Riccioni Luigi, Anzani Alfredo, Carlomagno Nicola, De Blasio Elvio, Renda Andrea, Rigotti Paolo, Rossi Giorgio, Petrini Flavia
Recenti Prog Med. 2021 Apr;112(4):250-261. doi: 10.1701/3584.35684.
In the common clinical practice the perioperative risk assessment of an acute surgical patient with advanced chronic comorbidities is carried out independently by surgeon and anesthesiologist, usually in two different steps. While the surgeon evaluates the risk mainly in relation to the surgical outcome, the perioperative risk assessment regarding the weight of the coexisting medical condition on the quality of recovery in the short- mid- and long-term is all about the anesthesiologist evaluation. When frailty and/or comorbidities are so serious that will make surgery seem futile, the patient's assessment on one hand, and the decisions regarding the further clinical waypoint on the other, have to be discussed firstly between surgeons and anesthesiologists before being shared with the patients and their relatives. This is mostly true in the event of an emergency surgical procedure. In regard, a consensus conference attended by a panel of experts respectively from the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) and the Italian Society of Surgery (SIC) was called for developing a shared clinical pathway aimed to select the best care option - operative vs palliative - in the best interest of the surgical patient with advanced chronic comorbidities, in emergency or elective condition. After two years, the panel of experts developed a position paper recommending, in case of potentially futile surgery, to assess the patient verifying two coexisting conditions ("Two Steps method"): Palliative Performance Scale <50%, and at least one of the following general clinical criteria: 1) more than one hospital admission within the last 12 months; 2) hospital admission from or awaiting admission to long-term care facilities, home care service, hospice; 3) chronic renal failure requiring weekly dialysis sessions; 4) home oxygen use and/or non-invasive ventilation. Under these conditions, the surgeon together with the anesthesiologist can share with the patient and/or his relatives the decision between palliative surgery or palliative care taking into account his wishes and preferences.
在常见的临床实践中，患有晚期慢性合并症的急性外科手术患者的围手术期风险评估通常由外科医生和麻醉师分两个不同步骤独立进行。外科医生主要评估与手术结果相关的风险，而围手术期风险评估中，关于并存疾病对短期、中期和长期恢复质量的影响则完全由麻醉师评估。当虚弱和/或合并症严重到使手术似乎徒劳无功时，一方面要对患者进行评估，另一方面要就进一步的临床路径做出决定，这必须首先在外科医生和麻醉师之间进行讨论，然后再告知患者及其亲属。在紧急外科手术的情况下尤其如此。为此，分别来自意大利麻醉、镇痛、复苏和重症监护学会（SIAARTI）和意大利外科学会（SIC）的专家小组召开了一次共识会议，以制定一条共享的临床路径，旨在为患有晚期慢性合并症的外科手术患者在紧急或择期情况下选择最佳的护理方案——手术治疗还是姑息治疗——以符合患者的最大利益。两年后，专家小组制定了一份立场文件，建议在可能徒劳无功的手术情况下，通过核实两个并存条件（“两步法”）来评估患者：姑息治疗表现量表<50%，以及以下至少一项一般临床标准：1）在过去12个月内住院超过一次；2）从长期护理机构入院或等待入院、接受家庭护理服务、临终关怀；3）需要每周进行透析治疗的慢性肾衰竭；4）家庭使用氧气和/或无创通气。在这些情况下，外科医生和麻醉师可以根据患者的意愿和偏好，与患者和/或其亲属分享关于姑息性手术或姑息治疗的决定。
