General Anesthesia - Clinical Tree

Although an anesthesiologist plays a critical role in the perioperative management of patients, it is important that the surgeon be familiar with the general principles of anesthesia and their potential impact on the surgical patient. Surgical care of the patient begins in the preoperative period and extends through the postoperative recovery; therefore understanding by the surgeon of anesthetic techniques and recognition and management of complications is essential. Communication between the surgeon and the anesthesiologist is paramount to good perioperative outcomes.

I

Preoperative Assessment and Preparation

A

Surgical Intervention OR Procedure Being Performed

1.
Careful attention must be paid to verification of site.

B

History and Chart Review

1.
Anesthesia history
- a.
  Past procedures requiring general or regional anesthesia: difficult airway, success of specific techniques, complications?
- b.
  Personal or family history of malignant hyperthermia
- c.
  History of postoperative nausea and vomiting (PONV)
- d.
  History of difficult intubation
2.
Current medications
- a.
  Special attention paid to anticoagulants, beta-blockers, antihypertensives, diuretics, oral hypoglycemics, and antidepressants, especially monoamine oxidase inhibitors
3.
Drug allergies (including latex)
4.
Review of systems
- a.
  Particular attention should be paid to pulmonary and cardiovascular history, including an assessment of functional status with documentation of level of activity.
5.
Consults
- a.
  Previous evaluation by medicine, cardiology, or anesthesia department
6.
Fasting status
- a.
  “Nothing by mouth (NPO) status” (see Chapter 16 for American Society of Anesthesiologists Guidelines)

C

Physical Examination

1.
Vital signs, including height and weight
2.
Airway examination
- a.
  Size of tongue versus pharynx (Mallampati classes I–IV; see Chapter 16 )
- b.
  Cervical spine mobility
- c.
  Anterior mandibular space—distance from the notch of the thyroid cartilage to the tip of the mentum (thyromental distance) while the head is maximally extended; less than 6 cm (receding mandible, short muscular neck) increases the risk for difficulty encountered during intubation.
- d.
  Dentition—noting loose, chipped, cracked teeth and dentures or dental appliances
3.
Neurologic examination —noting preexisting deficits, asymmetry
4.
Cardiovascular examination —noting murmurs, S3 gallop, jugular venous distention
5.
Respiratory examination
6.
Examination of regional anesthesia site (if applicable)
- a.
  Locating surface anatomy and noting abnormalities including signs of localized infection

D

Laboratory Data

1.
Complete blood cell count if history of anemia or ongoing bleeding
2.
Electrolytes (Na ⁺ , K ⁺ ), blood urea nitrogen, and creatinine for patients with a history of renal disease or currently taking diuretics
3.
Prothrombin time, international normalized ratio, and partial thromboplastin time if patient is taking anticoagulants or has history of coagulopathy

E

Radiology, Cardiology, Other Preoperative Testing

1.
Review relevant imaging (plain radiographs, computed tomography, magnetic resonance imaging, ultrasound)
2.
Echocardiogram, exercise or chemical stress test, electrocardiogram (EKG), cardiac catheterization results
3.
Pulmonary function tests (particularly if single lung ventilation is needed)

F

Assessment

1.
Make a detailed problem list including pertinent anesthetic, surgical, and medical issues.

Assign American Society of Anesthesiologists Physical Classification Status using Emergency designation if appropriate ( Table 9.1 ).

TABLE 9.1

American Society of Anesthesiologists (ASA) Classification System ^a

ASA I	A normal healthy patient
ASA II	A patient with mild systemic disease
ASA III	A patient with severe systemic disease
ASA IV	A patient with severe systemic disease that is a constant threat to life
ASA V	A moribund patient who is not expected to survive without the operation
ASA VI	A declared brain-dead patient whose organs are being removed for donor purposes

a The addition of “E” denotes emergency surgery, when delay in treatment would lead to a significant increase in the threat to life or body part.

G

Anesthetic PLAN

1.
Determine appropriate anesthetic technique (see Section II).
2.
Determine whether invasive monitoring (arterial line, central venous line, pulmonary artery catheter, transesophageal echocardiography, etc.) is necessary.
3.
Decide on method for postoperative pain control (intravenous [IV] narcotics, epidural, or nerve block).
4.
Make preliminary decision on patient’s postoperative destination (postanesthetic care unit or intensive care unit [ICU]).
5.
Determine whether special equipment is necessary (double-lumen endotracheal tube [ETT], fiberoptic bronchoscope, etc.).
6.
Explain associated risks and benefits to patient/guardian, and document conversation in the chart.

H

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