THE PREOPERATIVE OUTPATIENT-CLINIC IN GRAZ - THE FIRST 15 YEARS

In 1977 a new anaesthesiology preoperative evaluation clinic was started for evaluation of all elective surgical patients for their fitness to undergo anaesthesia. Physical examination, medical history and anaesthetic risk assessment are assessed in a standardized manner with the aid of computer menus. Comprehensive laboratory tests included electrocardiography, lung function assessment (vital capacity and forced exspiratory volume within 1 s), chest X-ray, and arterial blood gas analysis and blood chemistry analysis with an SMA-22 (System Multi Analyzer). At the conclusion of the preoperative evaluation, patients are classified according to ASA physical status, Goldman Cardiac Risk Index and an exercise classification such as NYHA. Only elective surgical patients are evaluated in this clinic. Within the last 15 years more than 75000 patients have been seen in our preoperative clinic, 91.8% of whom were cleared for surgery and anaesthesia after the initial evaluation. There were 1132 patients who needed preoperative treatment first. Only 4.4% were discharged without operation because too many risk factors for perioperative complications were present. We found that comprehensive preoperative evaluation in this clinic was more efficient than bedside evaluation and reduced examination time for the patient. In 1983 and 1985 we published two prospective/retrospective studies on the improvement of perioperative morbidity and mortality of selected patients undergoing non-cardiac surgery. We found that perioperative complications and adverse outcome correlated with preoperative data and physical examination. The main source of perioperative morbidity and mortality was the cardiovascular system, followed by nephrologic diseases, correlating exactly with preoperative BUN and plasma creatinine. These studies also underlined the value of the ASA physical status to predict perioperative outcome. Since 1988 all patients' data have been processed automatically by a computer system designed by clinic staff. Precise data evaluation, statistical analyses and selective studies of over 24000 patients can be performed easily. The cost of one examination in the anaesthesia clinic is OS 140 (DM 17). The price of the reagents for blood chemistry, blood gas analysis and the chest X-ray is OS 95 (DM 12). If preoperative tests were discontinued the laboratory staff could not be much reduced, because preoperative tests do not account for more than 10% of the workload and the system must work over 24 h. In total, therefore, examination of one patient costs OS 235 (DM 30). Compared with the total costs of the surgical procedure, this part is one of the smallest items. Even the anaesthetic management starting from intravenous induction with propofol or ketamine, followed by orotracheal intubation and inhalation anaesthesia with isoflurane or sevoflurane, costs more than this preoperative evaluation. This preanaesthetic examination procedure is easy to learn. Surgical specialties now routinely schedule patients for preoperative evaluation at the clinic. We feel that performing this comprehensive physical assessment reinforces basic concepts in anaesthesiology for the house doctors. All medical departments create specialists in each part of their sector. We think that anaesthetists should also optimize preoperative evaluation by concentrated well-organized practices.