Preoperative Assessment and Documentation

Healthy patients can safely drink fluids up to 2 hours before general anesthesia.

Patients claiming GERD symptoms can have varying risks for aspiration, and diagnosis quality may vary.

Occasional GERD symptoms are treated like other cases. Frequent GERD needs med/tech adjustments for potential aspiration risks.

Measurment of blood pressure, heart rate, respiratory rate, and temperature during the preoperative exam.

Inspection of the airway is part of a pre-operative examination, looking for any problems.

Examining the relevant anatomical areas (including infection/abnormalities) prior to regional anesthetics/invasive monitors.

A focused exam to detect any existing neurological deficits, especially before a regional procedure.

The anesthesiologist examines the patient's airway to ensure safety during the process.

Focuses on exercise tolerance, nutrition, cardiac/pulmonary/endocrine/kidney/liver function, electrolytes, metabolism, and airway/regional anesthesia issues.

Classifies patient risk/health status from 1 (healthy) to 5 (dying).

Determines if patient needs more cardiac evaluation or interventions before surgery.

Elective surgery allows time for more thorough cardiac assessment, unlike urgent surgeries with potentially deadly delays.

Postoperative respiratory issues (depression/failure) are common and can be worse if a patient is obese, has sleep apnea, older, has COPD, has low tolerance, depends on others, or heart failure.

Tests used to diagnose coronary artery disease, same in elective surgical patients and general patients.

Published and updated guidelines from medical societies (e.g., ASA) for evaluating patients before surgery.

A sleep disorder where breathing is repeatedly interrupted during sleep.

A group of lung diseases that block airflow to the lungs.

Identifies patients where surgery may harm more than help, adjusting anesthetic plans, providing risk estimates, and facilitating informed consent.

Patients whose health state is too poor for the procedure to improve their quality of life.

Modifying the anesthesia plan based on patient factors like difficult intubation, family history of complications, or infection near the surgical site.

Providing an estimate of the potential risks associated with the anesthetic.

Discussion of advantages and disadvantages of different surgical options, dependent on the proceduralist's expertise.

A system used to assess a patient's overall health status to predict perioperative risks in surgery.

A patient's agreement to the proposed anesthesia plan after receiving clear information about potential risks and benefits.

A thorough assessment of a patient's health before surgery or a procedure, usually including medical history, physical exam, medication list, allergies, and previous anesthetic experiences.

The discussion of the potential advantages and disadvantages of a surgical procedure, led and owned by the surgeon or proceduralist.

A system to categorize patients based on their overall health and surgical risk, used to guide anesthetic choices.

Tests to assess the heart and blood vessels, performed similarly in elective surgical patients and other patients with related health conditions.

Assessing long-term blood sugar control by measuring hemoglobin A1c.

Patients at risk of blood clots, often with certain medical implants or conditions (e.g., mechanical heart valves).

Delaying non-essential procedures for at least 1 month after coronary interventions (like stenting) to reduce risk.

Healthy patients can safely drink fluids up to two hours before general anesthesia, with evidence supporting carbohydrate/protein-containing fluids reducing nausea and dehydration.

Guidelines recommend delaying non-necessary surgeries for at least a month after coronary interventions.

Preoperative testing is valuable when it indicates a modifiable increased perioperative risk if abnormal results occur and if the test can detect the abnormality when present (avoidable risk if corrected). Testing helps reduce risk if it detects no abnormality.

A type of coronary stent that releases medication to prevent restenosis (re-narrowing of the artery).

A sensitive test correctly identifies an abnormality when present.

A specific test rarely identifies an abnormality when one is not present.

Surgeries scheduled within a year following a coronary intervention may need alternative treatments due to risks.

Anesthesia that numbs a specific area of the body, such as the spinal cord (neuraxial).

Premedication should be given with a specific purpose, not mindlessly.

Medical treatment using drugs to prevent blood clots.

A complete and updated medical history, including all medications, allergies, and previous anesthetic responses, is crucial for the preoperative evaluation.

A potentially dangerous complication of surgery where stomach contents enter the lungs.

The preoperative evaluation aims to identify patients where a specific medical treatment might improve their outcome, possibly delaying surgery.

Helps guide the anesthetic plan by identifying potential risks and ensuring patient safety during the procedure, potentially adjusting the procedure itself.

Increased risk in some patients, such as pregnant women or those with GERD or a full stomach.

Considered to have full stomachs, needing extra care and precautions.

Preoperative evaluation helps assess patient suitability & risk, leading to important discussions about informed consent.

Preparing the patient for surgery through lifestyle adjustments like smoking cessation, nutrition, exercise, or medication adjustments.

Varied, with guidelines from societies (like ASA) demonstrating differences and ongoing updates.

Published guidelines by the American Society of Anesthesiologists.

Testing for pregnancy involves detecting chorionic gonadotropin in urine or serum, though it's controversial and requires patient permission.

A legal doctrine allowing negligence to be inferred from the circumstances of an accident, especially when the harm or injury wouldn't likely occur unless negligence happened.

In US civil cases, causation needs only to be shown by a preponderance of evidence (more likely than not), not beyond a reasonable doubt.

Routine testing for HIV and coagulation studies are not typically indicated before surgery in healthy patients.

Urinalysis is not cost-effective in asymptomatic, healthy patients, but is sometimes required preoperatively by law.

Usually the plaintiff must prove injury was caused directly by the defendant's negligence.

Crucial for trust and understanding, especially with an anesthesiologist, who often meets the patient briefly before the procedure.

A preoperative visit from an anesthesiologist is more effective at reducing patient anxiety than pre-operative sedatives.

Patients must be informed of the procedure's risks, benefits, and alternatives before agreeing to it.

Sedative-hypnotics and opioids are rarely given before elective surgery, especially for outpatient and same-day cases.

Children, especially ages 2-10, may benefit from premedication (like midazolam or dexmedetomidine) to manage separation anxiety in the pre-op area.

Opportunities to build relationships and gather information, including family members (with patient consent).

Various factors can influence the likelihood of a malpractice suit, including the physician-patient relationship and the adequacy of informed consent.

Adults undergoing painful procedures (regional blocks, IV lines) may receive small doses of opioids (e.g., fentanyl) while awake.

Patients needing airway surgery or manipulation may benefit from anticholinergics (glycopyrrolate or atropine) to reduce secretions.

Patients expecting significant post-operative pain may receive multimodal analgesia (combining nonsteroidal anti-inflammatory drugs, acetaminophen, gabapentinoids, and anti-nausea drugs).

Premedication should be given intentionally, not routinely, for specific patient needs and procedures.

Notes documenting a patient's recovery from anesthesia, complications, postoperative condition, and discharge plan (e.g., inpatient, outpatient, ICU).

Inconsistent information in multiple simultaneous records (e.g., anesthesia record, nurses' notes, resuscitation record) which can be used in malpractice lawsuits for allegations of medical errors.

Significant events like cardiac arrest that necessitate special documentation beyond a standard record, to protect the physician.

The area where patients recover from anesthesia until stable.

Checking a recovering patient's condition (vital signs, stability) by an anesthesiologist until stable.

Postoperative notes should document the patient's general condition, anesthesia-related complications, and any treatments.

Lawyers who represent patients or families in cases alleging medical negligence or incompetence.

Records that lack necessary information or details, negatively impacting the defense against claims of fault.

Problems arising from the anesthetic procedures, like persistent issues or complications affecting the patient's recovery.