Chapter 7. The Anesthetic Plan for Healthy Patients

1. The main objectives in anesthetizing healthy patients are safety and efficacy.

2. The purpose of the anesthetic history and physical examination in healthy patients is 4-fold:

   • To elucidate the nature of the surgical problem and the specific requirements of the planned operation
   • To ensure that the patient is, in fact, healthy
   • To identify patient features that could complicate the anesthetic
   • To ascertain and document patient expectations and preferences

3. A successful anesthetic plan must take into account the needs of the patient, the surgeon, and the anesthesiologist.

4. Healthy patients can undergo most of their preoperative evaluation and preparation immediately before surgery.

5. Extensive evaluation and testing are rarely necessary in healthy patients undergoing uncomplicated surgical procedures.

6. Anesthetic monitoring has evolved greatly and is believed to prevent complications and improve outcomes.

7. Healthy patients rarely require more than basic, noninvasive monitoring.

8. Healthy patients occasionally undergo complicated surgical procedures that require additional and more invasive monitoring.

Like their medically ill counterparts, healthy patients undergo a variety of surgical procedures. By virtue of their favorable physical status, however, healthy patients generally undergo shorter and simpler operations. This is fortunate because surgical complexity is one contributor to perioperative risk. Healthy patients, by definition, are free of medical comorbidity, which is another contributor to perioperative risk. For purposes of this chapter, "healthy" patients are defined as American Society of Anesthesiologists1 (ASA) class I or II. Despite the fact that perioperative risk is low in healthy patients, development of an anesthetic plan is largely the same as that for patients with serious comorbidities. Successful development of this plan consists of several important steps. The first is a thorough evaluation of the patient via history and physical examination. In healthy patients, a key component of this evaluation is the history of perioperative, and specifically anesthetic, problems and complications. A successful plan must also take into account any special considerations that may be associated with the proposed surgical procedure. Finally, expectations and needs of both patient and surgeon must be taken into consideration. Of these, safety and efficacy are of utmost importance. This chapter reviews the evaluative phase of the anesthetic plan, with special focus on recognition and avoidance of complications that can occur in healthy patients. Focus is then placed on the derivation of a safe and efficacious anesthetic plan that will meet the needs of both patient and surgeon. Finally, we review the use of routine and special monitors in healthy patients undergoing elective operations.

History

Formulating an anesthetic plan begins with a thorough evaluation of the patient. The starting point for this evaluation is the complete history and physical examination. In October 2001, the ASA published a Practice Advisory for Preanesthesia Evaluation.2 This advisory provides guidelines regarding minimum requirements for the history, physical examination, testing, and timing of the preoperative assessment. Throughout this chapter we invoke principles of this advisory when specific issues relate to the healthy patient.

In the ...