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Assuming the patient’s condition merits it, the process of preparation for surgery starts with the specialist taking a history and examining the patient.
Examples of conditions that are important to identify in the pre-operative history are conditions that may have an adverse impact on the outcome of either surgery or anaesthesia. Every patient’s level of risk will be estimated, usually by classifying him or her according to the system adopted by the American Society of Anesthesiologists for assessing preoperative physical status. The higher the number awarded, the greater the chance of prolonged hospital stay or postoperative complications. Examples of conditions that add to the classification numbers are: A previous history of heart failure, coronary artery disease, history of a myocardial infarction, poorly controlled hypertension, symptomatic irregularities of the heartbeat (make you breathless or feint), hormone disorders (low thyroid), respiratory problems (shortness of breath), anaemia and insulin dependent diabetes. The range of a preoperative investigations and referrals depend on how well the patient is. If the patient is found to have a previously unknown condition (like diabetes or profound anaemia), has a significant past medical history (blood clots or recent heart attack) or is on medication that may need to be modified due to surgery (anticoagulants), then it is likely that the patient will be referred to an appropriate specialist to determine the cause and extent of the problem before surgery can go ahead. It is not just the patients current condition that is important, so too is the past medical history and that of the family, especially if untoward effects occurred as a result of anaesthesia (scoline apnea or malignant hyperthermia).
Patients’ current list of medications is important as it provides further information about any concurrent illness.
Herbal medications should be stopped at least 7 days before surgery, owing to the uncertainly over their actual contents and adverse effects on clotting. Common drugs that have been associated with withdrawal or rebound symptoms when discontinued preoperatively include selective serotonin reuptake inhibitors (SSRIs), beta-blockers, clonidine, statins, and corticosteroids. In general, most non-steroidal anti-inflammatory drugs may be stopped at least 3 days before surgery as they may interfere with clotting. ACE inhibitors (ramipril) and angiotensin receptor blockers may significantly intensify the hypotensive effects of anaesthesia. Among psychotropic drugs, SSRIs, benzodiazepines and antipsychotics are generally safe to continue perioperatively but the anaesthetist should be made aware. Patients should be encouraged to drink when ready, providing there are no contraindications. The anaesthetic team should consider further interventions for children at higher risk of regurgitation and aspiration. There is often controversy regarding the necessity of laboratory studies especially in health adults.
Patients using diuretics or digitalis require a current (7 days) serum potassium level and blood glucose levels should be obtained on the day of surgery for medication dependent diabetics.
A full blood count (FBC) and biochemistry screen are helpful if a patient is receiving chemotherapy. In addition, not all patients are candidates for surgery outside of the hospital, such as at a freestanding surgery center. Patients are normally contacted prior to hospital admission with written instructions on how to prepare for the surgery.
Most hospitals employ theatre checklists before a patient leaves the ward, on arrival in theatre and after a patient is put to sleep.
Until relatively recently surgical procedures requiring general anaesthesia were almost always conducted in well-equipped hospital environments in the presence of trained nurses and doctors.
Both the American physician based and nurse based professional bodies for anesthesia have issued guidelines and check lists that are designed to enhance patient safety. Does the doctor have credentials to perform the surgery in a hospital or outpatient surgery center? Will a qualified anesthesiologist or certified registered nurse anesthetist (supervised by an anesthesiologist or other qualified physician) give the anesthesia? Is the anesthesia equipment equivalent to that used in a hospital or ambulatory surgical facility?
Is the recovery area equipped similarly to one in a hospital or ambulatory surgery facility?
The patient should carry the results of laboratory or X-ray investigations to the place of surgery on the day of surgery. At the end of any surgical intervention the patients who have been sedated will be allowed to awaken by discontinuing the sedative drugs.


During the surgery the patients airway is protected either by a small plastic tube placed just in the mouth (Guedel), a laryngeal mask airway (LMA) or a tube (Endotracheal tube or ET tube) placed in the trachea usually via the mouth but sometimes via the nose. The PACU is where patients’ vital signs are observed and recorded postoperatively in the same manner as during the operation. For example a patient having bilateral knee replacements by the same surgeon, performing the same technique one after the other on the same day may reveal one severely painful joint and one with no pain at all. Pain relief on the ward may be achieved by a similar multi-modal method via the oral route or by intravenous painkillers administered via a CPU controlled syringe driver regulated by the patient on demand (PCA patient controlled analgesia). A period of at least 24 hours with an accompanying adult is usually recommended for patients who have had an anaesthetic. This person came to the emergency department with a painful bump after the wrist was hit by a car door. In the UK’s National Health Service a family doctor (General practitioner, GP) will act as the “gatekeeper”, only referring patients to a specialist if they think the condition merits it or on the insistence of a patient. They should ensure the patient is fully informed about their proposed procedure and the interventions that will need to be undertaken. A more detailed preoperative assessment (POA) will be obtained by either the patient’s family doctor, or a specially trained pre assessment nurse (PAC, pre assessment clinic) or the anesthesiologist (anaesthetist).
Patients classified as ASA IV and above are not normally candidates for elective surgery, only emergency surgery. 2 Deciding to stop or continue them should only ever occur following discussion with your surgeon or anaesthetist as the consequence of stopping drugs inappropriately may be disastrous. This is not always the case, for example if you have cardiac stents stopping aspirin may be dangerous. Their purpose is to avoid either vomiting or passive regurgitation into the back of the mouth where the stomach contents may access the lungs and impair oxygen uptake.
Routine preoperative laboratory screening is not cost-effective or predictive of postoperative complications. These include instructions on preoperative fasting, which medications to take or omit and skin preparation with chlorhexidine antiseptic. In the UK small hospitals and clinics, including dental surgeries have been actively discouraged from undertaking procedures requiring the services of an anaesthetist. All these Web sites provide excellent educational information for the public as well as brochures that can be obtained for personal use.
Acute deterioration in health should be notified to the hospital (colds or flu) especially if symptoms develop after contact with ill friends or family. Patients easily understand reasonable explanations regarding changes in operating list schedules due to equipment issues. The latter is usually placed with the help of muscle relaxants and is required when the surgery requires a patient’s chest to be ventilated mechanically. Patients are also observed for nausea, pain, low body temperature, and adequacy of urine output and completeness of fluid or blood replenishment. Patients should be made aware preoperatively of the possibility of both these side effects of anaesthesia. If pain is severe, intravenous doses of strong painkillers (morphine) may be injected in small repeated doses after short intervals until the pain is brought rapidly under control. This multi-modal technique for postoperative pain relief is time consuming but effective and is less prone to induce nausea and vomiting. Most anaesthetists will review their patients on the ward at the end of an operating list and before going home. Patients who try to mislead staff and attempt to drive themselves home may be reported to police authorities immediately for driving under the influence of intoxicating substances otherwise the hospital may be held equally culpable in the event of an accident. Primary care can help optimize patients’ fitness before surgery by offering advice on smoking cessation, exercise and weight reduction, and by optimizing treatment of chronic conditions such as diabetes and anaemia. Every patient should be given sufficient information that they can understand their own individual risk and thus make an informed decision about whether to proceed to surgery.
If the patient has a raised ASA classification and the proposed surgical procedure is major then they will be investigated to a greater degree.
Unfortunately many patients taking over-the-counter medicines and herbal or nutritional remedies omit to mention them (Complementary and alternative drugs, CADs).


Complementary and Alternative Drugs Use among Preoperative Patients: A Cross-Sectional Study in Italy Evidence-Based Complementary and Alternative Medicine. Conditions that increase this rare but avoidable risk include anxiety, ascites, esophageal surgery, narcotic use, pain, hiatus hernia, gastro esophageal reflux disease (GORD), bowel obstruction, diabetes, neurologic problems (seizures, head injury), pregnancy, recent dialysis and?a full stomach.
Information regarding length of hospital stay and sometimes anesthesia and postoperative care may also be available.
The primary motivation was patient safety and secondarily economies of scale when equipment purchases are being made. The effects of sedative and anaesthetic drugs wear off by simply discontinuing their administration to the patient. This tube is never removed before a patient can breath for himself or herself and is only removed by a trained anaesthetist or intensive care nurse. In the UK the point at which a patient asks for any pain relief is technically the point at which responsibility for the patient becomes the recovery nurse’s. At the same time non-steroidal anti-inflammatory drugs may be commenced and intravenous paracetamol (acetaminophen, Tylenol) given.
A resident doctor trained in advanced life support is usually on call for emergencies in good hospitals. 1 The American Society of Anesthesiologists’ (ASA) Practice Guidelines for Postanesthetic Care indicate that the following should be mandatory for all patients who have just received general anesthesia, regional anesthesia, or moderate or deep sedation: “As part of a recovery room discharge protocol, all patients should be required to have a responsible individual accompany them home,” to increase patient comfort and satisfaction and to reduce adverse outcomes.
Private hospitals, if contacted directly, will put patients in touch with specialists but they will still usually require a letter from their own doctor especially if the costs are to be covered by health insurance.
At this time the patient may be tested for MRSA using skin swabs applied to the groin and in the nose. Extubation is commonly done in the operating theatre where the drugs and equipment are readily at hand should they be, rarely, required. However the anaesthetist should always be available in the hospital until all their patients have been discharged from the recovery ward or admitted to an intensive care ward. Predicting the degree of postoperative pain that a patient should anticipate is impossible. Day case patients undergoing minor or even non-painful intermediate surgery will be discharged to the care of a responsible adult. Googling “preoperative medical history checklist images” reveals examples of such checklists. With the pressure of economics and the bureaucratic burden of hospital regulations there has been a trend to move towards an office based surgical service including procedures requiring general anaesthesia. Patients are transferred at this point to the recovery or post anaesthesia care ward (PACU).
In certain of the United States the PACU is considered an intensive care ward and strict patient to staff ratios are, or should be, observed. Whilst licensing regulations may be less stringent in an office-based practice, it is important that patients receive the same level of medical expertise and contemporary technology that would be found in larger hospitals. Some anesthetists avoid giving the antidote as these drugs may produce colic and a dry mouth.
However, more recent data have shown that care in ambulatory settings is comparable to hospitals and ambulatory surgery centers, especially when offices are accredited and their proceduralists are board-certified.2 There is a lack of state and federal oversight of office-based facilities. If no antidote is to be given then the degree of residual muscle relaxation is tested for by means of a nerve stimulator before the patient is allowed to wake up.
Increased regulation and standardization of care, such as the use of checklists and professional society guidelines, can help promote safer practices. 3 The demand for cosmetic surgery is considered one of the driving factors in the exponential growth of office-based anesthesia.




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