High-risk surgery that is complex and requires further planning, including postoperative destination e.g. HDU/ICU referral. See examples below.

Consider referring patients with complex surgical pathology.

Patients who are travelling from interstate/regional area may require phone PAC and liaison with GP for other relevant information, and may benefit from earlier than day-of-surgery preoperative anaesthesia evaluation to optimise them and reduce the risk of cancellation.

If you are unsure at any time, please approach the PAC anaesthetist for further advice; or if the PAC anaesthetist is unavailable, please contact the anaesthetist-in-charge on 0427 149 373 (Box Hill), or 9871 3759 (Maroondah).

Please review EMR and CPF for patient history and investigation results.

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A complex patient with multiple or unstable medical conditions, which require further optimisation and discussion regarding their fitness for surgery. See examples below.

It would be good to read through the patient's notes on CPF and summarise the patient's comorbidities and stability, as documented by the various medical subspecialties.

It would also be important to look up and summarise the latest investigation results, e.g. blood tests, ECG, echocardiogram, angiogram, respiratory function tests, CPET or other imaging results.

Patients who have been seen in PAC in the last 12 months and whose medical condition has remain unchanged, or patients who have had a recent (in the last 12 months) uneventful surgery/anaesthetic, MAY not need to go to anaesthetic PAC. Please ask the PAC anaesthetist if a referral is required.

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Are there any problems encountered with past anaesthestic, or any issues that may potentially complicate anaesthesia?

Some examples include:

• Anaphylaxis under anaesthesia
• Allergy to anaesthetic agent
• Known difficult airway
• Previous major neck or airway surgery
• Radiotherapy treatment near airway
• Personal or family history of anaesthetic issues, e.g. malignant hyperthermia or suxamethonium apnoea
• Severe spinal deformities, e.g. kyphosis or scoliosis
• Lung pathologies that may pose ventilation issues, e.g. bronchopleural fistula
• Very difficult IV access
• Patient reguest, e.g. severe needle phobia or anxiety/concerned about anaesthesia

Look at EMR under "Documentation" tab for previous anaesthesia encounters.

If the patient has been seen in PAC-Anaesthesia or had major surgery in the hospital in the last 2 years AND has remained medically stable during this time, they may not need to be seen by an anaesthetist again, unless specific anaesthesia-related issues, e.g. malignant hyperthermia.

However, we will always be more than happy to help you with any concerns or questions you may have.

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NSQIP Surgical Risk Calculator

Subjective assessment of functional capacity does not correlate well with major morbidity or mortality post elective non-cardiac surgery, and hence other validated tools such as the NSQIP Surgical Risk Calculator (tap here) may be used to estimate perioperative risk.

It would be useful to use the NSQIP Calculator for all your patients. When having the discussion with the anaesthetist, it would also help them have a better idea on the risk estimated for the particular patient.

Duke Activity Scale Index (DASI)

The Duke Activity Scale Index (tap here) is also good for objectively estimating a patient's functional status.

Subjectively assessed preoperative functional capacity did NOT accurately identify patients with poor cardiopulmonary fitness or predict postoperative morbidity or mortality.

DASI score of <34 has been associated with an increased risk of 30-day death, myocardial infarction and moderate-to-severe complications.

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Patients where surgical pathology might have significant haemodynamic or other effects, for example:

• SVC obstruction
• Tracheal compression
• Anterior mediastinal mass

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Management of postoperative pain in a patient with complex or chronic pain history can be very challenging.

The anaesthetist may advise you to refer the patient directly to the Acute Pain Service (APS) team.

• APS Registrar: 0435 603 844
• APS Nurse: 0477 321 237

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