Commentary by Dr. Robert Sladen, AnesthesiaWeb Advisory Board

The importance of the postoperative anesthetic visit: do repeated visits improve patient satisfaction or physician recognition?
Zwara DA. et al Anesthesia and Analgesia 1996;83:793-797.
[ read the abstract ]

(accompanying editorial) More or better - educating the patient about the anesthesiologist's role as perioperative physician
Klock PA, Roizen MF Anesthesia and Analgesia 1996;83:671-672.

The anesthesiologist as "perioperative physician" is a common catch-phrase in today's uncertain medical climate, as anesthesiologists struggle to establish a secure place in the new firmament of Managed Care. So we can expect increasing attention to be given to ways in which the anesthesiologist can be perceived as a "real doctor" and not just a technician by his or her patients and medical colleagues.

In an attempt to explore ways in which the anesthesiologist can foster the doctor-patient relationship, Zwara et al performed a study at Bowman Gray University reported in the October 1996 edition of ANESTHESIA AND ANALGESIA. Patients were visited by an anesthesiologist one, two or three times in the postoperative period. The authors appeared somewhat surprised to find that not only did an increasing number of postoperative visits not increase the patients' poor name recognition of their anesthesiologist (particularly in comparison with their surgeon), but it did little to improve their perception of the anesthesiologist as helpful, their anxiety about future anesthetics or their understanding of the anesthesiologist's role in their surgery.

In the accompanying editorial, Klock and Roizen suggest that the quality of the anesthesiologist's visit is likely to be more important than the quantity. They also point out the importance of a good preoperative visit with postoperative visits really being a component of the continuum of care. Nonetheless, they suggest that this study is a "wake up call" for anesthesiologists, and points to the need for investigating measures of patient satisfaction with such issues as postoperative pain, nausea and vomiting, return of bowel function etc. Clearly, in the current era of managed competition, the anesthesiologist needs to be attuned to consumer satisfaction as well as to the technical and professional obligations to the job at hand!


Small, oral dose of clonidine reduces the incidence of intraoperative myocardial ischemia in patients having vascular surgery
Stuehmeier K-D, Anesthesiology 1996;85:706-712.
[ read the abstract ]

Ischemic cardiac complications remain an important concern in the patient undergoing major vascular surgery. Some years ago the Cleveland Clinic performed cardiac catheterization on 1,000 consecutive patients undergoing vascular surgery - a feat which will probably never be repeated! They found that significant coronary artery disease existed in about 65% of patients, and in about 18%, surgically correctable coronary artery disease was found without any cardiac symptoms, resting ECG changes or history of congestive heart failure (Hertzer N: Clinical experience with preoperative coronary angiography. J Vasc Surg 2:510-514, 1985). Subsequently there has been an enormous amount of investigation performed on defining the most sensitive, specific and cost-effective means of evaluating risk for perioperative cardiac events in patients scheduled for vascular surgery.

In the October 1996 edition of ANESTHESIOLOGY, Stuehmeier and colleagues report the remarkable finding that a single 2 g/kg dose (about 0.15 mg for the average sized adult) of clonidine taken orally before surgery reduced the incidence of perioperative myocardial ischemic episodes by nearly 40%. Four patients in the placebo group went on to develop acute myocardial infarction after surgery compared with none in the treatment group, but the study size (297 patients) was of insufficient size for this to reach statistical significance. The greatest reduction in reversible ischemic episodes coincided with surgical stimulation. Moreover, this apparent myocardial protection occurred without overt differences in hemodynamic function or requirement for vasoactive drugs between the two groups.

Although this study probably raises more questions than it answers, it again draws attention to the unique pharmacologic profile of the alpha-2 adrenoreceptor agonists. These agents act centrally to decrease sympathetic outflow and norepinephrine levels, as well as providing anxiolysis, analgesia, antiemetic and antisialogogic actions - all of which would seem to be eminently desirable in a premedicant. The dose of clonidine given in this study appears almost homeopathic - and yet it appeared to confer significant myocardial protection.

The reader is also referred to another recently published study on the use of larger doses of clonidine in hypertensive patients undergoing major vascular surgery, in which it decreased anesthetic requirements and improved circulatory stability (Quinton L et al.: Clonidine for major vascular surgery in hypertensive patients: a double-blind, controlled, randomized study. Anesthesia and Analgesia 83:687-695, 1996). In fact, an increasing number of studies are presently being performed with newer, more potent and selective parenteral alpha-2 adrenoreceptor agonists such as dexmedetomidine and mefanazole. The next decade promises to launch this group of drugs into a permanent and important niche in the anesthesiologists' pharmacopoeia.