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Table of Contents  
Year : 2014  |  Volume : 8  |  Issue : 2  |  Page : 125-126  

Quaternary prevention in anesthesiology: Enhancing the socio-clinical standards

1 Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India
2 BRIDE Hospital, Karnal, Haryana, India
3 Department of Anesthesiia, Alsafwah Center, Office No(1209) Prince Mandouh Bin Abdelaziz Street, Riyadh, P.O.Box 22422 pin code 11495, Saudi Arabia

Date of Web Publication16-Jun-2014

Correspondence Address:
Sukhminder Jit Singh Bajwa
Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0259-1162.134470

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How to cite this article:
Bajwa SJ, Kalra S, Takrouri MM. Quaternary prevention in anesthesiology: Enhancing the socio-clinical standards. Anesth Essays Res 2014;8:125-6

How to cite this URL:
Bajwa SJ, Kalra S, Takrouri MM. Quaternary prevention in anesthesiology: Enhancing the socio-clinical standards. Anesth Essays Res [serial online] 2014 [cited 2022 May 19];8:125-6. Available from:

Anesthesiology is a rapidly expanding science. The number of sophisticated devices, technically advanced equipment and availability of newer drugs with higher safety margin has increased dramatically over the past few decades. The physical evidence is reflected in the wide variety of instruments and medicines stocked in operation theatres and critical care units today. This also means that the anesthesiologist is now able to craft almost infinite permutations and combinations of drugs and procedures in order to achieve safe, effective and well tolerated anesthesia.

Paradoxically, this is a bane as well as a boon. The geometric rise of anesthesiology related paraphernalia necessitates those anesthesiologists as well as other operating room and critical care providing health care professionals have to update their skills so as to ensure optimal utilization of modern developments. It also implies that the risk of errors has also increased in similar proportions, if not more.

In such a scenario, the concept of quaternary prevention needs to be highlighted. Not discussed from an anesthesiology perspective so far, quaternary prevention, a term coined by Jamoulle, needs to be used in general practice. [1] Defined as "action taken to identify patient at risk of overmedicalization, to protect him from new medical invasion and to suggest to him interventions, which are ethically acceptable," this concept is now accepted in various branches of medicine. [2]

The anesthesiologist, too, has a duty to ensure quaternary prevention in his routine practice. One must act to identify patients at risk of overmedication and inappropriate medication. These procedures can invariably lead to various medication errors and side-effects which can prove to be disastrous. [3] Attempts to achieve quaternary prevention should be initiated from pre-anesthetic clinic, where many patients present with prescription of unnecessary vitamins, polypharmacy, alternative and complementary medicines, or irrational combinations. [4],[5] A diplomatic suggestion to reduce pill burden and drug burden can be made at this stage, citing peri-operative health as a plausible reason. However, it has to be ensured that the advice does not end up in stopping of necessary medications meant to maintain the normal physiological mechanisms. The relevant investigations should be ordered so as to quantify the effects and side-effects of the present medications. Appropriate investigations done at this stage can help in planning and formulating effective therapeutic strategies. During surgery and in the post-operative period as well, only rational prescription of absolutely indicated drugs should be allowed and this can be monitored comprehensively by anesthesiologists if a culture of post-operative rounds is adopted in every health center. [6] Unnecessary use of higher order antibiotics for prophylactic purposes, alternative medicines, sedatives or painkillers, for example, should be discouraged. This helps fulfill the second domain of quaternary prevention, i.e. protecting the patient from new medical invasion. Only those interventions which are ethically acceptable, that is, backed by evidence, or by expert consensus, should be practiced. [7] There often exists a state of equipoise in anesthesia, when there is no definite opinion in favor of, or agonist, a variety of treatments available for a particular clinical situation. An example would be choosing between general anesthesia and neuraxial anesthesia for an upper abdominal surgery. Similar challenging situations can be encountered while administering anesthesia in special population of obstetrics, pediatrics and geriatrics and where one technique has to be chosen over other on an individual basis. Presence of co-morbidities can also affect anesthesia decision making in such circumstances. In such cases, a team-based, multi-disciplinary (surgery, medicine, anesthesiology) decision should be taken preferring the "less invasive" option, whereas keeping practical aspects such as availability of manpower, skills of professionals and physical resources in mind.

Another aspect of this quaternary prevention is the avoidance of promotion of any disease process. [8] This holds true to a larger extent in the critical care units, where risk of cross-infection is high and majority of times it is the health worker who is responsible for cross-infection with pathogens. Equally significant is the situation when an anesthesiologist, who is suffering from blood borne infection like acquired immune deficiency syndrome or hepatitis, transmits the causative organisms to the patients though inadvertently. [9]

The concept of quaternary prevention extends beyond therapeutics in anesthesiology. It also includes diagnostic issues, as well as supportive measures. The anesthesiologist should prescribe diagnostic tests and procedures keeping practical realities in mind. Advising an echocardiography for every pre-anesthetic patient, in a hospital with a waiting list extending into months, for example, could be an example of overmedicalization, medical invasion and ethically unacceptable behavior. Simultaneously, denying a relevant pre-operative investigation to a high risk cardiac patient could be termed medical negligence and is unacceptable. Within the operation theater and critical care unit, too, investigations must be ordered keeping both medical and socio-economic factors in mind. Sometimes, highly skilled procedures are undertaken either for research academics or training purposes for the post-graduates. This also implies to un-necessary performance of invasive procedures such as central venous line insertion in an otherwise healthy patient undergoing minimally invasive procedure where there is minimal risk of bleeding or dynamic fluid shifts. Similar instances can be cited where one keeps on performing neuraxial or epidural punctures in case of a difficult regional anesthesia in spite of repeated failures just as if to regain some "regional glory." The concept of logical empiricism holds good here and is definitely an important component of quaternary prevention. [7] As a matter of fact, quaternary prevention, for example, does not allow one to order serum electrolytes at four hourly intervals and plasma glucose estimations at hourly gaps, unless it is critically indicated or at least there is a competent and specialist healthcare provider trained to act upon those values. The resources are scarce in developing nations and care should be taken by every physician including anesthesiologist to optimally utilize them for care of operative and critically ill patients. [10]

The same logic extends to supportive measures as well. Ordering "non-medical" treatments such as air mattresses, neck supports, diapers, etc., especially in the post-operative and critical care unit makes sense only if these interventions are financially affordable and are demonstrated to improve anesthetic or clinical outcomes. The emphasis should be on adoption of qualitative methodologies and techniques with focus on patient centered care and should be economic and evidence based. [11],[12]

The concept of quaternary prevention is an important aspect of modern medical practice and is relevant for modern anesthesiology as well. As our specialty makes rapid strides in every field, we must not forget a primary dictum of the Hippocratic oaths; "primum non nocere" or "first do no harm." With this in mind, we should be able to identify patients at risk of overmedicalization, ensure that they are protected from unnecessary diagnostic and therapeutic invasion and provide ethically acceptable management options to them.

   References Top

1.De Vito EL. Quaternary prevention, a term not yet included in the Medical Subject Heading (MESH). Medicina (B Aires). 2013;73:187-90.  Back to cited text no. 1
2.Kuehlein T, Sghedoni D, Visentin G, Gérvas J, Jamoule M. Quaternary prevention: A task of the general practitioner. Prim Care 2010;10:350-4.  Back to cited text no. 2
3.Gautam PL. Minimizing medication errors: Moving attention from individual to system. J Anaesthesiol Clin Pharmacol 2013;29:293-4.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Bajwa SJ, Panda A. Alternative medicine and anesthesia: Implications and considerations in daily practice. Ayu 2012;33:475-80.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.Sehgal V, Bajwa SS, Sehgal R, Bajaj A, Khaira U, Kresse V. Polypharmacy and potentially inappropriate medication use as the precipitating factor in readmissions to the hospital. J Fam Med Prim Care 2013;2:194-9.  Back to cited text no. 5
6.Bajwa SS, Takrouri MM. Post-operative anesthesia rounds: Need of the hour. Anesth Essays Res 2013;7:291-3.  Back to cited text no. 6
  Medknow Journal  
7.Bajwa SJ, Kalra S. Logical empiricism in anesthesia: A step forward in modern day clinical practice. J Anaesthesiol Clin Pharmacol 2013;29:160-1.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.Gofrit ON, Shemer J, Leibovici D, Modan B, Shapira SC. Quaternary prevention: A new look at an old challenge. Isr Med Assoc J 2000;2:498-500.  Back to cited text no. 8
9.Bajwa SJ, Kaur J. Risk and safety concerns in anesthesiology practice: The present perspective. Anesth Essays Res 2012;6:14-20.  Back to cited text no. 9
  Medknow Journal  
10.Bajwa SK, Bajwa SJ. Delivering obstetrical critical care in developing nations. Int J Crit Illn Inj Sci 2012;2:32-9.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.Bajwa SJ, Kalra S. Qualitative research in anesthesiology: An essential practice and need of the hour. Saudi J Anaesth 2013;7:477-8.  Back to cited text no. 11
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12.Singh Bajwa SJ. Anesthesiology research and practice in developing nations: Economic and evidence-based patient-centered approach. J Anaesthesiol Clin Pharmacol 2013;29:295-6.  Back to cited text no. 12
[PUBMED]  Medknow Journal  


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