Recent guidelines in preoperative assessment, premedication&perioperative documentation

Abstract

Introduction: The corner stone of an effective preoperative evaluation are the history and physical examination, which should include a complete account of all medications taken by the patient in the recent past, and responses and reactions to previous anesthetics.Premedication is the administration of medication before anesthesia. Premedication is used to prepare the patient for anesthesia and to help provide optimal conditions for surgery. The anesthetic record is usually the sole documentation of an anesthetist’s interaction with his or her patient. Aim of the work: This work aims to review the recent guidelines in preoperative assessment, premedication and perioperative documentation to reach a conclusion and a protocol of management that can be applicable in our hospital. Materials and methods: This is a clinical review of recent guidelines in preoperative assessment ,premedication ,perioperative documentation based on explore other protocols and researches. The strategy followed in doing this review is as follow; Exploring the data allowed for the recent guidelines in preoperative assessment, premedication, perioperative documentation 1-Sites to be visited. 2-Recent searches in the last 5 years. 3-Search terms including preoperative assessment, patient preparation ,premedication ,perioperative documentation, anesthetic record . 4-Bibliographies of articles are also searched for relevant articles. 5-English language studies and full text studies will be preferred. Conclusion: The goals of the preanesthesia evaluation are twofold: first, to ensure that patients can safely tolerate anesthesia for planned surgical procedures; and second, to mitigate risks associated with the overall perioperative period, such as postoperative pulmonary or cardiac complications. The patient’s comorbidities and planned procedure must be considered when managing medications in the perioperative period. Accurate and thorough documentation is an essential element of high quality and safe medical care, and accordingly a basic responsibility of physician anesthesiologists.