Preoperative Evaluation

1. Pre Operative Assessment Care/Evaluation
• All Patients requiring anesthesia undergo a preoperative evaluation
• Clinical Practice of this assessment has changed dramatically
• Traditionally/Historically
• Patients were seen by Anesthesia provider on or before the day of
surgery
• Other responsibility were taken by the Surgeon or MRP

2. • Now the trend has changed
• anesthesiologists increasingly take on a leadership role
• in preoperative evaluation and preparation, well in advance of the
scheduled surgical procedure.
• Several factors have contributed to this change.

3. • First,
• few patients are admitted to the hospital before surgical procedures.
• OPD base and day base surgery
• Unjustifiable to admit one day before
• Insurance issue
• Second,
• increasing burden of medical comorbidity among surgical patients entails
sufficient time between the preanesthesia evaluation and the planned
surgical procedure
• Third,
• anesthesia care is no longer limited to the operating room. Perioperatove
care specialist

4. Preoperative Clinic
• Anesthesia Provider played a leading role in establishment of preop
clinic.
• For
• Evaluation Preparation for medical complex problem patient for
surgery
• Selective Referral, Specialized testing and intervention
• High level of efficiency and accuracy by anesthesiologist, in Hx,PE,Dx
• And planning of Perioperative management

5. Goals and Benefits of Pre anesthesia
evaluation
• Improve perioperative care
• 3% contribution in adverse events in AIMS without evaluation
• Goals are two folds
• To ensure the patient can safely tolerate anesthesia for planned
surgical procedure
• 2nd
• To mitigate risks associated with overall perioperative procedure
• Post op cardiac or pulmonary complications

6. • A time to take HX, focused Clinical Examination and documentation of
comorbidity
• Discussion of risk and benefits
• Anesthetic plan
• Possible complications
• Patient education
• Optimization of the patient
• Specialized investigation and interventions B blockade

7. The preanesthetic evaluation has specific
objectives, which include
1. establishing a doctor–patient relationship,
2. becoming familiar with the surgical illness and coexisting medical
conditions,
3. developing a management strategy for perioperative anesthetic
care,
4. obtaining informed consent for the anesthetic plan.

8. • The consultation is detailed in the patient's record and concludes
with the anesthetic options and their attendant risks and benefits.
• The overall goals of the preoperative assessment are to reduce
perioperative morbidity and mortality and allay patient anxiety.

9. II. History
• In a study 56% of the correct Diagnosis were made on history alone
• 73% with PE
• In CVS pt. HX 2/3 and PE ¼
• ECG and CXR helped only with 3% of Diagnosis
• Specialized test like cardiac stress test add 6%

10. The Variability in the words
• Patient and Physician use to describe the symptoms
• Chest Pain description
• Angina
• Tightness chest, squeezing pain
• Hx is not asking questions But right Question

11. • History can be taken by anesthesia staff in person
• Telephonic interview
• Patient can complete the form in person Paper or electronic version
• Remotely via web base link

12. • Relevant information is obtained by
• a chart review /Electronic form review
• followed by the patient interview.
• When the medical record is not available, the history obtained from
the patient may be supplemented by direct discussion with the
medical and surgical staff.

13. HOPI
• The Classic HOPI starts with the
• Indication for surgery
• Planned Procedure
• The development of the surgical condition
• Past and present therapies
• Current and past medical problems
• Past surigical procedures
• Anesthetic problems

16. • The history taken is valid for 30 days before the planned procedure
• Reassessment of the patient 48 hours before the procedure

17. • The anesthetist should learn
• the symptoms of the present surgical illness,
• the diagnostic studies performed, presumptive diagnosis, initial treatment,
and responses.
• Vital signs should be reviewed and fluid balance estimated.
•

18. B. Coexisting medical illnesses
• may complicate the surgical and anesthetic course.
• should be evaluated in a systematic “organ systems” approach
• with an emphasis on recent changes in symptoms, signs, and treatment
• In certain circumstances, preoperative specialty consultation may be
advisable.
• For answering specific questions regarding the interpretation of unusual
laboratory tests, unfamiliar drug therapies, or changes from the patient's
baseline status. Consultants should not be asked for a general “clearance”
for anesthesia because this is the specific responsibility of the
anesthesiologist.

19. Medications
• used to treat present or coexisting illnesses,
• their dosages, and schedules must be ascertained. Of special
importance are antihypertensive, antianginal, antiarrhythmic,
anticoagulant, anticonvulsant, and specific endocrine (e.g., insulin)
medications.
• The decision to continue medications during the preanesthetic
period depends

20. • on the severity of the underlying illness,
• the potential consequences of discontinuing treatment,
• the medication's half-life, and
• the likelihood of deleterious interactions with proposed anesthetic
agents.
• As a general rule, medications can be continued up to the time of
surgery.

21. D. Allergies and drug reactions.
• 1:10000 to 1:20000 , NMB 1:5200 to 1:6500
• 50-70% cases NMB,then Latex and AB
• Unusual, unexpected, or unpleasant
• reactions to perioperative medications and
• nonallergic adverse reactions,
• side effects, and
• drug interactions
• are relatively common.

22. • True allergic reactions are
• relatively uncommon. 3% death in anesthesia anaphlactoid
• The task of determining the exact nature of specific “reactions”
• may be difficult.
• Therefore, it is important to obtain a careful description of the
“allergic reaction” experience from the patient.

23. • 1. True allergic reactions
• by direct observation, chart documentation, or description by the
patient
• Any Drug that leads to
• skin manifestations (pruritus with hives or flushing),
• facial or oral swelling,
• shortness of breath, choking, wheezing,
• or vascular collapse
• should be considered to have elicited a true allergic reaction.

24. • Antibiotics
• especially sulfonamides,
• penicillins, and
• cephalosporin derivatives,
• are the most common allergens.

25. • Known allergy to shellfish or seafood
• with intravenous (IV) contrast dye and the
• heparin-reversing agent protamine may occur.
• Known allergy to soybean oil and egg yolk components

26. • A history of “allergy” to halothane or succinylcholine
• warrants special attention,
• because this my represent the occurrence of malignant
hyperthermia,
• halothane hepatitis,
• or prolonged paralysis caused by an abnormal allele responsible for
• production of plasma cholinesterase, an enzyme that metabolizes
succinylcholine.

27. • True allergy to the amide-type local anesthetics
• is exceedingly rare,
• although a syncopal episode, tachycardia, or palpitations in
• the dentist's chair or before starting an IV with injection of local
anesthetic may be falsely labeled as allergic.
• Ester-type local anesthetics (e.g., procaine) can produce anaphylaxis
• PABA preservative causative agent

28. • . Adverse reactions and side effects
• Many perioperative medications can produce memorable unpleasant
side effects
• (e.g., nausea, vomiting,
• and pruritus after narcotic administration)
• in a conscious patient.

29. • Certain rare but important drug interactions
• thiopental may precipitate a fatal episode of acute intermittent
porphyria,
• Pethidine /meperidine may produce a hypertensive crisis when
administered to patients treated with monoamine oxidase inhibitors.
• Newer antiparkinsonian drugs (anticholinesterases) may prolong
paralysis after succinylcholine administration.

30. . Anesthetic history
• Old anesthesia records Should be reviewed for
• Response to sedative/analgesic premedications and anesthetic agents.
• b. Ease of mask ventilation,
• direct laryngoscopy,
• and the size and type of laryngoscope blade
• and endotracheal tube used.
• c. Vascular access
• and invasive monitoring used and difficulties encountered.
• d2.

31. • . Perianesthetic complications
• adverse drug reactions,
• intraoperative awareness,
• dental injury,
• protracted PONV,
• cardiorespiratory instability,
• postoperative myocardial infarction or congestive heart failure,
• unexpected admission to an intensive care unit (ICU),
• prolonged emergence or intubation.
• Patients should be asked about prior anesthetics, including common
complaints such as postoperative nausea and hoarseness and specific
warnings from previous anesthetists describing prior anesthetic problems.

32. . Family history
• A history of adverse anesthetic outcomes in family members should
be evaluated.
• with open-ended questions, such as
• “Has anyone in your family experienced unusual or serious reactions
to anesthesia?”
• Patients should be specifically asked about a family
• history of malignant hyperthermia.
• G. Social history

33. Social history
• Smoking.Pack/year and quit smoking
• Drugs and alcohol
• Stimulant abuse
• Acute alcohol intoxication
• withdrawal from ethanol
• routine use of opioids and benzodiazepines

34. Review of systems
• Acute or chronic lung disease,
• ischemic heart disease,
• hypertension, and
• gastroesophageal reflux
• are examples of commonly encountered coexisting conditions that
increase the risk of perioperative morbidity and mortality. A minimum
review of systems should seek to elicit history of
• the following:

35. • . A minimum review of systems should seek to elicit history of
• the following:
• . A recent history of an upper respiratory infection
• . Asthma,
• . Preexisting coronary artery disease (CAD),
• Diabetes,
• . Untreated hypertension
• Hiatal hernia with esophageal reflux symptoms
• Likelihood of pregnancy

37. Physical examination
• should be thorough but focused.
• Special attention is directed toward
• evaluation of the airway,
• heart, lungs,
• neurologic examination.
• For regional anesthetic techniques
• , detailed assessment of the extremities and back is necessary.

38. Vital signs
• . Height and weight
• BMI can be Calculated
• Blood pressure
• Resting pulse
• . Respirations
• Saturation

40. Airway Examination

41. • Increased neck circumference (>17 inches in men or >16 inches in women)
• • Thyromental distance less than 7 cm with head in maximum extension
• • Higher Mallampati scores
• • Large tongue
• • Inability to protrude the mandible or lower teeth in front of the upper
teeth
• • Facial and neck deformities from previous surgery
• • Previous head and neck radiation
• • Head and neck trauma
• • Congenital abnormalities of the head and neck
• • Rheumatoid arthritis
• • Down syndrome
• • Scleroderma
• • Cervical spine disease or previous cervical spine surgery

42. Malampatti Classification

43. • . Note the size of the oral opening
• b. Measure thyromental distance.
• c. Document loose or chipped teeth
• , artificial crowns, dentures, and other dental appliances. d.
• Note the range of cervical spine motion
• in flexion, extension, and rotation.
• . Document tracheal deviation,

44. • . Precordium
• murmurs, gallop rhythms, or a pericardial rub.
• Lungs.
• reveal wheezing, rhonchi, or rales,
• Abdomen
• evidence of distention, masses, or ascites should be noted,
• because these might predispose
• to regurgitation or compromise ventilation

45. • Extremities
• Muscle wasting and weakness
• general distal perfusion,
• clubbing, cyanosis,
• and cutaneous infection (especially over sites of planned vascular
cannulation or regional nerve block).
• Ecchymosis or unexplained injuries, especially in children, women, or
• elderly patients, can be an indication of an abusive relationship.

46. • . Back
• Note any deformity, bruising, or infection.
• Neurologic examination
• Document mental status,
• cranial nerve function,
• cognition,
• and peripheral sensorimotor function.

47. PREOPERATIVE LABORATORY AND
DIAGNOSTIC STUDIES
• has become a central issue in delivering cost-effective health care to
surgical patients. The role of preoperative testing to screen
• for disease and to evaluate the patient’s fitness for surgery has been
extensively studied. Research in this field
• has largely concluded that a practice of routine preoperative testing
in all surgical patients, without consideration for their age or medical
condition, cannot be justified.
• Unnecessary testing is inefficient and expensive, and it entails
additional technical resources.

48. • Surgeon request more test than anesthesiologist
• Lab test ordering should be based on
• Medical History
• Proposed surgical procedure
• Potential for intraoperative blood loss
• Selective targeted preop testing reduces cost

49. • Recent hematocrit/hemoglobin level. There is no universally accepted
minimum hematocrit level before anesthesia. Hematocrits in the 25% to
30% range
• are well tolerated by otherwise healthy people but could result in ischemia
in patients with CAD. Each case must be evaluated individually for the
etiology
• and duration of anemia. If there is no obvious explanation for anemia, a
delay of surgery may be indicated. Healthy patients who are undergoing
minimally invasive procedures do not need routine hematocrit screen. A
hematocrit screen is recommended for neonates up to 6 months of age,
women over 50 years of age, and men over 65 years of age.

50. • Serum chemistry studies are ordered only when specifically indicated by the
history and physical examination. For example, blood urea nitrogen and
creatinine levels are indicated for patients over 65 years of age or for those with
chronic renal disease, diabetes, cardiovascular disease, intracranial
• disease, hepatic disease, morbid obesity, or in patients using diuretics, digoxin,
steroids, or aminoglycosides.
• 1. Hypokalemia is common in patients receiving diuretics and is usually readily
corrected by preoperative oral potassium supplementation. Most often, mild
• hypokalemia (2.8 to 3.5 mEq/L) should not preclude elective surgery. Efforts to
rapidly correct hypokalemia with IV replacement therapy may lead to
arrhythmias and cardiac arrest. In the face of marked hypokalemia with
arrhythmias, especially in the setting of digoxin use, a delay in surgery to allow
cautious correction is reasonable.

51. • Platelet function may be assessed by a history of easy bruising,
excessive bleeding from gums or minor cuts, and family history.
• 3. Coagulation studies are ordered only when clinically indicated
(e.g., history of a bleeding diathesis, anticoagulant use, or serious
systemic illness) or if
• postoperative anticoagulation is planned.

52. • An electrocardiogram (ECG) is advisable for men over 40 years of age
and women over 50 years of age. Although the resting ECG is not a
sensitive test
• for occult myocardial ischemia, an abnormal ECG mandates
correlation with history, physical examination, and prior ECGs and
may require further workup and consultation with a cardiologist
before surgery.
• D. Chest radiography should be performed only when clinically
indicated (e.g., heavy smokers, the elderly, and patients with major
organ system disease including malignancy and symptomatic heart
disease).

53. . Anesthesiologist–patient relationship
• The perioperative period is emotionally stressful for many patients
who may have fears about surgery (e.g., cancer, physical
disfigurement, postoperative
• pain, and even death) and anesthesia (e.g., loss of control, fear of not
waking up, waking up during surgery, postoperative nausea,
confusion, pain,
• paralysis, and headache). The anesthetist can alleviate many of these
fears and foster trust by

54. • . Conducting an unhurried organized interview in which you convey
to the patient that you are interested and understand his or her fears
and concerns. 2. Reassuring the patient that you will see the patient
in the operating room. If the physician performing the assessment will
not be the anesthetizing
• physician, the patient should be advised and reassured that their
concerns and needs will be competently relayed and addressed.
• 3. Informing the patient of the events of the perioperative period,
including:
•

55. • The time after which the patient must have nothing to eat or drink (nothing by mouth [NPO]).
• b. The estimated time of surgery.
• c. The need for sedative premedications (see section VIII.B.) and whether the patient's daily medications
should be continued as usual.
• d. The need for autologous blood donation. This usually is indicated for only a limited number of surgical
procedures such as total joint arthroplasty,
• radical prostatectomy, and extensive spine surgery.
• e. Management of aspirin and nonsteroidal anti-inflammatory drug (NSAID) therapy. Newer NSAIDs that
inhibit the cyclooxygenase-2 enzyme do not
• interfere with platelet function and do not need to be discontinued before surgery.
• f. Tasks to occur on the day of surgery (e.g., placement of IV or arterial catheters, routine monitoring devices,
epidural catheters) with reassurance that
• supplemental IV sedation and analgesia will be provided as necessary during this period.
• g. Postoperative recovery either in the postanesthesia care unit or ICU for closer observation.
• h. Plans for postoperative pain control.

56. Informed consent
• . Informed consent involves discussing the anesthetic plan, alternatives, and potential
complications in terms understandable to the lay person. It is strongly preferable that this
discussion is conducted and any forms written in the patient's native language.
• 1. Certain aspects of anesthetic management are outside the realm of common experience and
must be explicitly defined and discussed beforehand.
• Examples include endotracheal intubation, mechanical ventilation, invasive hemodynamic
monitoring, regional anesthesia techniques, blood product transfusion, and postoperative ICU
care.
• 2. Alternatives to the suggested management plan should be presented, because they may
become necessary if the planned procedure fails or if there is a change in clinical circumstances.
• 3. Risks associated with anesthesia-related procedures should be disclosed in a way that a
reasonable person would find helpful in making a decision. In general, disclosure applies to
complications that occur with a relatively high frequency, not to all remotely possible risks. The
anesthetist should familiarize the patient with the most frequent and severe complications of
common procedures, including:

61. • Regional anesthesia: headache, infection, local bleeding, nerve injury, and
drug reactions. In patients for whom a regional technique is planned, a
• discussion of general anesthesia and its attendant risks is suggested,
because general anesthesia “backup” may be necessary.
• b. General anesthesia: sore throat, hoarseness, nausea and vomiting,
dental injury, allergic drug reactions, and cardiac dysfunction (in patients
with
• known cardiac disease).
• c. Blood transfusion: fever, infectious hepatitis, HIV infection, and
hemolytic reactions.
• d. Vascular cannulations: peripheral nerve, tendon, or blood vessel injury;
hemothorax; pneumothorax; and infection.

62. Anesthesia consultant's note
• A concise legible statement of the date and time of the interview, the
planned procedure, and a description of any extraordinary
circumstances regarding the anesthesia (e.g., locations outside the
operating room).
• B. Relevant positive and negative findings from the history, physical
examination, and laboratory studies.
• C. A problem list that delineates all disease processes, their
treatments, and current functional limitations; medications and
allergies are included. D. An overall impression of the complexity of
the patient's medical condition

63. ASA Physical Status Classes:
• Class 1. A healthy patient (no physiologic, physical, or psychologic abnormalities).
• Class 2. A patient with mild systemic disease without limitation of daily activities.
• Class 3. A patient with severe systemic disease that limits activity but is not
incapacitating.
• Class 4. A patient with an incapacitating systemic disease that is a constant threat
to life.
• Class 5. A moribund patient not expected to survive 24 hours with or without
operation.
• Class 6. A declared brain-dead patient whose organs are being removed for donor
purposes.
• Note: If the procedure is performed as an emergency, an E is added to the
previously defined ASA Physical Status

64. The anesthesia plan
• in the hospital record is used to convey a general management strategy
(e.g., suggestions for further preoperative evaluation, premedications,
intraoperative monitoring, and postoperative care). If the author of the
plan is not scheduled to actually administer care on the day of
• surgery, this person should avoid defining precise details of the anesthetic
agents or techniques to be used, because these will be determined by the
anesthesia team providing care. In the healthy uncomplicated patient,
completion of a preanesthesia form is adequate, but when the history
needs to be detailed (i.e., the patient with cardiovascular disease) it
should be in a formal legible progress note. If important comorbid
problems are present, it is imperative to convey this information directly to
the anesthesia team responsible in advance of the surgery.

65. Guidelines for NPO status
• Generally, adults should not eat solids after midnight of the day
before surgery but may have clear fluids up to 2 hours before their
procedure.
• Infants or children may have milk, formula, breast milk, or solid food
up to 6 hours before surgery and clear liquids up to 2 hours before
surgery .
• More restrictive instructions may be necessary for some patients,
such as those with active reflux or those undergoing gastrointestinal
tract operations

66. Premedication
• In the Past virtually every patient received premedication before
arriving in the preoperative area. The belief was that all
• Patients benefitted from preoperative sedation and anticholinergic
+an opioid.
• With the move to outpatient surgery and “same-day” Hospital
admission,
• preoperative sedative ,hypnotics or opioids are now almost never
administered before patients arrive in the preoperative holding area
for Elective surgery.

67. • Children,especiallythoseaged2to10yearswho(alongwith
• theirparents)likelywillexperienceseparationanxietymaybenefitfro
m
• premedicationadministeredinthepreoperativeholdingarea.Thisto
picis
• discussedinChapter42.Oralorintravenousmidazolamornasal
• dexmedetomidinearecommonmethods.Adultsoftenreceiveintrav
enous
• midazolam(2–5mg)onceanintravenouslinehasbeenestablished.

68. • Children, especially those aged 2 to 10 years who likely will
experience separation anxiety may benefit from premedication
administered in the preoperative holding area.
• Oral or intravenous midazolam or nasal Dexmedetomidine
• Adults often receive intravenous midazolam (2–5 mg) once an
intravenous line has been established.

69. • Painful Procedure (eg,regional block or a CVP line insertion) when the
patient remains awake, small doses of opioid-fentanyl
• multimodal”analgesia, including various combinations
• Of NSAIDs, Paracetamol , gabapentinoids, and anti-nausea drugs in
the preoperative holding area.
• The fundamental message Here is that
• premedication should be given purposefully, not as a mindless
routine

70. • The goals of administering sedatives and analgesics before surgery are to
allay the patient's anxiety; prevent pain during vascular cannulation,
regional
• anesthesia procedures, or positioning; and facilitate a smooth induction of
anesthesia. It has been shown that the requirement for these drugs is
reduced after a thorough preoperative visit by an anesthesiologist.
• 1. In elderly, debilitated, or acutely intoxicated patients and in those with
upper airway obstruction or trauma, central apnea, neurologic
deterioration, or
• severe pulmonary or valvular heart disease, doses of sedatives and
analgesics should be reduced or withheld.
• 2. Patients addicted to opioids and barbiturates should be premedicated
sufficiently to prevent withdrawal during or shortly after surgery.

71. • Sedatives may be given to calm the anxious patient and help provide a
restful night of sleep before surgery. 1. Benzodiazepines
• a. Diazepam (Valium) rarely produces significant cardiovascular or
respiratory depression at recommended doses. A dose of 5 to 10 mg orally
(PO) 1 to 2 hours before surgery usually suffices. Diazepam should not be
given intramuscularly (IM) because injection is painful and absorption
unpredictable.
• b. Lorazepam (Ativan) may be used (1 to 2 mg PO) but usually causes more
intense amnesia and prolonged postoperative sedation.
• c. Midazolam (Versed), 1 to 3 mg IV or IM, is most frequently used in the
induction area as a supplemental premedicant and provides excellent
amnesia
• and sedation.

72. • . Barbiturates such as pentobarbital (Nembutal) are rarely used for
preoperative sedation, although they are occasionally used by
nonanesthetists for
• sedation during diagnostic procedures (e.g., endoscopy, magnetic
resonance imaging, and computed tomography).
• Opioids are most frequently given in the preoperative setting to relieve
pain (e.g., patient with a painful hip fracture) and occasionally when the
placement
• f extensive invasive monitoring devices is planned. Morphine is the
primary opioid used, because it has both analgesic and sedative properties.
Usual adult doses are 5 to 10 mg IM, 60 to 90 minutes before coming to
the operating room.

73. • Anticholinergics are seldom used preoperatively. Occasionally useful
agents include the following
• 1. Glycopyrrolate (0.2 to 0.4 mg IV for adults and 10 to 20 µg/kg for
pediatric patients) or atropine (0.4 to 0.6 mg IV for adults and 0.02 mg/kg
for pediatric
• patients) is given IV during ketamine induction and during oral/dental
surgery as an antisialagogue.
• 2. Scopolamine may be given in combination with morphine IM before
cardiac surgery to provide additional amnesia and sedation. The adult dose
is 0.3 to
• 0.4 mg IM.

74. • . Guidelines for prophylaxis for pulmonary aspiration have been
recommended by the ASA and may be beneficial for patients at high
risk for aspiration
• pneumonitis, including the parturient and those with a hiatal hernia
and reflux symptoms, a difficult airway, ileus, obesity, or central
nervous system depression.

75. • . Histamine (H2) antagonists produce a dose-related decrease in gastric acid production.
Cimetidine (Tagamet), 200 to 400 mg PO, IM, or IV, and
• ranitidine (Zantac), 150 to 300 mg PO or 50 to 100 mg IV or IM, significantly reduce both the
volume and acidity of gastric secretions. Multidose regimens (i.e., the night before and morning
of surgery) are the most effective, although parenteral administration may be used to achieve a
rapid (<1 hour) onset. Cimetidine has been shown to prolong the elimination of many drugs,
including theophylline, diazepam, propranolol, and lidocaine, potentially increasing the toxicity of
these agents. Ranitidine has not been associated with such side effects.
• 2. Nonparticulate antacids. Colloidal antacid suspensions effectively neutralize stomach acid but
can produce serious pneumonitis if aspirated. Nonsuspension antacids, such as citric acid
solutions (Bicitra, 30 to 60 mL, 30 minutes before induction), may be less effective in increasing
gastric pH,
• but their aspiration is less harmful.
• 3. Metoclopramide (Reglan) is a dopamine antagonist that enhances gastric emptying by
increasing lower esophageal sphincter tone while simultaneously
• relaxing the pylorus. An oral dose of 10 mg is given 1 to 2 hours before anesthesia or
intravenously in the induction area as soon as the IV is inserted. When administered
intravenously, it should be given slowly to avoid abdominal cramping. Metoclopramide also has
an antiemetic effect. Metoclopramide can precipitate a dystonic reaction, which can be treated
with diphenhydramine, 25 to 50 mg IV. Metoclopramide is contraindicated in the presence of
bowel obstruction, where it may increase retrograde peristalsis.

76. DOCUMENTATION
• Physician must document the care that they provide.
• Adequate documentation provides guidance to those who will
encounter the patient in the future.
• Permits others to assess the qualityof the care that was given
• Finally, adequate and organized documentation (as opposed to
inadequate and disorganized documentation) supports a potential defense
case should a claim for medical malpractice be filed.

77. Preoperative Assessment Note
• Should appear in the patient’s permanent medical record
• Should describe pertinent findings, including the
• Medical history,
• Anesthetic history,
• Current medications (whether they were taken on the day of surgery),
• Physical examination,
• ASA physical status,
• Laboratory results,
• interpretation of imaging,
• electrocardiograms,
• Pertinent recommendations of any consultants. A comment is particularly important
when a consultant’s recommendation will not be followed.

78. • anesthetic plan,
• Regional or general anesthesia or sedation will be used,
• whether invasive monitoring or other advanced techniques
• statement regarding the informed consent discussion with the
patient or guardian.

79. Documentation of the informed consent
discussion
• indicating that the plan, alternative plans, and their
advantages and
• disadvantages (including their relative risks) were
presented, understood, and
• accepted by the patient.
• Some centre consent by surgery including anesthesia

80. • Punjab Health Commission and JCI requires an immediate
preanesthetic “reevaluation” to determine whether the patient’s
status has changed in the time sincethe preoperative evaluation was
performed.
• This reevaluationmight include a review of the
• Medical record to search for any new
• laboratory results Or consultation reports
• if the patient was last seen on another date.

81. Intraoperative Anesthesia Record
• Serves many purposes.
• Documentation of intraoperative monitoring,
• A reference for future anesthetics for that patient,
• Source of data for quality assurance.
• This record should be
• terse, pertinent, and accurate.
• overthe traditional paper record or
• generated automatically and recorded electronically by
(AIMS)(HIMS).

82. Document the anesthetic care in the operating
room by including the following elements:
• A preoperative check of the anesthesia machine and other relevant
equipment
• A reevaluation of the patient immediately prior to Induction of
anesthesia
• Time of administration, dosage, and route of drugs given
intraoperatively
• Intraoperative estimates of blood loss and urinary output
• Results of laboratory tests obtained during the operation

83. • Intravenous fluids and any blood products administered
• Pertinent procedure notes (eg, for tracheal intubation or insertion of
invasive monitors)
• Any specialized intraoperative techniques such as hypotensive
anesthesia,
• one-lung ventilation, high-frequency jet ventilation, or cardiopulmonary
• bypass
• Timing and conduct of intraoperative events such as induction,
positioning, surgical incision, and extubation
• Unusual events or complications (eg, cardiac arrest)

84. • Condition of the patient at the time of “handoff” to the post
anesthesia or intensive care unit nurse
• Documenting critical incidents, such as a cardiac arrest.
• In such cases, a separate text note inserted in the patient’s medical
record may be necessary.

85. Postoperative Notes
• After accompanying the patient to the (PACU),
• The anesthesia provider should remain with the patient until normal
vital signs have been measured and the patient’s condition is deemed
stable.
• An unstable patient may require being “handed off” to another
physician.

86. Before discharge from the PACU,
• A note should be written by an anesthesiologist to document
the patient’s
• recovery from anesthesia, any apparent anesthesia-related
complications,
• immediate postoperative condition of the patient, and the
patient’s disposition
• (discharge to an outpatient area, an inpatient ward, an intensive
care unit, or home).

87. • Recovery from anesthesia should be assessed at least once
within
• 48 h after discharge from the PACU in all inpatients.
•

88. • Elements required by the Center for Medicare
and Medicaid
• Services in all postoperative notes.