12/7/2017 General Anesthesia: General Considerations, Preparation for General Anesthesia, The Process of Anesthesia

General Anesthesia
Updated: Nov 30, 2015
Author: Christopher D Press, MD; Chief Editor: Meda Raghavendra (Raghu), MD more...

Preparation for General Anesthesia

Safe and efficient anesthetic practices require certified personnel, appropriate medications and
equipment, and an optimized patient.

Minimum requirements for general anesthesia

Minimum infrastructure requirements for general anesthesia include a well-lit space of adequate
size; a source of pressurized oxygen (most commonly piped in); an effective suction device;
standard ASA (American Society of Anesthesiologists) monitors, including heart rate, blood
pressure, ECG, pulse oximetry, capnography, temperature; and inspired and exhaled
concentrations of oxygen and applicable anesthetic agents. [7, 8, 9]

Beyond this, some equipment is needed to deliver the anesthetic agent. This may be as simple as
needles and syringes, if the drugs are to be administered entirely intravenously. In most
circumstances, this means the availability of a properly serviced and maintained anesthetic gas
delivery machine.

An array of routine and emergency drugs, including Dantrolene sodium (the specific treatment for
malignant hyperthermia), airway management equipment, a cardiac defibrillator, and a recovery
room staffed by properly trained individuals completes the picture.

Preparing the patient

The patient should be adequately prepared. The most efficient method is for the patient to be
reviewed by the person responsible for giving the anesthetic well in advance of the surgery date.

Preoperative evaluation allows for proper laboratory monitoring, attention to any new or ongoing
medical conditions, discussion of any previous personal or familial adverse reactions to general
anesthetics, assessment of functional cardiac and pulmonary states, and development of an
effective and safe anesthetic plan. It also serves to relieve anxiety of the unknown surgical
environment for patients and their families. Overall, this process allows for optimization of the
patient in the perioperative setting. [10]

Physical examination associated with preoperative evaluations allow anesthesia providers to focus
specifically on expected airway conditions, including mouth opening, loose or problematic dentition,
limitations in neck range of motion, neck anatomy, and Mallampati presentations (see below). By
combining all factors, an appropriate plan for intubation can be outlined and extra steps, if
necessary, can be taken to prepare for fiberoptic bronchoscopy, video laryngoscopy, or various
other difficult airway interventions.

Airway management
Possible or definite difficulties with airway management include the following:

Small or receding jaw

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12/7/2017 General Anesthesia: General Considerations, Preparation for General Anesthesia, The Process of Anesthesia

Prominent maxillary teeth

Short neck
Limited neck extension
Poor dentition
Tumors of the face, mouth, neck, or throat
Facial trauma
Interdental fixation
Hard cervical collar
Halo traction

Various scoring systems have been created using orofacial measurements to predict difficult
intubation. The most widely used is the Mallampati score, which identifies patients in whom the
pharynx is not well visualized through the open mouth.

The Mallampati assessment is ideally performed when the patient is seated with the mouth open
and the tongue protruding without phonating. In many patients intubated for emergent indications,
this type of assessment is not possible. A crude assessment can be performed with the patient in
the supine position to gain an appreciation of the size of the mouth opening and the likelihood that
the tongue and oropharynx may be factors in successful intubation (see image below).

Mallampati classification.

High Mallampati scores have been shown to be predictive of difficult intubations. [11] However, no
one scoring system is near 100% sensitive or 100% specific. As a result, practitioners rely on
several criteria and their experience to assess the airway.

In addition to intubation during surgery, some patients may require unanticipated early
postoperative intubation. A large-scale study of 109,636 adult patients undergoing nonemergent,
noncardiac surgery identified risk factors for postoperative intubation. Independent predictors
include patient comorbidities such as chronic obstructive pulmonary disease, insulin-dependent
diabetes, active congestive heart failure, and hypertension. Severity of surgery is also an identified
risk factor. Half of unanticipated tracheal intubations occurred within the first 3 days after surgery
and were independently associated with a 9-fold increase in mortality. [12]

When suspicion of an adverse event is high but a similar anesthetic technique must be used again,
obtaining records and previous anesthetic records from previous operations or from other
institutions may be necessary.
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Other requirements

The need for coming to the operating room with an empty stomach is well known to health
professionals and the lay public. The reason for this is to reduce the risk of pulmonary aspiration
during general anesthesia when a patient loses his or her ability to voluntarily protect the airway.

Published guidelines recommend that solid food (including gum or candy) should be avoided
for 6 hours prior to the induction of anesthesia. [13]
Clear fluids (ie, water, Pedialyte, or Gatorade ONLY; no other liquids) should be avoided for
2-4 hours prior to the induction of anesthesia. [13]

Patients should continue to take regularly scheduled medications up to and including the morning
of surgery. Exceptions may include the following:

Anticoagulants to avoid increased surgical bleeding

Oral hypoglycemics (For example, metformin is an oral hypoglycemic agent that is
associated with the development of metabolic acidosis under general anesthesia.)
Monoamine oxidase inhibitors
Beta blocker therapy (However, beta blocker therapy should be continued perioperatively for
high-risk patients undergoing major noncardiac surgery. [14] )

Recent catastrophes under anesthesia have focused attention on the interaction between
nonprescribed medications and anesthetic drugs, including interactions with vitamins, herbal
preparations, traditional remedies, and food supplements. Good information on the exact content
of these supplement preparations is often hard to obtain. [15]

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