INITIAL ASSESSMENT

Failure to make a proper assessment of the patient’s condition is one of the commonest and most easily avoidable causes of mishaps associated with anaesthesia.

The initial assessment of a patient includes taking a full medical history. The events leading up to admission should be carefully considered: for example, following an accident:

The history is also important with non-trauma emergency surgery but, when there are delays in reaching hospital, perhaps of a week or even a month, the events that started the illness may have been forgotten.

The history of previous surgery is important. In areas of high HIV prevalence for example, peritonitis is a common complication 7–10 days after a caesarean section.

In the case of a child with a breathing difficulty, listen carefully to the history from the parent or guardian. Could there be a foreign body? If there is fever, croup or epiglottitis may be more likely. If a child has a sudden onset of airway obstruction you may learn, on questioning the parents, that the problem has been there intermittently for a longer period, making laryngeal polyps more likely.

In the case of an unconscious patient where there is no cause apparent, the history will usually give the diagnosis.

In the case of a patient needing surgery and anaesthesia, the pathological problem requiring surgery and the proposed operation are also of obvious importance. You will want to know how long the procedure is likely to take. Ask the patient about previous operations and anaesthetics and about any serious medical illnesses in the past.

After listening to the history, you should have some idea of a provisional diagnosis. Before starting the clinical examination, make an “end-of-the-bed” examination of such signs as:

CLINICAL EXAMINATION

CARDIOVASCULAR EXAMINATION

RESPIRATORY EXAMINATION

An emergency surgical case with concurrent cardiorespiratory disease will need careful postoperative management, oxygen and close monitoring.

ABDOMINAL EXAMINATION

You need to know as much as possible about intra-abdominal pathology. At the very least, this information will tell you about how long surgery will take and whether haemorrhage is likely.

Distended abdomen

If the abdomen is distended, palpation is not informative:

In such cases, urgent laparotomy is indicated with minimal delay.

Ultrasound scan is an important investigation in the management of the non-tympanic distended abdomen.

Soft abdomen

Palpation of a soft abdomen is more informative

CONSENT AND EXPECTATIONS

Always obtain the consent of the patient before any operation. If the patient is a child, get the parents’ consent. Try to find out the expectations of the patient and relatives.

The patient may have been sent to the operating room without explanation. Once you have decided on your anaesthetic technique, explain briefly to the patient what will happen, with reassurance that you will be present all the time to look after breathing and the function of the heart and to make sure that he or she feels no pain. Also explain what to expect on awakening, such as:

A few minutes of explanation and kindness in your approach will relieve many of the patient’s anxieties and make your task as anaesthetist much easier. Once this has been done, it is advisable to ask the patient (or the parents in the case of a child) to confirm by signing that they agree with what you are planning to do.

PREOPERATIVE FASTING AND FLUIDS

For non-emergency patients having general or major conduction anaesthesia, when there is no reason to suspect abnormal gastric or intestinal function, the periods of preoperative fasting which are generally accepted as safe are:

PREMEDICATION

The majority of anaesthetists do not premedicate their patients unless there is a specific indication. For example, in caesarean section, sodium citrate 0.3 mol/litre 30 ml may be given orally just before anaesthesia to reduce stomach acidity.

Anxiety may be prevented by temazepam 10–20 mg orally 2 hours preoperatively.

AT THE END OF THE ASSESSMENT

At the end of your assessment (history and examination), write down:

Make your notes clear to others. Write legibly with the date and time shown. Use medical terminology that other people also use. If you are referring a patient, a clear, legible referral letter is of great importance. Give dates and times, symptoms on admission and describe what treatments have been given so far.

Before starting any case, ask yourself: “Have I missed anything out?”

INVESTIGATIONS

Ask: “Will the investigation be useful?”

Routine investigations are frequently requested even when they have no direct bearing on the illness. Such “screening” investigations are expensive and may not be affordable or available in your hospital. Only ask for an investigation if:

We are fortunate in the management of emergencies: most of what we need to know for the safe conduct of anaesthesia can be learned at the bedside from physical signs. We are not as dependent on the laboratory for blood results to the same extent as a general physician. There is only one thing for which the clinician is totally dependent on the laboratory: blood for transfusion.

BLOOD TESTS

The following tests may be useful.




Blood cultures are useful if a range of antibiotics is available in response.
If an investigation that you would normally ask for is not available, you should still consider it in your management plan; it might become available at another time.

Radiography
The chest X-ray is a useful investigation of any chest trauma patient, especially before a chest drain is placed. Look for:

If the X-ray investigation involves taking the patient elsewhere, consider the risks of this unmonitored journey:

It is almost impossible to feel a pulse or look for breathing when moving with a patient in a corridor.

If an X-ray is not available, you will have to rely on your clinical skills instead or seek help to improve the diagnosis.

An ultrasound scan is useful for abdominal diagnosis in non-trauma patients.

MANAGEMENT PLAN

After preoperative assessment, make a management plan with the surgical practitioner. The options are:

Talk to your surgical colleague to make sure you each know what the other will do.

Either of the last two options must be decided on in the case of the “poor risk” patient. Is the patient poor risk or moribund? The distinction between the two is often not clear. The moribund patient cannot be saved, but the treatment should be continued until it is clearly futile.

A poor risk patient is often presented as an “emergency”, even though the case may have been neglected for days or weeks. Whether the system failed the patient or the patient failed to use the system, it is still an emergency.

Only your clinical experience, gained over many years, will enable you to manage these cases correctly, balancing the effective use of scarce resources on one side against the best interests of the patient on the other. You should take account of:

In anaesthesia, as in most areas of medicine and surgery, you will need at least as much knowledge and skill to make the right choice of technique as you will to implement it. The best anaesthetic in any given situation depends on your training and experience, the range of equipment and drugs available and the clinical situation.

However strong the indications may seem for using a particular technique, the best anaesthetic technique, especially in an emergency, will normally be one with which you are experienced and confident.

Some of the factors to bear in mind when choosing your anaesthetic technique are:

Not all these factors are of equal importance, but all should be considered, especially when the choice of technique is not obvious.