Preprocedural evaluation: considerations outside of the operating room.

PURPOSE OF REVIEW: There are an increasing number of procedures performed in locations outside of the operating room both for children and adults. From the perspective of the anesthesiologist, the preprocedural evaluation is essential in providing safe and high-quality care. This review focuses on the purpose, considerations and methods for providing information during the preprocedural evaluation process based on the most recent literature review. RECENT FINDINGS: Upon review of the literature, there is an agreement that a preprocedural evaluation is fundamental to the management of our patients. This evaluation is the process of clinical assessment that precedes the delivery of anesthesia for all procedures. Consideration must be given to information from many sources and consultation ordered only as necessary. A determination of the medical condition as indicated by the American Society of Anesthesiologists score must be applied. The evaluation process is relatively standard across institutions. It appears to be more clearly defined among adult patients particularly when presenting with multiple comorbidities, and will tend to be assessed days to weeks prior to the scheduled procedure. Differences may exist, however, among an institutions' overall approach to the preprocedural evaluation of children. Ultimately, the results are efforts by the institutions to improve efficiency, reduce delays and cancellation rates. SUMMARY: It is important for the anesthesia provider to perform a thorough preprocedural evaluation. Tests that are ordered as part of the evaluation are done to understand the current medical state, verify a condition or formulate a plan. Informed consent must be obtained and the risks and benefits of the anesthesia plan in a manner understandable to the patient and parent or care giver.Many pediatric patients undergoing procedures outside of the operating room are in good health, and their evaluation will be relatively routine. Other children will present with complex medical conditions that require more time for the evaluation process. This may include the consultation of a pediatric specialist(s) as a necessary step toward completion of the preprocedural evaluation.Similarly, there are adult patients undergoing procedures outside of the operating room, which will have a straightforward preprocedural evaluation and others are more complex. Disease states that might require further testing include diabetes, leukemia, kidney and liver disease, central nervous system disease, malabsorption syndrome, coronary artery disease, coagulopathies and patients on diuretics.

Differential diagnosis of delayed awakening from general anesthesia: a review.

With the general use of fast acting anesthetic agents, patients usually awaken quickly in the post operative period. However, sometimes recovery is protracted and the list of possible causes in long. Accurate diagnosis is key to institution of appropriate therapy.

Hypotension on induction: anaphylaxis or cardiac failure?

Identification of the cause of hypotension after induction of anesthesia is critical as treatment differs. We describe a case of anaphylaxis in a patient with severe cardiac disease, diagnosed by echocardiography and successfully treated with immediate cardiovascular resuscitation, epinephrine, vasopressors and antihistamines.

Integrating perioperative information from divergent sources.

The enormous diversity of physician practices, including specialists, and patient requirements and comorbidities make integration of appropriate perioperative information difficult. Lack of communicating computer systems adds to the difficulty of assembling data. Meta analysis and evidence-based studies indicate that far too many tests are performed perioperatively. Guidelines for appropriate perioperative management have been formulated by several specialties. Education as to current findings and requirements should be better communicated to surgeons, consultants, and patients to improve healthcare needs and at the same time decrease costs. Means to better communication by interpersonal collaboration are outlined.

Cerebral oximetry: a replacement for pulse oximetry?

Cerebral oximetry has been around for some 3 decades but has had a somewhat checkered history regarding application and reliability. More recently several monitors have been approved in the United States and elsewhere and the technique is emerging as a useful tool for assessing not only adequate cerebral oxygenation but also tissue oxygenation and perfusion in other organs.

Deceptive level after intrathecal block for cesarean section in a patient with prior abdominoplasty--a case report.

Abdominoplasty is performed in an increasing number of patients, both male and female. The removal and hence rearrangement of abdominal skin may make assessment of the dermatome level of a subarachnoid block difficult. Also patients may hesitate, or even forget, to reveal cosmetic surgeries during the preanesthetic interview. Therefore it is important to maintain a high index of suspicion in patients who have had bariatric surgery. In this report we present the case of a deceptive anesthetic level in a parturient with an undisclosed history of abdominoplasty who presented for Cesarean section.

Post-operative respiratory complications after palatoplasty in a 19-month-old female with Cornelia de Lange syndrome--a case report.

Cornelia De Lange syndrome is a rare genetically heterogeneous and sporadic syndrome, with an estimated prevalence of 1 in 10,000 to 30,000. The disorder may present many complications during anesthesia due to cardiac, gastrointestinal and airway anomalies. We report a case of an ex premature toddler presenting for repair of a cleft palate. Postoperatively she had respiratory distress, successfully treated by the anesthetic care team Causes for the complication are discussed.