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SCOPE OF THE PRACTICE OF ANESTHESIOLOGY

TASA ID: 1082

Anesthesiology is a recognized medical specialty. Anesthesiologists often work as perioperative physicians with responsibilities during the preoperative, intraoperative and postoperative periods to keep the patient comfortable and safe. Other recognized functions within the practice of anesthesiology include management of patients with acute and chronic pain, assisting in the management of cardiopulmonary resuscitation and advanced cardiac life support and the management of critically ill patients in intensive care units.  In today's medical environment with the increasing use of the Care Team Model to provide patient care services, anesthesiologists also provide onsite, immediately available medical direction of non-physician providers such as Certified Registered Nurse Anesthetists (CRNA's) who participate in the delivery of anesthesia care to the patient. The scope of the practice of anesthesiology also includes overseeing preoperative evaluation clinics and administrative responsibilities in the daily management of the operating room surgery schedule.

Fundamental to the practice of anesthesiology is the preoperative assessment of patients for anesthesia and surgery. The standard of care for preoperative evaluation requires that the anesthesia provider review the patient’s medical record, visit with the patient and perform a focused anesthesia history and physical exam.  The patient will be questioned about previous surgical experiences to determine if there have been any prior anesthesia complications.  An important aspect of this preoperative visit is to inform the patient of the planned anesthetic technique and discuss methods available, such as a peripheral nerve block and/or intravenous (IV) pain medications which might include narcotics, for the relief of postoperative pain.  Risks, benefits and alternatives to the anesthesia plan are discussed to the extent of the individual patient’s desire to know and patient questions are answered.  A written informed anesthesia consent is obtained from the patient or the patient’s legal guardian.  An informed patient often has less anxiety, and therefore, may have improved hemodynamic stability during the procedure.  Preventing intraoperative and postoperative complications through the identification of preoperative risk factors is always the preferred approach rather than having to treat these difficulties after they have occurred.

Intraoperatively, the anesthesia provider first applies the appropriate monitors to the patient, provides supplemental oxygen and then induces the planned anesthetic for the patient. Three common types of anesthesia are General Anesthesia, Regional Anesthesia and Monitored Anesthesia Care.  General Anesthesia involves rendering the patient unconscious and establishing a secured airway with any one of a number of different breathing tube devices depending on the planned procedure and underlying patient factors.  Mechanical ventilation is often employed.  Regional Anesthesia involves rendering the patient insensible to pain by injecting local anesthetic medication by a spinal, epidural or peripheral nerve block procedure.  Finally, Monitored Anesthesia Care usually involves providing sedatives and/or analgesics along with other medications as necessary for patient safety, while monitoring and supporting vital patient functions, including spontaneous breathing, without inducing unconsciousness.  Considerations that influence the choice of anesthetic technique include preference of the patient and/or surgeon, coexisting patient diseases, site and duration of the planned surgery, positioning of the patient during surgery and whether the surgery is elective or emergent.  In all of the above types of anesthesia, the anesthesia provider continually monitors and medically manages the patient to protect the patient's life functions and vital organs by providing oxygen, IV fluids, medications and/or blood products. The data obtained from the monitors is recorded into a graphical anesthesia record.

Recovery from anesthesia requires that the patient be taken to the Post Anesthesia Care Unit (PACU), also commonly referred to as the Recovery Room, for monitoring and care because of the physiologic derangements produced by anesthesia and surgery. The anesthesiologist or CRNA must provide the PACU nurse with pertinent details of the patient’s history, medical condition, anesthetic and surgery. The PACU nurse will continue to monitor the patient at regular intervals and keep the anesthesiologist informed of the patient's condition. The anesthesiologist will enter appropriate PACU orders to guide the nurse in the care of the patient.  Recovery from anesthesia is usually uneventful and routine, but a variety of physiologic disorders that can affect multiple organ systems may present and must be diagnosed and treated to ensure patient safety and comfort.  Physiologic disorders such as upper airway obstruction, hypoventilation, a low blood oxygen level known as hypoxemia, a slow or fast heart rate and/or irregular heart rhythm, low or high blood pressure, agitation, nausea, vomiting and pain can manifest in the PACU. Standards of care require the anesthesiologist to perform a post anesthetic evaluation to assess the patient’s readiness for discharge from the unit and treat any of these disorders should they occur. After the immediate and acute effects of anesthesia and surgery have dissipated and the patient's recovery in the PACU is complete and the patient is deemed stable by standard industry recovery criteria that include assessing vital signs, adequacy of breathing, wakefulness and pain control, the anesthesiologist discharges the patient to the next step-down phase of recovery before the patient leaves the facility for home, or to the patient's hospital room.

In this age of rapidly expanding medical knowledge, including new surgical and anesthesia techniques, drugs, equipment and technology, along with an emphasis on patient safety and quality of care, all within an environment of cost containment and incentives for production efficiency, patients with chronic and complex medical conditions will continue to present for surgery. At the end of the day, following standards of care and the need for cooperation and collaboration among healthcare professionals is especially relevant.

 

Reference: 

Stoelting, R.K. and Miller, R.D. (2007). Basics of Anesthesia, 5th Edition. Churchill Livingstone.

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This article discusses issues of general interest and does not give any specific legal or business advice pertaining to any specific circumstances.  Before acting upon any of its information, you should obtain appropriate advice from a lawyer or other qualified professional.

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