History: In the perioperative period, a comprehensive evaluation of the patient’s history and physical examination should be performed. Allergies, medications, and recent laboratory results should be reviewed. Relevant cardiac history should be collected and may affect choice of induction medications and cardiovascular monitoring. Evaluation of the timing of recent ingestion of liquids or solid food and any history of gastrointestinal disease such as gastroesophageal reflux is important and may guide in determining the preferable airway device (endotracheal tube [ETT] vs laryngeal mask airway [LMA]) when administering general anesthesia. Diabetic patients should have blood sugars checked before and during surgery to avoid hypoglycemia in the setting of NPO status (Table 11.1). The time of the last oral intake should be confirmed. The patient should be questioned about any individual or family history of difficulty with anesthesia, such as a difficult airway or malignant hyperthermia.
Table 11-1 ASA Practice Guidelines for Preoperative Fasting
Physical examination: The airway examination and evaluation of prior general anesthetics and airway management is a critical portion of the physical examination. If a difficult airway is predicted, alternative intubating devices such as a video laryngoscope and/or a bronchoscope should be available in the operating room (OR) and an awake fiberoptic intubation should be considered.
Pain management: In the perioperative setting, although general anesthesia might be the primary anesthetic for the procedure, the need for regional anesthesia for postoperative pain control should be discussed with the surgical team. Regional nerve block or neuraxial anesthesia should be performed in a timely manner without delaying the surgical procedure. Other medications such as acetaminophen, gabapentin, and cox-2 inhibitors administered before the surgery can reduce the opioid requirement and improve pain control after surgery.
Intravenous (IV) access: Adequate IV access should be obtained before entering the OR. The size and the number of IV catheters placed vary with the procedure, anticipated blood loss, and the need for continuous drug infusions. In patients with significant cardiovascular disease or risk of brain ischemia, blood pressure should be closely monitored during induction and an arterial catheter should be placed preoperatively. If medications used for cardiovascular support (eg, epinephrine and norepinephrine) are likely to be used, a central venous catheter may be placed either before or after induction, depending on whether these are anticipated to be needed on induction or only as the surgical procedure progresses.
Anxiety medications: The preoperative period is one of high anxiety. Reassurance can be effective in mitigating anxiety in most patients. When deemed appropriate, a benzodiazepine (eg, diazepam and midazolam) with or without a small dose of an opioid (eg, fentanyl or morphine) may be administered, particularly when additional preoperative procedures such as epidural catheter or arterial line placement are planned. Patients complaining of pain on arrival in the OR may be given analgesics in incremental amounts to alleviate symptoms. Dosages are based on the patient’s age, medical condition, and anticipated time of discharge. Appropriate monitoring should be used and resuscitative equipment available whenever benzodiazepines or opioids are administered IV.
Drugs to neutralize gastric acid and decrease gastric volume: H2-antagonists, proton-pump inhibitors, nonparticulate antacids, and metoclopramide may be indicated when the patient is at increased risk of aspiration of gastric contents (ie, recent meal, trauma, bowel obstruction, pregnancy, history of gastric surgery, increased intra-abdominal pressure, difficult airway, or history of active reflux). When the risk of aspiration is high, such as when bowel obstruction is present, a nasogastric tube should be placed and the stomach emptied before induction of anesthesia, while promotility drugs should be avoided as they may increase retrograde peristalsis.
Team huddle: Except in emergent circumstances, specific airway, blood loss, or other surgical concerns should be discussed with other members of the care team before taking the patient to the OR (see WHO Surgical Safety Checklist). For the patient at high risk for life-threatening complications (eg, airway loss, nonperfusing arrhythmia, massive hemorrhage, or air embolus), specialized equipment and/or extra help should be immediately available, and preoperatively reviewing pertinent sections of an emergency manual is recommended.