Through their national professional organization, the American Society of Anesthesiologists (ASA), anesthesiologists participate in many continuing medical education programs, legislative activities and public education. These include:
• The world’s largest international educational program for anesthesiologists — the five-day ASA Annual Meeting with an average attendance of more than 18,000.
• Comprehensive refresher courses for continuing medical education during the ASA Annual Meeting and regional courses and workshops throughout the year.
• Education and training in applications of new knowledge in the areas of patient safety, standards of care, practice guidelines and quality improvement.
• Web-based continuing education programs.
• Practice management seminars and publications for anesthesia practitioners and groups.
• Legislative and regulatory activities at the state and national levels through the ASA Washington Office.
• Public education programs, events and materials about the current and emerging technologies in anesthesiology that help patients to make educated choices about their anesthesia or pain management care.
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