for this installment of the anesthetic assessment let's go through previous anesthetic issues
postoperative nausea and vomiting and the family history so i really want to try and
shed some light on the subtleties of history taking and how to think like an anesthetist i
hope this will give you a jump start and speed up your learning curve when it comes to your
first few months as an anesthesia doctor the first thing i do is check past anesthetic records this
gives me a wealth of information about how the patient tolerated all aspects of the anesthesia
surgery and the immediate recovery period now there are things in the anesthesia record that
i always have a close look at first if there's any obvious notes or warnings this is the best
indication that something out of the ordinary has happened if something disastrous occurred
it's very rare that the anises would not have written a note or provided a letter to the patient
so there's always a record of how the airway was managed and if there was any difficulty often this
can be really really detailed for example i'll note whether bag mask ventilation was easy or
difficult what kind of airway designs device was used if it was a laryngeal mask airway the size
type and if there are any leaks and if i intubated the patient what was my view of the larynx
i'll put in a link to the summary of the cormac lehane grading system down below i want to write
down what endotracheal tube i needed the size and if i needed any assistance with
a video laryngoscope a bougie external laryngeal manipulation or anything else
next i look at the very start of the vital signs chart the details of the induction of anesthesia
is recorded here at the very start and i look closely at a few things i look closely at the
medications that were given and the dose i then look at whether one did the blood pressure drop
substantially and how much vasodepressor was given for example most young patients will be given
up to 200 milligrams of profile and it'd be rare to have a blood pressure drop below 80 systolic
and more than a few doses of metaraminol given but imagine if a patient was given
only 50 milligrams of profile and the blood pressure also fell somewhere low like 50
and multiple doses of metamoral and ephedrine were given i would be incredibly careful with
my induction for this patient in the future and might even change the plan altogether needless
to say if i ever see adrenaline prescribed on an anesthetic record that would be a serious red flag
to stop and find out exactly what happened finally i look at the post anesthesia recovery record
this gives me a wealth of information about how much pain and nausea the patient had
how it was treated and also prompts me to consider if i can change my anaesthetic to minimize these
problems for the future obviously there's a lot of information on the record but these
are the really high yield things to observe when you're starting out so chatting to the patient
when i ask my patient that first question whether they've had any problems with any prior anesthetic
it's really a screening question to uncover any rare but life-threatening conditions
or something less serious but still very important to the patient that might substantially improve
their preoperative progress this time here are some of the common responses i get and
how i approach them for example the patient might say i've had no problems this is the most common
response anaesthesia in developed countries is incredibly safe so this is the answer i expect
your patient might say that they've had severe pain this occasionally happens and it's our job to
dig deeper i won't go into all the complexities of pain management but this will prompt me to
find out whether i can do anything to make this operation less painful on this occasion i will
delve into whether the patient has a chronic pain syndrome or as risk factors for chronic
post-surgical pain what was the pain management regime the last time and is this operation likely
to cause more pain and can i improve the pain management plan this time every now and again the
patient might say they had trouble waking up from the anesthetic in my experience this is rarely
something that's serious and just that a patient probably took a little bit longer to be completely
alert after the anesthetic but i do check for any inherited conditions and more on that later
sometimes the patient will say something like my heart stopped or i almost died there's
obviously a very serious issue and something to escalate immediately to your supervisor
the approach i take is to find as many details as i can i gather information from as many sources
to find out exactly what happened i checked the previous anaesthetic record as mentioned chat to
the family members the previous synesthesis or the surgeon the result of this can be anything from
immediate postponement of the surgery and investigation of the patient's heart and
other things to finding out that the episode was probably idiosyncratic and to proceed with caution
but this is definitely a decision to be discussed with your supervisor one of the most common side
effects of anesthesia and surgery and a major cause of patient distress and prolonged recovery
is post-operative nausea and vomiting often abbreviated to p-o-n-v so i specifically ask if my
patient has had pnv after any anesthetic if they say yes you really need to get out the details
i want to know the time course was it one vomit in recovery or did it go on for hours or even days
did the previous anistos know about it and how did they treat it with these answers i'll be
able to escalate my management depending on the risk and severity now this organization called
the society for ambulatory anesthesia or samba has some really comprehensive guidelines which i will
link to in the notes finally i want to know if any family members had any issues with anesthesia
there's only a few major problems that i inherited these include malignant hyperthermia
pseudocholinesterase deficiency and some congenital cardiac conditions
many patients will know that this problem runs in their family's bloodline so again even though
it's a low yield question you do not want to overlook these life-threatening conditions
so that's a brief rundown on the past anesthetic history i hope you enjoyed this video
please check out the other videos and anesthesia assessment for more tips and
tricks
you