Holding room: your pre-surgical talk with your anesthesiologist

Anesthesia is a weird field relative to other medical specialties. We don't have a clinic where we get to talk to patients at length, going into great detail about their medical histories and forming a plan of action afterwards. We don't see patients in multiple follow up visits. Besides pathology, anesthesia is one of the few fields where the doctor talks very little with the patient. But the 10 to 20 minutes that we do talk to our patients, right before surgery, are among the most precious few minutes that any patient can spend with their doctor. This encounter, formally referred to as the preoperative evaluation, gives us the information we need to know in order to give you a safe and effective anesthetic.

Most of what we ask patients in the preoperative evaluation is pretty standard stuff. What are your medical problems? Related to that, what medicines do you take? Are you allergic to anything? In almost any doctor's office, in any specialty, you'd get these kinds of questions. There are a few more questions in our evaluation, some of which are asked by others, but most of which are unique to us, or at least focused on more closely by us.

I'll put these in a list.
1. When was the last time you ate something? This is perhaps the single most important question to answer correctly before getting anesthesia. The answer needs to be either "nothing since midnight" or "nothing in the last 6 hours". The question I always get from patients is "why?". The short answer is that anesthesia and a full stomach are a bad and potentially fatal combination. I'll explain in detail in a later blog.

2. Do you smoke? Doesn't every doctor ask that? And if you smoke, isn't it friggin'
annoying? For us anesthesiologists, it's a big deal, because if you are going to sleep, we may choose to place a breathing tube through your vocal cords and into your trachea to help you breathe, known as an intubation. If you smoke, it means that your upper airways and trachea are very reactive and sensitive to anything touching them, like a breathing tube. Everyone finds the breathing tube irritating, but smokers really hate it, and sometimes, their upper airways can constrict severely in response to it, a phenomenon known as bronchospasm. It is dangerous and can cause the flow of oxygen to the lungs to decrease significantly. There are lots of other anesthesia related issues with smoking. Smokers generally have worse lung function that nonsmokers, with lower baseline oxygen levels, and they are less responsive to oxygen in general. They produce significant amounts of mucus, which can clog the breathing tube and make it harder to give anesthetic gas and oxygen. If you smoke, there's nothing I can do about it, of course, but knowing it helps me prepare for what might happen and work around it.

3. Do you have any loose teeth? Can you open your mouth? These go along with the whole intubation theme. If you have teeth that are loose, it is theoretically possible that they could be damaged when the breathing tube is either placed or removed. It is rare but possible. And if you have caps, crowns, veneers, or other expensive work on your teeth, especially the front ones, we need to know that as well for the same reason. And as for opening your mouth, that tells us another very important piece of information. How wide you open your mouth, how big your tongue is, how long and wide your chin is - all of these tell us how easy or how difficult it will likely be to do your intubation.

4. Have you ever been told you snore? Kind of a personal question, huh? Not everyone asks it, but I do, and it tells me about how you'll act right after you fall asleep, before I've done the intubation. If you snore, it means you likely have a lot of extra soft tissue in your mouth which vibrates to cause the snoring, and which can collapse when under anesthesia, causing your airway to obstruct. This can get dangerous very quickly. The snoring question also leads to other issues, most notably obstructive sleep apnea, which also greatly increases the risk of going under anesthesia.

5. Has anyone in your family ever had a problem with anesthesia? Usually the answer we get is along the lines of how someone's mom or grandma threw up after anesthesia, but what we're looking for is a rare, usually hereditary, and potentially fatal reaction to anesthesia known as malignant hyperthermia (MH). People with MH develop extremely high and potentially fatal fever in response to very specific anesthetic agents. If caught in time, it can usually be treated, but it's scary. People with a personal or family history of MH can still receive anesthesia, but we need to know that history beforehand, because the OR and anesthesia machines have to be prepared in a very specific way to ensure safety. Don't worry if you don't know all the details about how your grandfather had some weird reaction to anesthesia 70
years ago. If we're the least bit suspicious, you'll get the safe (called a "non-triggering") anesthetic.

6. Do you drink? Use drugs? This is really important to answer truthfully, because lying can literally mean the difference between remembering surgery or not - or between life and death. If you drink alcohol heavily, the amount of anesthesia you require to stay asleep and have amnesia of the surgery is increased. Makes sense, huh? So tell us. As for drugs, they too increase your tolerance to anesthesia, especially heroin or other opioids. The real dangerous one, though, is cocaine. Cocaine sensitized and desensitizes your brain to certain drugs in dangerous ways. Most notably, cocaine in combination with certain blood pressure meeds used in anesthesia can cause extremely high, potentially fatally high, blood pressure increases. Or it can cause the blood pressure to sink to nothing, extremely resistant to all but the strongest drugs. If you use cocaine, we've gotta know that! I don't care or judge how you live your life; I just don't want you to die while receiving anesthesia.

7. How tall are you? How much do you weigh? No, we're not trying to be nosy. A lot of the drugs we give are dosed based on your weight, some on your "ideal" weight, but most on your actual weight. It just helps us be accurate with our drug dosing.