An anesthesiologist plays a vital role in preparing patients for surgery. In the hours and minutes leading up to a surgical procedure, the anesthesiologist takes steps to evaluate the patient, develop an anesthesia plan, obtain informed consent, start IV access, administer preoperative medications, and monitor the patient. Their actions help ensure the patient is optimized for surgery and experiences minimal pain and side effects from anesthesia.
Patient Evaluation
A key part of an anesthesiologist’s preoperative duties involves thoroughly evaluating the patient. This helps the anesthesiologist anticipate issues that may arise and develop an appropriate anesthesia plan. The evaluation typically includes:
- Reviewing the patient’s medical history – Looking for conditions like heart disease, lung disease, sleep apnea, drug allergies, previous issues with anesthesia, and other factors that may impact the administration of anesthesia.
- Conducting a physical examination – Assessing airway anatomy, heart and lung function, baseline vital signs, dentition, spine mobility, and other physiological factors.
- Ordering diagnostic tests – Tests like bloodwork, urinalysis, EKG, and chest X-ray provide additional information about the patient’s health that informs anesthesia care.
- Assessing airway and aspiration risk – Using exams and risk scores to evaluate whether the patient may have a difficult airway or be at risk for pulmonary aspiration.
- Reviewing patient NPO status – Ensuring the patient has followed nothing by mouth (NPO) guidelines prior to surgery to minimize the risk of aspiration under anesthesia.
- Determining anesthesia risk – Using the American Society of Anesthesiologists (ASA) Physical Status Classification System to categorize the patient’s anesthesia risk.
Thoroughly evaluating the patient prior to surgery allows the anesthesiologist to customize the anesthesia plan to the patient’s unique needs and risk factors.
Developing an Anesthesia Plan
After completing the patient evaluation, the anesthesiologist will develop an anesthesia care plan. This outlines the medications, dosages, monitoring, and techniques that will be used to keep the patient safe and comfortable throughout surgery. Key aspects of the anesthesia plan include:
- Type of anesthesia – General, regional, MAC, or combination.
- Airway management – Mask ventilation, intubation, LMA, etc.
- Access – IVs, central line, arterial line.
- Fluids – Rate and composition of IV fluids.
- Medications – Induction drugs, paralytics, vasopressors, antiemetics, analgesics.
- Monitors – Blood pressure cuff, EKG, pulse oximetry, capnography, temperature.
- Positioning – For patient safety and surgical access.
- Postoperative pain control – Regional blocks, NSAIDs, opioids.
The anesthesiologist bases the plan on the surgical procedure, their evaluation of the patient, and goals such as stability, airway protection, and pain control. They often discuss the plan with the surgeon to ensure it aligns with the operative procedure.
Obtaining Informed Consent
Before administering anesthesia, the anesthesiologist will meet with the patient to obtain their informed consent. This involves:
- Explaining the risks and benefits of the planned anesthetic.
- Reviewing potential side effects like nausea, sore throat, drowsiness.
- Discussing pain control options.
- Answering any patient questions.
- Having the patient sign a consent form confirming they understand the anesthesia plan.
Obtaining informed consent adheres to ethical principles and ensures patients understand what to expect with their anesthesia care.
Initiating IV Access
One of the key preoperative steps performed by the anesthesiologist is starting an IV line for the patient. This provides reliable vascular access for:
- Administering fluids – To maintain blood pressure and perfusion.
- Giving medications – Anesthetics, antibiotics, antiemetics.
- Obtaining blood samples – For blood gas and electrolyte analysis.
- Delivering blood products – If bleeding occurs.
The most common sites for IV placement are the forearm, hand, antecubital fossa, and external jugular vein. Ultrasound guidance may be used for difficult access. Some patients may require a central line or arterial catheter as well.
Administering Preoperative Medications
Before wheeling the patient into the operating room, the anesthesiologist often administers various perioperative medications. Examples include:
- Sedatives – Helps relax anxious patients before surgery.
- Opioids – Provide analgesia and enhance the effects of anesthesia medications.
- Antiemetics – Prevent postoperative nausea and vomiting.
- Antacids – Help reduce gastric acidity and aspiration risk.
- Corticosteroids – Reduce airway inflammation from intubation.
- Antibiotics – Prevent surgical site infections.
The choice and dosage is tailored to the patient’s needs and the type of surgery. The anesthesiologist carefully times the administration so the medications have maximal effect during surgery.
Patient Monitoring
Prior to and immediately after inducing anesthesia, the anesthesiologist diligently monitors the patient. This includes attaching EKG leads, pulse oximetry, non-invasive blood pressure cuff, temperature probe, and other monitors. Waveform capnography is used to monitor ventilations after the airway is secured. The anesthesiologist observes all these parameters closely to identify any changes requiring intervention to maintain patient stability.
Documentation
Throughout the preoperative period, the anesthesiologist documents their preparations and assessments in the patient’s medical record. This includes the evaluation findings, consent discussion, anesthesia plan, IV access, medication administration, and monitoring. Thorough documentation is essential for continuity of care and medicolegal purposes.
Time-Out
Before the surgeon makes the incision, the anesthesiology team participates in a time-out. This involves confirming aloud:
- Patient identity.
- Procedure to be performed.
- Correct surgical site marked.
- Antibiotics given.
- Essential imaging reviewed.
The time-out promotes patient safety and prevents errors in the operating room.
Anesthesia Induction
After completing the preoperative preparation steps, the anesthesiologist is ready to induce general anesthesia once the patient is moved into the OR. This involves sequentially administering anesthesia medications, securing the airway, ensuring unconsciousness, and completing final safety checks at the transition point from the preoperative to intraoperative period.
Conclusion
In the critical hour preceding surgery, the anesthesiologist undertakes important steps to get the patient ready for anesthesia and the operation. A systematic approach involves thoroughly evaluating the patient, creating an anesthesia plan, obtaining consent, starting IV access, administering preoperative medications, attaching monitors, documenting activities, and participating in the time-out. Careful preoperative preparation by the anesthesiologist promotes patient safety and improves surgical outcomes.