Download Development and Implementation of an Anesthesia

Development and Implementation of an Anesthesia-Led
Multidisciplinary High Risk Surgical Committee at a Specialty
Cancer Hospital
Use of a High Risk Surgical Committee may
improve the perioperative course of the complex
multi-morbid patient being considered for major
cancer surgery.
Case Summary
67yo woman with clear cell CA for
open radical nephrectomy.
PMHx: COPD (FEV1 of 22%, incalculable
DLCO, ambulatory desaturations while
on oxygen), poor functional status,
medication non-compliance and
continued smoking.
52yo woman with muscle invasive
bladder cancer for robotic cystectomy
with anterior pelvic exoneration.
PMHx: moyamoya disease with recent
CVA now status-post ECIC bypass,
recent NSTEMI due to hematuria while
on dual antiplatelet therapy, DM,
chronic pain and seizure disorder.
HRC Findings and Recommendations
-Surgery is preferred therapy but not urgent and
pt would benefit from optimization.
-Recommend sustained medication compliance,
complete smoking cessation and 6 weeks of
pulmonary rehabilitation followed by
pulmonology re-evaluation.
-If able to demonstrate significant improvement in
her pulmonary function patient will be reconsidered for the OR.
-Cystectomy is treatment of choice. Repeat bout
of significant hematuria may be life threatening.
Not risk prohibitive if patient agrees with
proceeding at elevated risk.
-Neurosurgery, cardiology and surgeon agree with
proceeding on ASA 81mg, strict hemodynamic
goals and intra-operative neuromonitoring.
-ICU, intra-operative monitoring and analgesic
plan discussed.
-Advanced directives and proxy prior to OR.
80yo male with 2nd recurrence of
invasive SCC of the oropharynx with
pharyngocutaneous fistula scheduled
for pharyngo-esophagectomy, left
carotid endarterectomy, gastric pullup
and reconstruction (2 day procedure).
Outcome
-8 months later FEV1 33%
with improved functional
capacity.
-Reconvened HRC
suggests minimally
invasive procedure.
-Surgery performed with
uncomplicated 5 day postop course.
-Advanced directives
completed.
-Pt to OR with uneventful
intra-operative course.
-Discharged home in
stable condition on postoperative day 10.
-Risk-benefit ratio discussion highlighted that the -Procedure cancelled.
procedure was unlikely to be curative, only
-Patient referred to
palliative care.
palliative to aid with secretions and tolerating
oral diet.
-Significant risks included (among other things) a
very high possibility of perioperative CVA and
death.
PMHx: SCCs status-post laryngectomy -Given advanced age and multiple comorbidities,
and radiation, HTN, CAD, aortic stenosis recommendation made to not proceed with
and a history of TIAs.
surgery.
-Referred to palliative care for symptom control.
Total Patients
Average Age
ASA 3 to 4 Ratio
Avg NSQIP Risk of Serious Complication
Avg NSQIP Risk of Any Complication
Avg NSQIP Risk of Pneumonia
Avg NSQIP Risk of Cardiac Complication
Avg NSQIP Risk of Wound Infection
Avg NSQIP Risk of UTI
Avg NSQIP Risk of Blood Clot
Avg NSQIP Risk of Kidney Failure
Avg NSQIP Risk of Return to OR
Avg NSQIP Risk of Discharge to Rehab
Avg NSQIP Risk of Mortality
SURGERY SURGERY NOT
PERFORMED PERFORMED
57
47
71
73
43 to 14
25 to 19
17%
22%
25%
29%
4%
6%
2%
3%
8%
7%
4%
5%
2%
2%
2%
3%
6%
7%
13%
22%
3%
4%
Roswell Park Cancer Institute is a NCI designated comprehensive cancer
treatment center located in Buffalo, NY. As the region’s only such
institution, we frequently evaluate medically complex patients for major
cancer surgery. In 2014 our Department of Anesthesia developed and
implemented a High Risk Surgical Committee (HRC) to better evaluate,
optimize and plan for the perioperative course of these challenging patients.
Methods:
All surgical patients are evaluated by the Anesthesia Perioperative Evaluation Clinic.
Criteria for requesting HRC review non-specific and liberal. Anyone may request HRC
review. The policy suggests that consideration be given to cases deemed high risk by
objective measure, patients with advanced systemic disease (especially poorly controlled
disease), patients of advanced age and/or with limited functional capacity, the frail and
patients in whom surgical risk may outweigh potential benefit. The NSQIP risk calculator
is commonly employed by APEC as our screening tool of choice.
Standard HRC composition includes: surgeon specific to the case, the Chair of Surgical
Oncology, an anesthesiologist, Director of APEC, Critical Care MD, Risk Management,
Palliative Care and consultants as indicated.
The meeting format has been standardized. It begins with a brief case review by the
surgical team. Additional pertinent information is then provided by the anesthesia team
or consultants. NSQIP risk calculator information is included whenever possible. Other
surgical service specific risk estimations are discussed when available.
Once all of the relevant information has been presented, a risk-benefit discussion
ensues with the goal of answering, “Is this case risk prohibitive?” In some more
information or work-up is necessary. If the case is deemed risk prohibitive, HRC may
make recommendations on alternative non-surgical options.
If the case is deemed to be “not risk prohibitive”, the discussion moves towards
optimizing the patient’s perioperative course. This may include: additional testing or
subspecialist clearances prior to the surgery, perioperative medication management,
prehabilitation, addressing Advanced Directives, recommendations regarding the
procedure (open vs. minimally invasive, downgrading to a lesser procedure), anesthetic
management (general vs. regional), fluid management, ventilation strategies, post-op
pain control, recommended intra-operative access/monitoring, pre-emptive planning for
possible case-specific complications, post-operative disposition and more.
A summary of the discussion is documented in the medical record.
Lessons Learned
• A HRC can be successfully developed and implemented
at a specialty cancer institution.
• Use of a HRC can lead to a more thorough
multidisciplinary evaluation of a candidate for major
cancer surgery as well as improve communication and
planning among multiple providers involved in all
phases of the patient’s perioperative care.
• Outcomes data to evaluate the impact of the model is
needed.
Dr. Raymond D. Sroka MD, PharmD; Dr. Timothy D. Quinn MD; Dr. Thomas Croucher MD; Dr. Ian Cohen MD, FCCP, FCCM, CLSSBB; Ruth Renner JD, CLSSBB.
Roswell Park Cancer Institute
Department of Anesthesiology, Critical Care and Pain Medicine
Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo