Advice for junior medical staff in PAC

The purpose of this page is to provide junior medical staff with information to assist them in preparing patients for elective surgery.

We are also happy to be contacted at any time.

General Advice for junior medical staff in Surgical PAC Clinics

• The Department of Anaesthesia and Perioperative Pain Medicine have prepared Unit-Specific Guidelines for pre-anaesthetic assessment of your surgical patients. These provide guidelines on:

  • Which patients should be referred to PAC-Anaesthesia; for certain operations all patients should be referred to PAC-Anaesthesia
  • Pre-anaesthetic investigations, with an emphasis on only ordering investigations that are going to change management, and on minimising delays and duplication. These guidelines are based primarily on recommendations made in Up to Date and Choosing Wisely
  • Which patients need an HDU/ICU bed, and other pre-operative planning issues

• Patients should be referred to PAC-Anaesthesia according to the Unit-Specific Guidelines. In general, referral to an anaesthetist is most appropriate when:

  • There are specific anaesthetic issues, such as previous problems with anaesthesia
  • There needs to be a specific discussion about perioperative risk
  • There are specific concerns about fitness for surgery
  • There are complex issues regarding acute pain management
  • The surgery is complex and high-risk, and there needs to be planning

• The Perioperative Medical Unit (PMU) have their own guidelines and referral pathway. In general, referral to PMU is more appropriate when:

  • There are multiple medical problems needing assessment and management before surgery
  • There are likely to be medical issues requiring PMU management in the immediate post-operative period
• It is recognised that there may be overlap between PMU and the PAC-Anaesthesia.
  It is relatively uncommon that a patient will need referral to both clinics.
  Please do not refer a patient to both clinics without discussion with the PAC-Anaesthesia anaesthetist or the PMU registrar. The Department of Anaesthesia and the Perioperative Medical Unit will liaise with each other as required.
• Patients who have been seen in PAC-Anaesthesia or had major surgery at this Hospital in the last 2 years, and who have remained medically stable during that time, do not generally need to be seen in PAC-Anaesthesia again. This is particularly relevant for orthopaedic arthroplasty patients who often have multiple operations
• Obesity – there is no absolute BMI cut-off above which patients must be referred to PAC-Anaesthesia. Patient weight or BMI needs to be considered alongside other risk factors including planned surgery and other co-morbidities. If in doubt, please contact the Anaesthetist in PAC-Anaesthesia or the Clinical Lead to discuss the details particular to your patient.

Patients having bariatric surgery do not need to be referred to PAC-Anaesthesia unless there are very specific anaesthetic-related issues. These patients will be seen in PMU clinic, and in general, PAC-Anaesthesia will only accept referrals for these patients from a PMU physician. Surgical residents or liaison nurses should not refer patients having bariatric surgery to PAC-Anaesthesia clinic.

How to refer your patient to PAC-Anaesthesia:

• All patients need a brief written referral (see e-form “Referral PAC-Anaesthesia” in MRO, under “Correspondence”)
• All referrals must include a completed NSQIP risk-assessment form, which can be completed in 3 minutes and copied from: https://riskcalculator.facs.org/RiskCalculator/

• Please liaise directly with the anaesthetist allocated to PAC-Anaesthesia in the following situations:

  • Where there is doubt as to whether the patient should be seen in PAC-Anaesthesia
  • Where it may be possible to avoid an extra appointment or visit to St Vincent’s (eg the patient lives in the country)
  • When organising investigations beforehand will help streamline the process
• If your patient requires referral to PAC-Anaesthesia (eg based on their surgery being a mandatory referral) and you are intending to not refer them, then you must contact the Anaesthesia Department to discuss
• Endoscopy patients – it is uncommon that a patient having an endoscopy will need to be seen in PAC-Anaesthesia. Do not refer endoscopy patients to PAC-Anaesthesia without speaking to the Clinical Lead first.