Pre-operative Evaluation

• History & physical, current problem list, medications (esp. anticoagulants, anti-hypertensives, diabetes meds)
• Relevant comorbidities and recent decompensations
• Imaging, labs, EKG, ECHO, stress test, PFTs, Holter/Zio
• Anesthesia tab in chart review — prior anesthetics, airway notes, intraop events
• Device interrogations (PPM/ICD)
• Allergies (drug, food, latex, environmental)
• Social: tobacco, alcohol, substances
• Functional capacity (METs — > 4 generally adequate)
• Anesthetic complications in family (MH, pseudocholinesterase deficiency)

1. Procedure - Surgeon, expected duration, positioning (steep T-burg / reverse T-burg → hemodynamic impact) - Surgical approach and expected blood loss

2. Monitoring - Standard ASA monitors - Arterial line / central line / PA catheter / TEE if indicated - Neuromonitoring (SSEP/MEP) — affects choice of TIVA - BIS/Sedline for processed EEG

3. Blood products - T&S vs cross-match based on EBL - Order set: "Intra-operative Blood Product and Lab Orders" - Separate orders to prepare and to send to OR ("call slip")

4. Induction - RSI vs standard - Agent choice given comorbidities - Airway: primary plan + backup plan(s)

5. Maintenance - Inhalational vs TIVA - Analgesia plan (opioid, regional, multimodal) - Anticipated pressors / fluids / labs

6. Emergence & disposition - Smooth vs controlled emergence (e.g., neurosurgery) - Extubation criteria - PACU vs ICU vs floor

• Pre-op navigator → Pre-op eval → Equipment requests
• Requests placed by ~10 pm the night before for first cases will be set up by anesthesia techs for AM start
• Equipment commonly requested: video laryngoscope, fiberoptic, special-size LMA/ETT, ultrasound, BIS, A-line/CVC kits, rapid infuser, cell saver

Key questions: - Site of surgery — above umbilicus → risk of EMI interference - Is patient pacemaker dependent? - Type of device, last interrogation - What does placing a magnet do? (varies by manufacturer) - Does device need reprogramming pre/post-op?

General principles: - Bipolar electrocautery preferred over monopolar - If monopolar required: short bursts, lowest energy, grounding pad away from device, return pathway not crossing device - For ICDs: a magnet over the device disables anti-tachy therapy (does NOT change pacing) - For pacemakers: a magnet usually places into asynchronous mode — useful if pacing-dependent and EMI is expected - Have external pacing pads and defibrillator in room - Contact device representative or pacemaker service when in doubt