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Why the pre-anesthesia assessment is important for patient safety

Anesthesia providers must plan ahead to minimize general anesthesia risks

I believe one of the great advances of modern medicine was the invention of general anesthesia, in Massachusetts, back in 1846.

While most of us tend to take anesthesia for granted these days, it certainly doesn’t come without risks. That’s why a thorough pre-anesthesia assessment is part of the standard of care and is critical to the safety of the patient facing the surgery requiring general anesthesia.

Before getting into the ins and outs of the pre-anesthesia assessment, we should first discuss who it is that will actually be doing the assessment and providing anesthesia services.

Who’s the real anesthesia provider?

There are two types of anesthesia providers who work in hospital or ambulatory surgery center operating rooms. One is a physician. The other is a nurse.

Anesthesiologists are medical doctors who completed medical school and post-graduate residency training.

Certified registered nurse anesthetists (CRNAs) are nurses with additional training in nurse anesthesia.

The CRNA industry is highly motivated by financial opportunities and has hired lobbyists to influence state legislatures to allow CRNAs to have increasingly independent practices—meaning with no anesthesiologist or physician supervision. In fact, a quick Google search would show you that the CRNA community believes that nurse anesthetists are just as qualified and effective to handle all aspects of anesthesia care as an anesthesiologist.

From my experience as a Houston, Texas medical malpractice lawyer, I don’t believe it. In case after case that I’ve handled where there was a problem during anesthesia care leading to a serious brain injury or death, the CRNA was in the operating room and the anesthesiologist was not.

Hospitals and surgery centers have figured out that it’s a lot cheaper to hire CRNAs to handle the bulk of anesthesia care, as opposed to anesthesiology physicians. In Texas, a common model used by hospitals and surgery centers has one anesthesiologist medically supervising up to five CRNAs at once.

I recently deposed an anesthesiologist in a wrongful death medical malpractice lawsuit in Houston. As is often the case, the anesthesiologist was in in the operating room or recovery room when the patient started going downhill. I asked her many patients she was handling at the same time and her answer was five.

Before you go into an operating room for an elective surgery, I recommend talking with your anesthesia providers so you know who will actually be in the operating room during your surgery. I believe that most patients would be uncomfortable if they knew that a nurse, not a physician, would be handling their operating room general anesthesia, at least without more information. Make sure that you’re comfortable with the education, training, and skills of the anesthesiologist or, more likely, CRNA, who will be handling your case.

Anesthesiologist physicians handle pre-anesthesia assessment of surgical patients most of the time in Texas. From the many victims of medical malpractice that I’ve visited with over the years, I’ve concluded that anesthesiologists rarely reveal that they’ll be largely absent from the operating room and that, instead, a case will be handled by a nurse anesthetist.

Pre-anesthesia assessment

I can boil down the purpose of the pre-anesthesia assessment into just two words: Prepare ahead. An anesthesiologist once described general anesthesia as a complex science that involves taking a patient basically to death’s door, without going so far that the patient can’t be revived.

It’s important to identify general inpatient-specific risk factors ahead of time so there will be adequate preparations to handle a respiratory or cardiac emergency during anesthesia care.

During the pre-anesthesia assessment, the anesthesiologist or anesthesia provider will consider factors including:

• All medications that the patient recently took.

• All health conditions of the patient.

• The patient’s vital signs. For instance, medical textbooks recommend delaying elective surgery for hypertensive patients until the blood pressure is less than 180/110.

• Whether the patient is obese.

• Whether the patient has been diagnosed with sleep apnea or frequently snores.

• Whether the patient has a history of an adverse reaction to anesthesia.

• On exam, whether there are any anatomical considerations that would make the patient at-risk for a difficult airway.

While some surgeons routinely require patients of all ages to be seen by a cardiologist for evaluation or clearance before an elective surgery, others don’t. The standard of care requires the anesthesiologist to consider and investigate any signs that could put the patient at risk, and this includes making an independent judgment of whether it’s safe to proceed with surgery without input from a cardiologist.

I represented the family of a middle-aged man who died as a result of an anesthesiologist’s inattention to some important signs that were obvious during a pre-anesthesia evaluation. The man was obese, had a history of snoring and was suspected of having sleep apnea, was being medically treated for hypertension, and had altered neck anatomy that would put him at a higher risk for establishing an airway with intubation.

About 15 minutes before the surgery was set to begin, the anesthesiologist and CRNA connected the patient to a three-lead EKG. The anesthesiologist noted in the record “possible ST elevation,” which is an EKG finding consistent with a myocardial infarction (heart attack).

The anesthesiologist ignored the finding, which should have been worked up with a 12-lead EKG. Instead, the anesthesiologist proceeded to administer general anesthesia, the surgery went forward, and shortly afterwards the patient died. On autopsy, the pathologist concluded that he had a heart attack—just like the “possible ST elevation” on the three-lead EKG suggested.

What you can do

You can reduce your risk of complications, serious injury, or even death from general anesthesia by being engaged in the pre-anesthesia process. Ask for a referral to a cardiologist for an exam or clearance. Be sure to disclose all medications and health conditions. Ask the anesthesia provider if anything about your body size or anatomy puts you at an increased risk, and discuss what plans are in place in case something goes wrong.

If you or a loved one has been seriously injured because of anesthesia malpractice, then I encourage you to contact a top-rated Houston, Texas medical malpractice attorney 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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