Anesthesia Considerations

for the Hospitalist

Lisa W. Vercollone, MD, PharmDa,*, Anthony Dela-Cruz, MDb, Trefan Archibald, MD
a
,
Rachel E. Thompson, MD, MPHc, David M. Rothenberg, MD, FCCMb

KEYWORDS
 Surgery  Perioperative  Anesthesia  Anesthesiologist  Hospitalist

HOSPITAL MEDICINE CLINICS CHECKLIST

1. The major classes of medications used during a surgical procedure to provide

anesthesia include anesthetics, analgesics, anxiolytics, and paralytics.
2. The 4 main stages of perioperative anesthesia care are preprocedural assess-
ment, induction, maintenance, and emergence.
3. The 4 levels of anesthesia depth as described by the American Society of
Anesthesiology are minimal sedation, conscious sedation, deep sedation,
and general anesthesia. They are defined by the patient’s level of responsive-
ness and need for ventilatory and hemodynamic support.
4. Regional anesthesia can provide analgesia and various degrees of motor
blockade to targeted regions of the body and is used when more directed
analgesia and anesthesia are desired.
5. Hospitalists should be aware of the potential adverse effects associated with
administering anesthesia, which include, but are not limited to, postoperative
nausea and vomiting, gastrointestinal dysfunction, delirium, cognitive decline,
and fever.
6. Mortalities, largely attributed to postoperative complications, have drastically
decreased since the creation of the field of anesthesia.
7. Hospitalists are well suited to aid in assessment and optimization of chronic
medical conditions by performing preoperative risk assessments, evaluation
of active signs or symptoms of medical disease or illness, assisting in opti-
mizing underlying medical disease, implementing risk reduction strategies,
and responding promptly to unavoidable medical complications.

CONTINUED

Disclosure: The authors have nothing to disclose.

a
Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA 98104, USA;
b
Department of Anesthesia, Rush University, 1653 West Congress Parkway, Jelke 7, Chicago, IL
60612, USA; c Division of General Internal Medicine, 986435 Nebraska Medical Center, Omaha,
NE 68198-6435, USA
* Corresponding author.
E-mail address: lisawv@uw.edu

Hosp Med Clin 5 (2016) 281–302

http://dx.doi.org/10.1016/j.ehmc.2015.11.010
2211-5943/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
282 Vercollone et al

CONTINUED
8. The perioperative surgical home is a model of delivering health care designed
to provide continuity and standardization to the perioperative period to make
sure that each patient receives optimal care.
9. The differences in training, expertise, knowledge, and areas of focus between
an anesthesiologist and a hospitalist allow for their collaboration to result in
synergistic care of perioperative patients.
10. Some of the major outcomes that improvement initiatives should monitor are
death, intraoperative and postoperative complications, patient satisfaction,
pain management, and readmission rates.

ANESTHESIA PRIMER

Regardless of the depth of anesthesia planned, the goal for a successful anesthetic in-
cludes the prescription of analgesia and sedation to accomplish adequate surgical
conditions while maintaining hemodynamic stability. The understanding of the cumu-
lative effect of anesthetic drugs, the impact of the planned procedure, and the patients’
current state of health all determine the anesthetic plan. The anesthesia sequence
often follows preprocedural assessment, induction, maintenance of anesthesia, and
emergence.

What medications help accomplish successful anesthesia?

Common anesthetic medications are categorized by their ability to accomplish the
goal of successful anesthesia, including providing any part or all of analgesia, anxiol-
ysis, sedation, and muscle relaxation.
Anesthetic Drugs
Anesthetic medications elicit their effects by inducing a reversible loss of sensation.
There are 2 major categories within this large group of medications: general and local.
General anesthetics are further divided into subcategories: inhaled volatile gases and
intravenous medications. They are used for both induction and maintenance of gen-
eral anesthesia by causing loss of consciousness in addition to loss of sensation.
In contrast, local anesthetics are commonly used to provide tissue and regional
anesthesia without causing loss of consciousness. Local anesthetics are limited by
their variable dose-dependent neural and cardiac toxicities. Tissue infiltration limits
the utility of local anesthetics to small and superficial areas of soft tissue. Local anes-
thetic injection is not useful in solid organs or surgeries covering a large area. Total
dose of local anesthetics are determined by each medication’s toxicity profile as
well as the absorption rate at the area being injected. Peripheral nerve blocks and neu-
raxial blocks using local anesthetics expand areas to be anesthetized to include entire
limbs or, in the case of neuraxial anesthesia, complete dermatomes with smaller
amounts of local anesthetic required. Although local anesthetics can provide
adequate analgesia in a surgical area, intravenous sedatives are commonly used in
conjunction in order to achieve anxiolysis, sedation, and amnesia.
Analgesics
Analgesics are medications that are different from anesthetics in that they do not
cause a loss of sensation but instead interfere with peripheral and central pain
 Anesthesia Considerations 283

pathways to decrease the perception of pain. It is also important to keep in mind that
these medications do not cause the amnesia component of sedation. Opioids are an
obvious choice for analgesia and thus are the most commonly used analgesics intra-
operatively. Opioids elicit their effects by selective agonism of the mu receptors found
primarily in the central nervous system. These medications have the potential for
serious adverse effects, such as respiratory depression and muscle rigidity, and there-
fore must be used judiciously. Opioid-associated muscle rigidity is normally seen dur-
ing the induction stage of anesthesia, caused by large, rapid bolus doses resulting in
high peak brain concentrations, and may require emergent use of neuromuscular
blockade in order to maintain adequate ventilation and oxygenation.1

Anxiolytics/Sedatives
Providing anxiolysis and/or deeper sedation for a procedure is almost always included
in the anesthetic plan. Common modern anxiolytics/sedatives include midazolam,
propofol, ketamine, and dexmedetomidine. Although midazolam and propofol are
excellent sedatives, they lack the ability to provide analgesia. Ketamine and dexmede-
tomidine have analgesic properties, but are seldom able to be used as a sole sedative
agent because of side effects and lack of amnestic properties, respectively.

Neuromuscular Blockers
Neuromuscular blockers block neurotransmission at the level of the neuromuscular
junction to cause muscle relaxation. They are useful in facilitating the placement of
an airway device in preparation for surgery or preventing spontaneous respirations
during surgery, and result in skeletal muscle relaxation. Neuromuscular blockers are
subdivided into depolarizing and nondepolarizing agents; both target the acetylcho-
line receptor on the motor endplates of striated muscle.
Depolarizing agents produce paralysis by binding to and persistently depolarizing
the acetylcholine receptor. Succinylcholine is the only currently available depolarizing
agent. It has the fastest onset as well as the shortest duration of action of all the par-
alytics. The most concerning, albeit rare, sequelae associated with succinylcholine are
malignant hyperthermia, in genetically susceptible individuals, and acute hyperkale-
mia. Risk factors for acute hyperkalemia include electrolyte abnormalities, digitalis
toxicity, chronic abdominal infection, subarachnoid hemorrhage, and central and pe-
ripheral nervous system degeneration.2
Nondepolarizing agents provide competitive antagonism of acetylcholine at the nico-
tinic receptor, resulting in muscle relaxation. They are further divided into subclasses:
aminosteroids and benzylisoquinoliniums. The pharmacokinetics of the aminosteroids
are influenced by renal and hepatic impairment. In contrast, the benzylisoquinoliniums
are metabolized by a process called Hoffman elimination, which is a spontaneous
degradation process that occurs in plasma and tissue and is independent of hepatic
or renal function, making it often the preferable option for patients with hepatic or renal
dysfunction (Table 1).

What are the stages of perioperative anesthesia care?

Anesthesiologists describe 4 stages of perioperative anesthesia care. Stage 1, the pre-

procedural assessment, can occur minutes to weeks before surgery depending on the
timeliness of the procedure (ie, elective, urgent, or emergent). An anesthesiologist tradi-
tionally performs the preprocedural assessment. However, there is increasing collabo-
ration of hospitalists with the anesthesia team in this role. The other 3 components
284 Vercollone et al

Table 1
Common medications used in anesthesia

Class Medications
Anesthetics
General Inhaled Hydrocarbons Halothane
— Ethers Isoflurane, sevoflurane, desflurane
— Other Nitric oxide, xenon
IV Barbiturates Thiopental, methohexital
— Benzodiazepines Midazolam
— Nonbenzodiazepines Etomidate
— — Ketamine
— — Propofol
Local — Ester Tetracaine, benzocaine, procaine,
chloroprocaine
— Amide Lidocaine, ropivacaine, prilocaine,
mepivacaine, bupivacaine
Analgesics — Opioids Morphine, hydromorphone,
remifentanil, sufentanil, fentanyl,
meperidine
— NSAIDs Ketorolac, ibuprofen
Sedatives — Benzodiazepines Midazolam
— Nonbenzodiazepines Propofol
— — Ketamine
— — Dexmedetomidine
NMB agents Depolarizing — Succinylcholine
Nondepolarizing Aminosteroids Vecuronium, rocuronium,
pancuronium, mivacurium
— Benzylisoquinoliniums Cisatracurium, atracurium,
doxacurium

Abbreviations: IV, intravenous; NMB, neuromuscular blocking; NSAIDs, nonsteroidal antiinflamma-

tory drugs.

(induction, maintenance of anesthesia, and emergence) are roles reserved for the anes-
thesiologist (Fig. 1).

Preprocedural Assessment
Patients can be evaluated in an outpatient clinic setting or in a preoperative unit
depending on what the situation permits. A focused history and physical is performed
with special attention given to the patient’s airway anatomy and cardiac and pulmo-
nary risk factors. The patient’s American Society of Anesthesiologists (ASA) class is
identified during this stage, which is a classification system used by anesthesiologists
to determine a patient’s preoperative health (Table 2). Final preparations, evaluations,

Fig. 1. Stages of anesthesia.

 Anesthesia Considerations 285

Table 2
ASA physical status classification

ASA Class Definition Examples

I A normal healthy patient Healthy, nonsmoking, no or minimal alcohol use
II A patient with mild Mild diseases only without substantive functional
systemic disease limitations. Examples include (but are not limited to)
current smoker, social alcohol drinker, pregnancy,
obesity (30<BMI<40), well-controlled DM/HTN, mild
lung disease
III A patient with severe Substantive functional limitations; 1 or more moderate
systemic disease to severe diseases. Examples include (but are not
limited to) poorly controlled DM or HTN, COPD,
morbid obesity (BMI 40), active hepatitis, alcohol
dependence or abuse, implanted pacemaker,
moderate reduction of ejection fraction, ESRD
undergoing regularly scheduled dialysis, premature
infant PCA <60 wk, history (>3 mo) of MI, CVA, TIA, or
CAD/stents
IV A patient with severe Examples include (but are not limited to) recent (<3 mo)
systemic disease that MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia
is a constant threat or severe valve dysfunction, severe reduction of
to life ejection fraction, sepsis, DIC, ARD, or ESRD not
undergoing regularly scheduled dialysis
V A moribund patient who Examples include (but are not limited to) ruptured
is not expected to abdominal/thoracic aneurysm, massive trauma,
survive without the intracranial bleed with mass effect, ischemic bowel if
operation there is significant cardiac disorder or multiple organ/
system dysfunction

Abbreviations: ARD, acute respiratory distress; BMI, body mass index; CAD, coronary artery disease;
COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident; DIC, disseminated
intravascular coagulation; DM, diabetes mellitus; ESRD, end-stage renal disease; HTN, hyperten-
sion; MI, myocardial infarction; PCA, post-conceptual age; TIA, transient ischemic attack.
From ASA Physical Status Classification System. 2014. Available at: https://www.asahq.org/
resources/clinical-information/asa-physical-status-classification-system. Accessed September 22,
2015.

and laboratory studies may be conducted. Although less invasive anesthetics, such as
regional or monitored anesthesia care (MAC), may be planned, preparations are often
made to escalate to a general anesthetic if the patient cannot tolerate the planned
anesthetic intraoperatively. Therefore, anesthesia risks and benefits are discussed
and informed consent is obtained when possible before medicating patients. Immedi-
ately before proceeding to the operating room, patients often receive small amounts of
a sedative to aid in anxiolysis and comfort.

Induction
The ASA minimum standards of monitoring include blood oxygenation via pulse oxim-
etry, ventilation via capnography, continuous electrocardiogram, body temperature,
as well as heart rate and blood pressure evaluation every 5 minutes. These monitors
are used throughout the administration of anesthesia until discharge from the posta-
nesthesia care unit.3 Whether the anesthetic plan is sedation or general anesthesia,
patients go through a period of induction from a conscious state to the onset of anes-
thesia. At this stage, a sedative dose or combination of sedatives strong enough to
bring the patient to an unconscious state are administered. Either intravenous or
286 Vercollone et al

inhaled anesthetics can be used for induction, with propofol being the most commonly
used. Reportedly, patients prefer the use of intravenous medications because of com-
plaints of claustrophobia provoked by having to wear a mask for inhaled medications.4
Adjunct medications may be used to facilitate induction, such as opioids or muscle
paralytics. Induction poses a risk of hemodynamic instability as a result of medication
side effects, which include vasodilatation and myocardial suppression. Increment bo-
luses of vasoconstrictors and sympathomimetics such as phenylephrine and ephed-
rine may be given to counteract this phenomenon. However, the stimulation from a
direct laryngoscopy and intubation is often enough to induce hypertension and tachy-
cardia. Given the variable stressors, preventing large hemodynamic fluctuations dur-
ing induction requires experience and a solid understanding of anesthesia.

Maintenance of Anesthesia
Anesthesia maintenance techniques are extremely variable and tailored to the specific
needs of the patient and procedure. The type and/or depth of anesthesia influence the
medications used for maintenance. It is more common to use an inhaled anesthetic
than an intravenous anesthetic because of better control of the depth of anesthesia,
reduction of medication accumulation, and lower cost. The ASA developed guidelines
for sedation and published definitions for the depth of anesthesia as a continuum from
sedation to general anesthesia (Table 3). Each stage in the continuum is characterized
by the patient’s level of responsiveness, anticipated or present hemodynamic
changes, and the likelihood of airway intervention being needed.4 The deeper stages
of MAC and general anesthesia are discussed later.

Emergence
Emergence from general anesthesia poses another risk for hemodynamic instability
and respiratory failure. During emergence, patients may begin to move to stimulation,
but still not be able to maintain adequate airway reflexes for tracheal extubation.
Neuromuscular blockade reversal with acetylcholinesterase inhibitors, such as
neostigmine (in combination with a drug to prevent the muscarinic side effects), is usu-
ally administered but the complete reversal of their effects may be difficult to deter-
mine. The intraoperative use of neuromuscular blocking agents and having an ASA
class of III or higher are independent risk factors for reintubation in the postanesthesia
care unit.5 The emergence stage requires close monitoring by both the anesthesia
team and specialized nurses trained in caring for postanesthesia and critically ill
patients.

Table 3
ASA continuum from sedation to general anesthesia

Conscious Deep Sedation General

Minimal Sedation Sedation (MAC) Anesthesia
Responsiveness Normal response Normal response Purposeful Unarousable to
to verbal stimuli to tactile stimuli response to painful stimuli
painful stimuli
Airway, No intervention No intervention Intervention by Induction by
ventilatory, needed needed anesthesia anesthesia
hemodynamic provider likely provider
management

Data from Rujirojindakul P, Geater AF, McNeil EB, et al. Risk factors for reintubation in the post-
anesthetic care unit. Br J of Anesth 2012;109(4):636–42.
 Anesthesia Considerations 287

What are the differences between the different depths of anesthesia?

The ASA defines 4 levels of depth of anesthesia (see Table 3). Deep sedation and gen-
eral anesthesia are reviewed in more detail later.

Monitored Anesthesia Care

During MAC, patients are unconscious but are able to maintain spontaneous ventilation
without the need for invasive mechanical support. MAC is one type of deep sedation/
analgesia as defined in the ASA sedation guidelines. Sedative boluses of benzodiaze-
pines or continuous infusions of propofol are common. Other sedatives may be used,
such as ketamine or dexmedetomidine, depending on the specific needs of the patient
and procedure. Although patients maintain spontaneous ventilation, interventions by
the anesthesiologist to relieve airway obstruction and treat hemodynamics are com-
mon. Adjunct anesthesia strategies, such as local and regional anesthesia, are used
to provide the analgesic component during MAC. Cataract surgery is often performed
under MAC while the ophthalmologist uses topical analgesics. These patients often
receive small doses of midazolam or in some cases low-dose infusions of propofol.

General Anesthesia
General anesthesia involves continuous ventilatory support and almost always in-
volves placement of an airway device. Airway devices allow the use of positive pres-
sure ventilation and reliable delivery of volatile anesthetic gas through the breathing
circuit. Neuromuscular blockade during tracheal intubation can be used to facilitate
successful placement. A balance of sedatives and analgesics with or without volatile
anesthetic gases can be adequate to prevent patient movement without the need for
paralytics.

What is regional anesthesia and when might it be the preferred method?

Regional anesthesia can provide analgesia and various degrees of motor blockade to
targeted regions of the body by peripheral nerve blockade or neuraxial blockade. Pe-
ripheral nerve blockade is performed by administering anesthesia to a targeted major
nerve root, whereas neuraxial blockade targets nerves of the central nervous system.
Two common forms of neuraxial anesthesia are spinal (ie, subarachnoid) anesthesia
and epidural anesthesia. For example, regional anesthesia is commonly part of the
approach for a total joint replacement, using an epidural catheter. Anesthetizing
less of the body allows more directed analgesia and anesthesia. The choice to use
regional anesthesia is determined by the body regions in need of anesthesia, the po-
tential for local anesthetic toxicity, as well as the difficulty of the block procedure. In
the setting of regional anesthesia, sedation is often implemented concomitantly, at
times as minimal sedation or even as conscious sedation. One benefit of regional
anesthesia is that in certain situations the catheters can be maintained for hours to
days following a procedure, significantly improving postoperative analgesia.

ACUTE SEQUELAE OF ANESTHESIA

Which acute anesthesia complications should hospitalists be aware of?

Hospitalists should be aware of the potential adverse effects associated with admin-
istering anesthesia. Table 4 describes the most commonly occurring complications by
system and details specific risk factors and prevention strategies.
 288
Table 4
Acute sequelae of anesthesia

System Incidence Definition Pathogenesis Risk Factors Prevention Management Complications

Neurologic
Perioperative 35% of all surgical 2 types: Multifactorial and Advanced age Assess risk before Minimize limb Increased
delirium6–13 patients Emergence: onset not completely Male gender surgery restraints, tubes, long-term
70% of all elderly of delirium in understood Dementia Minimize transfers catheters, and mortality
surgical patients the Combination of Depression Reorientation drains Persistent
perioperative surgical stress, Visual impairment exercises Establish sleep-wake cognitive
period and anesthesia and Intraoperative Avoid dehydration cycle decline
resolves in <24 h medication side hypotension and constipation Antipsychotics: Poor
Postoperative: effects, surgical Postoperative Assess for hypoxia haloperidol, functional
brief period of stress, and hypoxia Monitor for infection olanzapine, and outcomes
postoperative cerebral Opioids Encourage mobility risperidone Increased
lucency abnormalities Uncontrolled pain Address pain length
followed by Review medications of stay
delirium lasting Promote good
1–3 d nutrition
Sleep hygiene
Postoperative 10%–15% after Cognitive Poorly understood Advanced age — Neuropsychological Premature
cognitive major noncardiac deterioration, Proposed to be Low education level examination departure
decline8,9,12 surgery often subtle, caused by History of CVA from or a
>50% of elderly temporally physiologic Major surgery delay in
patients after related to stress–related return to the
cardiac and surgery, lasting perioperative workplace
noncardiac weeks to months period that Increased
surgery exacerbates an mortality
underlying Decreased
preexisting quality
condition of of life
reduced cognitive
reserve
 Perioperative 0.1% noncardiac Ischemic or Intraoperative: Advanced age Perioperative statin Immediate Increased
stroke9,12,14 surgical patients; hemorrhagic cardiac surgery; Female gender and b-blocker neurology consult long-term
increases to 2% CVA that occurs embolic Prior CVA or TIA administration in Neuroimaging mortality
with the presence within the 30- Noncardiac surgery; Other medical patients Supportive care Residual
of 5 risk factors d postoperative embolic and comorbidities: undergoing CABG Consider intra- neurologic
4%–5% of cardiac period with thrombotic atrial fibrillation, (perioperative b- arterial deficits
and carotid almost half of Postoperative: hypertension, blockers may thrombolytic vs Increased
endarterectomy cases occurring emboli and ESRD, cardiac increase risk in mechanical length
surgical patients in first 24 h thrombotic events disease, tobacco noncardiac surgical thrombectomy in of stay
from atrial use patients) nonneurosurgical
fibrillation, acute Antithrombotic patients
MI, or cessation
coagulopathy High-risk surgeries
Gastrointestinal
PONV15–17 Overall 30% of Nausea, vomiting, Signal Female gender Moderate to severe Combination Increased
patients or retching communication of Prior history of risk, consider therapy (2 length
10%–80% within the first noxious stimuli motion sickness prophylaxis with classes): of stay
depending on risk 24–48 h involving the or PONV dexamethasone  Antihistamines Prolonged
factors following brain structures Nonsmoker ondansetron Anticholinergics recovery
surgery distributed Postoperative Consider addition of (scopolamine) time
throughout the opioid treatment an neurokinin-1 5-HT3 antagonists Esophageal
medulla antagonist Dopamine rupture
oblongata of the Avoid inhalation antagonists Wound
brainstem anesthetics. (nitric Phenothiazines dehiscence
involving the oxide, desflurane, Steroids Aspiration
chemoreceptor sevoflurane) (dexamethasone) pneumonitis
trigger zone and Preferred anesthesia: IV crystalloids or pneumonia
nucleus tractus total IV anesthesia,
solitarius propofol

(continued on next page)

289
 290
Table 4
(continued )
System Incidence Definition Pathogenesis Risk Factors Prevention Management Complications
PGID18–21 Up to 100%; varies Uncoordinated A complex interplay Increasing age Minimal access Medications: Increased VTE
widely in the bowel motility between Male gender techniques  Epidural risk
literature after surgery neurogenic, Opioid use Optimize fluid neostigmine Decreased
resulting in inflammatory, Hypoalbuminemia balance  Laxatives mobility
disruption of humoral, fluid and Abdominal or pelvic Epidural preferred  5-HT4 agonists Prolonged
bowel content electrolyte, and surgery rather than  Mu-receptor length
transit or medication Open surgery general antagonists of stay
inability to adverse drug Emergency surgery Minimize opioids Nutrition: Poor patient
tolerate food reactions resulting  Early oral feeding satisfaction
Postsurgery onset: in abdominal  Chewing gum scores
<3–5 d: distention, Avoid routine use of
Expected/normal obstipation, nasogastric tubes
occurrence PONV, and
> 3–5 d; pathologic abdominal
tenderness
Genitourinary
Postoperative 5%–70% of all Urinary retention Neurotransmission Advanced age Avoid medications Bladder Autonomic
urinary surgical patients of 600 mL blockade during Male gender associated with catheterization response
retention22 for >2 h in the spinal anesthesia Concomitant urinary retention: Bladder Infection
postoperative Administration of neurologic  Anticholinergics ultrasonography Bladder
period medications disease  b-Blockers Ensuring overdistention
interfering with Lengthy surgery  Sympathomimetics predischarge void Altered mental
bladder function  Alpha agonists status
(bladder Pain
hypotonia,
increased urethral
resistance)
Metabolic
Postoperative 10%–40% of all Temp of 38 C up Usually an — — Focused evaluation In general
fever23,24 major surgical to 48 h after inflammatory Fevers within first benign
patients procedure response to 72 h in the
surgery caused by absence of focal
circulating signs or symptoms
cytokines in do not require
absence of further evaluation
infection Consider scheduled
acetaminophen
Pulmonary
Postoperative 0.2%–3.4% of the Pulmonary gas Disruption of Advanced age Appropriate Obtain arterial High
respiratory general surgery exchange respiratory muscle Low albumin level perioperative fluid blood gas postoperative
failure25 population impairment function in the Renal insufficiency management Mechanical mortality
resulting in the setting of general History of COPD or Optimize nutrition ventilation Unplanned or
inability to be anesthesia smoking preoperatively prolonged
extubated 48 h resulting in airway Poor functional Smoking cessation mechanical
after surgery closure and status Optimize respiratory ventilation
atelectasis Type of surgery: status in patients Pneumonia
compounded by  Abdominal aortic with comorbid
hypoventilation, aneurysm repair conditions
pulmonary  Thoracotomy
edema, and  Colon resection
bronchospasms  Head and neck

(continued on next page)

291
 292
Table 4
(continued )
System Incidence Definition Pathogenesis Risk Factors Prevention Management Complications
Cardiovascular
Perioperative 4%–35% of all Onset within 2 h of Activation of History of Maintaining Continue home Bleeding
hypertension26–28 surgical patients surgery and may sympathetic hypertension compliance with medications when complications
persist up to nervous system Type of surgery: home possible CVA
24–48 h leading to an  Cardiothoracic antihypertensive Decrease blood MI
Intraoperative: increase in  Vascular medications pressure by no Cardiac
>20% increase afterload  Head and neck before surgery more than 25% in arrhythmia
in blood secondary to  Neurosurgery acute phase with CHF
pressure 5 vasoconstriction goal to return to
hypertensive baseline during
emergency 24–48 h
Postoperative: SBP IV therapy:
190 mm Hg  Nitroprusside
and/or DBP >100  Nitroglycerin
mm Hg on 2  Labetalol
consecutive  Nicardipine
readings
following
surgery
 Arrhythmias29,30 10%–40% after Most often Stress of surgery and Advanced age Avoid electrolyte Chemical or Sudden death
cardiothoracic supraventricular anesthesia results Male gender abnormalities electrical Embolic CVA
surgery tachycardia in an increase in Medical cardioversion Syncope
4%–20% (atrial sympathetic and comorbidities: Treat underlying
noncardiothoracic fibrillation, hormonal activity  CHF cause
surgery PSVT, MAT) and activation of  Valvulopathy
Ventricular are inflammatory  Asthma
rare pathways  SVA
Occurring with the Direct mechanical PAC on preopera-
first 4 d after irritation of tive ECG
surgery pericardium or ASA 3
myocardium Preoperative
during hypokalemia
cardiothoracic
surgery
Intraoperative 5%–99% of all Varies greatly in Iatrogenic: Advanced age — Fluid resuscitation Increased 30-d
hypotension27,31–34 surgical patients the literature  Inadequate intra- Perioperative Blood products and 1-y
depending on Arterial SBP operative fluid antihypertensives Vasopressors mortality
defined <100 mm Hg or a and blood prod- Lengthy duration of Tilting surgical table Perioperative
breakpoints decrease of 30% uct resuscitation general Lightening stroke
less than  Preoperative med- anesthesia anesthesia MI
preoperative ications or anes- Poor functional Acute kidney
SBP baseline thesia resulting in capacity injury
Arterial SBP decreased vascular Decreased plasma Postoperative
<80 mm Hg resistance volume cognitive
Decrease in SBP Cardiogenic shock Uncontrolled dysfunction
of >20% (MI, arrhythmia, hypertension
compared with pulmonary embo- Intra-abdominal or
preoperative lism) vascular surgery
SBP Distributive shock
MAP<55 mm Hg (sepsis, anaphylaxis)

Abbreviations: 5-HT, serotonin; CABG, coronary artery bypass graft; CHF, congestive heart failure; DBP, diastolic blood pressure; ECG, electrocardiography; MAP, mean arterial
pressure; MAT, multifocal atrial tachycardia; PAC, premature atrial contraction; PGID, postoperative gastrointestinal dysfunction; PONV, postoperative nausea and vomiting;
PSVT, paroxysmal supraventricular tachycardia; SBP, systolic blood pressure; SVA, supraventricular arrhythmia; VTE, venous thromboembolism.
Data from Refs.6–34

293
294 Vercollone et al

The common postoperative sequelae likely to be encountered by hospitalists involved

in postoperative care are nausea and vomiting, gastrointestinal dysfunction, delirium,
cognitive impairment, and fever. Although postoperative pain is an extremely important
topic, it is not covered in this article. However, the most common sequelae of anes-
thesia are rarely life threatening: postoperative nausea and vomiting (PONV) and post-
operative gastrointestinal dysfunction. Patients often describe PONV as the most
undesirable complication of surgery, even more so than postoperative pain. Hospital-
ists caring for postoperative patients are also required to be proficient at the diagnosis
and treatment of common neurologic sequelae, namely postoperative delirium and
postoperative cognitive decline. This requirement applies especially in the elderly pop-
ulation, who are much more susceptible to neurologic insult. Postoperative fever is
another common sequela and can occur up to 48 to 72 hours postoperatively. Hospital-
ists should understand that infection is rarely the cause of a postoperative fever and be
able to perform a focused evaluation. This approach not only avoids costly evaluations
but also spares patients from unnecessary and potentially painful procedures.

THE HOSPITALIST AND QUALITY IMPROVEMENT

Are anesthesia complications or surgical complications more deadly?

Given that an estimated two-thirds of inpatient costs are perioperative, perioperative
care has become a main focus of improvement initiatives.35,36 In the Institute of Med-
icine’s report To Err Is Human: Building a Safer Health System, the field of anesthesia
was credited for the drastically decreased mortalities from 2 per 10,000 anesthetic
procedures in the early 1980s to 1 per 200,000 to 300,000 in the developed world
nearing 2000 when the report came out.37 Meanwhile, the National Surgical Quality
Improvement Project (NSQIP) data from the mid-2000s showed that surgical mortal-
ities range from 3.5% to 6.9%, thus implicating not anesthesia but postoperative com-
plications in surgical deaths.38 Both NSQIP and Medicare data show that complication
rates are similar between the hospitals with the highest and lowest surgical mortalities.
This observation has led to the consensus that variation in surgical mortality is caused
in part by failure to rescue patients from complications.38–42 The Institute of Medicine
has identified failure to rescue as a key target for improvement.43,44

What roles do hospitalists play in the perioperative period?

Hospitalists have emerged as leaders in perioperative medicine and important mem-

bers of the perioperative care team. Multiple studies have shown hospitalists’ benefi-
cial influence on perioperative care. Hospitalist comanagement of patients having
vascular surgery has been associated with decreased in-hospital mortality, improved
patient safety, and better pain scores, as well as superior reports from residents
regarding perceived improvements in patient care and education.45 In a prospective
cohort study, comanagement of elderly patients with hip fractures was shown to
have a mortality benefit at 6 months, reduce surgical delays, and decrease hospital
length of stay.46 A third study showed a reduction in overall surgical mortality, length
of stay, and cost with hospitalist/intensivist comanagement among a wide variety of
surgical patients.47 Other studies have shown comanagement to be associated with
lower cost and length of stay with no effect on other clinical outcomes among ortho-
pedic, cardiothoracic, and neurosurgical populations.48–56
Hospitalists have a significant role in the preoperative assessment in some institu-
tions. Hospitalists are well suited to aid in assessment and optimization of chronic
 Anesthesia Considerations 295

medical conditions as well as to assist in planning for the hospital stay. This role can
include performing preoperative risk assessments, evaluation of active signs or symp-
toms of medical disease or illness, assisting in optimizing underlying medical disease,
implementing risk reduction strategies, and responding promptly to unavoidable med-
ical complications.
The American Board of Internal Medicine and American Board of Family Practice
include comanagement and perioperative topics in their Focused Practice in Hospital
Medicine Maintenance of Certification programs. The Society of Hospital Medicine
has listed perioperative medicine among its core competencies, developed guide-
lines, and placed significant focus on it with respect to its educational efforts and
the publications that are available through them.57,58

What is the perioperative surgical home (PSH)?

From the 1990s and into the early 2000s 3 key events contributed to the development
of the PSH:
1. Rotondi and colleagues59 developed their perioperative process at the Department
of Anesthesiology at the University of Pittsburgh
2. The Veterans’ Association’s NSQIP developed a process to improve the quality of
surgical care60–62
3. International efforts to improve care began, such as enhanced recover after
surgery63,64
In the setting of the American Recovery and Reinvestment Act of 2009 and The Pa-
tient Protection and Affordable Care Act of 2010, the time was right to develop new
models of care focused on controlling costs, improving health care delivery, and
improving quality.65,66 Paralleling the idea of a patient-centered medical home in the
outpatient setting,67–69 the PSH has been a growing area of discussion.70–72 The
ASA defines the PSH as a “patient centered, innovative model of delivering health
care during the entire patient surgical/procedural experience; from the time of the de-
cision for surgery until the patient has recovered and returned to the care of his or her
Patient Centered Medical Home or primary care provider.” (Fig. 2).73 Goals of the
PSH include physician leadership engagement, patient optimization for surgery, timely
scheduling, evidence-informed care pathways, expert surgical and anesthetic are,
facilitated rehabilitation, measurement of patient-centered outcomes, continuous per-
formance improvement, and facilitated return to primary care.73 The PSH is designed
to provide continuity and standardization to the perioperative period to make sure that
each patient receives the right care, at the right place, and at the right time. Although
the PSHs at various health care institutions are heterogeneous in their structure and
components, a recent literature review by Kash and colleagues74 reviewed 63 US-
based studies and 54 non-US studies that showed generally positive effect on cost
and outcomes. This finding is likely to lead to continued emphasis on perioperative
care improvement through the PSH model.

Can hospitalists and anesthesiologists provide complimentary and collaborative

perioperative care?

The PSH requires an inpatient physician to comanage along with the surgeon in
certain situations; in most models hospitalists (generally internal medicine trained)
or anesthesiologists (especially in intensive care units) have stepped into this role.
There is some debate on which specialty is better suited to fill this role.75–87 The
 296
Vercollone et al
Fig. 2. Goals and supporting microsystems of a patient-centered PSH. QI, quality improvement. (Adapted from American Society of Anesthesiologists.
Perioperative surgical home: vision, strategic principles and definition. 2013. Available at: http://www.asahq.org/w/w/link.aspx?_id5F4B6FE
52C7824248BF88E22020EB9C15&_z5z. Accessed July 29, 2015.)
 Table 5
Improvement outcomes for perioperative care programs

Outcome Measure Definition

ACS NSQIP Death —
Any complication Superficial incisional SSI, deep incisional SSI, organ space SSI, wound disruption,
pneumonia, unplanned intubation, PE, ventilator >48 h, progressive renal
insufficiency, acute renal failure, UTI, stroke, cardiac arrest, MI, DVT, systemic sepsis
Serious complication Death, cardiac arrest, MI, pneumonia, progressive renal insufficiency, acute renal
failure, PE, DVT, return to the operating room, deep incisional SSI, organ space SSI,
systemic sepsis, unplanned intubation, UTI, wound disruption
Pneumonia —
Cardiac event Cardiac arrest or MI
Surgical site infection —
Urinary tract infection —
Venous thromboembolism —
Renal failure Progressive renal insufficiency or acute renal failure
ASA-AQI (1–7 d Patient satisfaction Fields should be compatible with CAHPS Surgical survey. Recommended domains for
outcomes) assessment include Waiting time, Adequacy of Consent Process, Staff Courtesy,
Respect for Privacy, Successful IV Starts/Difficulty with Lines
PONV “Since discharge from the recovery room, I have had nausea and or vomiting.”:
Five-point scale: never, occasionally, some, often, constantly
Adequacy of pain management “Since discharge from the recovery room, my pain has been well-controlled.”:

Anesthesia Considerations
Five-point scale: always, mostly, somewhat, rarely, never
Unanticipated awareness during anesthesia —
Unplanned emergency department visit —
Unplanned readmission to the hospital —
Other New neurologic injury, sore throat, eye irritation, difficulties with memory, headache,
infection at the site of an anesthesia procedure, pneumonia, central line–associated
blood stream infection

Abbreviations: ACS, American College of Surgeons; AQI, Anesthesia Quality Institute; DVT, deep vein thrombosis; PE, pulmonary embolism; SSI, surgical site infec-
tion; UTI, urinary tract infection.

297
298 Vercollone et al

authors think that there are complimentary roles for both disciplines to develop a
collaborative approach. Anesthesiologists provide expertise in preparation for anes-
thesia, intraoperative management, and at times in intensive care units postopera-
tively. Hospitalists contribute expertise in inpatient and outpatient management of
the aged and comorbid populations and are thus well suited to assist in caring for
and anticipating surgical complications that are the main driver of perioperative
morbidity and cost. Hospitalists are also well prepared to assist in standardizing pre-
operative assessments of chronic medical conditions. By 2020, 55 million people in
the United States will be 65 years of age or older and 81 million will have multiple
chronic medical conditions.88–91 Along with this national demographic shift, patients
undergoing surgery are increasingly complex, both from older age and greater med-
ical comorbidity. Working closely together, surgeons, hospitalists, and anesthesiolo-
gists can create successful processes of care that fit best for each local institution.

What outcomes should improvement initiatives monitor?

It is important for hospitalists who care for surgical patients to be aware of the Amer-
ican College of Surgery NSQIP list of surgical complications and the core measure
recommendations of the ASA-Anesthesia Quality Institute (Table 5).92,93

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