The Preanaesthesia Period: Preoperative Consultation

Clinical assessment

Preoperative testing

Consent and explanation

Telephonic and electronic prescription of premedication drugs

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These standards apply to all patients who receive general or regional anaesthesia, sedation or monitored anaesthesia care. Under unusual circumstances, e.g., extreme emergencies, these standards may be modified. When this is the case, the circumstances must be documented in the patient’s record. At a minimum, a focused preoperative evaluation of the airway, lungs and heart must be carried out and vital signs documented.

The anaesthetist shall be responsible for determining the patient’s medical status, developing a plan of anaesthesia care and acquainting the patient or the responsible adult with the proposed plan, including financial implications.

Appropriate informed consent for anaesthesia should be obtained.

Information is obtained by reviewing the medical record, interviewing the patient regarding the medical history, previous anaesthesia experience, drug therapy, current disease and aspects that may influence perioperative decisions, physical examination and results from special investigations, medical tests or consultations.

Further consultation or investigations may be ordered at this stage, and specific preparation may be implemented.

Results should also be reviewed before anaesthesia. Unnecessary testing may lead to patient harm.

The responsible anaesthetist shall verify that the above has been properly performed and documented in the patient’s record.

Patients with high severity of disease and/or high invasiveness of surgery should be evaluated before the day of surgery. Patients with low severity of disease and medium or low invasiveness of surgery could be evaluated on or before the day of surgery.

Ideally, the anaesthetist who will conduct the anaesthesia should visit the patient before the operation.

At the time of the preoperative consultation, drugs for premedication should be prescribed in writing and signed for on the appropriate document by the anaesthetist or the staff member taking the anaesthetist’s orders.

Premedication may be indicated for sedation, pain management or treatment of underlying disease. This prescription should be available for other persons in the perioperative team to prevent incompatible or duplicate treatment administration.

Clinical assessment

Medical history

The anaesthetist should obtain and record the information by taking a formal history, which may be supplemented with a questionnaire. Electronic/internet questionnaires to elicit patient information may be helpful in providing the anaesthetist with information but must be supplemented by a face-to-face encounter and examination. The patient’s history should include previous or present illnesses, previous anaesthesia and/ or surgical complications, current and recent drug therapy, unusual reactions to drugs, adverse effects in family members to anaesthesia and any further information deemed necessary for the assessment of the individual patient. The patient’s ASA physical status category should be documented.

Physical examination

The above history should be supplemented by a complete physical examination during the preoperative consultation. This includes evaluation of the airway and appropriate systems.

Additional information that might be necessary should be included, e.g.:

• Accurate measurement of the patient’s weight and height should be provided.
• Clinical assessment of cardiovascular and respiratory status should be carried out as considered appropriate by the anaesthetist.
• BP reading should be taken.
• A further systemic examination should be conducted, as is relevant.
• Side-room urine examination should be undertaken, if indicated.

Preoperative testing

Preoperative tests should not be carried out routinely. Taking blood can be a traumatic experience in children. Tests should only be done if they are crucial for optimising patients for surgery. Indications should be documented and based on medical records, history, and physical examination information. Unless the patient’s condition changes acutely, results of tests carried out up to six months before the procedure should be acceptable.

Special investigations are expensive and should only be considered if they change your management of the patient. Duplication of information should be avoided, e.g., information gained from a cardiac echocardiogram in some clinical scenarios may make the need for an ECG and CXR unnecessary.

A 12-lead electrocardiograph

This is not routinely indicated, but in the case of a history that is suggestive of cardiac or pulmonary disease may be indicated in the following circumstances or when symptomatic:

• Recent myocardial infarction or angina
• Congenital heart disease
• Arrhythmia, particularly if symptomatic
• Any previous heart disease or condition predisposing to cardiovascular disease
• Longstanding hypertension
• History of dyspnoea, blackouts and palpitations
• Poorly controlled diabetes
• Older age
• Chronic respiratory disease
• Other risk factors

A chest X-ray

This should be available where:

• Clinical examination indicates lung pathology with remaining functional impairment
• There is a history of haemoptysis
• There is a recent history of thoracic injury
• Clinical grounds to suspect pulmonary hypertension
• Other indications

Preoperative haemoglobin

This should not be carried out routinely but may be indicated by:

• Type and invasiveness of surgery
• Liver disease or renal disease
• Clinical anaemia
• Extremes of age
• Bleeding
• Other haematological diseases

Other special investigations

Other special investigations, such as electrolytes, blood sugar, blood urea and creatinine, coagulation studies, pulmonary function tests, functional tests of cardiac function and echocardiography, should be considered in the light of the findings of the preoperative assessment.

Consent and explanation

1. Informed consent must be obtained.
2. SASA highly recommends that a facility or provincial policy guide the processes/procedures for obtaining informed consent (an example of such a policy can be found at Appendix H). SASA further recommends that anaesthesia-specific consent forms related to all aspects of the anaesthesia service are available (an example of such a form can be found at Appendix H).
3. The patient or guardian must be fully informed regarding all aspects of the planned anaesthesia, including the financial implications. A written fee estimate is required to facilitate this communication in the private sector.
4. The anaesthetist may need to confirm that proper arrangements have been made regarding the scheduling of the procedure.
5. The patient’s fears must be allayed, and information and reassurance should be given. The technique of anaesthesia must be discussed with the patient or caregiver.
6. Only the more common and relevant risks of anaesthesia need to be explained to the patient and/or their family. Explanation of risks should not necessarily include rare and uncommon outcomes that could incur undue anxiety. However, catastrophic outcomes, e.g., death or paralysis, should be mentioned, even if extremely rare. The anaesthetist should, however, explain relatively rare or low-impact risks if this may impact a patient specifically.
7. Explanations and answers to questions posed by the patient should be frank but must be tailored according to:
   • The ability of the patient to grasp the implications fully.
   • The patient’s existing medical knowledge and medical background.
8. It is preferable that a written information sheet with simple information on fasting, anaesthesia, and pain relief is provided to elective patients before hospital admission.
9. The patient is entitled to know the qualifications and experience of the anaesthetist. SASA recommends that the patient is informed about the qualifications and experience of the anaesthetist during the preoperative consultation.

Telephonic and electronic prescription of premedication drugs

Ideally, the patient should be seen in person to prescribe premedication. If the patient is admitted on the same day of surgery and the anaesthetist is busy in theatre, premedication can be prescribed telephonically. A detailed history of the patient, as well as the admission criteria, such as age, weight, and gender, must be available to the anaesthetist. The patient must be attended to by a registered nurse who will observe the patient after premedication. The overall responsibility will remain with the anaesthetist.

- SASA highly recommends that a facility or provincial policy guide the processes/procedures for obtaining informed consent. - SASA further recommends that anaesthesia-specific consent forms related to all aspects of the anaesthesia service are available. - SASA recommends that the patient is informed about the qualifications and experience of the anaesthetist during the preoperative consultation.

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South African Society of Anaesthesiologists (SASA) Practice Guidelines_2022_Reviewed by: A Burke