Before surgery, thorough preparation helps prevent complications. Here are the essential questions and assessments:

1. Patient History & Medical Background

• Medical Conditions:
  • What comorbidities (e.g., obesity, sleep apnea, hypertension) does the patient have?
  • Are there any previous anesthesia complications or allergies?
  • Mainly look for and screen for obstructive sleep apnea, GERD, cardiac history (does the patient have any stents in). We want to know everything about the patient so we can optimize them for surgery, along knowing What to expect during surgery.
• Medications:
  • Which medications is the patient taking, and could they interact with anesthesia?
  • Make sure you check if they have had any reactions to anesthesia, any food allergies as well (some preparations of propofol have egg/soy lecithin).
    • One of the big adverse reactions regarding anesthesia is known as malignant hyperthermia. Be sure to check if the patient has any history of this or if their family has a history of it.
• Surgical History:
  • Has the patient undergone anesthesia before? What was their response?

2. Airway Assessment

• Anatomical Evaluation:
  • What is the Mallampati score, thyromental distance, and does the patient exhibit features (e.g., short neck, limited neck extension) that might predict a difficult airway?
• Anticipated Challenges:
  • Is there an increased risk of difficult mask ventilation or intubation?
• Equipment Preparation:
  • Is a difficult airway cart and advanced tools (e.g., video laryngoscope) ready if needed?

3. Anesthesia & Surgical Planning

• Anesthetic Technique:
  • What type of anesthesia is planned (general, regional, sedation)?
  • Are there plans to use adjuncts like regional blocks for postoperative pain?
• Risk Stratification:
  • What is the patient’s ASA classification, and how does it affect our plan?
• Team Communication:
  • Have all team members reviewed the plan, including any contingency strategies for airway management?

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Intra-op at Induction: Ensuring a Smooth Start

Once in the operating room, the focus shifts to executing the plan safely. At the induction phase, consider these critical questions:

1. Patient Preparation

• Preoxygenation:
  • Has the patient been adequately preoxygenated to extend the safe apnea time?
• Monitoring Check:
  • Are all monitors (ECG, pulse oximetry, capnography, blood pressure) attached and functioning properly?

2. Induction Process

• Induction Agents:
  • Which IV induction agents (e.g., Propofol) are being used, and are they dosed according to the patient’s clinical status?
• Rapid Sequence Induction (RSI):
  • Is succinylcholine available for a rapid onset of muscle relaxation?
  • Follow-Up: Once succinylcholine wears off, is rocuronium ready to maintain neuromuscular blockade for the duration of the surgery?

3. Airway Management

• Equipment Readiness:
  • Is the difficult airway equipment (e.g., video laryngoscope) immediately accessible?
• Plan Confirmation:
  • Has the airway management strategy been clearly communicated among the team?

4. Continuous Monitoring & Adjustments

• Ventilator Settings:
  • Are ventilator parameters adjusted appropriately, taking into account the patient’s specific needs (e.g., MAC adjustments for volatile agents)?
• Neuromuscular Monitoring:
  • Is neuromuscular function (using tools like Train-of-Four monitoring) being continuously assessed to ensure proper muscle relaxation and timely reversal?

📚 References

1️⃣ Miller RD. Miller’s Anesthesia. 9th ed. Philadelphia, PA: Elsevier; 2020.

2️⃣ Morgan GE, Mikhail MS, Murray MJ. Morgan & Mikhail’s Clinical Anesthesiology. 6th ed. New York, NY: McGraw Hill; 2018.

3️⃣ Steiner J. Anesthesia Made Easy: The Survival Guide to Make Your First Anesthesia Rotation a Success. 2nd ed. Independently Published; 2019.