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A pre-anesthesia assessment protects patients from avoidable risks during general anesthesia and surgery Contact Now

Why is a proper pre-anesthesia evaluation so important?

A pre-anesthesia assessment protects patients from avoidable risks during general anesthesia and surgery

Anesthesiologists are physicians with specialized training to put people asleep or render them unconscious during surgery. Certified registered nurse anesthetists (CRNAs) are nurses, rather than physicians, with additional training to perform similar tasks.

Anesthetic medications have a powerful impact on the whole body. In the operating room, anesthesia providers play the critical role of monitoring and protecting life functions and vital organs, including the brain, heart, lungs, kidneys, liver, endocrine system, skin integrity, and nervous system, from the stress of anesthesia and surgery.

When a patient crashes during surgery—meaning there’s a reduction or loss in respiratory or cardiac function—it’s the anesthesiologist or CRNA who’s responsible for stabilizing the patient.

While these are the most well-known responsibilities of anesthesiologists and CRNAs, there are other important safety duties that they also must perform before administering any anesthetic medications.

The American Society of Anesthesiologists (ASA) defines the standard of care for pre-operative or pre-anesthesia workup. It defines the role of anesthesiologists to include:

• Assessment and preparation of patients for anesthesia.

• Determination of the patient’s medical status and developing and prescribing a plan of anesthesia care.

• Documenting an assessment and an anesthetic plan in the patient’s medical record.

Pre-anesthesia assessment

ASA guidelines dictate that anesthesiologists perform a pre-anesthesia evaluation of each patient before the delivery of anesthesia care. This sets the standard of care, requiring the anesthesiologist to:

• Review the available medical record.

• Interview the patient to discuss medical history, previous anesthetic experiences, and medical therapy.

• Perform a focused examination to assess those aspects of the patient’s physical condition that might affect decisions regarding perioperative risk and management.

• Order and review any pertinent available tests and consultations as necessary for the safe delivery of anesthesia care.

Reviewing the medical records

The medical records that are available for review will depend on where the surgical procedure is being performed. If it is at an outpatient or ambulatory surgery center, the medical record will typically be pretty thin. On the other hand, if the surgery is proceeding at a hospital, then the full range of documentation would be available to the anesthesia provider through the electronic medical record system.

In medical malpractice cases, a frequent question is what exactly does an anesthesiologist or CRNA need to review in the medical record. Many anesthesia experts believe that the language from the ASA guidelines mandating review of the “available medical record” requires, at a minimum, reviewing key records, including:

• Emergency room records related to the current admission.

• Laboratory reports.

• Radiology reports.

• EKG/ECG reports.

• Progress and consultant notes from physicians.

• Recent nursing notes.

When an anesthesiologist fails to review the necessary medical records before allowing surgery to proceed, it can needlessly place the patient at risk.

Focused examination

The pre-anesthesia assessment focused examination means that the anesthesiologist should target and identify potential risks. Here are some examples.

A patient with a large body habitus or obesity automatically has an increased risk of sleep apnea. Sleep apnea is well known to be a significant risk factor for anesthesia. An anesthesiologist should perform a focused examination of the patient’s airway structures, including the mouth, throat, and neck.

For patients with a permanent tracheostomy, the anesthesiologist is required to investigate the site with the goal of being prepared in case of an airway emergency.

The consequences of a poor pre-anesthesia evaluation

Here at Painter Law Firm, we recently have been working on a medical malpractice case involving a patient who arrived in the hospital by ambulance following a high-speed motor vehicle accident where the airbags deployed. The emergency room (ER) providers documented seatbelt marks on the patient’s abdomen because of the high velocity of the crash.

Strangely, neither the ambulance crew nor anyone who saw the patient in the emergency room protected his neck and cervical spine with a simple device called a c-collar. According to the emergency room records, a nurse practitioner cleared the patient’s neck only two minutes after arrival.

Under these circumstances, medical experts have explained that it’s impossible to clear the cervical spine (meaning that it’s stable) with a CT scan of the neck. There’s no way that happened within two minutes after arrival into the ER.

By the time the patient was taken to the operating room a few hours later to address abdominal bleeding, the patient’s cervical spine still hadn’t been cleared by an appropriate CT scan and he still wasn’t in a c-collar.

Both of these are important factors that directly influence how the anesthesia provider will begin administrating anesthesia. When the cervical spine and neck are not at risk, the anesthesiologist will typically hyper-extend the neck to intubate (insert a breathing tube through the patient’s mouth and into the airway of) the patient. Without c-spine clearance, though, an anesthesia provider should never use the standard approach, but should instead use a fiber-optic scope for intubation. To do otherwise would risk breaking the patient’s neck or causing a spinal cord injury.

An anesthesiologist and CRNA were involved with the patient’s pre-operative evaluation and anesthesia care in the operating room. Incredibly, the anesthesia providers proceeded with the standard intubation, despite the lack of cervical spine clearance or c-collar to protect the patient’s neck.

Our medical experts question whether any pre-anesthesia assessment was performed because these issues should have easily been identified. If the anesthesiologist or CRNA did the pre-anesthesia assessment, it still raises other questions, including how they missed these important findings and why they didn’t delay the surgery until proper cervical spine clearance was obtained.

As a result of these omissions, as well as negligence on the part of other healthcare providers during this hospitalization, the patient is now quadriplegic.

If you’ve been seriously injured because of poor anesthesia care, then contact an experienced, top-rated Houston, Texas medical malpractice lawyer for help in evaluating your potential case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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