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CHAPTER 1 Anesthetic Assessment and Premedication
The preoperative visit, Special investigations, Informing the patient, Anesthetic history and examination, Medical referral, Premedication, Risk assessment, Further reading.
The preoperative visit
The main aim is to assess the patient’s fitness for anesthesia and there is no doubt that this is best performed by and anesthetist, preferably the one who is going to administer the anesthetic. The visit allows the most suitable anesthetic technique to be determined, any potential interactions between concurrent diseases and anesthesia anticipated, and finally provides an explanation and reassurance for the patient. Where there is coexisting illness, every opportunity must be taken to improve the patient’s condition prior to surgery. This may mean seeking advice from other specialists to optimize treatments, although the final decision will rest with the anesthetist. In an ideal world, all patients would be seen by their anesthetist sufficiently ahead of the planned surgery to allow any problems identified to be treated without interfering with the smooth running of the operating list. For elective surgery, patients are rarely admitted more than 24 hours in advance and may not be seen by the anesthetist until the evening prior to surgery. The anesthetist frequently relies upon the junior surgical staff to ensure that all patients have a full history and examination so that during their visit they can concentrate on the areas of relevance to anesthesia as detailed below. There are three situations where special arrangements are usually made.
Patients with complex medical or surgical problems. The patient is often admitted several days before surgery and the anesthetist is actively involved in optimizing their condition prior to anesthesia and surgery.
Surgical emergencies. Often only a few hours separates admission and operation in these patients. The anesthetist must be informed as soon as the decision to operate has been made and their advice sought about the need for urgent investigations or treatment. This may occasionally mean delays in surgery, particularly if resuscitation is required.
Day-case patients. These are patients who are planned, non-resident admissions. They are generally ‘fitter’, having been selected specifically for this type of admission, Anesthetic assessment is often carried out by the surgeon or a designated clinic nurse according to a protocol, and the patient’s first contact with the anesthetist is on arrival in the day-case unit. Some units run a preanesthetic assessment clinic.
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