Longnecker Anesthesia 3rd Edition 2018

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1
Evolution of Anesthesiology 
as a Clinical Discipline: 
A Lesson in Developing 
Professionalism
Raisa D. Nguyen 
Douglas R. Bacon 
KEY POINTS
1. The history of anesthesiology is an interesting and complicated story of 
professionals seeking to understand the anesthetic state and to safely anes-
thetize patients.
2. Shortly after the first public demonstration of ether anesthesia on October 16, 
1846, by William Thomas Green Morton, the news spread across the world. 
Initially, anesthetics were administered based on written descriptions in the 
lay press.
3. London physician John Snow worked out the physics of vaporization of vola-
tile agents by observation of ether and chloroform and used this information 
to design vaporizers and anesthetic techniques that were safer for the patient.
4. The first professional organization devoted to anesthesia was the London 
Society of Anaesthetists, founded on May 30, 1893. The first similar group in 
the United States was the Long Island Society organized by Adolph Frederick 
Erdmann on October 6, 1905. This eventually became the American Society of 
Anesthesiologists.
5. Francis Hoffer McMechan organized professional anesthesia in 1912 by help-
ing to create the first national organization, the Associated Anesthetists of 
America, and went on to found several national and international organiza-
tions, of which the International Anesthesia Research Society (IARS) remains 
active. He was the founding editor of the first journal in the world devoted 
to the specialty, Current Researches in Anesthesia and Analgesia, which is cur-
rently published as Anesthesia and Analgesia.
6. Ralph Waters is credited with founding the first academic department of 
anesthesia at the University of Wisconsin in 1927. Much of the current resi-
dency structure comes from this seminal department. This helped establish 
the specialty on an equal footing with other medical specialties.
7. John Lundy at the Mayo Clinic organized the Anaesthetists Travel Club, whose 
members were the leading young anesthetists of the United States and 
Canada. These individuals helped create the American Board of Anesthesiol-
ogy (ABA), which defined what it meant to be an anesthesiologist in the 
United States.
8. The need for specialists in World War II exposed a large number of young 
physicians and nurses to anesthetic practice. After the war, physicians 
returned and helped create the tremendous growth of anesthesiology in the 
1950s-1960s, while the nurses greatly expanded nurse anesthesia.
9. In the mid-1950s, the World Federation of Societies of Anesthesiologists 
(WFSA) was formed, which culminated from a dream that began in the late 
1930s. The WFSA made it possible for nations with a long tradition of physi-
cian specialization in anesthesia to help train practitioners and introduce the 
specialty to new countries.
10. In the 1980s, the Anesthesia Patient Safety Foundation (APSF) and the Foun-
dation for Anesthesia Education and Research (FAER) were created. They are 
additional examples of the professionalism demonstrated by physician lead-
ers throughout anesthesiology’s history. These organizations work to create a 
safe anesthetic environment and to support educational and research efforts 
in the specialty.
INTRODUCTION
The quest for insensibility to the surgeon’s knife is a primordial one. 
Stretching back to antiquity, physicians have sought ways to render a 
pain-free surgery. Many different regimens were tried with varying suc-
cess until October 16, 1846, when surgical anesthesia was publicly dem-
onstrated by William Morton at Massachusetts General Hospital. Yet, 
there remained a long road to the current operating room full of elec-
tronic machines whose sole purpose is to measure the physiologic 
parameters of the anesthetized patient. How did anesthesiology evolve 
from a simple glass globe inhaler to the vast array of machines that 
makes the modern operating room?
The history of anesthesiology is the history of those who have 
devoted their career to the administration of anesthetics. Without phy-
sicians interested in the anesthetic state and the ability to adapt to new 
conditions demanded of anesthesiologists by surgeons, there would be 
neither modern surgery nor the specialty of anesthesiology. Many indi-
viduals displayed professionalism beyond what was required or 
expected; others seem reprehensible by “modern” standards. Although 
many would not consider themselves specialists in anesthesia, their 
contributions were critical in advancing the specialty. The development 
of anesthesiology can be told as the history of involved physicians who 
dedicated themselves to providing safer, more focused care of the 
patient, first in the operating room and later in the critical care unit and 
pain clinic. The story begins in ancient Egypt and continues to evolve 
in untold ways.
PREHISTORY: THE QUEST FOR SURGICAL 
ANESTHESIA
Imagine for a moment that there is no surgical anesthesia. The Edwin 
Smith Papyrus describes 48 surgical cases done from 3000 to 2500 BC. 
Although no specific anesthetic agent is mentioned, within the papyrus 
there is evidence of compression anesthesia. In one instance, a surgeon 
compresses the antecubital fossa while operating on the hand; in another 
instance, the patient compresses his brachial plexus while the surgeon 
operates on his palm.1 The ancient Chinese reported the use of an anes-
thetic for surgery in the 2nd century BC.2 The use of hemp smoke as an 
anesthetic was noted in India3 long before Western medicine developed 
crude forms of anesthesia.
During the Middle Ages and early Renaissance, a mixture of herbs 
boiled into a sponge was created to induce anesthesia. At the time of sur-
gery, the sponge was placed in water and the vapors inhaled. Although the 
vinca alkaloids were a major component of the drugs used in the spongia 
somnifera, the resultant anesthetic was less than satisfactory. Another 
Renaissance solution was the use of parallel lines of ice placed around the 
incision. This was effective for simple operations and found use in the 
Russo-Finnish War of 1939-1940.4 Alcohol consumed in sufficient quanti-
ties was noted to render individuals insensible and was thus used as a 
standard against which all anesthetics could be measured.3
Introduction to Anesthesiology
1
C H A P T E R
1
P A R T
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2 PART 1: Introduction to Anesthesiology
By the 1840s, the effects of nitrous oxide and diethyl ether were 
already well known. Medical students knew them as intoxicants. In 
1800, Humphry Davy described the intoxicating effects in his book, 
Researches Chemical and Philosophical: Chiefly Concerning Nitrous 
Oxide. Ether, first synthesized in the 1500s, had been observed to lessen 
the “air hunger” of asthmatics.5 In January 1842, in Rochester, New York, 
medical student William E. Clark anesthetized a classmate’s sister using 
ether for a molar extraction. Instructed not to pursue this observation as 
it most likely was a “hysterical reaction of women,” Clarke continued his 
training and became a respected Chicago area physician.6
Two months later in rural Georgia, Dr. Crawford Long, who had 
hosted parties where ether was used as an intoxicant, used the drug to 
render James Venable insensitive to the removal of tumors from his 
neck. Long charged Venable $2 for the anesthetic, thus delineating anes-
thesia as part of a physician’s professional service. In 1844, Hartford, 
Connecticut, dentist Horace Wells discovered during a show that when 
an individual was intoxicated by nitrous oxide, pain was abolished. Wells 
himself underwent a painless tooth removal performed by his partner 
using nitrous oxide. Soon, he was using “painless dentistry” as part of his 
professional advertisement. He even attempted to demonstrate a pain-
less tooth extraction at Massachusetts General Hospital in 1844, but 
although the patient had no memory of the event, it wasconsidered a 
failure because he groaned during the demonstration.7
By the mid-1800s, there were sufficient observations about specific 
agents that could potentially abolish surgical pain. In rural Jefferson, 
Georgia, surgery with ether anesthesia was occurring on a limited scale. 
Yet, Long felt he lacked sufficient cases to study the effects of this new 
agent.8 Wells’s use of nitrous oxide was groundbreaking, but he lacked the 
emotional stability to overcome his failed demonstration.9 Thus, the stage 
was set for another dentist to demonstrate reproducible surgical anesthe-
sia, giving birth to what would become the specialty of anesthesiology.
DISCOVERY
On October 16, 1846, Morton provided surgical anesthesia for Gilbert 
Abbott for the removal of a jaw tumor at Massachusetts General Hospital.10 
On completing the operation, surgeon John Collins Warren remarked, 
“Gentlemen, this is no humbug.” The miracle of pain-free surgery so 
impressed the Boston medical establishment that letters were sent to 
colleagues across the world. Considerable scholarship has been spent 
discerning when and where these letters arrived and who first provided 
anesthesia in each new location. The generally accepted view of the 
spread of anesthesia to the United Kingdom is a letter from Jacob Big-
elow to Francis Boot. However, by careful study of the ships sailing 
between Boston and Liverpool, another letter, written almost 2 weeks 
before Bigelow’s and only 12 days after the public demonstration of 
ether, arrived in England on November 1, 1846. Interestingly, this letter 
was to a patent attorney.11
Morton wanted to patent the process of administering ether and 
wrote to the foremost patent attorney in England to secure rights in the 
United States and United Kingdom9 and perhaps the world. He even 
tried to patent ether itself, calling his anesthetizing mixture “Letheon.” 
However, ether’s distinctive odor gave away the true nature of the con-
coction. The Boston medical establishment had convinced Morton to 
allow Massachusetts General Hospital to use Letheon free of charge. 
Unfortunately for Morton, because ether was well known and easy to 
synthesize and its effects reproducible without “Morton’s Inhaler,” the 
patent was unenforceable. He would spend the rest of his life seeking 
compensation for patent infringement, fighting with the medical estab-
lishment into the halls of Congress.8 Morton clearly was not the embodi-
ment of medical professionalism as we understand it today.
Given the nature of communication in the 1840s, news of Morton’s 
achievement traveled quickly. On December 16, 1846, ether anesthesia 
arrived in London in the form of a letter. On December 19, the first ether 
anesthetic was given in the United Kingdom for a tooth extraction. On 
December 21, the famous surgeon Robert Liston amputated a butler’s leg 
and uttered the words, “This Yankee dodge beats mesmerism hollow.” By 
early 1847, anesthetics were being given across Europe. By June 1847, 
news had spread to Australia.12 Peter Parker, minister and physician mis-
sionary, on October 4, 1847, gave the first anesthetics in China.13
For the history of the specialty of anesthesiology, what is interesting is 
how willing physicians and dentists were to use ether to induce insensi-
bility. Consider for a moment that outside Boston, no one had actually 
witnessed surgical anesthesia. Many accounts, especially those reaching 
South Africa and Australia, were newspaper articles or letters to the edi-
tor, often signed by a pseudonym. The hope that these medical profes-
sionals had, their desperation to adequately alleviate pain, and their 
desire to help patients may have been the motivation to try this new 
technique. Yet, when viewed from the perspective of current early 21st 
century medicine, this willingness to go on purely written accounts, 
often in the lay press, without the collaborating voices of the medical 
profession, seems dangerous and without regard for the basic principle 
of medicine: first do no harm.
And, what of the surgeons? Surgical pain limited operations to those 
that could be performed quickly. Anesthesia obviated the need for speed, 
presenting the possibility of operating within the visceral cavities for 
hours rather than seconds. But, as the physicians responsible for the 
patient, long before the specialty of anesthesiology would be defined, 
we wonder why these professionals were willing to risk lives to find 
an anesthetic. What does this say to the modern student of medical 
professionalism?
JOHN SNOW, SPECIALIZATION, AND EARLY 
PROFESSIONALISM
As reprehensible as Morton’s actions appear in patenting his “discovery,” 
Morton was acting within the ethics of his time. The American Medical 
Association (AMA) was only just beginning. Five months before the public 
demonstration of ether, the National Medical Convention met for the first 
time in May 1846 and began to write a code of medical ethics; 1 year later, 
the code was adopted. Morton’s actions were covered under section 4:
Equally derogatory to professional character is it, for a physician to hold 
a patent for any surgical instrument, or medicine, or to dispense a secret 
nostrum, whether it be the composition or exclusive property of himself 
or others. For, if such nostrum be of real e�cacy, any concealment regard-
ing it is inconsistent with bene�cence and professional liberality.14
Thus, at the time Morton was trying to patent ether and its vaporiza-
tion apparatus, the medical field was issuing statements against such 
behavior.
In contrast, London physician John Snow (Figure 1-1) began to study 
the chemical and physical properties of ether and by 1847 had developed 
a vaporizer. However, unlike Morton, “Snow never patented any 
FIGURE 1-1. John Snow. [Used with permission from Wood Library-Museum of 
Anesthesiology.]
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CHAPTER 1: Evolution of Anesthesiology as a Clinical Discipline: A Lesson in Developing Professionalism 3 
apparatus he designed. On the contrary, he published clear descriptions, 
including engraved figures, so that others could copy them if they 
chose.”15 By careful observation, he discerned ether’s vaporization character-
istics. His vaporizer (Figure 1-2) was made of coiled copper (Figure 1-3), 
an excellent heat-conducting metal, housed in a water bath to ensure 
constant temperature of the ether. Thus, Snow was able to calculate the 
amount of ether a patient would require within a few years of the discov-
ery of anesthesia.13
Following the introduction of chloroform as an anesthetic in 1847 by 
Edinburgh obstetrician James Young Simpson, Snow also began to 
investigate it. He used his experience with ether as a guide for investigat-
ing chloroform’s properties. He concluded that it was far safer to give this 
new anesthetic in measured quantities through an inhaler as opposed to 
the handkerchief method, whereby chloroform was applied to a cloth 
and held close to the nose and mouth because the anesthetic depth of the 
patient could not be adequately controlled. Snow’s deliberate nature and 
strong powers of observation allowed him to create a calibrated, temper-
ature-compensated chloroform vaporizer.13
Snow is unique among his London colleagues. In a day when opera-
tions were still rarely performed, Snow specialized in anesthetics. In 
some ways, his expert knowledge allowed him entrée into the upper 
echelons of both social and physician circles. Perhaps this is best illus-
trated by his care of Queen Victoria for the birth of her last two children. 
While Snow did not use his inhaler for the Queen, he also did not induce 
a full anesthetic state. Rather, he strove for analgesia with chloroform, 
thus creating a form of obstetrical analgesia, chloroform a la reine, which 
would persist in various forms over the next century.13
Aside from discerning the physics of vaporization, Snow was intensely 
interested in outcome data. He studiedevery report concerning a death 
under anesthesia and often had data in advance of the published death 
reports. He commented extensively on Hannah Greener’s death, thought 
to be the first death under anesthesia in the world.16 In his posthumous 
book, On Chloroform and Other Anesthetics,17 published in 1858, Snow 
compiled the first 50 deaths under chloroform with comments about the 
pathophysiology present. His spirit of inquiry, which extended from 
benchtop to autopsy, helped him to understand the nature of the anes-
thetic process and the agents that produced insensibility, thus the scien-
tific underpinnings of a specialty.18
A PROFESSION EMERGES
After Snow’s untimely death in 1858, anesthesia faded into the medical 
background. In larger cities, there were those who made a majority of 
their clinical income from providing anesthesia, yet it would not be until 
the advent of Listerism and the “taming” of infection that operations 
would become more frequent. As the number of operations increased, so 
did the need for anesthesia, and unfortunately, mortality became an 
issue. Chloroform was responsible for seemingly inexplicable deaths. 
Ether appeared to be safer, yet its side effects of nausea and vomiting and 
its prolonged induction compared to chloroform’s made it less than 
ideal. Surgeons began to search for alternative methods for the adminis-
tration of anesthetics.
In 1884, Carl Koller, an ophthalmology resident in Vienna, was intro-
duced by Sigmund Freud to a new crystalline substance called cocaine. 
Koller sought a local anesthetic to replace ether anesthesia for eye opera-
tions. Because fine suture material to close the eye wound did not yet 
exist, any postoperative retching could potentially cause vision loss. 
Therefore, when Koller’s tongue became numb from droplets of a solu-
tion containing cocaine, he made the conceptual leap that this same 
solution could be applied to the cornea with similar anesthetic effects. 
Before long, he had numbed the eyes of several animals, a fellow inves-
tigator, and himself. He took this new topical anesthetic to the clinic and 
used it with great success. On September 15, 1884, Koller’s paper on the 
subject was accepted at the German Ophthalmological Society meeting 
in Heidelberg. But, because Koller was unable to afford travel expenses, 
his colleague, Dr. Josef Brettauer, presented the paper for him.19
While Koller continued his career in ophthalmology, eventually 
immigrating to the United States, other physicians modified this new 
form of anesthesia into an alternative to general narcosis. One of the 
early practitioners was William Halstead, future chair of surgery at Johns 
Hopkins University, who was in Vienna at the time of Koller’s discovery. 
Using cocaine topically, Halstead dissected down to a nerve and directly 
anesthetized it. Much of his work he did on himself, regrettably leading 
to a cocaine addiction.20 Another of the pioneers of regional anesthesia 
was German surgeon Carl Ludwig Schleich, who developed the 
FIGURE 1-3. Coil from Snow’s vaporizer. [Used with permission from Wood Library-
Museum of Anesthesiology.]
FIGURE 1-2. Snow’s vaporizer. [Used with permission from 
Wood Library-Museum of Anesthesiology.]
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4 PART 1: Introduction to Anesthesiology
technique of infiltration anesthesia.21 Combining infiltration techniques 
with the newly discovered lumbar puncture, another academic German 
surgeon, August Bier, initiated spinal anesthesia in the late 1890s. Work-
ing with his fellow, August Hildebrandt, Bier successfully cannulated the 
subarachnoid space of Hildebrandt and produced a satisfactory anes-
thetic state. Hildebrandt was unsuccessful in cannulating Bier’s sub-
arachnoid space; however, both men suffered postdural-puncture 
headaches.22 Ten years later, Bier described an intravenous regional 
anesthetic technique, which is still known as the Bier block.23
At the same time that regional anesthesia was being developed in 
Germany, concern over the safety of chloroform, especially when com-
pared to ether, was developing. In India, then a colony of England, a 
Chloroform Commission was seated in Hyderabad in an attempt to 
determine which anesthetic agent was safest. Funded by the Nizam of 
Hyderabad, the 1888 study of anesthetic agents was an effort to discover 
whether there was an intrinsic mortality associated with chloroform. 
Sadly, the findings were tainted by the British medical officer in charge, 
Dr. Edward Lawrie, a strong chloroform proponent who trained in chlo-
roform’s birthplace of Edinburgh. The findings of the Hyderabad Chlo-
roform Commission were tainted, and a second commission was 
ordered, which also was inconclusive. Yet, what was important in these 
commissions is that physicians were studying anesthesia and trying to 
increase patient safety. For many physicians, it was slowly becoming 
apparent that there was a need for a specialty practice of anesthesia.24
In the early 20th century, the AMA set up a commission to study 
anesthetics and in 1908 issued a preliminary report.25 All forms of anes-
thesia were accounted for, including spinal anesthesia and various com-
binations of inhalational agents. The conclusions of the report are 
interesting and foreshadowed the development of a separate specialty:
All the newer methods demand expertness, experience, and special appa-
ratus. �ey appeal especially to the surgeons who are equipped with the 
paraphernalia of expensive and highly specialized clinics. �ey are little 
suited to physicians in general practice. For the latter great class of prac-
titioners, the old general anesthetics, chloroform and ether, will probably 
hold their own until increasing experience has enabled us to simplify and 
to make safe the newer and more novel methods.25
The commission had three interesting recommendations:
1. For the general practitioner and all anesthetists not specially skilled, 
ether administered by the open-drop method must be the anesthetic 
of choice.
2. The use of chloroform, particularly for minor operations, is discour-
aged unless given by an expert.
3. The training of skilled anesthetists is encouraged, and undergraduate 
students should be more generally instructed in the use of anesthetics.25
The last suggestion of the commission took two interesting paths. In 
many of the operating rooms across the United States, nurses began to 
administer anesthetics. More reliable than the casual anesthetist, these 
individuals developed great skill, especially in the administration of open-
drop ether. At the Mayo Clinic in Rochester, Minnesota, the nurses were 
renowned for their skill; physicians and other nurses traveled across the 
country and the world to observe and learn this skill. Alice Magaw, perhaps 
the most famous of the early Mayo Clinic nurse anesthetists, published a 
series of articles at the turn of the century outlining her techniques.26
THE RISE OF THE SPECIALIST
The second path, that for the physician specialist, would take the better 
part of the 20th century. On October 6, 1905, a group of eight physicians 
and a medical student in Brooklyn, New York, led by Adolph Frederick 
Erdmann (Figure 1-4), gathered to discuss the problem of anesthetics. 
Like the AMA commission, these young physicians believed that there 
was more to giving an anesthetic than simply dropping ether on a cloth 
held near a patient’s face and that there needed to be discussions and a 
free exchange of scientific and practical information.27 This was the 
second specialty group in the world that was created, the first being 
the London Society of Anesthetists in 1893, and it would become the 
catalyst for the development and recognition of physician specialists in 
anesthesia.28 Thus, the Long Island Society of Anesthetists (LISA) was 
born. The society met quarterly with a short business meeting followed 
by the presentation of two or three papers and perhaps the demonstra-tion of a new anesthetic technique or apparatus. Science aside, the soci-
ety provided a “support” group for those seeking to improve their 
anesthetic skills and a forum to exchange ideas and to deal with prob-
lems beyond the science of anesthesia.27
The group flourished, and in 1912, it moved to New York City and was 
renamed the New York Society of Anesthetists (NYSA). By the mid-1920s, 
the group encompassed the entire state of New York, and by 1936, it had 
become a national organization.29 Its transformation focused on the recog-
nition of physicians who primarily anesthetized patients as specialists.
The first significant political move of the NYSA was a motion put 
before the AMA House of Delegates, asking for a section on anesthet-
ics in 1912. The NYSA was concerned about nonphysicians giving 
anesthetics and echoed some of the findings of the AMA’s Commis-
sion on Anesthetics 6 years earlier.29 James Gwathmey (Figure 1-5), 
FIGURE 1-4. Adolph Frederick Erdmann. [Used with permission from Wood Library-
Museum of Anesthesiology.]
FIGURE 1-5. James Tayloe Gwathmey. [Used with permission from Wood Library-
Museum of Anesthesiology.]
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CHAPTER 1: Evolution of Anesthesiology as a Clinical Discipline: A Lesson in Developing Professionalism 5 
the society’s president, was developing a new method of anesthesia—
rectal ether. Like chloroform, rectal ether could be unpredictable and 
needed to be administered by someone familiar with its use and with 
the effects of anesthesia in general.30 The quest for a section within the 
AMA was, in some ways, the beginning of a quest for patient safety in 
anesthesia, a movement that would take the specialty by storm in the 
late 20th century.
The motion was denied by the AMA House of Delegates, but Gwath-
mey and Francis Hoeffer McMechan (Figure 1-6) gathered the defeated 
physician anesthetists and created the American Association of Anes-
thetists (AAA). This was the first national group of physician anesthe-
tists in the United States. They met the following year (1913) for a day 
of papers, mostly clinical in origin, followed by a dinner with spouses 
(Figure 1-7). A day devoted to the science of anesthesia is memorable; 
it signified a group, however small, that was willing to be recognized as 
specialists in anesthetics, uniting to move the field forward.29
The AAA, and its successor, the Associated Anesthetists of the United 
States and Canada, were run by McMechan. A third-generation physi-
cian who entered anesthesia against the advice of his physician father, 
McMechan developed crippling rheumatoid arthritis and was out of 
clinical practice by 1911. He was a visionary who desired to see anesthe-
sia “stand shoulder to shoulder” with surgery and internal medicine on 
a worldwide scale. He realized that without a place to publish papers on 
the specialty and without a place to gather the news of the various societ-
ies and names of physicians practicing anesthesia, the specialty would be 
doomed. McMehan convinced his friend Joseph McDonald, the editor 
of the American Journal of Surgery, to publish a supplement on anesthe-
sia, giving the physician specialty its first US quarterly. McMechan also 
edited the Yearbook of Anesthesia from 1914 to 1919, compiling all of the 
papers published in the specialty in the preceding year into a single 
volume.31
McMechan understood that the specialty would never develop as a 
discipline within medicine without a strong scientific underpinning, so 
he organized a society devoted to research in anesthesia, first nationally, 
then internationally in the mid-1920s. The International Anesthesia 
Research Society (IARS) brought together basic science researchers and 
the physicians most in need of their talents. Most important, the IARS 
sponsored the first journal in the world devoted to anesthesiology, Cur-
rent Researches in Anesthesia and Analgesia.32
The education of physician specialists, especially in the postgraduate 
period, was another of McMechan’s concerns. Partnering with Ralph 
Waters, an opportunity emerged at the University of Wisconsin in 1926 
as its medical school transformed itself from a 2-year institution offering 
only basic science education into a 4-year curriculum with all clinical 
sciences. One addition was a section on anesthesia, headed by Waters, in 
the department of surgery. Waters immediately began to teach anesthe-
sia to medical students and interns. He collaborated with basic science 
researchers, first on problems of carbon dioxide absorbance and later on 
all aspects of anesthesiology through various members of his depart-
ment. Perhaps most important, Waters established the first residency 
training program in an academic center, which was 3 years beyond the 
intern experience. Years 1 and 3 were clinical, while year 2 was devoted 
to laboratory research. Two weekly conferences were established, one 
discussing the week’s cases in a format similar to current morbidity and 
mortality conferences and another devoted to current anesthesia litera-
ture. By 1933, the teaching program was the envy of the world, and 
Waters understood that one final step had to be taken. He sent one of his 
faculty members and an early graduate of the program, Emery Roven-
stine, to Bellevue Hospital and New York University to try to replicate 
the University of Wisconsin department. Rovenstine was successful 
beyond any expectation, and in some ways, his graduates would eclipse 
the contributions of Waters’s graduates in the development of academic 
anesthesiology.33
In 1929, the Anaesthetists Travel Club was organized by John Lundy 
at Mayo Clinic. The group was created along the lines of the Society of 
Clinical Surgery, with members going to other members’ institutions to 
witness their anesthetic practice. The oldest member was Lahey Clinic 
anesthesiologist Lincoln Sise (55 years old); the youngest members 
were Philadelphian and future first editor of Anesthesiology Henry Ruth 
(30 years old) and Mayo resident Ralph Tovell (28 years old). These 
young, influential anesthesiologists were those “standing in line” in the 
McMechan organization or those who believed that McMechan’s inter-
national vision of the specialty, while important, would not solve domes-
tic issues. The Travel Club would come to dominate the NYSA and 
become the nidus of leadership for the effort to create the American 
Board of Anesthesiology (ABA).34
In June 1933, in Milwaukee, Wisconsin, the nurse anesthetists held 
their first national meeting of the National Association of Nurse Anes-
thetists. The meeting was notable for a letter of greeting from Everts 
Graham, MD, then professor of surgery at Washington University in 
St. Louis and a linchpin in the organization of the ABA some 5 years 
later. The American Hospital Association was a sponsor of the 
meeting, and in addition to clinics held at local hospitals, the meet-
ing stressed the importance of a well-organized department of 
FIGURE 1-6. Francis Hoeffer McMechan. [Used with permission from Wood Library-
Museum of Anesthesiology.]
FIGURE 1-7. Program of the first meeting of the American Association of Anesthetists, 
June 18, 1913, Minneapolis, Minnesota. [Used with permission from Wood Library-Museum 
of Anesthesiology.]
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6 PART 1: Introduction to Anesthesiology
anesthesiology. It is curious to see many of the same administrative 
issues that the physician specialists were struggling with were also 
present at this meeting.26
THE CREATION OF THE AMERICAN BOARD OF 
ANESTHESIOLOGY
The gains in clinical practice in the 1920s and 1930s are best summed up 
by Harold Griffith, a leading Canadian physician anesthetist; in 1939, he 
wrote the following:
Seventeen years ago when I began to give anesthetics, the anesthesia 
equipment in the small hospital which has ever since been my hospital 
home, consisted of bottles of etherand chloroform and a few face masks. 
�is was typical of the fairly well-equipped hospitals of that time. Today 
in that hospital there are eight gas machines of various models, suction 
equipment in every room, oxygen- and helium-therapy equipment, at 
least ��een di�erent anesthetic agents, and much technical equipment 
for their administration. �is transformation has been taking place eve-
rywhere in anesthesia.35
Economic reasons played a role in the need to define a specialist in 
anesthesia because physician anesthetists were not well compensated 
and faced competition from a number of groups. Surgeons, for example, 
could hire a nurse to help in the office and give anesthetics, while the 
surgeon charged a fee for both anesthesia and surgery. The income gen-
erated from the anesthetic fee was in excess of what he paid the nurse 
and therefore profitable. Similarly, hospitals could hire nurses to give 
anesthetics and make an extra profit. Finally, general practitioners 
would refer cases to surgeons with the caveat that they could give the 
anesthetic and collect the anesthetic fee for themselves.36
McMechan proposed the International College of Anesthetists 
(ICA) and certified the first fellows in 1935, but there were two serious 
problems with his certification process. First and foremost, the clinical 
criteria were weak. The applicant only needed to document 10 anes-
thetic cases to be eligible. In one instance, an intern rotating on the 
anesthesia service for 1 month wrote up the necessary cases and 
became certified. In another, a surgeon who only occasionally gave 
anesthetics successfully completed the necessary paperwork. Certifi-
cate in hand, he attempted to become the head of a hospital division of 
anesthesia. The second issue with the ICA was that it had no standing 
with the AMA, meaning the certificate was not “official” in the United 
States.37
Members of the Anaesthetists Travel Club, especially Paul Wood, 
John Lundy, and Ralph Waters, believed that certification was essen-
tial if anesthesiology was going to be recognized as equal to other 
specialties. Using AMA criteria, which included documentation of 
either postgraduate training in the specialty or 2500 cases in which 
the applicant had administered the anesthetic, Wood and his col-
leagues at the NYSA created a special classification of members called 
“fellows.” This new form of membership was extremely popular, and 
the NYSA’s membership skyrocketed. Now national, the society 
changed its name to the American Society of Anesthetists in February 
1936, and in 1945, they were renamed the American Society of Anes-
thesiologists (ASA).38
Waters, working closely with the chair of surgery at the University of 
Wisconsin, Erwin Schmidt (Figure 1-8), was able to secure an agree-
ment for the ABA to be created as a subboard of the American Board of 
Surgery. Using AMA criteria, which included the stipulation that the 
physician must practice the specialty full time, the ABA was created in 
1938. The ABA’s first written examination, held in March 1939, was in 
essay format with five subjects: pharmacology, anatomy, physics and 
chemistry, pathology, and physiology. There was also an oral examina-
tion and a practical at the candidate’s place of practice.39
WORLD WAR II AND BEYOND
The New York World’s Fair opened on April 30, 1939, on the eve of 
World War II. In the Hall of Man, an anesthesiology exhibit (Figure 1-9) 
allowed the general public to learn more about the specialty. The exhibit 
was paid for by the Winthrope Chemical Company at a cost equivalent 
to several million dollars today. This proved that anesthesia had enough 
of a market impact that industry was willing to spend lavishly to support 
such a display. Second, the clinical practice of anesthesiology had 
become both complex and commonplace enough that the lay public 
would recognize and want to learn about it.40
At the same time, Lewis Wright was hired by Squibb Pharmaceuti-
cals to investigate new anesthesia drugs, including curare. Wright was 
a self-taught anesthesiologist who, in midcareer, took a leave of 
absence from his job at Squibb and did a residency with Emery Roven-
stine at Bellevue Hospital.41 Wright gave some of the first commercially 
prepared curare to Rovenstine and Emmanuel Papper. However, Pap-
per felt that the agent was a poor anesthetic, as all the test animals 
stopped breathing when it was administered to them.42 It was Harold 
Griffith and Enid Johnson, of Montreal, who discovered curare’s true 
value in anesthesia.43
As the United States plunged into World War II, the anesthesia 
community was determined not to repeat the mistakes of World War 
I. Physician anesthetists were in short supply and often ran from 
unit to unit training corpsmen in ether administration by open 
drop.44 By the early 1940s, anesthesia had become too complex for 
this to be successful. The leaders of the ASA worked with the armed 
forces and developed 90-day courses to train medical officers in the 
basics of anesthesia. These young physicians managed many horrific 
clinical situations and were able to decrease mortality.45 Among 
these new anesthetists was Samuel Lieberman, who won the Legion 
of Merit for his work in the South Pacific. By using continuous spi-
nal anesthesia, he decreased the mortality from abdominal wounds 
from 46% to 12.5%.46
Returning from the war, these physicians had tremendous clinical 
experience, especially with regional anesthesia. Nerve blocks were 
invaluable because corpsmen could take vital signs and talk to the sol-
dier while the operation was ongoing, freeing the anesthesiologist to 
treat others. Likewise, these military anesthesiologists had extensive 
experience with transfusion and fluid therapy. About 40% of them 
sought additional formal training. Thus, the specialty expanded tre-
mendously, not only because of the returning physicians, but also 
because their surgeon colleagues demanded physician involvement in 
anesthesia.47
Nurse anesthetists likewise answered the call, creating courses to train 
nurses as anesthetists. They served with distinction throughout the con-
flict and would answer the call again and again during all of the US 
FIGURE 1-8. Erwin Schmidt. [Used with permission from Wood Library-Museum of 
Anesthesiology.]
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CHAPTER 1: Evolution of Anesthesiology as a Clinical Discipline: A Lesson in Developing Professionalism 7 
armed conflicts. At the end of World War II, the first qualifying exams 
for nurse anesthetists were administered. During the 1950s, certification 
of training programs occurred.26
THE SECOND HALF OF THE 20TH CENTURY
McMechan’s vision of an international community of anesthesiologists 
came to fruition in the 1950s. The first world meeting of anesthesiolo-
gists had been scheduled for Paris in the spring of 1940 but was canceled 
as the German army invaded. By the early 1950s, Europe was starting to 
recover from the effects of the war, and the original French organizers 
were still interested in making the meeting a reality. Working within the 
European community and Canada and with help from the World Heath 
Organization, preliminary meetings were organized and the structure of 
the World Federation of Societies of Anesthesiologists (WFSA) was cre-
ated. The first World Congress, held at the Hague in the Netherlands in 
1955, was a success despite the absence of the ASA. The WFSA wanted 
to bring the best clinical practice of the specialty to the forefront, and the 
World Congress was a way to unite anesthesiologists from all walks of 
life to discuss problems and seek solutions.47
Interestingly, the ASA did not join the WFSA until the late 1950s. This 
reluctance was multifactorial. First, because WFSA dues were on a per 
capita basis, the ASA felt that they would be providing the majority of 
the finances of the organization without an equal voice in its govern-
ment. There was also hesitancyto join an organization that contained 
communists. Time, dialogue, and the WFSA’s performance eliminated 
those fears.48
Along with the international concerns, the specialty faced a challenge 
in the United States as well. There was a significant part of the anesthe-
siology community, from the 1940s on, that felt that no physician should 
accept a contract for services and allow a third party, such as a hospital 
or other employer, to bill in the physician’s name. This edict was 
enforced by the ASA through the component societies, for an anesthesi-
ologist could not be a member if he or she was not a component society 
member. Membership was denied if the prospective anesthesiologist was 
employed under a contract rather than accepting a fee for service. Fur-
thermore, to be eligible to take the ABA examination, an anesthesiolo-
gist had to be an ASA member.49 In response to this, the Association of 
University Anesthesiologists (AUA) was formed. The majority of aca-
demic anesthesiologists were employed by the university for a salary, in 
violation of the ASA edict. The establishment of the organization is 
important not only as a protest, but also because it underscores how 
important academics had become to the fledgling field in the 30 years 
between the creation of the Waters department to the first 
AUA meeting.50 It was a rapid expansion that continued to delineate the 
scientific underpinnings of the specialty. The AUA was also the first 
subspecialty society formed in anesthesiology, and it worked to promote 
scientific research and teaching.
In the 1960s, the US government created the National Institutes of 
Health (NIH) to support medical research, and Emmanuel Papper 
(Figure 1-10) was invited to Washington, D.C., to help organize it. 
Dr. Papper worked tirelessly to see that anesthesiologists were treated 
fairly by the NIH and were eligible for funding. However, he was 
unable to secure an independent study section for anesthesia, and the 
battle to obtain this for the specialty remains a leading agenda item 
for many.42
The decade of the 1970s was one of crisis for anesthesiology. To 
ensure billing that was commensurate with services, the ASA had 
endorsed a relative value guide that helped place a unit value on work 
FIGURE 1-9. Postcard image of the anesthesia exhibit at the 1939 World’s Fair. [Used with permission from Wood Library-Museum of Anesthesiology.]
FIGURE 1-10. Emmanuel Papper. [Used with permission from Wood Library-Museum 
of Anesthesiology.]
Longnecker_Part01_p0001-0034.indd 7 05/05/17 3:48 PM
8 PART 1: Introduction to Anesthesiology
done by the physician. Other specialties, including orthopedics and 
radiology, had adopted similar guides, but the Federal Trade Commis-
sion saw this as a monopolistic practice. All other specialties agreed 
to cease and desist; the ASA instead went to court. After a 2-week 
trial, the judge ruled that the relative value guide did not represent a 
monopolistic practice; rather, it was simply a tool that applied mone-
tary value differently in different parts of the country. In one of his-
tory’s little ironies, 30 years after the verdict, the federal government 
now considers relative value guides as the preferred billing method. 
The 1970s also saw another federal government suit against the ASA 
over fee for service versus an employed model. Thirty years before the 
legal action, the ASA had adopted a criterion for membership in the 
1940s that stated that anesthesiologists would work on a fee-for-
service basis similar to internists and surgeons and not as salaried 
employees of hospitals. In the 1970s, this was viewed by the federal 
government as restraint of trade, and while there was little chance of 
a successful suit, both sides agreed to cease and desist, having little 
desire for another expensive court battle.51
The 1970s also saw the beginnings of the anesthesiology subspecialty 
movement. In 1968, discussions and preliminary meetings were held 
that led to the formation of the Society for Obstetric Anesthesia and 
Perinatology. Formed in Kansas City in 1969, the group remains diverse, 
with anesthesiologists, obstetricians, and perinatologists presenting 
work of common interest.52 Likewise in the early 1970s, Maurice Albin 
and others interested in neuroanesthesia created the Society of Neurosur-
gical Anesthesia; in 1973, John Mitchenfelder became the first president.53 
In 1975, the American Society of Regional Anesthesia (ASRA) was 
re-formed, although without knowledge of the prior group formed by 
Gaston Labat in the 1920s. Publishing the first subspecialty journal, 
Regional Anesthesia, the society provided a place for peer-reviewed 
scholarly publication in regional anesthesia. Coupled with the annual 
meeting, the society also provided a forum for anesthesiologists inter-
ested in pain medicine. Eventually, the society would change its name to 
the American Society of Regional Anesthesia and Pain Medicine and 
that of the journal to Regional Anesthesia and Pain Medicine, emphasiz-
ing the importance of this emerging field.54 In the mid-1970s, the Society 
of Cardiovascular Anesthesiologists emerged, disseminating informa-
tion about cardiopulmonary bypass and the emerging field of vascular 
surgery.
The 1980s, by contrast, witnessed the development of two organiza-
tions that have served anesthesiology well. The Foundation for Anesthe-
sia Education and Research (FAER) has a special interest in 
anesthesiologists just beginning their careers and has supported a suc-
cessful starter grant program. Indeed, many of the leaders of academic 
anesthesiology in the early 21st century began their careers with a FAER 
grant. At the same time that the FAER was being formed, the Anesthesia 
Patient Safety Foundation (APSF) was created to prevent patients from 
ever being harmed by an anesthetic. The APSF has joined the academic, 
private practice, and industrial communities to work toward decreasing 
anesthetic risk. The establishment of the Harvard standards of monitor-
ing, at the beginning of the APSF, was an important step in this direc-
tion. The APSF is the model for the patient safety movement across the 
country and is used by the AMA as a model for its patient safety 
foundation.55
The anesthesiology subspecialty movement continued into the 1980s. 
In 1987, the first meeting of the Society for Pediatric Anesthesia was 
held. An outgrowth of the anesthesia section of the American Academy 
of Pediatrics, the society strove to be inclusive of all anesthesiologists 
interested in caring for children undergoing anesthesia, not simply anes-
thesiologists in full-time pediatric practice. Another society formed in 
the mid-1980s was the Society for Ambulatory Anesthesia.56 In response 
to the growing trend of outpatient surgery, the society strives for the 
highest standards in anesthesia care in the ambulatory setting.57 Like-
wise, the American Society of Critical Care Anesthesiologists was 
formed to establish a forum for anesthesiologists interested in the criti-
cal care setting.58
During the 1990s, the ABA recognized the trend toward subspecial-
ization by creating special qualifications that could be added to board 
certification in anesthesiology in both critical care and pain medicine. 
This trend continues, with added qualifications currently available in 
palliative care and pediatrics. One of the greatest challenges of modern-
day anesthesiology involves the proper role for these additional ABA 
credentials for general anesthesiologists whose practice also includes the 
care of children or those in intensive care units or hospices. It remains 
for practitioners, facilities, the ABA, and the ASA to develop guidelines 
that support subspecialty care where appropriate without limiting the 
delivery of anesthesia care in settings where the skills of the general 
anesthesiologist are commensurate with the challenge (not unlike the 
challenges in all of medicine relative to primary vs specialtycare in the 
21st century).
INTRODUCTION OF THE ANESTHESIA ASSISTANT
In the 1960s, yet another shortage of anesthesia providers led to the 
beginning of the anesthesiology assistant (AA) profession. After study-
ing the educational pathway for anesthesiologists and nurse anesthetists, 
they created a new educational paradigm for a midlevel anesthesia prac-
titioner that included a premedical background in college. This person 
would perform the same role as the nurse anesthetists but would be 
readily able to go on to medical school if appropriate.
The concept became reality in 1969 when the first AA training pro-
gram began accepting students at Emory University in Atlanta, Georgia, 
followed shortly thereafter by a second program at Case Western 
Reserve University in Cleveland, Ohio. Since that time, the number of 
practicing AAs and their educational programs has grown steadily.59
Despite also being midlevel providers with similar job descriptions, 
AAs differ slightly from nurse anesthetists. Rather than having a nursing 
educational background, AAs require a science/premedical background 
that would theoretically allow them to enter medical school more easily 
than nurse anesthetists if, in the future, they so desired.60
CONCLUSIONS
By comparison with most other medical specialties, the history of clini-
cal anesthesia is short. Perhaps Francis Hoeffer McMechan summed it 
best when in 1935 he wrote the following:
Anesthesia was the gi� of pioneer doctors and dentists to su�ering 
humanity, and every signi�cant advance in its science and practice has 
been contributed by doctors, dentists, and research workers of similar 
standing. In contrast, technicians have added nothing of any consequence. 
Anesthetics are among the most potent and dangerous drugs used in the 
practice of medicine; they penetrate to every cell and organ of the body 
and may cause almost instant or delayed death by their toxic e�ects. �e 
dosage of general inhalation anesthetics cannot be prescribed in advance 
but must be determined from moment to moment during administration. 
�e dosage of local and other anesthetics must be determined by the risk 
of the patient, the nature and duration of the operation to be done—
certainly a challenge to the knowledge and experience of the keenest doctor. 
No patient should ever be given an anesthetic whose condition and risk 
has not been diagnosed in advance of the operation, so that every resource 
of medical science can be used to lessen the risk and make the recovery 
more assuring. Certainly in this preoperative evaluation and the selection 
of the safest anesthetic and best method of administration, the medical 
anesthetist is more in a position to act as a consultant than a technician. …
�e safety of the patient demands that the anesthetist be able to treat 
every complication that may arise from the anesthetic itself by the use of 
methods of treatment that may be indicated. �e medical anesthetist can 
do this, the technician cannot. More recent developments have extended 
the �eld of medical anesthesia to include resuscitation, oxygen therapy, 
and therapeutic nerve block for intractable pain, and treatment of various 
conditions of disease, and the rehabilitation of the disabled—all �elds of 
practice quite beyond the capacity of the technician.”61
McMechan’s vision of professionalism, and its 21st century equiva-
lents, needs to continue to guide the specialty. The history of anesthesia 
is interesting, filled with fascinating events and people, and is replete 
with the highest examples of professionalism—the best is yet to come.
Longnecker_Part01_p0001-0034.indd 8 05/05/17 3:48 PM
CHAPTER 2: The Scope and Future of Anesthesia Practice 9 
KEY REFERENCES
•	 Bacon DR. The World Federation of Societies of Anesthesiologists 
(WFSA): McMechan’s final legacy. Anesth Analg. 1997;84:1130-1135.
•	 Bacon DR, Lema MJ. To define a specialty: a brief history of the 
American Board of Anesthesiology’s first written examination. 
J Clin Anesth. 1992;4:489-497.
•	 Bacon DR, Lema MJ, McGoldrick KE, eds. The American Society 
of Anesthesiologists: A Century of Challenges and Progress. Park 
Ridge, IL: Wood Library-Museum of Anesthesiology Press; 2005.
•	 Bankert M. Watchful Care: A History of America’s Nurse Anesthetists. 
New York, NY: Continuum; 1989.
•	 Fenster J. Ether Day. New York, NY: HarperCollins; 2001.
•	 Goerig M, Agarwal K, Schulte am Esch J. The versatile August Bier 
(1861-1949), father of spinal anesthesia. J Clin Anesth. 2000;12: 
561-569.
•	 Johansen PV, Paneth N, Rachman S, Rip M. Cholera, Chloroform, 
and the Science of Medicine: A Life of John Snow. New York, NY: 
Oxford University Press; 2003.
•	 Smith HM, Bacon DR. The history of anesthesia. In: Barash P, 
Cullen B, Stoelting R, eds. Clinical Anesthesia. 5th ed. Philadel-
phia, PA: Lippincott Williams & Wilkins; 2005:3-26.
•	 Waisel DB. The role of World War II and the European theater of 
operations in the development of anesthesiology as a physician 
specialty in the USA. Anesthesiology. 2001;94(5):907-914.
•	 Wells CJ. Francis Hoeffer McMechan. Curr Res Anesth Analg. 
1948;27(suppl):1-19.
REFERENCES
Complete references are available online at www.LongneckerAnesthesiology 
.com.
The Scope and Future of 
Anesthesia Practice
Tess Murray 
Michael S. Avidan
Alex S. Evers 
KEY POINTS
1. The operating room remains the primary focus for the vast majority of 
practitioners.
2. The practitioner’s primary responsibility is to ensure patients’ comfort and 
safety when they are exposed to the trespass of surgery and other invasive 
procedures.
3. The intraoperative conduct of anesthesia has both immediate and long-term 
effects on patient safety and outcomes postoperatively.
4. The provision of safe anesthetic care across geographically dispersed sites and 
encompassing wide ranges of patient health, in an economically responsible 
manner, is a challenge that anesthesiologists need to address proactively.
5. The personal administration of every anesthetic is not feasible due to workforce 
limitations; team-based anesthesia care is required to meet the demand for 
anesthesia services.
2
C H A P T E R
6. Meeting the personnel, safety, and cost demands of the future will require that 
providers overcome the political infighting between organized anesthesiology 
and nurse anesthesia, especially in an era when the majority of these individual 
providers work together effectively.
7. Many believe it is important for the future of the specialty that anesthesiolo-
gists assume a broader role in perioperative medicine.
8. Advances in knowledge and technology have created an opportunity for anes-
thesiologists to address the scientific questions at the core of the specialty as 
well as a variety of important clinical problems.
9. Future opportunities for anesthesiologists include greater involvement in 
pharmacogenomics, business, and health care systems management and the 
development of new technologies, while continuing to lead and develop tra-
ditional areas, such as operating room anesthesia, critical care, pain medicine, 
teaching, research, and resuscitation.
Anesthesiology arose as a medical specialty because the dangers asso-
ciated with anesthetic drugs and techniques demanded administration 
by skilled and knowledgeable physicians. As safer drugs were devel-
oped and physiologic monitoring improved, the need for anesthesiolo-
gists was propelled by increasing surgical complexity and severity of 
patient illness, as well as by increasing expectations for patient safety. 
Whereas the original raison d’être for the specialty remains today, a 
variety of professional and economic factors have challenged anesthe-
siology and produced large “swings of fortune” during the past few 
decades.
During the 1970s and 1980s, the emergence of critical care attracted 
many talented medical students to American anesthesiology training 
programs. However, these were halcyon days for anesthesiologistsprac-
ticing in the operating room, where professional income was high, job 
opportunities were ample, and increasing surgical complexity demanded 
an increasing level of medical knowledge and skills. Thus, there was little 
incentive for anesthesiologists to expand their roles beyond the confines 
of the operating suites, and many trainees who were initially attracted by 
critical care subsequently practiced operating room anesthesia only. In 
contrast, anesthesiologists in Europe and Canada were expanding their 
roles during this same period in the burgeoning subspecialties of pain, 
intensive care, and resuscitation.
In the mid-1990s, gloom beset anesthesiology in the United States as 
predictions, widely reported in lay press such as the Wall Street Journal, 
suggested that the need for anesthesiologists would decrease dramati-
cally in an anticipated managed care environment. Medical graduates 
were discouraged from pursuing careers in anesthesiology, and resi-
dency programs contracted dramatically. But, these predictions were 
wildly inaccurate. In the last 10 years, US anesthesiology programs have 
enjoyed a revival, and many talented medical graduates have chosen to 
enter the specialty.1 Another encouraging recent trend has been the 
marked increased in the proportion of US finishing residents who are 
choosing to pursue fellowships to bolster their specialist knowledge and 
refine their clinical skills. All of the traditional anesthesiology subspe-
cialties (eg, pain medicine, critical care, pediatrics, clinical scientist) are 
benefiting from this growing cadre of subspecialists, and new subspe-
cialties are on the rise (eg, sleep medicine and health care administra-
tion). Anesthesiologists in other parts of the world have also experienced 
fluctuating fortunes.
The future of anesthesiology depends on several factors, including 
changes in surgical and interventional practice, technological advances 
in anesthesiology, the evolving scope of anesthesia practice, and the role 
of nonphysicians (eg, nurse anesthetists and anesthesia physician assis-
tants), and physicians trained in other specialties, in the provision of 
anesthesia care. The evolution of health care financing and the con-
solidation of private practice groups into large regional and national 
multispecialty consortia will also continue to influence trends in anes-
thesia practice. This chapter reviews briefly the current scope of anes-
thetic practice and offers some possible scenarios for future directions of 
the specialty.
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http://www.LongneckerAnesthesiology.com
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10 PART 1: Introduction to Anesthesiology
The introduction of free-standing ambulatory surgery centers and 
office-based surgical suites where anesthesia is administered raises other 
concerns. The demands for safe anesthesia care provided in numerous 
remote locations with a wide range of severity of patient illnesses present 
significant challenges to the workforce, financing, and practice of anes-
thesiology that anesthesiologists need to address proactively.
Current practice models vary widely in both the United States and 
worldwide. In the United States, some anesthesiologists (or practice 
groups) personally provide all anesthetic care regardless of complexity, 
an approach that is also common in the United Kingdom, Canada, and 
Australia. In other practices, anesthesiologists supervise other clini-
cians (eg, nurse anesthetists, residents, or anesthesia assistants) in 
more than one operating room, a practice model found in many 
European countries, including the Netherlands, France, Denmark, 
Switzerland, and Norway. Currently, at least 50% of anesthesia care in 
the United States involves nurse anesthetists, and anesthesia practice 
worldwide often includes some form of nonphysician clinician or phy-
sician who is not a fully trained anesthesiologist. Some reports asserted 
that nonanesthesiologists can safely provide anesthesia for selected 
procedures (eg, colonoscopy) and patients,21 and that nurse anesthe-
tists perform no worse than trained anesthesiologists in simulated 
patient emergencies22 (see Chapter 21 for an in-depth discussion of 
risk in anesthesia, including an assessment of the validity of several of 
the practice pattern comparisons). It is also clear that patients with 
minimal physiological reserve, those undergoing major interventions, 
and those with complex medical problems likely require the direct 
involvement of a skilled anesthesiologist to enhance patient safety.23,24
Unfortunately, too often practitioner skill and experience are not 
matched to these factors but determined by availability of clinicians or 
the use of a fixed model of care delivery, rather than one that is tailored 
to the specific clinical situation. This is a fruitful area for further health 
services research by anesthesiologists to ensure proper matching of 
resources to the clinical needs.
The expectations for operating room anesthesia can be simply stated: 
We need to provide an ever-increasing quality of perioperative care at a 
lower cost. In turn, these expectations and predictions require that the 
anesthesiology community consider who will, or should, provide each 
component of anesthesia care; what levels of knowledge and skill will be 
required of each clinician; and how the responsibility for care will be 
organized, managed, and rewarded. It is arithmetically impossible to 
provide a fully trained individual anesthesiologist for every anesthetic 
procedure.25 Further, the increasing demands for anesthesia services 
(aging population, proliferation of ambulatory surgery centers, escalating 
demand for nonsurgical anesthesia and sedation) will outstrip even the 
most aggressive output of anesthesiologists. Medical schools simply 
would not have the capacity to provide sufficient graduates to populate 
a large increase in the number of anesthesiology residents, and the cur-
rent economic environment does not have the resources to sustain such 
an expansion.
For reasons of both anesthesiologist availability and cost, it is thus 
apparent that the future of anesthesia practice will involve an increasing 
role for nonphysician clinicians. How can this be made compatible with 
the demands for increasing safety and quality? This can be accomplished 
by involving skilled anesthesiologists in the cognitive aspects of every 
anesthetic. This will require coordination and cooperation with nonphy-
sician clinicians, allowing them to perform at the highest levels compat-
ible with their training, knowledge, and experience, while ensuring that 
a fully trained specialist is involved in planning and managing care for 
high-risk cases and is readily available for complex diagnostic and thera-
peutic decision-making.
Technological developments in monitoring and information systems 
should facilitate these changes. The development and expansion of tele-
medicine in critical care units, and the demonstration of resulting 
improved patient outcomes,26-28 provide one model of care that could be 
feasible even in communities where an anesthesiologist is not physically 
present.29
Meeting the personnel, safety, and cost demands of the future will 
require that providers overcome the political infighting between orga-
nized anesthesiology and nurse anesthesia, especially in an era when the 
majority of these individual providers work together effectively Further, 
OPERATING ROOM ANESTHESIA
The operating room remains the primary focus for the vast majority of 
anesthesiologists. The anesthesiologist’s primary responsibility in this 
arena is to ensure patients’ comfort and safety when they are exposed to 
the trespass of surgery; this includes protecting the patient from pain, 
undesired awareness, and organ system injury and fostering full recov-
ery from the surgical and anesthetic interventions (not simply the emer-
gence from anesthesia). Over thepast decades, it has become increasingly 
clear that the intraoperative conduct of anesthesia has profound effects 
on patient safety, surgical outcomes, and comfort in the postoperative 
period. For example, modest intraoperative hypothermia can either 
increase the incidence of wound infection2 or provide neuroprotection,3
depending on the clinical situation. Some studies have also shown an 
influence by anesthetic management on broader outcomes,4 including 
surgical mortality5 and even recurrence of certain cancers.6
Anesthesiologists are increasingly sophisticated in their understanding 
of patient safety, and they are focusing on such issues as appropriate peri-
operative medications, antibiotic prophylaxis and infection control, 
multimodal analgesia, maintenance of normothermia and normoglyce-
mia, and appropriate fluid and electrolyte therapy. A recent observational 
study demonstrated an almost 2-fold increase in coronary artery bypass 
graft surgical mortality in “low-performance” anesthesiologists com-
pared to “high-performance” anesthesiologists, highlighting the possible 
impact that individual providers can have on patient outcomes. A grow-
ing responsibility for overall postoperative outcomes raises new expecta-
tions for knowledge and skills of the practicing anesthesiologist and 
challenges our previously narrower definitions of anesthetic outcome.7
Despite the demands imposed by increasing severity of illness in sur-
gical patients, growing surgical complexity, and more comprehensive 
postoperative considerations, anesthesiology is often viewed as a victim 
of its own perceived success. The widely cited study from the United 
Kingdom in the 1980s, the Confidential Enquiry Into Perioperative 
Deaths (CEPOD), reported that patients undergoing general anesthesia 
have a 1 in 185,000 chance of dying as a consequence of anesthetic mis-
adventure,8-10 a finding highlighted in the Institute of Medicine report on 
medical errors11 that cited anesthesiology as the specialty that had best 
addressed safety issues (see Chapters 3, 21, and 22 for more comprehen-
sive reviews of quality and safety in anesthesia practice). More recent 
studies have confirmed low anesthesia-attributable mortality rates in 
developed countries, ranging from less than 1 in 10:00012 to 1 in 40,000 
or 1 in 120,000 cases.13 However, developing countries continue to have 
mortality rates that are an order of magnitude greater (141 events per 
million anesthetics in developing countries vs 25 events per million in 
developed countries).14 Despite the accepted improvements in periop-
erative mortality, the exact rate may be greater than recently reported. 
Further, the reported mortality rates vary significantly due to differences 
in definitions and reporting sources.15
As a result of the major improvements in anesthesia-attributable mor-
tality over the last several decades, the perception of anesthesia as “safe” 
has encouraged nonphysician anesthesia clinicians to advocate for inde-
pendent practice, with over a dozen US states choosing to opt out of 
mandatory physician supervision. It has also suggested to insurers that 
anesthesia care by a physician anesthesiologist is needlessly expensive. 
While some studies have suggested that rates of mortality associated with 
anesthesia are actually higher than those publicized,15 the fact remains that 
the field has made significant strides in reducing these rates. However, as 
Ronald Miller warned in his 2009 Rovenstine lecture, anesthesiologists 
cannot “content ourselves with the fact that few patients experience intra-
operative death due solely to anesthetic mishap.”16 Overall surgical mortal-
ity remains as high as 4% in the week following surgery,17 and almost 40% 
of in-hospital adverse events are related to surgical operations.18 Many 
problems in perioperative safety remain to be addressed, and anesthesi-
ologists must be willing to share responsibility with our surgical colleagues 
for a broader range of outcomes to truly be co-equal partners in the evolu-
tion of twenty-first-century health care systems.19
Challenges to anesthesiology are exacerbated by the massive expan-
sion in demand for anesthesia services for a variety of nonoperative 
procedures, ranging from cerebral aneurysm coiling to pediatric seda-
tion for procedures20 and general anesthesia for screening colonoscopy. 
Longnecker_Part01_p0001-0034.indd 10 05/05/17 3:48 PM
CHAPTER 2: The Scope and Future of Anesthesia Practice 11 
the training of anesthesiologists will increasingly need to encompass the 
development of skills in managing team-based care when working with 
other anesthesia clinicians. It is in the interests of public safety and 
health care delivery that unity be forged among anesthesia clinicians 
under the leadership of specialist anesthesiologists, whose medical 
training and education are required for complex medical decision-
making, supplemented by the skills and abilities of nonphysician clini-
cians who further enhance this team approach.
OUTSIDE THE OPERATING ROOM
 � PREOPERATIVE CARE
Perioperative morbidity is frequently attributable to poor preoperative 
patient assessment and preparation. These roles have always been inte-
gral to the anesthesiologist’s practice. However, as patients increasingly 
present to the hospital on the day of service, it has become necessary to 
ensure that patients are properly evaluated well before the immediate 
preoperative interval. Recognizing this need has led to burgeoning pre-
operative assessment clinics, where problems such as ischemic heart 
disease, pulmonary disease, or sleep apnea may be evaluated and appro-
priate perioperative interventions may be planned (see Chapter 5 for a 
detailed discussion of the benefits and operation of preoperative clinics). 
In some practice settings, preoperative assessment of complicated 
patients has been largely relegated to nonanesthesiology trained physi-
cians or physician extenders. In other settings, the challenge of same-day 
surgery admission has left preoperative assessment as a day-of-surgery 
activity; neither of these approaches is uniformly optimal. Almost all 
models for the future practice of anesthesia include greater involvement 
of anesthesiologists in the continuum of patient care and thus a greater 
role in patient outcomes. From this standpoint, it is essential that anes-
thesiologists continue to play an integral role in preoperative assessment 
clinics. This should also be a key component of anesthesia resident train-
ing programs, for it represents an important aspect of patient safety and 
the future anesthesia practice.
 � PAIN MEDICINE
Doctors cannot always cure disease, but they should always try to allevi-
ate suffering. Physical pain is among the most unpleasant of human 
experiences. Anesthesiologists are often involved in the management of 
severe pain associated with surgery, and the perioperative use of analge-
sics constitutes an important component of anesthetic care. Anesthesi-
ologists are more comfortable with opiate administration than many 
other physicians, because of both their knowledge of pharmacology 
(especially opioid pharmacology) and their skill and experience in man-
aging side effects, such as respiratory depression. Anesthesiologists have 
pioneered regional anesthetic techniques, many of which are applicable 
to the treatment of chronic intractable pain. Increasing numbers of anes-
thesiologists are specializing in pain management, and the effective 
relief of pain will remain an important component of the anesthesiolo-
gist’s role even for those who do not subspecialize specifically in pain 
medicine.
 � CRITICAL CARE MEDICINE
Anesthesiologists pioneered the development of critical care medicine,30 
and in many countries outside the United States, anesthesiologists con-
stitute the bulk of the physician workforce in critical care. In most of 
Europe, full training in critical care is an integral component of an 
anesthesiaresidency, and critical care anesthesiologists are responsible 
for organizing and staffing most hospital critical care units. In contrast, 
US anesthesia residents receive only a few months of critical care train-
ing, and anesthesiologists constitute a minority of the nation’s critical 
care physicians. Many believe that part of the future of the specialty will 
be an increased commitment of anesthesiologists to critical care medi-
cine. To achieve this, leading academic programs must expand their 
critical care fellowships and promote critical care as a financially viable 
and intellectually rewarding subspecialty for talented graduating 
residents.
 � CLINICAL SERVICES ADMINISTRATION
The operating suite is a complex environment, one that often has not 
been efficiently managed. Anesthesiologists are an integral component 
of this important but unwieldy organization. The need for effective 
management and administration is being increasingly recognized, and 
anesthesiologists are often sought for this management function. In 
many countries, including in Europe and North America, anesthesi-
ologists are acquiring formal training in health care management and 
business administration. Today’s doctors, even in academic institu-
tions and national health services, cannot afford to isolate themselves 
from the realities of reimbursement, cost, efficiency, patient satisfac-
tion, and overall system performance, and there appears to be a bright 
future for physician leaders in health care organizations. Anesthesiolo-
gists are, and will continue to be, an important part of this manage-
ment evolution.
 � PATIENT SAFETY
Anesthesiologists have been at the forefront of pioneering patient safety. 
The improvements have been so dramatic that liability insurance for 
anesthesia practice continues to decrease while that for most other spe-
cialties has steadily increased (some dramatically). The Anesthesia 
Patient Safety Foundation (APSF) was founded in the United States in 
1984 with the expressed purpose of ensuring “that no patient shall be 
harmed by the effects of anesthesia.” Since 1985, the Committee on Pro-
fessional Liability of the American Society of Anesthesiologists (ASA) 
has been studying records of closed malpractice claim files for anesthe-
sia-related patient injuries.31 Over 10,000 claims have been studied. 
Similar safety foundations and incident review boards have been estab-
lished in many other countries; in 1987, the Australian Patient Safety 
Foundation was established,32 and the national CEPOD was started in 
the United Kingdom in 1989. Analysis of critical incidents has rein-
forced the value of physiologic monitoring in improving patient safety. 
The results also confirmed the value of structured algorithms in anes-
thesia care by documenting favorable outcomes in a range of life-
threatening crises during anesthesia. Changes in consultant practice, 
increased medical audits, appropriate matching of specialist experience 
to patients’ medical conditions, and increased awareness of the need for 
critical care services have all been affected through these inquiries.33
Critical events occur within the context of complex system failures, 
and anesthesiologists have developed safeguards to decrease the likeli-
hood that human error may result in patient harm. Examples include 
audible alarm settings and automated anesthesia machine checks, the 
pin index safety system, and written “checklists.” A seminal study 
showed how the routine implementation in hospitals around the world 
of a simple 19-item surgical safety checklist designed to improve team 
communication and consistency of care markedly reduced 30-day com-
plications (from 11% to 7%) and deaths (from 1.5% to 0.8%) associated 
with surgery.34 Expertise in patient safety should be developed and 
translated into the broader medical context, including application in 
areas not historically viewed as the purview of anesthesia practice (such 
as diagnostic and treatment suites, obstetrical suites, intensive care units, 
and intermediate care units).
 � RESEARCH
Anesthesiology has a vibrant history of research and intellectual contri-
butions to clinical medicine. Historically, anesthesia research has 
focused on laboratory investigations in physiology and pharmacology 
and their application to patient care. These contributions have improved 
the safety of anesthesia and surgery and constituted pioneering efforts in 
the initial application of scientific principles to individual patient care. 
Previously, many of the scientific questions at the core of anesthesiology 
were relatively inaccessible to investigation; this stemmed from the 
absence of tools to study the mechanisms of the complex behaviors (eg, 
consciousness, memory, pain) that anesthesiologists manipulate. 
Advances in cellular physiology, molecular biology, genetics, functional 
imaging, and behavioral sciences, and the application of advanced statis-
tical and mathematical models, have enabled serious investigation of 
Longnecker_Part01_p0001-0034.indd 11 05/05/17 3:48 PM
12 PART 1: Introduction to Anesthesiology
these behaviors. It is thus now possible that the fundamental mysteries 
of anesthesia (including the molecular mechanism of the hypnotic, 
amnestic, and analgesic effects of anesthetics agents) will be solved. 
These same scientific tools also make it feasible to define the mecha-
nisms of hyperalgesia and chronic pain and to design more effective 
treatments. Finally, advances in the understanding and manipulation of 
inflammation and the immune response provide a new opportunity to 
delineate how organ system injury occurs in the perioperative period 
and how to detect it and to identify strategies for protection of the brain, 
heart, kidneys, and other organs. Collectively, recent advances in knowl-
edge and technology create an enormous opportunity for anesthesiology 
to address the scientific questions at the core of the specialty, as well as a 
variety of important clinical problems. Innovative anesthesiology train-
ing programs are offering integrated scholarship tracks to the most 
academically competitive residency applicants, and several programs are 
offering fellowships in clinical and translational research.
The application of information technology and epidemiologic tech-
niques (often referred to as outcomes research) to the perioperative 
period has also created new research opportunities for anesthesiology. 
These approaches quantify and describe perioperative morbidity and 
mortality and have facilitated recognition of patterns and causes of 
adverse patient outcomes. Recognizing the need for detailed periopera-
tive clinical data, the ASA established the Anesthesia Quality Institute in 
2008. The institute houses the National Anesthesia Clinical Outcomes 
Registry, a recognized patient data registry containing more than 22 million 
surgical cases35 and the anesthesia-specific data elements that are essen-
tial for comprehensive perioperative clinical research.36,37 The registry is 
combined with other data sources to enable clinician benchmarking, 
quality improvement, research, public reporting, credentialing, and 
maintenance of certification.
Academic anesthesia has been challenged at times over the years, 
with decreased academic funding of some departments and a decreas-
ing share of extramural grant funds.38 One reason put forward for 
reduced funding for anesthesia research is that the current safety of 
anesthesia implies that anesthesia research is not a pressing public 
health concern. As noted, this may be a misconception; while intraop-
erative mortality is rare, postoperative mortality and major morbidity 
still occur commonly, and anesthesia care has been shown to contribute 
to this process, both positively and negatively. There is much room for 
improvement before any field can conclude that we have overcome the 
hurdles in surgical care that challenge the extremes of age, those with 
significant comorbidities,or those undergoing extensive surgical proce-
dures. Many of the advances in these areas will come from improved 
perioperative care, built on evidence-based techniques that are con-
firmed by careful clinical investigation and innovation. The National 
Institutes of Health continue to prioritize multidisciplinary and multi-
center research initiatives along with translational research, where 
advances in the basic sciences, including genetics, can lead to progress 
in the clinical arena. A strong commitment to research will be necessary 
to ensure the continued advance of the specialty and ensure that anes-
thesiology remains a mainstream medical discipline that contributes to 
the overall good of society.
EDUCATION AND TRAINING
Clearly, the future of the specialty requires a robust commitment to 
education and training at all levels, from undergraduate medical educa-
tion through the most advanced subspecialty levels. Strong training 
programs depend on an excellent teaching faculty, ample and diverse 
clinical cases, a well-organized teaching program, and an emphasis on 
the knowledge required for future as well as current practice. Adequate 
funding for anesthesiology education by the federal government, by 
teaching hospitals, and by our specialty societies is imperative if the 
specialty is to flourish in future decades. Many of the models for the 
future practice of anesthesia include an expansion of the scope of resi-
dency and fellowship training,39 and some envision a drastic reorganiza-
tion of the education process.40 It is clear that the next generation of 
anesthesiologists must be skilled in preoperative assessment, critical 
care, pain management, supervision of nonphysician clinicians, and 
operating room administration. There must also be continued emphasis 
on fellowship programs, with formal recognition of fellowships in areas 
such as regional anesthesia, transplant anesthesia, and obstetric anesthe-
sia, and the expansion of new fellowships in health care management 
and business administration.
To attract high-caliber applicants to anesthesiology, it is important 
that medical students continue to receive adequate exposure to the spe-
cialty. In addition to perioperative medicine and pain medicine, anes-
thesiologists are well placed to teach medical students applied respiratory 
and cardiovascular physiology, several aspects of neuroscience, and 
numerous aspects of pharmacology, in addition to their more traditional 
educational roles in resuscitation and emergency airway management. 
The model of academic anesthesia care facilitates excellent learning, 
with medical students able to spend high-quality one-on-one time with 
experienced anesthesiologists.
 � SIMULATION
The aerospace industry has long appreciated the value of simulation in 
increasing safety and decreasing errors. Within the medical profession, 
anesthesiologists have been among the first to recognize the potential 
role of simulation in improving both education and patient safety. 
Anesthesiologists established the validity of simulation facilities41 in 
training anesthesiologists in the management of infrequent but life-
threatening problems that arise in the operating room. It has become 
apparent that simulation is useful for teaching other topics that are not 
unique to anesthesia practice (eg, diagnosis and management of pneu-
mothorax, hemorrhagic shock, myocardial infarction, insertion of 
central vascular catheters). Increasingly, physician and nursing profes-
sionals, including those in critical care and emergency medicine, are 
seeking time in simulation facilities for purposes of training and honing 
their skills in crisis management. Simulation centers are mushrooming 
internationally and are also being embraced by medical schools. Anes-
thesiologists have led this initiative, and it is important that we continue 
to lead innovation in this evolving field of technology. Maintenance of 
certification is increasingly emphasized for specialist medical practice 
and is particularly valued by the public.42 Simulation offers a practical 
method to assess anesthesiologists and other practicing clinicians, and 
it is being used in both initial certification and maintenance of certifica-
tion programs.43-45
PUBLIC PERCEPTION OF ANESTHESIOLOGISTS
Anesthesiology is one of the largest physician-based specialties, but few 
mainstream medical specialties are as poorly understood by members of 
the public and by other health professionals.46 Many patients do not real-
ize that anesthesiologists are doctors, and fewer understand that they 
have responsibilities outside the operating room.46 Even a high level of 
health literacy is not associated with better understanding of the role of 
anesthesiologists, as demonstrated by a recent study performed at the 
Mayo Clinic.47 In studies from Saudi Arabia, Singapore, Pakistan, and 
the West Indies, only 55% to 66% of patients were aware that anesthesi-
ologists are physicians, and most patients had a limited knowledge of the 
anesthesiologists’ roles.48-51 A few studies from Europe have reported 
high levels of recognition of anesthesiologists as specialist physicians52; 
at the same time, many patients also thought that the anesthesiologists 
played a subservient role to the surgical team,53,54 and the majority of 
studies do not demonstrate such a high level of awareness.55 In response 
to these deficits, many anesthesia societies around the world are recog-
nizing and celebrating World Anesthesia Day on October 16 to com-
memorate the anniversary of the first ether anesthetic at Massachusetts 
General Hospital in Boston. This work to heighten awareness and 
improve the perception of anesthesiologists and their essential functions 
among the general population and other physician societies may be 
important to the future of the specialty in several respects, including 
allocation of research funding, quality of applicants to residencies, and 
the future role of anesthesiologists within health care in general.
A Scandinavian study explored perceptions of the anesthesiologist’s 
role: “Professional Artist, Good Samaritan, Servant and Co-coordinator: 
Four Ways of Understanding the Anaesthetist’s Work.”56 According to 
Longnecker_Part01_p0001-0034.indd 12 05/05/17 3:48 PM
CHAPTER 2: The Scope and Future of Anesthesia Practice 13 
these authors, the current scope of anesthesia practice encompasses the 
following:
1. The provision of safe anesthesia while controlling patients’ vital 
functions.
2. Helping patients, including the alleviation of pain and anxiety.
3. Providing service to the whole hospital, including support to other 
doctors and nurses who are caring for severely ill patients.
4. Participation in the organization and direction of the operating suites 
to ensure that schedules run smoothly.
Whereas these are essential and important components of the spe-
cialty, even collectively they do not encompass the spectrum of anesthe-
siology as we view it currently, or as we look to the future, which seems 
particularly attractive if we maintain a comprehensive view of the 
opportunities for our discipline.
THE FUTURE OF ANESTHESIA PRACTICE AND 
EDUCATION
The future of the specialty depends on several key drivers: (1) the vision 
and actions of organized anesthesiology; (2) technological changes in 
surgery and anesthesiology; (3) the changing demographics of the US 
population, which is skewing toward the elderly; and (4) the directions 
chosen by residency programs, the principal trainers of future anesthe-
siologists. Economic forces—including in the United States the expan-
sion of alternative risk-based payment models such as accountable care 
organizations, bundled care payments and value-based purchasing, the 
Patient Protection and Affordable Care Act of 2010, and the consolida-
tion of anesthesia practices into regional and national multispecialty 
groups—cannot be ignored. These drivers will influence the attractive-
ness of anesthesiologyas a specialty choice for medical students, the 
career paths of young anesthesiologists, and the scope and organization 
of anesthetic practice.
Future anesthesiologists will face challenging choices. New drugs and 
increasingly sophisticated monitoring continue to facilitate safer anes-
thesia. Such technological advances will allow more effective remote 
supervision of anesthesia clinicians. There will be steady growth in the 
demand for anesthesia services both within and beyond the operating 
suites. Anesthesiology training programs will have to decide whether to 
expand their ranks to meet current service needs or whether to refine 
their training and practice models according to anticipated future condi-
tions. It is highly unlikely that anesthesiologists alone will be able to 
meet all the demands for anesthesia services, especially as the specialty 
continues to expand into areas such as critical care medicine and pain 
medicine.
To meet future challenges, many foresee the expansion of periopera-
tive medicine, which includes the spectrum of care from preoperative 
assessment to postoperative care, as the best opportunity for the spe-
cialty to thrive, prosper, and address future health needs of the popula-
tion.39,40,57-60 While there is a vision that future anesthesiologists will 
practice as much outside as inside operating rooms,61 the expansion of 
anesthesiologists’ activities could lead to dilution of the specialty’s iden-
tity, endangering the vitality of anesthesiology in an era of sweeping 
changes in health care delivery systems.62 There are examples of this in 
other disciplines, such as internal medicine, where the move to subspe-
cialization has plundered the ranks of primary care internists, for 
example. Further, an expansion of anesthesiology practice into nonop-
erative domains of perioperative medicine may also be challenged by 
other specialties that seek similar roles. Anesthesiology may thrive and 
expand its reach, or it may have its subspecialties amputated, leaving it 
as a restricted specialty bound to the operating room (Figure 2-1).
As an academic specialty, anesthesiology evolved from fundamental 
contributions to health care, including the prevention of pain from sur-
gery and the development of critical care medicine, cardiopulmonary 
resuscitation, and pain medicine.63 In recent years, many advances have 
occurred in the basic science of anesthesiology; these involve mecha-
nisms of pain, receptor physiology, modes of action of anesthetic agents, 
and cellular responses to sepsis, for example. If anesthesiology is to 
flourish as an academic specialty, it is crucial that research is pursued 
and encouraged. Without intellectual advances, anesthesiology is in 
danger of becoming a sterile technical discipline.63 University depart-
ments of anesthesiology are increasingly experiencing pressure to 
emphasize clinical delivery at the expense of academic pursuits. If they 
succumb to these pressures, this will threaten undergraduate periopera-
tive medicine teaching, development of critical appraisal skills among 
anesthesiologists, and the future of research programs that are the life-
blood of new advances that support all of health care.64 The irony would 
be that by immersing themselves entirely in the clinical arena, anesthe-
siologists would neglect the education of medical students and trainees, 
thus jeopardizing the future of clinical anesthesiology practice.
While it is easy to teach others as we were taught or as we practice 
today, focus on the future is an essential element of education. Long-
term success for the specialty will depend on our efforts in undergradu-
ate and graduate medical education, whereas short-term success will 
depend on our efforts in the continuing medical education of current 
practitioners.65 A different approach will be required to redefine the 
scope of the practice with broadened training to provide increased 
expertise in the evolving medical marketplace. This approach will likely 
include solid training in business, informatics, data management, and 
critical thinking on outcomes.19,40 This paradigm shift may be 
A
B
FIGURE 2-1. The future of anesthesiology: two possible outcomes. A. The specialty may 
come to resemble a bloated octopus, based only in the operating room with all its tentacles 
amputated. B. Anesthesiology may retain its integral role in the operating room but expand its 
tentacles in other areas, such as critical care, pain medicine, medical education, health system 
management, simulation, resuscitation, and research.
Longnecker_Part01_p0001-0034.indd 13 05/05/17 3:48 PM
14 PART 1: Introduction to Anesthesiology
challenging and requires redirection, reallocation of assets, reeducation, 
and a new mindset. If successfully applied, however, it presents a means 
to strengthen the respected position of the specialty and to promote the 
medical care and practice of perioperative specialists in the rapidly 
changing landscape of modern medicine.66
VISIONS OF THE FUTURE
 � SCENARIO 1: TO EACH PATIENT A DEDICATED ANESTHESIOLOGIST
The scenario of a dedicated anesthesiologist for each patient is the cur-
rent model of anesthesia care in much of the developed world, and many 
in the United States are adherents to this model. Most American resi-
dency programs are structured to train anesthesiologists to practice in 
this model. As discussed previously in this chapter, it is unlikely that this 
model of anesthesia care will be sustainable given the mismatch between 
surgical demand and anesthesiology personnel and the increasing pres-
sure to reduce the cost of anesthesia. Embracing the team-based model 
of care delivery is required to meet current and future demands and is 
also consistent with trends in other health care disciplines.
 � SCENARIO 2: PHYSICIANS FOR THE PERIOPERATIVE PERIOD: THE 
PERIOPERATIVE SURGICAL HOME
Over the past 14 years, the ASA, American Board of Anesthesiology, and 
Accreditation Council for Graduate Medical Education have worked to 
develop the perioperative surgical home (PSH) model, for which the 
underlying principle is coordination of care throughout the entire peri-
operative period under the leadership of anesthesiologists.39,67,68 The 
ASA Learning Collaborative on the Perioperative Surgical Home69 is 
currently gathering data from numerous practices around the country 
that are implementing the model or parts of the model. Given that the 
patient-centered medical home (the basis for the PSH) has not shown 
consistent benefits for all patients and that some supporters of the PSH 
acknowledge it may not work in every population,39 it is crucial that the 
model be rigorously evaluated with regard to economic considerations, 
its effectiveness, and its applicability to diverse practices.70-72 Significant 
inertia still must be overcome for the PSH to become a reality.
 � SCENARIO 3: PROCESS MANAGERS AND PERIOPERATIVE CARE 
DIRECTORS
Although the Perioperative Surgical Home necessitates a reorganization of 
the practice of anesthesia, some envision a future that includes an even 
more drastic re-engineering of the specialty, including the way anesthesi-
ologists are trained and how and where anesthesiologists practice.40 In 
order to achieve such re-engineering, anesthesiologists will require formal 
training in healthcare business, process management and finance, and a 
broadening of their medical knowledge and experience. Perhaps most 
importantly, anesthesiologists would have to be trained to supervise 
others effectively and to work collaboratively and effectively with non-
physician colleagues as care directors throughout the perioperative period. 
This model sometimes runs counter to the current training process, but 
there are already anesthesia programs that are offering novel fellowships 
such as operating room management. If this model is to succeed, residen-
cies and academic programs will have to undergo major paradigm shifts.
 � MEETING THECHALLENGE OF CHANGE
In an era of drastic revolution in health care, anesthesiologists can do 
much more “to enhance healthcare beyond prevention of intraoperative 
death,”60 for certainly the specialty has much to offer beyond this. As anes-
thesiology looks to meet the demands of the future, it can make use of 
those same factors that allowed the field to make such advances in patient 
safety: outcomes orientation, team care, efficiency orientation, and site-of-
care flexibility.60 These factors will serve the specialty well as it adapts and 
responds to the transformation of modern medicine. Change will be 
driven by several imperatives, including shifting demographics, techno-
logical advances, patterns of surgery, and economic realities. There will be 
an increasing number of elderly people, high-risk obstetric patients, and 
children with complex medical problems requiring surgery. Thus, it is 
important to further increase the safety of all surgical, anesthetic, and 
perioperative care to minimize both short-term morbidity and long-term 
deterioration when vulnerable patients undergo surgery and anesthesia. 
Anesthesiologists must look beyond a limited view of responsibility for 
patient outcomes lest our contribution to medicine be trivialized.19
Improved monitoring, safer drugs, less-invasive surgery, and sophisti-
cated communication networks may allow anesthesiologists and other 
anesthesia clinicians to extend their roles without compromising patient 
safety. Intensive care units may serve as a useful model, where one nurse 
attends to one or two critically ill patients and a small number of physi-
cians, with one experienced intensivist, regularly assess all the patients 
and modify treatment plans over the course of the day. A derivative of 
this model could be conceptualized for future operating room anesthesia 
care with the inclusion of information technology advances based on 
telemedicine. As individual patients present with their genetic profiles, 
it may become possible to tailor anesthetic and analgesic therapy with 
increased efficacy and decreased side effects. This pharmacogenomic 
model would represent a major advance in patient safety.
CONCLUSION
Health care systems and processes are evolving at a rapid rate. Anesthe-
siology as a specialty must adapt to the changes support societal needs 
and to ensure that anesthesiologists remain valuable and essential lead-
ers in the health care system of the future. Anesthesiologists must extend 
their physician skills in multiple areas and increasingly pursue subspe-
cialty fellowships. Anesthesiologists have knowledge and skills that 
bring meaningful value in nearly all areas of medicine. Apart from tra-
ditional areas of involvement, such as operating room anesthesia, critical 
care, pain medicine, teaching, research, and resuscitation, there will be 
future opportunities for anesthesiologists in areas such as pharmacoge-
nomics, health care system management, and new technologies.
KEY REFERENCES
•	 Brennan TA, Horwitz RI, Duffy FD, Cassel CK, Goode LD, Lipner 
RS. The role of physician specialty board certification status in the 
quality movement. JAMA. 2004;292(9):1038-1043.
•	 Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist 
to reduce morbidity and mortality in a global population. N Engl 
J Med. 2009;360(5):491-499.
•	 Lagasse RS. Anesthesia safety: model or myth? A review of the 
published literature and analysis of current original data. Anesthe-
siology. 2002;97:1609-1617.
•	 Larsson J, Holmstrom I, Rosenqvist U. Professional artist, good 
Samaritan, servant and co-ordinator: four ways of understanding 
the anaesthetist’s work. Acta Anaesthesiol Scand. 2003;47:787-793.
•	 Noordzij PG, Poldermans D, Schouten O, Bax JJ, Schreiner FA, 
Boersma E. Postoperative mortality in the Netherlands: a popula-
tion-based analysis of surgery-specific risk in adults. Anesthesiol-
ogy. 2010;112(5):1105-1115.
•	 Schwinn DA, Balser JR. Anesthesiology physician scientists in 
academic medicine: a wake-up call. Anesthesiology. 2006;104: 
170-178.
•	 Stoelting, R. Pioneering Safety: Executive Summary of the APSF 
response to the Institute of Medicine Report. Anesthesia Patient 
Safety Foundation. 9 September 2015. www.apsf.org. Accessed on 
31 January 2017.
•	 Warner MA. Who better than anesthesiologists? The 44th Roven-
stine lecture. Anesthesiology. 2006;104:1094-1101.
REFERENCES
Complete references are available online at www.LongneckerAnesthesiology 
.com.
Longnecker_Part01_p0001-0034.indd 14 05/05/17 3:48 PM
http://www.apsf.org
http://www.LongneckerAnesthesiology.com
http://www.LongneckerAnesthesiology.com
CHAPTER 3: Safety and Quality: The Guiding Principles of Patient-Centered Care 15 
Safety and Quality: The 
Guiding Principles of 
Patient-Centered Care
May C. M. Pian-Smith 
Nirav Kamdar 
David E. Longnecker 
Jeffrey B. Cooper 
KEY POINTS
1. The patient should be the focus of anesthesia care.
2. The goal of anesthesia care must be to ensure that no patient is harmed.
3. Preventing harm is challenging because care is complex and serious adverse 
events are relatively rare and often the result of many causes rather than a 
single one.
4. Weaknesses in “the system” are often the source of serious adverse events that 
are sometimes attributed to clinical incompetence.
5. Vigilance alone is not enough; a strategy of error prevention is required to 
prevent harm.
6. Organizations, departments, and groups must use a top-down, integrated 
approach and a commitment to creating a safe environment and system for 
safety.
7. Safety must be the first priority to create an organization that operates at the 
highest level of reliability.
8. Anesthesia professionals must employ a broad array of safety tactics as a 
foundation for their anesthesia practice.
9. Teamwork and communication among the perioperative caregivers are critical 
components of patient safety.
10. High-quality, safe anesthesia practice also requires a proactive, forward-look-
ing approach that identifies successes and disseminates their characteristics 
widely to ensure resilience in the system.
Patients expect high quality and complete safety from their anesthesia 
providers. They fear the possibility of experiencing pain, awareness dur-
ing surgery, and the potential for serious complications, including 
death.1,2 Patients are even apprehensive about what anesthesia providers 
consider as routine or “minor complications,” such as postoperative 
nausea and vomiting. Our empathy and our resolve to address these 
concerns are fundamental tenets for patient-centered care across the 
spectrum of anesthesia practice. Anesthesia providers develop a comfort 
with their craft, despite its inherent dangers. Over time, the administra-
tion of potentially lethal drugs, the management of apnea, and the con-
trol of altered physiologic systems become almost routine. With 
experience, these providers may even take for granted the inherently 
hazardous art and science of rendering patients insensible to pain, 
unconscious, and paralyzed. While meeting these patient needs demands 
knowledge, skills, and continuous vigilance from each individual practi-
tioner, equally important is a system design that ensures safe practitio-
ners; provides the appropriate drugs, technologies, policies, and 
procedures to foster safe practice; monitors performance of the entire 
process (including both outcomes and patient satisfaction); identifies 
safety and quality problems; and implements corrections. All of these 
rely on and contribute to a culture of safety and quality at all levels of the 
system—a culture that supports these needs not only in words but also 
in deeds and actions.
In 2001, an Institute of Medicine (IOM) committee identified patient 
safety, quality of care, and patient-centered care (ie, individualized care) 
as progressively increasing levels of excellence in the overall health care 
process.3 This view is consistent with the tenetsof other organizations 
that serve the public while dealing with potentially lethal outcomes (eg, 
3
C H A P T E R the commercial aviation industry). In short, safety is the foundation on 
which quality (eg, the application of evidence-based approaches) and 
then patient-centeredness are built, but all are required to meet the goal 
of highest-quality care.
The demands for quality and safety start with the patient’s needs and are 
guided by the needs of the physicians performing the procedure (medical, 
surgical, or diagnostic) that requires anesthesia care. Sometimes, these are 
competing expectations, requiring thoughtful trade-offs based on essen-
tial priorities. When balancing these trade-offs, involvement of the patient 
is a key to positive patient satisfaction with the overall process.
Every subsequent chapter in this text has the delivery of safe and high-
quality care as its primary objectives. This chapter defines a strategy and 
generic principles for achieving these objectives, centering on the 
patient while also meeting the other demands of modern perioperative 
care (see Box 3-1 for definitions of key terms). Subsequent sections in 
this book provide specific elements of evidence-based anesthesia care 
that are required to meet these strategic objectives.
BOX 3-1
The key terms commonly used to discuss quality and patient safety include the 
following:
•	 Patient-centered care encompasses the qualities of compassion, empathy, open 
and complete communication, and responsiveness to the needs and preferences 
of each patient.3
•	 Quality of care is the extent to which health services for individuals and popula-
tions increase the likelihood of desired health outcomes and are consistent with 
current professional knowledge.4
•	 Patient safety is the avoidance, prevention, and amelioration of adverse out-
comes or injuries stemming from the processes of health care. These events 
include “errors,” “deviations,” and “accidents.” Safety emerges from the interac-
tions among the components of the system; it does not reside in a single person, 
device, or department. Improving safety depends on learning how safety 
emerges from the interactions of the components through analysis of “near 
misses” and adverse outcomes or injuries. Patient safety is a subset of health 
care quality.5
•	 Quality improvement. The US Agency for Healthcare Research and Quality 
defined high-quality health care as “doing the right thing, at the right time, 
in the right way.”6 Quality improvement is the process used by individuals and 
organizations to ensure that these goals are met through a system of constant 
scrutiny, measurement, review, and revision.7
•	 Adverse event is an injury caused by medical management that results in 
measurable disability.8
•	 Accident is an unplanned, unexpected, and undesired event, usually with an 
adverse consequence.9
•	 Error is when a planned sequence of mental or physical activities fails to achieve 
its intended outcome and these failures cannot be attributed to the intervention 
of some chance agency.10
•	 Near miss is an event or situation that could have resulted in an accident, injury, 
or illness but did not, either by chance or through timely intervention.7 Also 
known as close call or near hit.
•	 Human factors refers to the scientific discipline concerned with understanding 
interactions between humans and other elements of a system and to the profes-
sion that applies theory, principles, data, and methods to design to optimize 
human well-being and overall system performance.11
•	 Risk management is the clinical and administrative activities undertaken to 
identify, evaluate, and reduce the risk of injury to patients, staff, and visi-
tors and to identify, evaluate, and reduce the risk of loss to the organization 
itself.12
•	 Resilience allows adaptation to change during times of ambiguity or adversity. 
By anticipating threats and opportunities and having flexible responses to 
changing demands and continuous learning from both successes and failures, 
focus can shift toward promotion of quality and innovation.13
Longnecker_Part01_p0001-0034.indd 15 05/05/17 3:48 PM
16 PART 1: Introduction to Anesthesiology
DEFINING QUALITY AND SAFETY
The concepts of quality and safety are a continuum. Some view safety as 
a subset of quality; most agree that quality care must be founded on safe 
care. One important difference is that quality is generally measured in 
terms of success in achieving desired outcomes, whereas safety is mea-
sured in failures, particularly catastrophic failures. Success in achieving 
the desired outcomes includes not only a safe experience but also one 
that incorporates the elements of evidence-based medicine, especially 
because personal provider experience is almost never adequate to evalu-
ate either the overall positive or the overall negative consequences of a 
specific drug, technique, or procedure. Because anesthesia is generally 
not therapeutic, complete safety must be the most important goal of 
every anesthetic. This means a goal that no patient is harmed from the 
effects of the overall anesthesia encounter. This may seem unattainable. 
But, as described further in this chapter, adopting such lofty goals and 
committing to achieve them leads to greater safety and better care.
To the benefit of all, quality and safety have attained increasing 
importance in modern health care. There is a rich history of attention to 
the processes of improving care. Those activities can be traced to the 
work of Donabedian, who developed principles by which quality can be 
measured and improved for health care in general, but with specific 
applications to hospital care.14 It was only in the late 1990s that the con-
cept of patient safety was raised to prominence in the broad health care 
environment, a result of a landmark study of medical error.14 Yet, in 
anesthesia, patient safety has a much richer history.15 Indeed, the spe-
cialty of anesthesiology is often identified as the earliest adopter of 
patient safety principles, and it is lauded for achieving dramatic 
improvements in outcomes (see Anesthesia Risk and Accidents for the 
history of patient safety in anesthesia).16
The concepts of patient safety, quality improvement, and risk man-
agement are related but have important distinctions. Patient safety 
focuses on prevention of injury. Quality improvement generally deals 
with the broader spectrum of quality, including the success of treat-
ments (see Chapter 22). Historically, risk management addressed the 
aftermath of adverse outcomes, especially legal issues, disclosure to 
patients, malpractice, and avoidance of financial loss for insurers. But 
now, modern risk management employs proactive patient safety goals, 
based on the principle that prevention of injuries via error reduction 
and system improvements reduces the adverse events from which mal-
practice awards arise. As modern health care is often plagued by a “cost 
conundrum” of continuing elevating costs, quality and safety choices 
must be weighed against the value that they provide for the patient 
experience and safety in relation to the cost for obtaining better 
outcomes.17
Because safety focuses on preventing rare events, it is much harder to 
develop an evidence base for actions that create safety. Randomized 
controlled trials, although possible for testing many types of quality 
improvement practices, are almost unheard of for trials of safety prac-
tices. Many safety initiatives arise from investigation of serious adverse 
events. More intuitive arguments and judgments guide the implementa-
tion of safety principles.
ANESTHESIA RISK AND ACCIDENTS
The roots of safety run deep in anesthesiology. Dating to the first survey 
of anesthetic deaths,18,19 there has been a regular and continuous self-
examination within the anesthesia profession to understand the causes 
of harm and how to prevent them. In the modern era of health care, 
anesthesiawas the specialty that coined the term patient safety, which is 
now in the lexicon of health care and broadly applied to all medical 
disciplines.
 � HISTORY OF PATIENT SAFETY IN ANESTHESIA
The history of safety in anesthesiology may have begun with the first 
description and review of an anesthetic death—that of Hannah Greener, 
who died in 1848 during administration of chloroform for amputation 
of her large toe.20 Although outcome studies were reported over the years, 
it was not until the landmark study of Beecher and Todd that a large 
population was sampled and specific causality suggested.21 Other studies 
followed during the 1950s and 1960s, with a focus generally on the mor-
bidity and mortality associated with general or regional anesthesia and 
the cause of death or serious injury in surgical patients.22,23
Safety interventions in the 1950s and 1960s focused on the development 
of safety features of anesthesia equipment. Features such as the fail-safe 
system for protecting against loss of oxygen supply pressure and pin-
indexing of gas cylinders to prevent their interchange are still in use today.
The concept of “patient” safety arose in the early 1980s, in response to 
several factors. The first study of the contribution of human error in 
anesthesia was reported in 1978, followed by larger studies that focused 
on the sources of errors and strategies for their prevention.24,25 In these 
studies, Cooper et al studied “critical incidents” to elucidate the mecha-
nisms of what were then called anesthesia “mishaps” as multidimen-
sional, resulting from a number of errors and other contributing factors 
to each event. Other reports described attributes of a specific event, such 
as disconnection in the breathing circuit, the relief of one anesthesia 
provider by another, and other generic contributors to critical events. 
Several studies replicated the methods and general findings in other set-
tings and countries.26,27
A “crisis” of increasing costs for malpractice insurance for anesthesi-
ologists prompted intense interest in tort reform and in reducing the 
number of adverse events that led to claims. The American Society of 
Anesthesiologists (ASA), under its then-president, Ellison C. Pierce Jr, 
MD, led this initiative, which resulted in the formation in 1985 of the 
Anesthesia Patient Safety Foundation.28 Its activities represented the first 
organized efforts in health care to address patient safety as a single topic. 
The ASA later sponsored studies of closed malpractice claims, which led 
to numerous reports about causes of the most severe adverse events and 
their trends.29
Many efforts contributed to what appears to be a substantial reduction 
in catastrophic adverse anesthesia outcomes among relatively healthy 
patients.30 Among these were improvements in educational programs; 
safer drugs and equipment; more intense patient monitoring (especially 
oxygen analyzers, pulse oximetry, and capnography); and new technologies 
for managing difficult airways (a specific contributor to numerous severe 
adverse outcomes). Standards and guidelines for anesthesia care also played 
a role in reducing adverse events. In 1986, the Harvard Medical School 
Department of Anesthesia promulgated the first standards for care31; these 
were later adopted by the ASA as national standards. It is claimed that 
these standards are associated with a reduction in serious outcomes 
among ASA physical status (ASA-PS) 1 and 2 patients in the ensuing 
years.31 Many other standards and guidelines followed. Box 3-2 sum-
marizes key milestones in the path to safer anesthesia care.
The 1999 publication of the IOM report To Err Is Human: Building a 
Safer Healthcare System catalyzed a national movement in patient 
BOX 3-2 
Key Historical Influences Leading to Increasing Patient Safety in Anesthesia
Research in human error, human factors, and closed claims.
Development and routine use of pulse goniometry.
Development and routine use of capnography.
Enhanced alarms and safety features in anesthesia machines/workstations.
Development of safer anesthetic drugs.
Anesthesia Patient Safety Foundation focus on patient safety.
American Society of Anesthesiologists adoption of standards and guidelines for safe 
practice.
Development of new airway tools (eg, �ber-optic bronchoscopy and video laryngoscopy).
Emphasis on safety culture: cognitive science and crew resource management.
Utilization of simulation for enhanced training, identi�cation of latent errors, and 
assessment.
Longnecker_Part01_p0001-0034.indd 16 05/05/17 3:48 PM
CHAPTER 3: Safety and Quality: The Guiding Principles of Patient-Centered Care 17 
safety.32 It and subsequent reports recommended fundamental changes 
in the health care system to combat a problem with deep roots in the way 
patient care is organized (or disorganized), particularly the culture of 
health care that did not place a high priority on the overall safety of 
patients relative to the delivery of specific services. The IOM’s report, as 
well as other writings, singled out anesthesiology as the one specialty 
that addressed patient safety early and with positive results.
 � CURRENT STATE OF KNOWLEDGE OF ANESTHESIA RISK AND 
RELATIONSHIP TO ERROR
There is a general belief that the risk of preventable death or injury from 
anesthesia is relatively low compared with many other medical and non-
medical risks. Yet, there are no accurate estimates of the rate of adverse 
outcomes in general or for an individual patient presenting with specific 
risk factors. One reason is that there are no standard methods for assign-
ing causality appropriately among numerous factors, including anesthe-
sia, surgery, the facility (and its systems), and the patient’s disease. 
Particularly in the United States, the fear of malpractice claims hinders 
reporting and open, candid discussion of errors. Federal legislation, 
similar to that enacted in Australia in the late 1980s, now protects vol-
untary reporting.33 Despite the absence of strong evidence, estimates of 
the risk of untoward outcome to a relatively healthy patient are believed 
to be on the order of 1 in 100,000 patients.34,35 However, for patients 
presenting at greater risk, the risk may be on the order of 1 in 10,000, 
which is not different from early estimates for all patients.34,36
Through the recent establishment of the Anesthesia Quality Institute 
(AQI) in 2010 through the ASA, there is an increasingly robust mecha-
nism for tracking and evaluating anesthesia care and opportunities for 
improvement. The AQI provides an infrastructure for achieving three 
important goals: aggregating electronic data from all anesthetics in the 
United States, collecting narratives about critical events, and disseminat-
ing these data for the purposes of science, education, and quality 
improvement. Within the auspices of the AQI, the National Anesthesia 
Clinical Outcomes Registry (NACOR) is the largest registry of its kind, 
in 2014-2015 capturing 25% of all anesthetics procedures performed in 
the United States, and allowing for individual practitioner metrics and 
local quality improvements.37-40 Chapter 21 includes a comprehensive 
discussion of risk, mortality, and morbidity.
ACCIDENT MODELS
Most people, both in and out of health care, seek to assign blame to 
specific individuals for specific lapses in performance associated with an 
adverse event. Yet, the evidence demonstrates that most injurious acci-
dents are typically complex events for which there is no single cause.41-43 
Although it would be possible to envision a scenario in which a specific 
act by one individual led to an accident, assigning such pinpoint causal-
ity is not a useful approach to accident prevention. Substantial research 
is targeted at learning how accidents occur and how humans are 
involved in that process. The science emerging from that research sup-
ports the concept that there are few simple solutions for prevention of 
accidents.However, it offers possible strategies and tactics for lowering 
the potential for accidents by preventing human error and its precursors 
(ie, the factors that promote and propagate errors) and by creating resil-
ience in systems to respond to those errors that will inevitably occur 
despite the best of intentions and preventive actions.
The goal of adverse-event-free anesthesia care can be achieved only by 
applying a broad spectrum of prevention strategies and building resil-
ience throughout the entire system of anesthesia care, for the overall 
system is no stronger than its weakest links. This section examines sev-
eral models and issues at the organizational and human levels to inform 
our thinking about designing for failure.
 � THE “SYSTEM” OF ANESTHESIA CARE
Whereas anesthesia could be viewed simply as a single provider admin-
istering drugs to a single patient, that narrow perspective does not rep-
resent the intricate and multidimensional processes that characterize 
care delivery. Rather, the anesthesia encounter consists of several 
components that comprise the “system of anesthesia care.” Classically, 
the anesthesia processes can be thought of broadly in three phases: pre-
anesthetic planning and preparation, provision of anesthesia for the 
procedure, and postanesthesia care. Within each of these phases, the 
anesthesia provider performs a set of tasks intended to provide quality 
care for the patient, surgeon, or other operator and the health care orga-
nization. Achieving safety and quality requires that these anesthesia 
activities be synchronized with the needs of other providers, allied 
health professionals, technical staff, support staff, hospital or organiza-
tion programs, and, especially, the patient’s needs and expectations. 
More recently, the ASA has expanded the scope of the three phases of 
anesthesia care, further encompassing the perioperative period, includ-
ing the preadmission to postdischarge period within the perioperative 
surgical home (PSH).44 The increasingly complex interactions between 
all of these components comprise a “system” of care that has yet to be 
fully modeled for the perioperative experience. Further, this “anesthesia 
system” takes place within a system of systems that includes the overall 
course of care, and numerous elements of this larger system may interact 
with anesthesia care at multiple points in the delivery process. Such 
interactions often contribute to a less-than-optimal experience for the 
patient.
The Accreditation Council for Graduate Medical Education (ACGME) 
has established a set of eight competencies that must be met for all medi-
cal trainees.45 One competency is to understand and know how to prac-
tice within a system of health care. That requirement arose in recognition 
of the interdependencies among all the members of the care team and 
the larger system in which they operate. In the case of anesthesia, that 
implies having an understanding of the requirements and needs of all 
other participants in the perioperative system and implementing an 
anesthesia plan that appropriately meets these various needs, rather than 
acting individually in an insular fashion.
 � MODELS OF ORGANIZATIONAL FAILURE
James T. Reason is perhaps the most widely cited author for conceptual-
izing the mechanisms of human error and system failures, although his 
work is founded on the basic work of Rasmussen. Their thinking derives 
from research in high-hazard industries, such as nuclear power, aviation, 
and chemical manufacture. Gaba offered insightful interpretations of this 
work and other research as it applies specifically to anesthesia practice.43 
The basic concepts are relatively simple: Accidents are not one dimen-
sional; rather, they are the result of the interaction of several elements; 
each accident is somewhat unique in the way that elements combine to 
result in injury. (Note that in the context of “safety,” we are addressing 
only those adverse outcomes that could be prevented given the applica-
tion of current knowledge; death or injury that appears to be caused 
primarily by the patient’s disease process or the unpredictable influences 
of drugs or operation likely cannot be altered by safety interventions.) 
Reason depicted the process of accident evolution in what is widely 
referred to as the “Swiss cheese” model (Figure 3-1).10
The Swiss cheese model illustrates that accidents are typically the 
result of a series of events that include precursors, which trigger or allow 
the chain of events that result in the final (active) adverse event. Reason 
termed these precursors latent errors. This concept is now widely 
accepted in understanding health care system failures. Latent factors 
exist regularly in any work environment. They have the potential for 
initiating or propagating an evolving accident. Examples are failure to 
maintain equipment or replace obsolete equipment, selection of low-
quality supply items, poor scheduling practices that promote haste or 
fatigue, and case scheduling and staffing models that allow assignment 
of relatively inexperienced clinicians to unfamiliar cases or high-risk 
patients. Cultural influences are an important source of latent failures. 
Examples include the pressure to proceed with cases in remote locations 
where the resources are insufficient to meet minimal anesthesia safety 
requirements, pressures to move rapidly to avoid “turnover delays,” pres-
sures to assign an inexperienced provider to a case to “keep the schedule 
moving,” a hostile atmosphere within an operating room that limits 
communication of concerns about quality and safety, and failure to heed 
a patient’s warnings or concerns. Latent errors rarely lead to an immedi-
ate accident. Rather, they can be seen as a lurking enemy, or, as Reason 
Longnecker_Part01_p0001-0034.indd 17 05/05/17 3:48 PM
18 PART 1: Introduction to Anesthesiology
called them, “resident pathogens,” awaiting the circumstances that will 
combine to produce a catastrophic outcome, often in ways that are 
unusual and what may be called “unpredictable.” Avoiding the conse-
quences of latent errors requires broad defenses and resilience through-
out the system to mitigate evolving failure that results from alignment of 
the “holes in the cheese.”
Reason’s model highlights the need for broad and varying mecha-
nisms to trap errors and failures during the patient’s health care encoun-
ter and thus mitigate or prevent the full cascade from unfolding. His 
work on managing risk begins at the organizational level and offers a 
spectrum of strategies and tactics for accident prevention. Both the atti-
tude and actions of the organization and each individual in the chain of 
care can either bolster or undermine those defense mechanisms.
There is a competing theory that postulates that prevention is not 
always possible or even probable. The normal accident theory (NAT), as 
described by Perrow,41 characterizes some industrial systems as particu-
larly resistant to strategies for prevention of catastrophic accidents if the 
systems are both complex and “tightly coupled”; that is, the connections 
between processes are such that one quickly affects the other in ways 
that can evolve into an accident that is not predictable by deterministic 
analysis. Fortunately, although all the patient and provider processes 
involved in anesthesia administration may create a “complex” system, 
they are not usually tightly coupled to the extent envisioned in Perrow’s 
model, although it may occur in certain high-risk patients whose disease 
processes present a less-stable condition. Still, Perrow’s NAT provides 
many lessons for anesthesia practice and for constructing resilient sys-
tems to minimize the potential for accidents.
Of special concern is that some protections and safety features can 
actually make systems more complex, mask impending problems, and 
impart a false sense of security. Further, certain prevention or mitigation 
strategiesmay affect other parts of the system in unanticipated ways and 
thus lead to new, unexpected risks. Anesthesia has many examples: Pulse 
oximetry can lead to practicing closer to the edge of acceptable levels of 
oxygenation or inappropriate assumptions that a functioning pulse oxim-
eter implies adequate blood flow; automated noninvasive blood pressure 
monitors can fail to cycle and thus continue to present falsely high read-
ings even in the presence of blood loss; or alarms on anesthesia monitors 
may be turned off to avoid “distraction” during the procedure. Moreover, 
the relative safety of anesthesia itself has been called an “insidious haz-
ard,” for some become complacent about anesthesia care and vigilance 
and assume that nothing will go wrong based on prior experience.25
Complacency about safety based on prior experiences has led to 
major disasters in a variety of organizations; a prime example is the loss 
of the orbiter (“shuttle”) Columbia on February 1, 2003. The Columbia 
Accident Investigation Board identified a number of contributing latent 
factors that resulted in complacency within the National Aeronautics 
and Space Administration (NASA). A key factor was the acceptance of 
“normal deviation” (see the discussion of normalization of deviance in 
the section on the high-reliability organization model). Another was the 
loss of checks and balances that should have guided NASA safety efforts. 
Many of these latent factors resulted from the lack of serious events in 
the years immediately preceding the loss of Columbia.46
Reason’s commentary about creating effective defenses against acci-
dents fits well for anesthesia:
If eternal vigilance is the price of liberty, then chronic unease is the price 
of safety. Studies of high-reliability organizations—systems that have 
fewer than their share of accidents—indicate that the people who oper-
ate and manage them tend to assume that each day will be a bad day and 
act accordingly. But this is not an easy state to sustain, particularly when 
the thing about which one is uneasy has either not happened or has hap-
pened a long time ago, and perhaps in another organization. Nor is this 
Cassandra-like attitude likely to be well received within certain organiza-
tional cultures.42
 � MODELS OF HUMAN ERROR/FAILURE
There has been a strong reliance on “vigilance” during anesthesia as the 
primary approach to error prevention, so much that the word is the motto 
of the ASA. Vigilance means sustaining attention.47 It has been defined as 
having three components: alertness, selection of information, and con-
scious effort. It is a much more complex process than is immediately 
apparent, and vigilance is the subject of much investigation in many fields 
that require sustained attention to ensure safety and performance. The 
observant practitioner is aware of some of the many ways that vigilance 
can be thwarted and performance degraded. Further, vigilance is only one 
of a complex set of elements that comprise safe anesthesia practice.
The modern theory of accident causality and safety views the human 
as a component of a system. Most experts now tend to play down the 
operator’s responsibility for accidents, perhaps because so often the atten-
tion and blame have been so heavily directed at those who are the last line 
of defense.48 In fact, there is substantial evidence about human error and 
how humans interact with systems in diverse ways to either help or hin-
der the accident process. The vast majority of research has been in indus-
try, most notably aviation and nuclear power applications, but there has 
been substantial investigation in anesthesia, where some of the earliest 
studies of human error and human factors in health care are found.
The studies of critical incidents mentioned previously identified the 
basic issue of human error as a component of what were termed mishaps. 
FIGURE 3-1. “Swiss cheese” model of accidents in anesthesia. 
[Reproduced with permission from Reason J: Managing the Risk of 
Organizational Accidents. Aldershot, Hants, UK: Ashgate Publishing; 
1997.]
Triggering
events and
precursors
Accident!
Excessive
regulation
Fear of
litigation
Production
pressure
Poor
communication
Device failure
Distraction
Unsafe acts
Fatigue
Complexity
Poor design
Conflict
Cost cutting
Government
Organization 
(latent failures)
Team
Technology
Anesthesia provider
Longnecker_Part01_p0001-0034.indd 18 05/05/17 3:48 PM
CHAPTER 3: Safety and Quality: The Guiding Principles of Patient-Centered Care 19 
Factors associated with mishaps, what would now be called latent factors, 
were identified, such as lapses in training, equipment design weaknesses, 
and the contribution of fatigue. In these and other areas, the science of 
human performance and human factors has revealed much more about 
the weaknesses of humans and the many ways in which we can fail, 
including how system design and other factors can influence our perfor-
mance and conspire to weaken even the most expert clinician.
Human error is the subject of intense investigation in the fields of 
human factors, ergonomics, and industrial psychology. Again, James 
Reason provided an overview of the subject.10 Performance is defined at 
three levels: skill based, rule based, and knowledge based. Error is 
defined as the failure of planned actions to achieve their desired ends 
without the intervention of some unforeseeable event. Errors are divided 
into two main types: slips and mistakes (Box 3-3). The thoughtful prac-
titioner will consider that his or her slips and mistakes vary in type and 
cause, most of all recognizing that all forms of error require efforts 
toward prevention, or mitigation of their consequences because errors 
occur despite the best of efforts.
Many factors influence vigilance and performance (performance-
shaping factors), including fatigue and sleep deprivation, environmental 
influences, production pressures, human-interface design, and team-
work. Other factors associated with adverse events in anesthesia that 
either may promote errors or may foster their propagation have been 
identified.24,25 We consider some as examples of the issues that anesthesia 
providers must address to maintain accident-free performance through-
out a professional career. Measures to prevent performance decrement 
or to help maintain optimal performance are described in the section 
Creating Safety at the Organizational and Departmental Levels.
Fatigue and Sleep Deprivation There is evidence (in trainees) that 
shows an association between sleep deprivation and human errors, 
including lack of attention to task, serious auto accidents, and medical 
errors involving both diagnosis and treatment.47,49,50 There are many 
examples of large-scale industrial accidents for which sleep deprivation 
or fatigue was identified as a major contributing factor.
Howard et al reviewed the literature on sleep and fatigue with particu-
lar reference to anesthesia.51 Among the key findings were the following: 
(1) Inadequate sleep degrades performance; (2) individuals require dif-
ferent amounts of sleep to feel awake and alert; (3) the failure to obtain 
adequate sleep results in a sleep “debt” that is cumulative and can only 
be reduced by sleep to pay back the debt; (4) circadian rhythms have an 
important influence on both the tendency to sleep and the ability to 
sleep, with the circadian lull associated with degraded performance 
between 2 and 6 am and 2 and 6 pm; and (5) stimulants such as caffeine 
can aid in maintaining alertness and wakefulness, but side effects must 
be understood to use these effectively.52
In response to sleep deprivation data and the highly publicized and 
tragic death of Libby Zion at a New York Hospital, the ACGME insti-
tuted a policy in 2003 for a reduction in resident duty hours with a 
subsequent revision to intern duty hours in 2011. The impact of reduced 
duty hours has been variable. Studies showed reduced attentionalfail-
ures among interns working in the intensive care unit50 and decreased 
short-term mortality in high-risk medical patients53 but did not show 
clear mortality reductions in surgical patients.53 A meta-analysis by 
Jamal and colleagues revealed no overall significant improvement with 
decreased duty hours, thus suggesting that individual practitioner per-
formance is only one element contributing to safer care in surgery.54
BOX 3-3
Slips and Mistakes
Slip: The plan is adequate, but the actions fail to go as planned. These are unintended 
failures of execution, also referred to as lapses, trips, or fumbles. They are further divided 
into attentional slips of action and lapses of memory.
Mistake: The actions conform to plan, but the plan is inadequate to achieve its intended 
outcome. Mistakes are divided into rule based (eg, misapplication of normally good rules 
but not correct for this situation) and knowledge based (eg, incorrectly thinking out a 
solution for which there is no prepackaged solution).
Transitions Among Care Providers (“Handoffs” or “Handovers”) 
There are conflicting findings about the impact of handoffs or hando-
vers among anesthesia providers to mitigate the effects of fatigue, bore-
dom, hunger, and so forth. Cooper et al examined critical incidents 
associated with relief of one anesthesia provider by another.55 They 
concluded that, overall, relief provided more benefit from detecting 
undiscovered problems than harm from transferring responsibility to a 
provider with less serial knowledge of the specific patient and proce-
dure. These conclusions were verified by interpretation of data from a 
similar study by Short et al.56 More recently, Arbous et al found that a 
change of anesthesiologists was associated with greater incidence of 
severe morbidity and mortality.57 Yet, routine breaks are generally found 
to be useful and necessary in anesthesia and in high-hazard industries. 
Provisions for adequate transfer of critical information and situational 
awareness are required.
Cooper suggested a specific set of guidelines for conduct of handoffs, 
which was recently updated.58,59 The hazards of transitions in care are 
now more widely recognized in health care and receiving increasing 
attention for remediation.60,61 More handoffs now occur among trainees 
as a result of ACGME work-limitation requirements that are intended to 
mitigate the consequences of sleep deprivation and fatigue. Lane-Fall 
et al reviewed recommendations for content and resident training curricula 
for anesthesia handoffs, with particular attention to the I-PASS∗ handoff 
protocol, which was originally designed for pediatric settings but is also 
applicable to perioperative transitions.62,63 They advocated linking hand-
offs to improved clinical and patient-centered outcomes and identifying 
best practices for anesthesia handoffs in different clinical settings.
Environmental Factors Many environmental factors can affect the 
performance of the anesthesia provider. Among these are noise, extremes 
of temperature and humidity, lighting, and toxic vapors.64 Listening to 
music or reading during anesthesia administration are controversial 
issues with conflicting trade-offs.65,66 There are no robust studies in 
health care or simple extrapolations from studies in other fields to guide 
the development of evidence-based standards. Rather, good judgment 
appears to be the best guideline. Background music can alleviate stress 
and boredom, but different musical tastes may lead to varying effects 
among the operating team. Loud music or other noises can obscure 
verbal communications and be especially disruptive during periods of 
high workload or management of critical events. Access to electronic 
resources in the operating room from computers, smartphones, and 
tablets offers practitioners practical tools to instantly look up informa-
tion for a case, manage perioperative issues, and alleviate boredom dur-
ing uneventful intervals. However, it also opens avenues of distraction 
that can denigrate vigilance and patient safety. Although not yet specifi-
cally reported in the anesthesia literature, there is concern from both the 
public and practitioners regarding “distracted doctoring.”67 Electronic 
distractions are intuitively problematic and would be difficult to justify 
in an accident investigation involving pilots, air traffic controllers, train 
operators, or anesthesia providers, among others.
Human Factors and Human Interface Design Human factors engi-
neering (HFE) is a broad field that encompasses all of the different 
aspects in which humans interact with systems.68 The importance of 
human factors, especially the design of the human-machine interface, is 
well known in other fields but greatly underappreciated in health care.11 
The goal of HFE is to “design tools, machines, and systems that take into 
account human capabilities, limitations, and characteristics.”69 Given 
that anesthesia is technology intensive, human factors play an important 
role in prevention of errors and adverse outcomes.
Several studies examined how the design of displays and of anesthesia 
alarms have an impact on equipment use and errors.64,70,71 The results 
indicated that technology is not generally well designed to accommodate 
the ways people use it. There are numerous examples of how the design 
of a device interface can be especially dangerous.72-74 The design of anes-
thesia monitors is particularly problematic. Anesthesia providers work 
in facilities that have various models or different suppliers of devices. 
∗I-PASS: I = illness severity, P = patient summary, A = action list, S = situational awareness 
and contingency plans, S = synthesis by receiver.
Longnecker_Part01_p0001-0034.indd 19 05/05/17 3:48 PM
20 PART 1: Introduction to Anesthesiology
For example, differences in software design or data displays can cause 
confusion and distract the provider from other important tasks that 
should have higher priority. A new standard requiring attention to 
human factors in the design of medical devices is intended to address 
these issues, but it will be years until the effects can be felt.75
Production Pressure Production pressure refers to “overt or covert 
pressures and incentives on personnel to place production, not safety, as 
their primary priority.”76 Based on a survey of anesthesiologists in Cali-
fornia, Gaba et al reported that nearly half of the respondents had wit-
nessed instances of what they believed to be unsafe actions by an 
anesthesiologist because of production pressure.76 These included inter-
nal pressures (eg, to foster good relations with a surgeon, accrue per-
sonal income) and external pressures (eg, proceed rather than cancel a 
case to appease patient or family, accept an unfamiliar patient or proce-
dure to foster facility throughput).
Teamwork The importance of good teamwork and communication is 
now more widely recognized in health care, especially for surgical teams. 
A substantial body of literature from high-hazard domains, especially 
aviation, and in health care demonstrates the value of teamwork for suc-
cessfully preventing and managing critical situations.77-79 Gaba et al were 
the first to develop teamwork and crisis management training techniques 
for health care, adapting crew resource management (CRM) techniques 
from aviation for applications in anesthesia.80 These approaches have 
since been extended to nearly all health care settings but are particularly 
applicable to those where rapid action is required to successfully treat 
acute complex events, such as dire surgical emergencies.81
Box 3-4 lists some characteristics of effective teams.77,82,83 These defi-
nitions and characteristics, derived from other industries, generally 
apply to health care and to anesthesia practice. Good teamwork can 
prevent errors or mitigate their impact. Teamwork is vital to the success-
ful management of critical events. The team within which anesthesia 
providerswork varies depending on the setting, but it typically includes 
at least a surgeon, a circulating nurse, a surgical technician, and other 
support personnel, including environmental workers; technicians (eg, 
blood bank, laboratory, or radiology); and clerical personnel. Within the 
broad system of care, the team can include those who provide care pre- 
and postoperatively and specialists, such as radiologists, pathologists, 
and intensivists. The immediate operative team has been given the most 
attention for training and research.
Surgical teams have several distinguishing features that create obsta-
cles to effective performance. The hierarchy in surgical care places phy-
sicians above other workers. It is common for surgeons to be accorded 
higher status and to assume a self-designated role of “captain of the ship.” 
Whereas leadership is a key feature for team success, the person in that 
role should vary depending on the situation. Similarly, some anesthesia 
providers may treat other team members as subordinates rather than 
colleagues. High-reliability organization (HRO) theory (see The Elements 
of Safe, High-Quality Anesthesia Care and the discussion of the HRO 
model in that section), which is based on characteristics of organizations 
that function at high levels of safety, calls for a nonhierarchal culture in 
which the leader is the one with the most expertise, not the highest sta-
tus. Conflict among these roles can complicate the management of acute 
operative events, especially when the care team does not work together 
regularly (eg, during nights and weekends when the care team consists 
of “night call” personnel from various work rosters).
SOME SPECIFIC HAZARDS ASSOCIATED WITH 
ANESTHESIA
There are a seemingly infinite number of case reports of specific hazards 
and complications of anesthesia that were largely preventable, although 
a litany of isolated cases is perhaps less helpful than a series of organized 
observations. Studies of closed malpractice claims, funded by the ASA, 
have examined many of these events in a more systematic manner, one 
that assists in developing action plans for reducing risks. These closed 
claims studies have explored several categories of adverse outcomes, the 
most notable addressing errors related to airway management, monitor-
ing, sudden cardiac arrest during spinal anesthesia, equipment failures, 
and nerve injuries.29,84,85
 � ADVERSE RESPIRATORY EVENTS
Events associated with management of respiration are the most serious 
remaining hazards in anesthesia, as evidenced by data from the ASA 
closed-claims analyses.84 The three most common causes of death and 
brain damage are inadequate ventilation, esophageal intubation, and 
difficult tracheal intubation. The large majority of cases in the first two 
groups were judged to have been preventable if “better monitoring” had 
been used. For management of the difficult airway, prevention is more 
challenging. Peterson et al reported that “persistent failed attempts at 
intubation were associated with an outcome of death or brain damage in 
claims in which a ‘cannot ventilate and cannot intubate’ emergency situ-
ation developed prior to surgical incision.”86 They concluded that this 
was supporting evidence for limiting conventional ventilation efforts to 
three attempts before using other strategies.
Despite substantial advances in technologies that aid endotracheal 
intubation and some helpful, although far from foolproof, methods of 
airway assessment, there remain many opportunities for unanticipated 
difficulties with airway management, tracheal intubation, and effective 
ventilation (see Chapter 32). Each is an opportunity for a serious adverse 
outcome. Although airway management skills are greatly emphasized 
during training, there is great variance in experience and abilities among 
anesthesia providers, as are the opportunities to practice emergency 
skills. Thus, periodic retraining and practice in the application of diffi-
cult airway management protocols is prudent. (This is an example of the 
value of simulation as a tool for learning and maintaining skills that may 
be needed infrequently but are essential for patient safety.)
 � MONITORING AND ALARMS
Failure to monitor the patient adequately is an important contributor to 
anesthesia-adverse events. Aside from failures of vigilance, which are 
often related to performance-shaping factors, monitoring technology 
design and lack of experience with technology can contribute to adverse 
outcomes. There are numerous ways in which pulse oximetry, capnogra-
phy, and automated noninvasive blood pressure monitors can give false 
information, leading to missed or incorrect diagnoses. The failure to use 
alarms has led to a requirement in the relevant standard that when a 
pulse oximeter is used, the variable pulse pitch tone and low-threshold 
alarm of the oximeter must always be audible.87 Similarly, when capnog-
raphy is used, the end-tidal carbon dioxide alarm must be audible.
 � MEDICATION ERRORS
Medication errors are among the most frequent errors in anesthesia and 
in health care practice in general.25 Similarity of drug names, containers, 
BOX 3-4
Some Effective Practices of High-Performance Teams
Introduce all members of the team to each other at the start of each procedure.
Regularly conduct preoperative briefings with the entire operative team, which can be 
done via a speci�c checklist as described by Lingard et al.82
Use speci�c communication protocols within the team (SBAR is gaining increasing accept-
ance. It calls for a speci�c sequence for describing the patient’s status: the situation, the 
background, assessment, and recommendations).79
Establish communication standards such as “read back” of all verbal orders (eg, 
medications).
Conduct debriefings with the team following unusual occurrences, near misses, or critical 
events.
Establish an environment that encourages cross-monitoring and backup behaviors across 
the entire team.
Create a language that signi�es recognition of potential hazards.
Practice for emergency situations.
Longnecker_Part01_p0001-0034.indd 20 05/05/17 3:48 PM
CHAPTER 3: Safety and Quality: The Guiding Principles of Patient-Centered Care 21 
and label colors contributes to the ease by which such errors can be 
made, especially during periods of high stress. Dosing errors are also 
common and related to the frequent need for individual numerical cal-
culations when drawing and mixing drugs for bolus administration or 
intravenous infusion. Choosing the wrong form of drug (eg, among 
various insulin formulations), flushing a catheter with a solution con-
taining another potent drug, and confusion in the programming of infu-
sion pumps are other examples of ways in which patients can be injured.
An obvious recommendation for prevention of some medication 
errors is to admonish the provider to read the label carefully.88 Another 
tactic is to read each label three times. Yet, human factors issues are 
widely recognized as contributing greatly to medication errors, espe-
cially because of similarity of drug names, the small or obscure print on 
vials or ampoules, and the failure to organize medication carts opti-
mally to avoid errors. Distractions and production pressure also are 
likely contributors to medication errors. No universal remedy for pre-
vention has been identified. There is a standard for label colors and 
grouping by drug type, but some argue that it is unlikely to be effective, 
and, if anything, all drug labels should be in black and white to force 
careful reading of the drug identity and concentration.89 Numerous 
health care organizations may implement bar-code technology to 
address this hazard in other clinical environments, but this practice is 
not widespread.
 � COGNITIVE ERRORS
While cognitive errors have been studied extensively in the field of cog-
nitive psychology, their contribution to errors in medical and anesthesi-
ology-related decision-makinghave only been appreciated since the 
turn of the millennium. Gaba has described three forms of fixation 
errors, including “this and only this” (fixating on a single diagnostic pos-
sibility to the exclusion of others—a form of “tunnel vision”), “every-
thing but this” (searching among many possibilities but not including 
the real explanation), and “everything is OK” (persistent belief that there 
is no problem in spite of substantive signs there is a problem).80 More 
recently, Stiegler and colleagues have catalogued cognitive errors spe-
cific to anesthesiologists based on previous cognitive psychology work 
(see Box 3-5).90-94 Based on an anesthesiology faculty survey, the most 
prevalent cognitive errors in anesthesiology were anchoring, availability 
bias, and premature closure.92 Stiegler and colleagues studied cognitive 
processes for decision-making, rationalization, and diagnosis among 
anesthesiologists90,91 and determined that anesthesia care, which requires 
rapid and complex decision-making, is particularly prone and suscepti-
ble to cognitive and decision-making errors. As practitioners, anesthesi-
ologists should be aware of the cognitive difficulties that can lead to 
decision and diagnostic errors, embrace the possibility that decision and 
diagnostic errors will occur, and employ preventive tactics to avoid 
error, discussed further in this chapter.
 � EQUIPMENT ERRORS AND FAILURES
Current anesthesia machines and associated technology incorporate 
substantial safety features (see Chapter 35), which have been developed 
over decades in response to specific series of patient injuries associated 
with failure or misuse of equipment. Equipment failure is frequent and 
can occur in many ways, but it rarely causes injury directly.24,87,88 When 
there is an equipment-associated injury, it is more likely to be from 
misuse than from overt failure of a device. Whereas the end user may 
BOX 3-5
Cognitive Error Catalogue
Cognitive Error Definition Illustration
Anchoring Focusing on one issue at the expense of understanding the whole 
situation
While troubleshooting an alarm on an infusion pump, you are unaware of sudden 
surgical bleeding and hypotension
Availability bias Choosing a diagnosis because it is in the forefront of your mind due to an 
emotionally charged memory of a bad experience
Diagnosing simple bronchospasm as anaphylaxis because you once had a case of 
anaphylaxis that had a very poor outcome
Premature closure Accepting a diagnosis prematurely, failure to consider reasonable 
differential of possibilities
Assuming that hypotension in a trauma patient is due to bleeding and missing 
the pneumothorax
Feedback bias Misinterpretation of no feedback as “positive” feedback Belief that you have never had a case of unintentional awareness because you 
have never received a complaint about it
Confirmation bias Seeking or acknowledging only information that confirms the desired or 
suspected diagnosis
Repeatedly cycling an arterial pressure cuff, changing cuff sizes, and changing 
locations, because you “do not believe” the low reading
Framing effect Subsequent thinking is swayed by leading aspects of initial presentation After being told by a colleague, “this patient was extremely anxious preopera-
tively,” you attribute postoperative agitation to her personality rather than low 
blood sugar
Commission bias Tendency toward action rather than inaction; performing unindicated 
maneuvers, deviating from protocol; may be due to overconfidence, 
desperation, or pressure from others
“Better safe than sorry” insertion of additional unnecessary invasive monitors or 
access, potentially resulting in a complication
Overconfidence bias Inappropriate boldness, not recognizing the need for help, tendency to 
believe we are infallible
Delay in calling for help when you have trouble intubating because you are sure 
you will eventually succeed
Omission bias Hesitation to start emergency maneuvers for fear of being wrong or 
causing harm; tendency toward inaction
Delay in calling for chest tube placements when you suspect a pneumothorax 
because you may be wrong and you will be responsible for that procedure
Sunk costs Unwillingness to let go of a failing diagnosis or decision, especially if 
much time/resources have already been allocated; ego may play a role
Having decided that a patient needs an awake fiber-optic intubation, refusing to 
consider alternative plans despite multiple unsuccessful attempts
Visceral bias Countertransference; our negative or positive feelings about a patient 
influencing our decisions
Not troubleshooting an epidural for a laboring patient because she is “high main-
tenance” or a “complainer”
Zebra retreat Rare diagnosis figures prominently among possibilities, but physician is 
hesitant to pursue it
Try to “explain away” hypercarbia when malignant hyperthermia (MH) should be 
considered
Unpacking principle Failure to elicit all relevant information, especially during transfer of care Omission of key test results, medical history, or surgical event
Psych-out error Medical causes for behavioral problems are missed in favor of psycho-
logical diagnosis
Elderly patient in postanesthesia care unit is combative—prescribing restraints 
instead of considering hypoxia
Reproduced with permission from Stiegler MP, Neelankavil JP, Canales C, et al: Cognitive errors detected in anaesthesiology: a literature review and pilot study, Br J Anaesth. 2012 Feb;108(2):229-235.
Longnecker_Part01_p0001-0034.indd 21 05/05/17 3:48 PM
22 PART 1: Introduction to Anesthesiology
be at fault, human factors research dictates that causes related to the 
design of technology and the lack of training and practice are equally, if 
not more, responsible. Among the legendary failures associated with 
poor human factors are the failure to turn on a ventilator that was 
briefly suspended during measurement of cardiac output or perfor-
mance of radiologic studies or the accidental, unnoticed disconnection 
of an intravenous or arterial pressure cannula, leading to blood loss or 
failure of fluid or drug administration. Users can reduce hazards by 
ensuring they obtain adequate training before using a new device, con-
ducting a systematic preuse inspection of devices, and using backup 
monitoring devices as aids to vigilance. Never turning off an alarm is an 
essential precept to safe care.
 � ERRORS ASSOCIATED WITH A LACK OF STANDARD PRACTICE AND 
UNUSUAL SITUATIONS
Due to the constantly evolving complexities of anesthesia, every avenue 
for a potential adverse event cannot be predicted, and system safety 
protocols cannot prevent every possible medical error. In fact, adverse 
events can emerge, without anticipation, from usual circumstances, 
unfamiliarity with new equipment or new environments, and even pit-
falls into which we would not fall in the absence of acute stress. A few 
examples include leaving a Passy-Muir valve on a tracheostomy and 
therefore causing lung barotrauma or administering undiluted phenyt-
oin, thus causing refractory hypotension and fatal arrhythmias. Goldha-
ber-Fiebert and Cooper offered many such examples based on a 
convenient sample of clinician experiences.59
As a result, anesthesia provider organizations must be prepared to 
react to the unexpected with an environment that supports the indi-
vidual practitioner during the acute situation and provides mecha-
nisms for the organization to learn from an usual event. The 
remainder of this chapter provides both theory and practical strate-
gies to develop an organization that learns from the unexpected. 
However, this type of culture change starts from the individual pro-
vider who embraces the fact that unexpected events will occur, who 
reports unexpected events for further review, and who participates in 
the channels to improve the ultimate safety of the entire organization. 
This type of culture change ultimately augments the resilience of an 
organization to adverse eventsand helps an organization manage 
events that support both the practitioner and ultimately the next 
patient undergoing anesthesia.
THE DIMENSIONS OF QUALITY
Numerous definitions of quality exist, but a widely accepted definition is 
that of the IOM, noted previously: Quality is the “extent to which health 
services for individuals and populations increase the likelihood of 
desired health outcomes and are consistent with current professional 
knowledge.”4 Thus, quality represents not a distinct entity or end point 
but a continuum in the process of meeting the rational expectations of 
others who interact with the providers of health care services. High-
quality anesthesia care implies satisfaction in several domains, including 
patient-centeredness, efficiency, cost-effectiveness, communication, col-
laboration and responsiveness to other members of the surgical or pro-
cedural team, and a proactive view toward performance improvement. 
Two major concepts are inherent in the IOM definition of quality: 
measurement (ie, “outcomes”) and evidence-based care (ie, “current 
professional knowledge”). Inherent in the definition of quality is the 
view that safety is the essential foundation for quality and that high-
quality practice cannot be achieved in the absence of safe practice. 
Another definition is that of the Agency for Health Care Research, also 
noted previously: Quality is “doing the right thing, at the right time, in 
the right way, for the right person—and having the best possible 
results.”6
Donabedian, a pioneer in the genesis of the quality movement, pro-
posed that quality could be evaluated by examining its major compo-
nents: structure, process, and outcomes.14 Structure involves the 
facilities and environment in which care is delivered (eg, governance, 
policies and procedures, and specific details, such as cleanliness, attrac-
tiveness, ease of access, noise levels, privacy); process involves how care 
is actually delivered, including the interactions between clinicians and 
patients (eg, the elements of communication, including listening, sensi-
tivity, compassion, the development of trust); outcomes involve mea-
sures of results of the care provided (eg, mortality, morbidity, speed of 
recovery). Inherent in these evaluations of quality are the patients’ 
perspectives on each of these areas; thus, the role of the consumer 
(especially the patient) in the evaluation of health care quality has 
increased considerably in recent years.
The IOM went further in defining quality, by identifying six desired 
characteristics of health care. Thus, high-quality care should be safe, 
timely, effective, efficient, equitable, and patient centered (often abbrevi-
ated as STEEEP, for ease of recall). Here, also, the concepts of measure-
ment and current knowledge are apparent throughout.
The relationships among providers are key elements in the care pro-
cess, especially in an era when complex care management is provided by 
specialists and subspecialists who focus on specific aspects of care. That 
complexity often leads to communication lapses and fragmentation 
without subsequent integration into a coordinated system of care that 
focuses on the patient’s needs for understanding, planning, and deci-
sion-making. Thus, patients often rate communication as one of the 
most important components in the evaluation of quality health care, 
whereas physicians often rate technical abilities as considerably more 
important than communication.95
Eliminating these lapses in communication is essential for both 
patient compliance and patient satisfaction; eliminating the lapses ben-
efits both process and outcome in the delivery of care. Further, it mini-
mizes the frustrations that patients and families experience as a result of 
conflicting or inadequate communications among professionals, leading 
to mistrust of the provider by the consumer. Finally, the development of 
relationship-centered care teams, in which all parties have developed a 
pattern of open communication and mutual respect and trust, increases 
both safety and quality in multiple industries, including health care.96
A holistic approach to quality and safety should include analysis of 
successes as well as failures. Our work occurs within a complex system, 
and promoting adaptability and resilience among practitioners and 
organizations will mitigate harm even during times of stress and uncer-
tainty. Shifting focus from a preoccupation about failures to an apprecia-
tion of opportunities depends on and contributes to an authentic safety 
culture.13
These concepts apply as much to the discipline of anesthesiology as to 
other disciplines in health care. Anesthesia providers, as individuals and 
departments, must institute these principles, including practical mea-
surement of outcomes and the development of relationship-centered 
clinical teams, if they expect to practice at the higher levels of the quality 
spectrum (ie, beyond the fundamental level of safe practice).
THE ELEMENTS OF SAFE, HIGHQUALITY 
ANESTHESIA CARE
Creating a safe, high-quality practice of anesthesia depends on a combi-
nation of broad strategies and effective tactics for day-to-day work. 
Many models for establishing safe environments and practices and for 
ensuring quality have been described, but there is no empirical evidence 
from controlled studies to demonstrate that a specific model is superior 
to others. Still, there is face validity from qualitative studies in specific 
industries and organizations to suggest that having an overall systematic 
approach leads to both safer and higher-quality care. Indeed, a com-
bined report from the National Academy of Engineering and the IOM 
emphasized that systems approaches to health care delivery were most 
likely to transform health care to deliver the goals of safe, timely, effec-
tive, efficient patient-centered care in the future.97
 � THE HIGHRELIABILITY ORGANIZATION MODEL
Although experts promulgated several models for managing quality (see 
Chapter 22), there are fewer directed primarily at safety. For the latter, 
expert consensus formulated the concept of the HRO from observations 
in highly hazardous industries that, despite operating under conditions of 
high risk, have many fewer serious accidents than expected.98,99 Such 
industries included naval aviation and nuclear power. Weick and Sutcliffe 
Longnecker_Part01_p0001-0034.indd 22 05/05/17 3:48 PM
CHAPTER 3: Safety and Quality: The Guiding Principles of Patient-Centered Care 23 
further described how organizations can be successful if they appropri-
ately “manage uncertainty.”100 Gaba applied these concepts to health care.43
Weick and Sutcliffe100 listed the five key elements that characterize a 
typical HRO: preoccupation with failure, reluctance to simplify interpreta-
tions, sensitivity to operations, commitment to resilience, and deference to 
expertise. Simply stated, an organization that is truly committed to pre-
vention of failure and harm puts safety as its number one priority. In a 
true HRO, the interests of production and speed do not supersede the 
need to ensure safety.43
An HRO is never complacent about the potential for failure, always 
considering what may go wrong with current or new systems. It worries 
about the small details of how people actually do their work, not how 
management imagines how it is supposed to be done. It recognizes that 
no matter how much prevention is done, errors and unpredictable fail-
ures will still occur; thus, it prepares for failure and practices regularly 
for both failure prevention and recovery. And, in solving problems or 
managing a crisis, it defers to those who have the most expertise rather 
than adhering to seniority or rank.
Practically speaking, HROs are also noted for organizational learning, 
certainly not only from accidents and near misses but also from suc-
cesses. Health care now embraces the process of root cause analysis 
(RCA).12 An RCA is applied toanalysis of potentially harmful events in 
an effort to understand the many elements that contribute to an event. It 
is not enough to analyze; practitioners must put the findings to use to 
design and implement corrective intervention. Failure mode and effect 
analysis (FMEA) is one of several industry techniques to study new 
processes proactively before an adverse event occurs.101 Safety analysts 
use FMEA to identify potential failure modes and key points where bar-
riers are needed to minimize the potential for failure (see Chapter 22 for 
a more detailed discussion of RCA and FMEA as risk-reduction strate-
gies). However, a unilateral focus on errors (ie, failures) misses the 
opportunities to identify behaviors and practices that are highly success-
ful. These also should not be ignored, for dissemination and widespread 
implementation of these characteristics are essential features of resilient 
systems and HROs that avoid future failures. Techniques such as “pro-
spective hindsight,” wherein an operational team (manufacturers, oil 
and gas prospectors, etc) envision a future failure or disaster and then 
investigate in detail the factors that contributed to that simulated failure, 
are viewed as effective tools for ensuring future success. Too often, suc-
cess is taken for granted in health care and not studied or disseminated 
widely due to complacency.
Vaughan described the concept of “normalization of deviance” that 
arises when an otherwise safe organization drifts into unsafe condi-
tions.102 In analyzing the sociological features of the disintegration of the 
Challenger orbiter (“shuttle”) in 1986, Vaughan identified how NASA, 
under intense financial and political pressures, evolved from an organi-
zation that had once highly valued safety to one that gave production a 
higher priority. In anesthesia practice, production and other pressures 
can also result in the normalization of unsafe practices. Philipp and col-
leagues have advocated that many such shortcuts should not be normal-
ized. Examples include failure to examine laboratory values prior to an 
operation, failure to place standard monitors prior to performing a 
peripheral nerve block for regional anesthesia, failure to properly moni-
tor effects of neuromuscular blocking agents in every patient, and 
removing monitors at the end of general anesthesia before the patient is 
fully awake and stable.103
This critical shift in emphasis has direct applications to anesthesia and 
surgery. To ensure safety and quality, strategies and tactics must be 
implemented at all levels throughout an organization, from senior man-
agement to bedside provider. That process has two major elements of 
responsibility: the organization and the individual.
 � CREATING SAFETY AT THE ORGANIZATIONAL AND DEPARTMENTAL 
LEVELS
The organization is responsible for creating a safe culture throughout its 
various levels (Chapter 22 focuses on quality improvement at the depart-
mental and system levels). Culture is the “shared values and beliefs that 
interact with an organization’s structures and control systems to produce 
behavioral norms.”42 More simply stated, it is “the way we do things 
around here.” Cultural characteristics are usually deeply ingrained, not 
immediately visible, and often difficult to modify. Yet, it is the culture that 
defines the overall commitment of an organization to safety. Although 
highest reliability can likely only be achieved within a consistent culture 
of safety across an organization, the perioperative subcultures and anes-
thesia practices and departments can establish strong safety cultures 
within their sphere of influence. Mohr et al referred to these smaller ele-
ments as “microsystem environments” and emphasized that safety and 
quality must be applied at these levels, as well as in the more global 
“macrosystems environments” (ie, it must be brought from the corporate 
or departmental office to the bedside to be effective).104 In contrast, the 
individual practitioner working in various environments (eg, locum 
tenens practice) may find it difficult to achieve an overall high-quality 
safe practice in an organization that gives only lip service to safety.
There is a growing literature about safety culture (also referred to as 
climate; the terms are similar but not synonymous) in health care.105,106 
One technique to assess the organizational culture is to conduct periodic 
surveys. Helmreich and Merritt reported on use of one survey instru-
ment, the Operating Room Management Questionnaire, and compared 
attitudes of surgeons to pilots, whose safety culture is generally believed 
to be superior to that found in many industries as a result of long-stand-
ing attention to safety training and interventions.107 Although there are 
many similarities with pilots, surgeons often expressed attitudes that 
interruptions in the continuity of care was a greater risk than fatigue, a 
view that is not aligned with the principles of safety science. These views 
have been tempered by more current evidence and by the regulations on 
work hours imposed by ACGME and others. Flin et al reported on results 
of a survey from anesthesia departments in the United Kingdom with a 
similar finding about the effects of stress and fatigue.108 Although percep-
tions of teamwork were generally positive, only 65% of respondents per-
ceived that operating room personnel worked well together as a team. 
Respondents also reported variable compliance with procedures and 
policies. Similar findings have been replicated for operating room 
teams.108 Notably, physicians and nurses have different perceptions of the 
quality of teamwork by their colleagues—physicians generally rate them-
selves as much better team players than do their nursing colleagues.
Extrapolating from the previous descriptors of an HRO, we can imag-
ine that a safe perioperative culture demonstrably places safety as its 
priority with regular meetings of the group and teams; provides organi-
zational learning via reporting systems that are open, fair, and not puni-
tive; has a formal and active quality improvement process; implements 
corrective actions on learning of unsafe practices; has policies and pro-
cedures that define standard operations; has regular training for com-
mon emergencies; is nonhierarchical during emergencies; rewards those 
who raise safety concerns and has open discussions about those con-
cerns; has processes for briefing and debriefing about near misses and 
adverse events; has standard processes for communication among pro-
viders, especially for transitions in care; and uses other similar processes 
and attributes. Relatively few organizations have these attributes, espe-
cially those related to multispecialty analyses of the causes of errors and 
adverse events; too often, these analyses take place in parallel processes 
that result in the allocation of blame rather than resolution of the root 
causes that are embedded in the larger system or the interfaces between 
services or providers
There has been much more attention given in recent years to improv-
ing safety culture in the operating room. Sacks et al reviewed the litera-
ture on interventions aimed at improving teamwork, communication, 
and safety climate.109 They concluded that there are “promising interven-
tions” for improving safety culture and that “culture improvement 
appears to be associated with other positive effects, including better 
patient outcomes and enhanced healthcare efficiency (p. 465)” (such as 
reduced postoperative complications and mortality and fewer operating 
room delays, respectively). Weller et al presented a framework for over-
coming barriers to a positive safety culture and suggested a “seven-step 
plan to overcome the barriers to effective team communication that 
incorporates education, psychological and organizational strategies.”110
At the heart of that plan is improving information sharing throughout 
the patient care process (Box 3-6).
Morerecently, the medical industry is drawing from business and orga-
nizational-behavior literature regarding team training and “psychological 
Longnecker_Part01_p0001-0034.indd 23 05/05/17 3:48 PM
24 PART 1: Introduction to Anesthesiology
safety” and how it influences organizational learning, quality, and safety. 
Edmondson highlighted the importance of organizational culture to pro-
mote strong positive team environments to create “learning organizations” 
that, ultimately, add value and produce better performance within product 
or service industries. Her work endorses several facets of organizations that 
promote a learning culture and foster innovation and resilience: creating 
safe environments for individuals to speak up and report problems that they 
recognize, as well as creating an environment that invites collaboration, 
experimentation, and reflection.111 She advocates for a “task interdepen-
dence” approach, one in which connectedness and cross-monitoring allow 
for team success even during times of uncertainty and challenge. As anes-
thesiologists represent medical leaders in the operative and perioperative 
environments, it is imperative for anesthesia practitioners to employ leader-
ship strategies that promote teamwork and safety culture within their medi-
cal organization.
When there is an adverse event, in addition to the impact on the 
patient, there is almost always a negative impact on the provider who 
was involved. Anesthesiologists may be at higher risk for stress-related 
disorders,112,113 as suggested by higher drug abuse and suicide rates.114
From survey responses of 659 anesthesiologists, Gazoni et al reported 
that 84% had been involved in at least one unanticipated death or serious 
injury. The most common emotional consequences included repetitive 
reliving of the event, anxiety, guilt, fear of litigation, depression, sleep-
lessness, fear of judgment by colleagues, anger, professional self-doubt, 
and defensiveness. Sixty-seven percent of those involved with a cata-
strophic event felt that their ability to provide patient care was compro-
mised in the first 4 hours after the event. But, only 7% were given time 
off. It is not yet known the extent of more long-term impact, and some 
respondents reported they felt like they never made a complete recovery.115 
Some guidance for providing support for the provider, which may also 
be protective for care to subsequent patients, is beginning to be sug-
gested, but research is in its early stages.116
 � PRACTICAL ELEMENTS FOR THE PRACTITIONER FOR PRODUCING 
SAFE, HIGHQUALITY PATIENT CARE
Importance of Instilling Values of Patient Safety, Quality, and 
Patient-Centeredness Safety demands that each individual, as well 
as the organization, make preventing any injury or harm to the patient 
the highest priority. For the individual clinician, a continual commit-
ment to safe practice includes avoidance of unnecessary risk-taking and 
avoidance of corner cutting, an almost-unending anticipation of what 
might go wrong, projection of actions in anticipation of failure, and, 
above all, mindfulness. Weick and Sutcliffe described mindfulness for 
HROs as organizing in such a way that they “better notice the unex-
pected in the making and halt its development.”100 The concept applies 
equally to the individual practitioners and members of the periopera-
tive care team.
Clinicians have a good reason aside from patient safety to be eternally 
mindful: Those who lead, design, and manage local care systems may 
have an equal or greater responsibility for an adverse event. But, when 
systems fail, blame is usually assigned, fairly or not, to the clinician clos-
est to the last action in the chain. Protecting oneself from the impact of 
system failures is, if nothing else, an act of self-preservation.
Just Culture James Reason introduced the concept of “just culture” to rec-
oncile the tension between “no blame” of individual practitioners and 
accountability about what is acceptable or unacceptable behavior.42 In 
the past decade, David Marx further developed this concept and differ-
entiated between “human error,” “at-risk behavior,” and “reckless behav-
ior.” As shown in Box 3-7, these breaches in duty to the patient should 
elicit system and institutional responses of consoling the provider, 
coaching the provider, or disciplining the provider, respectively.117 Leon-
ard and Frankel developed a corresponding algorithm to assess if care-
givers’ actions were the result of impaired judgment, malicious action, 
reckless action, risky action, or unintentional error and linked this 
assessment with recommended responses.118 Ultimately, balancing a 
“no-blame” culture (one that seeks to bolster systems-based solutions to 
head off inevitable human errors) with consistent and clear standards for 
individual professional accountability allows us to ensure high-quality 
patient care.
Maintaining Vigilance and Mitigating Performance Decrement 
Although anesthesia practitioners cannot solely rely on vigilance to pro-
tect the patient from harm, it remains the strongest underpinning of 
safety in anesthesia. This requires that the anesthesia provider must 
maintain alertness and be aware of, compensate for, and counteract the 
forces working against vigilance. This also requires mindfulness about 
the state of one’s own vigilance.
Fatigue and sleep deprivation are probably the most common causes 
of lapses in vigilance. Howard et al have recommended several “fatigue 
countermeasures,”51 and a 2009 IOM report has explored this in detail.119 
Such countermeasures include education about the effects of fatigue on 
vigilance; limiting duty hours to avoid fatigue; using good sleep hygiene 
(regular bedtime and wake-up time; restricting alcohol, caffeine, and 
nicotine use; creating good conditions for sleep); rest breaks; strategic 
napping; and selected medications, if necessary.
BOX 3-6
Seven Actions to Overcome Barriers to Team Communication in Health Care
Action Description
Teach effective communi-
cation strategies
Teaching structured methods of communication, such as 
“SBAR” handovers, can improve patient outcomes.
Train teams together Teams that work together should train together. Train-
ing that includes all members of the team improves 
outcomes.
Train teams using 
simulation
Using simulation is a safe way to practice new com-
munication techniques, and it increases interdisciplinary 
understanding.
Define inclusive teams Redefine the team of health care professionals from a 
collection of disciplines to a cohesive whole with common 
goals.
Create democratic teams Each member of the team should feel valued; creating flat 
hierarchies encourages open team communication.
Support teamwork with 
protocols
Use procedures that encourage information and proce-
dure sharing among the whole team, such as checklists, 
briefings, and information technology (IT) solutions.
Develop an organiza-
tional culture
Senior champions and department heads supporting 
health care teams must recognize the imperative of inter-
professional collaboration for safety.
Reproduced with permission from Weller J, Boyd M, Cumin D: Teams, tribes and patient safety: over-
coming barriers to effective teamwork in healthcare. Postgrad Med J. 2014 Mar;90(1061):149-154.
BOX 3-7
Simplified Version of Marx’s Just Culture Model
Mechanisms of 
Breach in Duty 
to Patient Description
Appropriate 
Response by 
the Systema
Human error An inadvertent act by a caregiver 
(a “slip” or “mistake”)
Console the 
provider
At-risk behavior Taking shortcuts: conscious drift away from 
safe behaviors; caregiver violates a safety rule 
but doesn’t perceive it as likely to cause harm 
(the equivalent of rolling through a stop sign)
Coach the 
provider
Reckless behavior Conscious choice by caregiver to engage in 
behavior that he or she knows poses signifi-
cant risk; ignoring required safety steps
Discipline the 
provider
aImportantly, Marx noted thatthese responses should be independent of the actual patient outcome.
Data from Marx D: Patient safety and the “just culture”: a primer for health care executives, 
April 17, 2001.
Longnecker_Part01_p0001-0034.indd 24 05/05/17 3:48 PM
CHAPTER 3: Safety and Quality: The Guiding Principles of Patient-Centered Care 25 
There is little evidence to support a specific time between breaks, 
but awareness of a fatigued state can suggest when a break is needed. 
Naps are often inconsistent with daily clinical routines but may be 
appropriate when routines are disrupted or during “on-call” intervals. 
Optimal nap times are on the order of 45 to 60 minutes to improve 
alertness while minimizing sleep inertia on awakening. Napping is best 
done when circadian rhythms enable sleep (between 2 and 6 pm and 2 
and 6 am) and is more difficult to do when circadian rhythms encour-
age wakefulness. The evidence that napping improves performance of 
flight crews is strong enough that appropriate napping is recom-
mended during long-duration flights.120 Providers can use caffeine 
judiciously to compensate for fatigue.51 Excessive use or inappropriate 
timing of caffeine use can have the negative consequence of preventing 
subsequent sleep.
Handoffs and Transfers of Care Relief breaks, either during a proce-
dure or at a change of shift, are a double-edged sword, providing an 
opportunity to identify an undiscovered problem or to create a new 
problem because of decreased situational awareness by the relieving 
provider.55,56 Although safety experts recommended following a pre-
planned protocol to optimize information transfer during the handoff, 
much debate still surrounds our understanding of the effectiveness of 
such handoffs or how medical practitioners should conduct them.58,59,121
A comprehensive review of articles published between 2002 and 2012 
revealed that while clinical outcomes were not necessarily improved, 
information transfer was certainly enhanced.122 A recent prospective 
observational study showed improved relay and retention of patient 
information when anesthesia providers used an electronic handoff tool; 
there was also improved clinician satisfaction about the quality of 
communication.123
Preparation The failure to prepare adequately for anesthesia adminis-
tration often contributes to anesthesia critical incidents.24,25,124 Prepara-
tion encompasses a large set of issues, including complete preoperative 
assessment (see Preoperative Assessment and Planning); ensuring avail-
ability of emergency drugs, equipment, and supplies; checking the func-
tion of equipment (especially using the recommended procedure for 
ensuring functionality of the anesthesia machine125); and ensuring com-
munication pathways in the event of an emergency.
Preoperative Assessment and Planning Preoperative assessment 
and planning involve evaluation of the patient and development of the 
anesthesia plan, which includes the anesthetic technique, the require-
ments for monitoring, and the plans for postoperative care, all of which 
must be consistent with the wishes of the patient, the needs of the sur-
geon or other operator (eg, radiologist, cardiologist), and the resources 
of the facility. (Preoperative evaluation is considered in Chapter 5 and 
for specific conditions in their respective chapters throughout this text.) 
Similarly, an anesthetic plan must be developed that is consistent with 
both patient wishes and operator requirements and with the plans for 
postoperative care. Chapter 6 addresses the development of the anes-
thetic plan in detail.
Monitoring Because failure to monitor is so often associated with 
adverse outcomes, this issue deserves special attention. The safe practitio-
ner follows the standards promulgated by the ASA except in truly extraor-
dinary situations, and should those occur, he or she documents the reason 
for noncompliance. Critical alarms should never be disabled.126
Human Factors Although the individual anesthesia provider has little 
control over the design of equipment and local systems, he or she does 
have substantial control over many of the human factors features that are 
part of the environment. Attention to the organized arrangement of sup-
plies and drugs, especially adherence to consistent labeling of drugs, and 
establishing and adhering to local standards are examples. Care to keep 
arterial and intravenous cannulas and monitoring cables orderly, ensur-
ing reasonable lighting, and reducing clutter, noise, and distractions are 
general, sound safety practices. Control of noise levels and background 
music can be contentious issues among staff, surgeons, and anesthesia 
providers, who sometimes are urged to compromise the principle that 
patient safety takes preeminence. Reasonable efforts should be made to 
reach compromise, and music should be discontinued during manage-
ment of critical events.
Teamwork Although teamwork can be seen as a subset of working 
within a system of care, it also includes specific practices for improving 
safety. A variety of health care institutions have implemented teamwork 
training, and there is evidence to demonstrate the effectiveness of train-
ing in improving teamwork performance and some evidence that it 
improves outcomes.104 Anesthesia providers have employed crisis 
resource management and simulation specifically for training teamwork 
skills and performance (see sections that follow). There are different 
approaches to training, but the principles are similar. Teamwork needs 
should be assessed for the specific environment; all team members must 
be motivated and engaged in accepting the need for teamwork and agree 
about skills and behaviors they will adopt; health care institutions must 
teach and anesthesia professionals must practice and periodically rein-
force these behaviors via drills and didactic sessions.77,127 Several reports 
have described teamwork training programs for full operating room 
teams.128,129
The preoperative checklist developed by the World Health Organiza-
tion’s Safe Surgery program is specifically intended to promote team-
work and has been demonstrated to be effective in improving surgical 
outcomes.130,131 All anesthesia professionals should actively and seriously 
participate in the preoperative briefing that uses a form of the WHO 
checklist.130
Routine Practice for Managing Emergencies Because critical events 
are relatively rare and demand expert and effective treatment, it is 
important to practice skills periodically. Schwid and O’Donnell demon-
strated that advanced cardiac life support skills are generally maintained 
for only approximately 6 months.132 Periodic training includes practice 
in management of the unanticipated difficult airway, generic skills in 
anesthesia crisis resource management (ACRM; see next section), and 
drills for operating room fires and other specific anesthetic emergencies, 
such as malignant hyperthermia.
Applying Systematic Crisis Management Techniques Anesthesia 
crisis resource management is an organized set of principles for manag-
ing crisis situations in anesthesia. Adapted by Gaba et al from crisis 
resource management (CRM) in aviation, it consists of several founding 
principles for effective management of acute events.80,133-135 ACRM prin-
ciples are a subset of teamwork training principles that are particularly 
focused on managing critical events. Although there is no single adopted 
standard, the following principles are generally applicable:
 • Seek assistance early and quickly—inform others on the surgical team 
and call for extra assistance as soon as unusual circumstances are 
recognized.
•	 Establish clarity of roles for each person involved in management of 
the event; especially identify who will manage the event (event 
manager).
•	 Use effective communication processes, including reading back of 
instructions, being clear to whom directions are being given.
•	 Use resources effectively and identify what additionalresources 
(people, supplies, equipment, transportation, etc) are available to 
manage the situation.
•	 Maintain situational awareness and avoid fixations, which are perhaps 
the most challenging tasks as situational awareness is difficult to 
retrieve once it is lost. Having one person act as event manager, 
observing the big picture rather than becoming immersed in the 
details, is thought to be effective.
Simulation has been shown to be an effective technique for learning 
and maintenance of CRM skills.
Simulation Increasingly, health care institutions use simulation to 
address many of the issues discussed in this chapter. High-hazard indus-
tries have applied simulation for years, but its applications in health care 
arose from pioneering work in anesthesia.136,137 Simulation is a technique 
that replicates reality in ways that allow deliberate, repetitive practice for 
many applications. It can use technologies that represent clinical care 
with relatively high or low clinical, environmental, or psychological 
fidelity depending on the training objectives and philosophy.138 Increas-
ingly, health care systems use sophisticated mannequin and task trainers 
for high-fidelity simulation. Yet, simpler task trainers suffice for many 
Longnecker_Part01_p0001-0034.indd 25 05/05/17 3:48 PM
26 PART 1: Introduction to Anesthesiology
purposes (eg, for learning basic intubation or difficult airway manage-
ment skills, skills in placing central venous catheters, regional anesthe-
sia). There is evidence that a variety of computer-based simulators and 
trainers are effective for obtaining knowledge and skills for the manage-
ment of acute events.139
For patient safety, simulation is especially useful for training novices 
without exposing patients to risk. As well, health care institutions can 
use it for periodic training for the purposes noted previously, particu-
larly for training in the management of critical events using the CRM 
concepts principles. One of several models of computer-controlled man-
nequin is used to simulate the patient; the instructor varies the physiol-
ogy, anatomy, and life signs to simulate normal or abnormal 
situations.136,140 In high-fidelity simulation, institutions use props and 
actors to create realism, which many believe strengthen learner engage-
ment. The early applications were for the anesthesia “crew” of the larger 
surgical team. More recently, simulations have involved training for 
entire operative teams.129
In addition to other skills, these CRM training sessions reinforce the 
concept that all team members are expected to communicate openly and 
without hesitation regarding safety-related matters. Examples include 
confirming a directive with closed-loop communication, also known as 
a “read back” (eg, “heparin, xx units, has been administered,” “I’m con-
firming that these are Mrs. Jones’s radiographs”), to speaking out when 
a concern for safety exists (eg, “Are you sure you should be prepping the 
right hand? The consent says left.” or “Have you noticed that this 
patient’s blood pressure has been falling over the past several minutes?”). 
Researchers have used simulation to observe baseline behaviors, practice 
idealized behaviors, evoke discussion about barriers and enablers of 
desired behavior, and measure the impact of deliberate training.141,142 
Training sessions use patient care scenarios to elicit treatment and 
behavioral responses from the individuals or teams being trained. 
Debriefing using videotapes of the session are conducted to review 
actions. The debriefing is critical to elicit understanding and behavior 
change. Debriefing skills must be learned and are challenging new 
behaviors for instructors who use simulation. Various techniques have 
been described.138,143,144 Simulation training has been demonstrated to be 
effective across a variety of clinical domains for improving both clinical/
technical and behavioral skills.83,133,145-147
Most academic anesthesia training programs now either have their 
own designated simulation programs or share resources with other 
departments in their hospitals or communities. Simulators of various 
types are being deployed in hospitals of essentially all types of sizes. 
Although there are no data on the actual numbers of simulation pro-
grams, there is a growing community of simulation professionals, evi-
denced by the existence of a society and journal.
The American Board of Anesthesiology highly encourages simulation 
training experience with both technical and behavioral crisis manage-
ment practice as the preferred activity to fulfill the highest level require-
ment (part IV) for maintenance of certification of anesthesia credentials 
(MOCA).148 There is strong evidence that participation in the program 
motivates positive changes in patient safety practices and anecdotal evi-
dence of how such training has saved lives. The ASA led a process for 
endorsing anesthesia simulation programs that are qualified to offer that 
training. Currently, the simulation requirement is purely formative (ie, 
skill enhancing). It is likely that the experience of other industries will be 
repeated, and, after sufficient validation, some summative (ie, pass or 
fail) requirements may well be implemented. The very use of simulation 
is a sign of a move toward a deeper culture of safety in anesthesia and 
other clinical disciplines.
Cognitive Aids and Checklists Ample evidence for the benefit of 
cognitive aids and checklists exist in the HRO literature. In the last 
decade, more evidence has accrued showing the benefit of checklists and 
protocols in the medical literature. Within surgery, anesthesiology, and 
critical care, some of the pioneering work comes from Pronovost, who 
introduced the use of “bundles” of specific practices, organized as a check-
list, to reduce central line infection rates to almost negligible levels.149-152 
Gawande expanded Pronovost’s work to use checklists in surgical care, 
leading an international effort to develop and evaluate the impact of the 
World Health Organization’s Safe Surgery Checklist prior to all surgical 
procedures.130,131,153,154 This tool has had widespread diffusion to 
operating rooms internationally and has been associated with decreased 
surgical complication rates in particular studies. Gawande highlighted 
the success of checklists for complicated medical care in his popular 
book, The Checklist Manifesto, which challenges the medical community 
to develop more protocols for medical care that calls for complicated and 
timely steps to achieve high outcomes of success.155
Increasingly in the last decade, surgeons and anesthesiologists have 
shown interest in using cognitive aids during acute crisis situations.156 
Studies in the last decade reported good awareness of cognitive aids when 
hospitals implement them,157 and users of cognitive aids reported that the 
tools help during real events.157,158 Recently, Arriaga et al showed with 
high-fidelity simulation that the adoption and adherence to a surgical 
crisis checklist or cognitive aid increased adherence to lifesaving pro-
cesses by 17%, and that a survey of study participants showed that 97% 
would want to have a cognitive aid or checklist if the same crisis occurred 
during an operation158; this work replicates results from previous smaller 
studies that demonstrated performance improvements among those par-
ticipants who used cognitive aids.159,160 Although studies have shown 
performance improvements using cognitive aids, anesthesiologists must 
still be mindful that these tools can serve as distractions and lead to other 
cognitive errors, particularly when diagnoses are unclear.161
Infection Control Care in the safe use and sterility of all anesthesia 
systems is essential, especially in the modern hospital environment where 
hospital-acquired infections with resistant organisms (eg, methicillin- or 
vancomycin-resistant Staphylococcus aureus organisms) are increasingly 
common.Adherence to carefully timed protocols for antibiotic adminis-
tration in the perioperative interval reduces postoperative wound infec-
tion.162 Surgical wound infection rates are increased 3-fold by hypothermia 
and reduced by perioperative oxygen administration.163,164 The impor-
tance of using strict sterile technique protocols for placing central venous 
catheters and other venous or arterial access is now well documented: 
Multi-institutional studies identified contaminated stopcocks in 20%-
45% of cases sampled. Peripheral intravenous cannulations may directly 
contribute to 6% of hospital-acquired bacteremias. Microbiological 
analyses have identified anesthesiologists’ hands, operating room envi-
ronment, and the patient as sources of contamination, and this contami-
nation has been linked with 30-day postoperative infections and patient 
mortality.152,165-168 There is simply no excuse for laxity in adherence to 
following prescribed protocols.
Following Standards and Practice Guidelines The ASA has estab-
lished a large set of practice standards and guidelines.169 Standardization 
of practices across providers is widely accepted as a critical component 
for safety and reliability. Box 3-8 lists common practice standards. Each 
practitioner is obligated to be familiar with such guidelines and apply 
them appropriately in his or her practice. Similarly, health care facilities 
are required to establish local policies and procedures to ensure stan-
dardization of basic practices. These also must be known and followed.
INVOLVING THE PATIENT IN SAFETY AND 
QUALITY
Increasingly, patient advocates are encouraging patients to take a role in 
ensuring the safety of their own care.170 Anesthesia professionals should 
embrace and encourage this concept because it benefits patient and 
provider alike. Providers should also be concerned with the patient’s 
perceptions of the quality of care and consider more than just the needs 
of the direct surgical process. There are several ways in which these 
goals can be achieved.
To encourage patient involvement, anesthesia providers can take 
actions to foster “patient-centered communication,” which has been 
defined as including the following171:
 • Eliciting and understanding the patient’s perspectives—concerns, 
ideas, expectations, needs, feelings, and functioning.
•	 Understanding the patient within his or her unique psychosocial context.
•	 Reaching a shared understanding of the problem and its treatment 
with the patient that is concordant with the patient’s values.
•	 Helping patients share power and responsibility by involving them in 
choices to the degree that they wish to be involved.
Longnecker_Part01_p0001-0034.indd 26 05/05/17 3:48 PM
CHAPTER 4: Ethics and Conflicts of Interest in Anesthesia Practice 27 
What specific things can anesthesia providers do to involve patients in 
their own care that will improve not only satisfaction but also safety? 
Consider the following:
 • Tell the patient as much as practical (assessing how much the patient 
can handle knowing) about the process of anesthesia care the patient 
will experience.
•	 Provide information preoperatively about the process of anesthesia 
care and expectations; several references are available on the Internet 
in addition to books and pamphlets.
•	 Encourage the patient to speak up if the patient does not understand 
something or believes something is inappropriate, such as drugs being 
given, absence of hand washing or glove wearing.
•	 Involve the patient’s family members in care whenever practical.
•	 Advise the patient to contact you if there are any concerns or possible 
side effects after the anesthetic.
•	 In concert with other providers, disclose errors and adverse events (a 
strategy that enhances trust and decreases skepticism in concerned 
patients).
•	 Involve patients on committees that are concerned with the design of 
anesthetizing locations and in the process of patient flow and family 
communication in such facilities.
SUMMARY AND CONCLUSIONS
The concepts of quality, safety, and patient-centeredness are prominent 
themes throughout American health care, and they have been embraced 
by patients and affirmed by third-party payers, specialty societies, and 
health care organizations, both governmental and private. Despite the 
increased focus on these factors, the goals have yet to be met, especially 
because most initiatives have focused on individual practitioners or 
within specific disciplines. To achieve the full goals of quality and safety, 
the processes must include systematic approaches that cross the 
BOX 3-8
Key Standards of Care of the American Society of Anesthesiologists
Alarm Management for Anesthesia Professionals, Statement on (2013)
Ambulatory Anesthesia and Surgery, Guidelines for (2013)
Avoidance of Medication Errors in Neuraxial Anesthesia, Statement on (2010)
Basic Anesthetic Monitoring, Standards for (2011)
Clinical Privileges in Anesthesiology, Guidelines for Delineation of (2013)
Critical Care by Anesthesiologists, Guidelines for the Practice of (2014)
Di�cult Airway, Guidelines for the Management of (2014)
Documentation of Anesthesia Care, Statement on (2013)
Ethical Practice of Anesthesiology, Guidelines for the (2013)
Labeling Pharmaceuticals for Use in Anesthesiology, Statement on (2009)
Nonoperating Room Anesthetizing Locations, Statement on (2013)
Obstetric Anesthesia, Practice Guidelines (2015)
Obstetrics, Guidelines for Neuraxial Anesthesia, Guidelines for (2014)
Obstetrics Optimal Goals for Anesthesia Care (2016)
O�ce-Based Anesthesia, Guidelines for (2014)
Patient Care in Anesthesiology, Guidelines for (2011)
Perioperative Blood Management, Guidelines for (2014)
Postanesthesia Care, Standards for (2014)
Preanesthesia Care, Basic Standards for (2010)
Security of Medications in the Operating Room, Statement of (2013)
Data from American Society of Anesthesiologists
boundaries of specialties, clinical services, and facilities. In short, the 
delivery of care must be recognized as a complex matrix of interactions 
among multiple providers, including both clinicians and facilities, all 
interacting with one another in a system of systems. The specialty of 
anesthesiology is a leader in the development of patient safety approaches 
within its discipline; the next steps involve building safety and quality 
into this larger system of care. Anesthesia providers can contribute sig-
nificantly to achieving these goals by participating fully in the system-of-
systems approach, as well as by building highly reliable microsystems 
within their department or group. These approaches are best under-
stood by adopting a patient-centered approach, whereby all providers 
interpret the integrated care process from the patient’s viewpoint and 
include that viewpoint in the design and delivery of care.
KEY REFERENCES
•	 Anesthesia Patient Safety Foundation. Anesthesia Patient Safety 
Newsletter. http://www.apsf.org. Accessed November 28, 2016.
•	 Baker DP, Salas E, King H, et al. The role of teamwork in the pro-
fessional education of physicians: current status and assessment 
recommendations. Jt Comm J Qual Patient Saf. 2005;31(4):185-202.
•	 Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and 
equipment failures in anesthesia management: considerations for 
prevention and detection. Anesthesiology. 1984;60(1):34-42.
•	 Edmondson AC. Teaming: How Organizations Learn, Innovate, 
and Compete in the knowledge Economy. San Francisco, CA: 
Jossey-Bass; 2012.
•	 Gaba D, Fish K, Howard S. Crisis Management in Anesthesiology. 
2nd ed. Philadelphia, PA: Saunders; 2015.
•	 Gaba DM, Howard SK, Fish K, et al. Simulation-based training in 
anesthesia crisis resource management (ACRM): a decade of expe-
rience. Simul Gaming. 2001;32(2):175-193.
•	 Kohn LT, Corrigan JM, Donaldson MSE. To Err Is Human: Build-
ing a Safer Healthcare System. Washington, DC: National Academy 
Press; 1999.
•	 Reason J. Managingthe Risk of Organizational Accidents. Alder-
shot, Hants, UK: Ashgate Publishing; 1997.
•	 Wachter RM. Understanding Patient Safety. 2nd ed. New York, NY: 
McGraw-Hill Medical; 2012.
REFERENCES
Complete references are available online at www.LongneckerAnesthesiology 
.com.
Ethics and Conflicts of 
Interest in Anesthesia 
Practice
David B. Waisel 
KEY POINTS
1. Treat patients and families with the grace and consideration you would want 
for your family.
2. Anesthesiologists are obligated to “own” the advancement and advocacy of 
all things anesthesiology.
4
C H A P T E R
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http://www.apsf.org
http://www.LongneckerAnesthesiology.com
http://www.LongneckerAnesthesiology.com
28 PART 1: Introduction to Anesthesiology
3. The goal of informed consent is to meet the patient’s needs as the patient 
defines them. This may include providing reassurance, titrating disclosure, 
and following the patient’s lead regarding participation in decision-making.
4. Competent patients have a virtually unlimited right to refuse potentially 
life-sustaining medical treatment. “Potentially” is used to emphasize the 
uncertainty that a treatment will be life sustaining.
5. Patients with limited decision-making capacity should participate in decision-
making to the extent their capacity permits.
6. The risk of liability for honoring properly documented limitation on potentially 
life-sustaining medical therapy is no more than the risk of not honoring it.
7. Patients opting for goal-directed perioperative do not resuscitate (DNR) 
orders usually choose to authorize temporary therapeutic interventions to 
manage easily reversible events.
8. Physician Orders for Life-Sustaining Treatment (POLST) are medical orders 
valid across health care sites that comprehensively document the patient’s 
preferred end-of-life care.
9. Clinicians face conflicts of interest in daily practice from production pressure, 
interactions with industry, and safety and quality care initiatives. Clinicians 
need to recognize potential conflicts, characterize the potential severity of the 
conflict, and determine the likelihood and resultant harm of the influence or 
the appearance of influence.
10. The discipline of medical ethics provides expertise in recognizing, analyzing, 
and managing ethical dilemmas.
PATIENTCLINICIAN RELATIONSHIP
The goal of informed consent is to meet the patient’s needs as the patient 
defines them.1,2 This may include providing reassurance, titrating disclo-
sure, and following the patient’s lead regarding participation in decision-
making.3 Most of the time, patients want sufficient information to make 
substantially autonomous informed decisions. “Substantially” empha-
sizes that the realistic goal for consent is to sufficiently, as compared to 
fully, inform the patient.
 � COMPONENTS OF INFORMED CONSENT
Decision-Making Capacity Patients have decision-making capacity 
when they are capable of making a specific decision at a specific time. 
Patients show capacity by understanding proposed treatments, alterna-
tives, and consequences of proceeding or not proceeding and have the 
ability to express a preference based on rational, internally consistent 
reasoning. Decision-making capacity is different from competency. The 
bedside clinician determines decision-making capacity for a specific 
decision, whereas competency is a legal determination of the global 
abilities required to provide legal and other authorizations.4 Adults are 
presumed competent.
Clinicians should pay attention to the decision-making capacity of 
patients with temporary or more permanent limitations in decision-
making capacity.5 Patients with more permanent limitations in decision-
making capacity should be encouraged to participate in decision-making 
to the extent of their abilities. Sedated patients with temporarily limited 
decision-making capacity should be assessed for decision-making 
capacity with regard to the specific decision. Decisions with riskier con-
sequences require more comprehensive decision-making capacity. In 
patients with temporarily insufficient decision-making capacity, clini-
cians should delay nonemergent treatment until patients regain suffi-
cient decision-making capacity.
Voluntariness Clinicians should only perform procedures on compe-
tent patients who participate willingly. Clinicians manipulate patients by 
distorting, downplaying, or omitting information to influence decision-
making. Clinicians hinder voluntariness when they chemically or physi-
cally restrain patients who have sufficient decision-making capacity.6 
For example, in Shine v Vega, Shine, a competent adult, went to the 
hospital for treatment of an asthma attack.7 The emergency department 
attending Vega recommended tracheal intubation. Shine refused. Later, 
Shine and her sister tried to leave but were forcibly detained. Shine was 
restrained, and Vega intubated her trachea. The Massachusetts Supreme 
Court stated that the competent patient has a right to refuse potentially 
life-sustaining medical treatment (LSMT), even if this decision is con-
sidered unwise.
Disclosure Disclosure is the process of supplying relevant information 
to the decision-maker. Skilled disclosure builds trust and facilitates 
patient self-determination.
The predominant legal standard in the United States is the reasonable 
person standard, which requires disclosure of information based on 
what a theoretical reasonable person would consider material for deci-
sion-making. However, the preferences of the reasonable person are not 
precisely defined by statute or case law.2 Further, patients vary in their 
desire to receive information. Survey data indicated that 92% of patients 
believed that common but less-consequential risks should be discussed, 
and 80% of patients believed that rare but severe risks should be dis-
cussed.8 Patient preferences for disclosure cannot be wholly predicted 
from socioeconomic status, age, sex, ethnicity, and history of previous 
surgery. Variation in clinicians’ customary practices of risk disclosure 
indicates the complexity of using the “reasonable person” standard to 
guide clinical practice.9-12
Given that certain patients prefer either a less-extensive or more com-
prehensive disclosure than the typical patient, clinicians should tailor 
information to the patient’s preferences. Clinicians do this by highlight-
ing options that affect the perioperative experience, such as regional 
versus general anesthesia, and by informing patients about significant 
risks that the clinician considers relevant to decision-making, including 
how risks may vary by anesthetic technique.1,13 Clinicians should also 
prepare patients for common but less-severe risks, such as postoperative 
nausea and vomiting. Patients should be informed whether trainees are 
participating in care.
To customize disclosure, clinicians may ask patients whether they 
want more information. For example, if there are no significant risks 
relevant to decision-making, the clinician can say, “There are significant 
but very rare risks of receiving anesthesia. Would you like me to tell you 
about them?” Although the likelihood of being sued based on informed 
consent malpractice issues is very rare, increasing satisfaction by meet-
ing the patients’ needs likely decreases complaints and lawsuits.14 In any 
case, disclosure does not prevent medical malpractice liability for 
adverse events. Liability is based on negligence theory and depends 
mainly on whether the standard of care was met and if the failure to 
meet the standard of care was a proximate cause of injury.
The original concept of therapeutic privilege permitted physicians to 
withhold information if disclosure would prevent patients from making 
a rational decision.15 More recently, some suggest a valid use for thera-
peutic privilege is to give patients’ time to adjust to jarring events, to 
prevent stress-impaired decision-making, andto preserve hope.16-18
Recommendation Clinicians should highlight the advantages and 
disadvantages of options and recommend a plan by explaining how well 
each option suits the patient’s preferences.
Understanding It is difficult to determine if a patient substantially 
understands the risks, benefits, and indications of the proposed proce-
dures. Translating population data into data relevant and understand-
able to the patient is problematic. Biases affect both clinician and patient 
understanding of risks. In addition, patients commonly misunderstand 
frequently used terms, such as anaphylaxis, antibiotics, aspiration, fast-
ing, local anesthesia, reflux, and sedation.19
The teach-back method has been suggested to assess patient under-
standing during the informed consent process. Patients are asked to 
articulate key information about the proposed treatment to help clini-
cians redress gaps or misunderstandings. In chronic disease, the teach-
back method may improve disease-specific knowledge and adherence to 
the clinical plan.20 It is unclear how the teach-back method would affect 
the acute situation of perioperative anesthesia.
Most research relating to understanding is based on the less-applica-
ble surrogate end points of recall of information or patient satisfaction. 
Recalling information does not reflect the ability of patients to under-
stand and use information, and lack of recall does not mean inadequate 
Longnecker_Part01_p0001-0034.indd 28 05/05/17 3:48 PM
CHAPTER 4: Ethics and Conflicts of Interest in Anesthesia Practice 29 
understanding and use of information. Recall is generally poor.21,22 Even 
the most successful interventions improve recall to only about 50% of 
the presented information. Written information and multimedia presen-
tations may improve recall.23-25 Pain and distress do not seem to compro-
mise the ability to recall risks; treating pain tends to improve participation 
in the informed consent process.
Decision Patients vary in their preferences for participation in deci-
sion-making.3,26,27 The desire to participate in the decision-making pro-
cess may be a function of extent of illness, gender, age, ethnicity, social 
status, and level of education.27 It is legally and ethically superior for 
clinicians to meet the patient’s needs by tailoring participation in deci-
sion-making to the patient.1,14
Clinicians should obtain informed refusal when patients refuse rec-
ommendations or request a relevantly suboptimal technique. The con-
cept underlying informed refusal is that these patients need to be more 
extensively informed about risks, benefits, and alternatives when they 
desire inadvisable techniques. Clinicians are not ethically obligated to 
provide care for these patients in nonemergent situations, although they 
may wish to assist in finding a willing colleague.
Autonomous Authorization Clinicians should seek the patient’s 
explicit authorization to perform a specific procedure.
 � ISSUES IN INFORMED CONSENT
Refusing to Provide Care Society’s interest in preserving the moral 
fabric of individual clinicians permits anesthesia providers to withdraw 
from care with which they morally disagree, such as the elective termi-
nation of pregnancy. Clinicians may be obligated to make a reasonable 
effort to find a willing colleague, although some find this recommenda-
tion ethically objectionable. Whether clinicians should perform emer-
gent care that violates their conscience is controversial. Some argue that 
the altruistic obligation toward patients cannot supersede a clinician’s 
most cherished values.28 Others argue that medicine is foremost a ser-
vice profession with obligations to society, and in extreme circumstances 
clinicians are obligated to put patients first.29 This argument is rooted in 
the social contract the profession of medicine has with society.30
Clinicians may refuse to provide care only after extensive consider-
ation and perhaps consultation with colleagues. Clinicians may not 
refuse to care for patients based on race, gender, or disease status, such 
as the patient with an infectious disease. Clinicians should refuse to 
provide nonemergent care if they do not feel that the environment, 
including their own and other clinicians’ abilities, operating room capa-
bilities, and consultative and postoperative care, provides a sufficient 
quality of care. Institutional policies may minimize conflict in these 
situations.31
Emergency Situations Clinicians should seek informed consent as 
practicable in emergency situations. The assumption is that patients 
want potentially LSMT. Reversibility is the key to determining how to 
intervene when there is incomplete evidence that the patient would 
prefer not to receive emergency treatment. For example, because tra-
cheal intubation is reversible, it is appropriate to intubate the trachea of 
the unconscious patient when there is insufficient documentation of 
preferences, even if a relative declares that the patient’s preferences 
would be to refuse tracheal intubation. Therapy may be withdrawn later 
if appropriate. In this case, the slight burden of temporary tracheal intu-
bation is traded for improved clarification and certainty of the patient’s 
wishes.
Irreversible interventions do not offer this opportunity. Consider the 
unconscious Jehovah’s Witness patient with a critically low hemoglobin. 
Transfusion represents irreversible contamination. However, because 
the standard is an explicit refusal of potentially LSMT, clinicians should 
probably provide transfusion in the absence of unambiguous evidence.
Jehovah’s Witness Jehovah’s Witnesses interpret biblical scripture to 
mean that those who take in human blood shall be “cut off ” from eternal 
life.32 Case law unequivocally supports the rights of adult patients to 
refuse transfusion therapy. Physicians have not been held liable when 
honoring a properly documented refusal of potentially life-sustaining 
transfusion therapy, even in the face of maternal or fetal death.33
Jehovah’s Witness patients consider transfusion therapy preferences as 
a “matter of conscience.” Primary concerns center on whether it is blood 
from another human and whether their own blood has been outside the 
body. Thus, blood components, autologous blood, and banked blood are 
generally unacceptable. Some patients will accept blood harvested intra-
operatively and returned while being kept in a closed loop, such as with 
cell salvage of shed blood or presurgical removal of blood. Some patients 
will accept recombinant erythropoietin, which depending on the brand 
contains small amounts of human albumin. Acceptable techniques 
include synthetic colloid solutions, erythropoietin-stimulating protein, 
and preoperative iron. Precisely documenting patient preferences forces 
clarification of acceptable interventions. Nonemergent care should pro-
ceed only if all clinicians are wholly certain they can satisfy the patient’s 
requirements.
Confidentiality Clinicians are obligated to protect patient information 
from unauthorized and unnecessary disclosure. For example, clinicians 
should seek permission from patients before sharing information with 
family members. Clinicians should know and comply with public privacy 
guidelines. In particular, electronic medical and financial records may 
lead to inappropriate distribution of sensitive personal information.34
Pediatric Ethics Patients, parents, other surrogate decision-makers, 
and clinicians use the concepts of best interest, informed assent, and 
informed permission to guide decision-making about health care for 
minors (Table 4-1).35 The best interest standard is used when the ability 
to apply self-determination is impossible, such as with an infant or a 
child with severe developmental delay. The parent or surrogate deci-
sion-maker should then apply what they believe to be in the best inter-
ests of the child, but this decision must be within an acceptable range of 
decision-making. Parentsmay not opt for grossly inappropriate over-
treatment or undertreatment.36 Whether clinicians should intervene 
about potentially inappropriate treatment depends primarily on the 
amount of harm to the child by the therapy or its absence, the likeli-
hood of a successful therapy, and the overall risk-to-benefit ratio. Inter-
ventions include ethics consultation, legal consultation, and legal 
intervention.
Pediatric patients should participate in decision-making to the extent 
their development permits. Clinicians therefore should incorporate 
informed assent with older children. The extent of participation of chil-
dren should increase throughout adolescence depending on the patient’s 
maturity and the consequences of the decision. Clinicians should respect 
the right of adolescents not to assent to a procedure. In those cases, 
achieving assent may necessitate further discussions with patients, par-
ents, and other clinicians, and such discussions may best take place away 
from the operating room.
Loss of confidentiality may lead adolescents to curtail or delay seeking 
medical care or be less forthright about information, particularly when 
care involves sexually transmitted infections, contraception, and mental 
health.37 Clinicians may want to ask sensitive questions privately. 
Although clinicians should encourage adolescents to be forthright with 
 TABLE 41 Graduated Involvement of Minors in Medical Decision-Making
This broad outline should be viewed as a guide. Specific circumstances should be taken 
into consideration.
Age (years) Decision-Making Capacity Techniques
<6 None Best interest standard
6-12 Developing Informed permission
Informed assent
13-18 Mostly developed Informed assent
Informed permission
Mature minor Developed, as legally determined by a 
judge, for a specific decision
Informed consent
Emancipated minor Developed, as determined by statutes 
defining eligible situations (eg, being 
married, in the military, economically 
independent)
Informed consent
Longnecker_Part01_p0001-0034.indd 29 05/05/17 3:48 PM
30 PART 1: Introduction to Anesthesiology
their parents, clinicians should maintain the confidentiality of adoles-
cents unless prohibited by reporting statues.38 State statutes may limit 
the clinician to informing only the adolescent about a positive preg-
nancy test.
Emancipated minors and adolescents declared mature minors are 
authorized to make their own health care decisions. State statutes may 
award emancipated minor status to adolescents in the military, who are 
married, who have children, and who are economically independent. 
Judges may award mature minor status if the adolescent is capable of 
giving legal consent in a specific situation.39-41 Judges base mature minor 
decisions on the maturity of the child and the consequences of the 
decision.
Disclosure and Apology Patients desire appropriate disclosures and 
apologies about medical errors.42 On the whole, physicians and admin-
istrators agree. But fear, lack of training, and inadequate support limit 
the ability of physicians to disclose and apologize.42,43
Disclosure is a factual description of an event. An apology is an 
expression of sorrow, often successfully framed as a wish statement such 
as “I wish things were different.”44
More than half the states have laws prohibiting the admission of apol-
ogy or sympathy (“I am sorry she had to go to the intensive care unit.”) 
as evidence of wrongdoing, but many do not prohibit the admission of 
disclosures of errors (“I didn’t mean to miss her cardiac ischemia.”).45 
The quality of these laws vary, and an apology conceivably may influ-
ence whether legal action is sought or is successful.46,47 Sincere disclo-
sures and apologies followed by appropriate follow-up generally improve 
patient satisfaction and trust, possibly forestalling legal action. Hiding or 
dissembling about an event infuriates patients and spurs lawsuits.
When disclosing potential errors, clinicians should be precise about 
communicating only what is known. It is helpful to include an expert in 
apology and disclosure in the conversation; if that person is unavailable, 
a second person in the room helps with explanations and facilitating 
practical matters. Clinicians should not speculate about what is not 
known, particularly about fault. Initial disclosure should occur promptly 
and should focus on the medical implications of the event. A specific 
permanent contact person should be identified to be the liaison for the 
patient and family. The contact person should be able to answer ques-
tions, arrange meetings, explain the results of the investigation, and 
describe the plan to prevent comparable events.
On the systems level, an approach called “disclosure, apology, and 
offer” discloses freely, provides fair compensation, and defends accept-
able care. The goals are to increase transparency, reduce adversarial 
relationships, improve patient safety, and decrease legal action and 
costs.48,49 The approach of disclosure, apology, and offer has decreased 
malpractice risks and costs, although it can occasionally prompt litigious 
behavior.48-50
For disclosure, apology, and offer to work, it needs to be practiced 
consistently and even-handedly. Goals and strategies need to be aligned. 
Physicians may shoulder more risk because settlements may need to be 
reported to authorities, such as the National Practitioner Data Bank. On 
the other hand, in some situations, hospital systems may prefer to delay 
compensation, hamstringing disclosure, apology, and offer and leading 
physicians to distrust administration. Inconsistency, favoritism, and 
selfishness shatter this approach.
ETHICAL AND LEGAL ASPECTS OF ENDOFLIFE 
CARE
The Supreme Court has grounded the virtually unlimited right of a 
competent patient to refuse treatment in the liberty interest of the Four-
teenth Amendment, which states, “No State shall make or enforce any 
law which shall abridge the privileges or immunities of citizens of the 
United States; nor shall any State deprive any person of life, liberty or 
property.”
For the incompetent patient, formal written or oral directives are the 
preferred method of directing end-of-life care. If a patient does not have 
declared preferences, surrogates direct care by using their judgment of 
what the patient would have chosen. For the never-competent patient or 
the opaque patient, the best interest standard is used.
A substituted interests model proposes that clinicians integrate substi-
tuted judgment and best interests.51 Surrogates articulate the patient’s 
values and beliefs, which is less burdensome than declaring the patient’s 
specific preferences. Clinicians and surrogates work together to deter-
mine what would be in the best interest of the specific patient.
 � PERIOPERATIVE LIMITATIONS ON POTENTIALLY LIFESUSTAINING 
MEDICAL TREATMENTS
Patients have the right to limit unwanted perioperative treatment. 
Patients implement limitations on potentially LSMT (of which periop-
erative do-not-resuscitate [DNR] orders are one type) because the likely 
burdens outweigh the potential benefits. These patients seek interven-
tions to reduce pain, improve vascular access and treat urgent problems 
unrelated to the primary disease. But, desiring these benefits does not 
minimize their desire to avoid potential burdens of resuscitation, such as 
extensive ventilatory support, cognitive deficits, or physical limitations 
that can follow resuscitation. “Potentially” is used to emphasize the 
uncertainty that a therapy will be life sustaining. The caveat of uncer-
tainty may help clinicians communicate more successfully with patients.
The American Society of Anesthesiologists and the American Col-
lege of Surgeons recommend mandatory reevaluation of DNR orders 
before proceeding with perioperative treament.52,53 Most patients expect 
this reevaluation. Revaluation should consider the goals for surgery and 
end-of-life care.54 In reevaluating the DNRorder, clinicians should 
emphasize pertinent differences between perioperative and ward care 
(Table 4-2).
Perioperative DNR orders should be clarified and documented using 
the goal-directed approach.55,56 The goal-directed approach permits 
patients to communicate their goals for surgery and end-of-life care in 
terms of outcomes. (“I do not want to suffer in the intensive care unit for 
my last 3 months.”) Patients then authorize clinicians to use clinical 
judgment to determine how specific interventions will affect achieving 
the goals. Perioperative clinicians can weigh the etiology of the event, 
the effects of clinical interventions, and detailed knowledge of the goals 
for end-of-life care to tailor the extent of resuscitation to the likelihood 
of achieving those goals. To do so effectively requires attention to pub-
lished literature. The viable survival rate of all patients after periopera-
tive arrest is 25%; the application of these data to patients with limitation 
of potentially LSMT is uncertain given their likely more debilitated 
state.57 Given the fluidity of our knowledge about successful resuscita-
tion, the goal-directed approach promotes trials of therapy, such as car-
dioversion, that test assumptions about whether a therapy will achieve 
the patient’s goals.58,59
Reevaluation should include determining preferences for postopera-
tive trials of therapy. Anesthesia providers should consult with the clini-
cians responsible for postoperative care to ensure that those clinicians 
have adequate understanding of the goals of end-of-life care.
 TABLE 42 Components of a Perioperative Do-Not-Resuscitate Discussion55,56
• Planned procedure and anticipated benefit
• Advantages and opportunities of having specific, identified clinicians providing therapy
for a defined period
• Likelihood of requiring resuscitation
• Reversibility of likely causes requiring resuscitation
• Description of potential interventions and their consequences
• Chances of successful resuscitation, including improved outcomes of witnessed arrests
compared with unwitnessed arrests
• Ranges of outcomes with and without resuscitation
• Responses to iatrogenic events
• Intended and possible venues and types of postoperative care
• Postoperative timing and mechanisms for reevaluation of the DNR order
• Establishment of an agreement through a goal-directed approach or revocation of the
DNR order for the perioperative period
• Documentation
Abbreviation: DNR = do not resuscitate.
Longnecker_Part01_p0001-0034.indd 30 05/05/17 3:48 PM
CHAPTER 4: Ethics and Conflicts of Interest in Anesthesia Practice 31 
Patients opting for goal-directed perioperative DNR orders usually 
choose to authorize temporary therapeutic interventions to manage eas-
ily reversible events, but they reject interventions likely to result in per-
manent sequelae, such as neurologic impairment or dependence on 
life-sustaining technology.52 For example, a dysrhythmia that responds 
quickly to intravenous therapy and cardioversion would be characterized 
as a temporary, easily reversible event unlikely to have significant 
sequelae. But, extended therapy would be more likely to result in unac-
ceptable burdens and postoperative decrements in functional status. In 
that case, it would be appropriate to cease resuscitation. Clinicians should 
base decisions on continuing resuscitation on the likelihoods of out-
comes; absolute certainty not only is not required but also is a standard 
that impairs honoring the patient’s goals to avoid end-of-life burdens.
Iatrogenicity should not influence the extent of resuscitation.60 
Patients initiate limitations on LSMT to minimize potential burdens. 
From the patient’s perspective, the outcome is relevant, not the cause. 
Clinicians should base the extent of the resuscitation on achieving the 
patient’s goals.
The “temporary-and-reversible” goal-directed perioperative DNR 
order can be documented, for example, as the following: “The patient 
desires resuscitative efforts during surgery and in the postanesthesia 
care unit only if the adverse events are believed to be both temporary 
and reversible, in the clinical judgment of the attending anesthesiologists 
and surgeons.” With the patient’s permission, clinicians may want to 
include selected family members in the reevaluation discussion to 
enable the best communication of the patient’s preferences.
 � PHYSICIAN ORDERS FOR LIFESUSTAINING TREATMENT
Advance care planning enables patients to declare preferences for treat-
ment in case they become unable to do so. Advance directives describe 
preferences for treatment, but are often poorly followed and are unable to 
capture the vagaries of complex medical care. Assigning a surrogate 
decision-maker through a durable power of attorney for health care deci-
sions is often ineffective because patients do not communicate their 
preferences to their surrogates or surrogates may have difficulty with 
following through with the declared preferences.61 Arising more than 
20 years ago, Physician Orders for Life-Sustaining Treatment (POLST) 
have recently increased in popularity.62 POLST may be used alone or in 
conjunction with other forms of advanced care planning.
Nearly all US states have or are developing a program. Programs differ 
slightly by state, but at the core, POLST uses medical orders to document 
patient preferences in a portable document that is valid across different 
settings. POLST documents may have several sections. In a typical 
POLST document,63 the first section covers code status, such as attempt 
or do not attempt resuscitation; the second section covers preferences 
for medical interventions, such as full treatment, trial of full treatment, 
and selective treatment of medical conditions; the third section covers 
preferences for management of artificial nutrition; and the fourth sec-
tion includes appropriate signatures.
The strength of POLST comes from being a medical order portable 
across health care sites. Because they are medical orders, POLST can 
affect the use and extent of emergency medical treatment. The richer 
guidance in POLST, as compared to documenting only code status, may 
lead to treatment more consistent with the patient’s preferences.64 Most 
surveyed clinicians felt that POLST increased the frequency and facili-
tated end-of-life care discussions, prevented unwanted resuscitation, are 
mostly stable over time, and successfully bridge settings.65-67 A minority 
of clinicians reported difficulty in using the form,68,69 addressing issues 
broached by POLST, transferring POLST across settings, managing fam-
ily disagreements, and having time for the necessary discussions.70,71 
More research is needed to more fully appreciate the effects of POLST 
on bridging health care sites, directing medical care, and understanding 
the stability of patient preferences as described on the form.72,73
 � BARRIERS TO HONORING LIMITATIONS ON POTENTIALLY LIFE
SUSTAINING MEDICAL TREATMENT
Barriers to honoring limitations on potentially life-sustaining treatment 
center on clinician attitudes and inadequate knowledge about policy, 
law, and ethics (Table 4-3).74-80 Clinicians tend to honor limitations on 
resuscitation in patients who are closer to dying and patients seeking 
palliative therapy. However, patients prioritize functional status when 
choosing to limit resuscitation.60 In clinical practice, inadequate time 
and a lack of standardized procedures impair the reevaluation of the 
DNR order.
The risk of liability for honoring properly documented perioperative 
DNR orders is no more than the risk of not honoring it. Many states 
include clinician immunity provisions in statues addressing DNR 
orders. Immunity provisions tend to protect clinicians from liability as 
long as they follow statutory requirements and act in good faith.
 � POTENTIALLY INAPPROPRIATE TREATMENT
Treatment may be considered potentially inappropriate when the treat-
ment may achieve thepatient’s goals but physicians feel that instituting 
treatment would be ethically inappropriate.81 “Potentially inappropriate” 
is more precise than “futile,” which should be reserved for situations 
when an intervention cannot accomplish a physiologic goal. Potentially 
indicates that determination of inappropriateness is still pending, and 
inappropriate indicates that this decision involves both value and techni-
cal judgments.
Potentially inappropriate treatment requests often arise from a break-
down of communication. Proactive communication and early involve-
ment of expert consultation may decrease the occurrence and the 
intractability of these events. If a treatment conflict is unresolved after 
addressing communication, institutions should have a process for reso-
lution that includes obtaining additional medical opinions and using an 
interdisciplinary hospital panel to review the case. Good policies are 
public and explicate procedures for identifying stakeholders, imple-
menting the policy, resolving conflicts, and initiating appellate 
mechanisms.
PROFESSIONAL OBLIGATIONS AND MANAGING 
POTENTIAL CONFLICTS OF INTEREST
Conflict of interest has been defined as “a set of conditions in which 
professional judgment concerning a primary interest (such as patient’s 
welfare or the validity of research) tends to be unduly influenced by a 
secondary interest (p. 573).”82 Although commonly viewed as financial 
benefits, secondary interests also include personal and professional gains, 
 TABLE 43 Barriers to Limitations on Potentially Life-Sustaining Therapy74-78
Anesthesiologists may care for patients who would appear to benefit from limitations on 
potentially life-sustaining therapy. Although the choice may be well considered, at times 
barriers prevent thoughtful assessment of the goals of end-of-life care. Understanding 
these barriers may be helpful.
Patient and Family Barriers
•	 	Unrealistic	expectations	about	prognosis	or	effectiveness	of	treatment
•	 	Inadequate	education/guidance	from	clinicians
•	 	Guilt	(often	arising	from	minimal	contact	with	the	patient),	leading	to	overtreatment
•	 	Emotional	overtones	of	“causing	death”
•	 	Stories	about	“miraculous”	cures
•	 	Mistrust	of	clinicians,	hospitals,	or	medical	system
•	 	Personal	beliefs
•	 	Denial	of	death
Clinician Barriers
• No process in place for addressing end-of-life goals
• Unrealistic expectations about prognosis or effectiveness of treatment
• Inadequate communication with patient or surrogates regarding end-of-life goals
• Inadequate communication among clinicians regarding end-of-life goals
• Disagreement among clinicians about the benefit-to-burden ratio of treatment
• Influence from recent personal, hospital, or national events
• No clearly identified physician coordinating care
Longnecker_Part01_p0001-0034.indd 31 05/05/17 3:48 PM
32 PART 1: Introduction to Anesthesiology
such as prestige, promotion, personal gratification, and respect. Conflict 
of interest is characterized as potential because individuals are placed in 
situations that create the opportunity for conflicts of interest. Clinicians 
need to recognize potential conflicts, characterize the potential severity 
of the conflicts, and determine the likelihood and resultant harm of the 
influence or the appearance of influence.
 � CLINICAL PRODUCTION PRESSURE
Clinicians face potential conflicts of interest from production pressure. 
Production pressure is the “internal or external pressure on the anes-
thesia professional to keep the OR schedule moving along speedily.”83 
Production pressure can influence clinical practice by affecting the 
extent of preoperative discussions, the postponement of cases, the use of 
invasive monitoring, and the placement of catheters for postoperative 
analgesia. Production pressure may encourage clinicians to provide 
anesthesia outside their skill set or in inappropriate situations.84 Second-
ary gains for clinicians may include increased referrals, positive feed-
back, heightened reputation, and misplaced internal pride. Clinicians 
should carefully consider and frequently reassess whether economic and 
administrative pressures induce inappropriate changes in behavior. 
Concerns are often best addressed by implementing systems that reduce 
production pressures.
 � INTERACTION WITH INDUSTRY
Interaction with industry is widespread and results in potential conflicts 
of interest for clinicians.85-87 Overwhelming evidence indicates that inti-
macy with industry unconsciously affects prescribing behavior, perhaps 
through unrecognized feelings of gratitude, reciprocity, or obligation.88,89 
Physicians may also rationalize accepting industry gifts because of sac-
rifices made in terms of education, time, and compensation.90 Physicians 
may legitimately claim they do not consciously adjust their clinical prac-
tice. But, consider that a core strategy of advertising is to influence 
unwitting patrons through familiarity and positive associations.
The claim that industry provides necessary education about the avail-
ability and use of medications is belied by the need for physicians to have 
unbiased information and unaffected decision-making. Although physi-
cians supposedly independently evaluate industry information, busy 
physicians with insufficient abilities to critically evaluate studies devolve 
into accepting industry materials “as is.” Industry representatives and 
materials routinely overrepresent the benefits and underrepresent the 
risks of drugs. Cynicism is the best defense.
Prohibiting relationships between academic health centers and indus-
try is counterproductive. More appropriate goals are greater participa-
tion, the use of guidelines, and more rigorous oversight.91 For example, 
in clinical trials, academic researchers should participate in trial devel-
opment, have the right to examine the raw data, and be able to publish 
data without the company’s authorization. Industry relationships with 
powerful members of the hospital community should be examined to 
determine if the potential for influence can be minimized.87
Relationships are examined through the Open Payments program 
instituted by the Physician Payments Sunshine Act of the Affordable 
Care Act.92,93 This program makes public the information about financial 
relationships among industry, physicians, and hospitals. In the last 
5 months of 2013, the Open Payments program reported data from 
325,000 physicians receiving 2,430,000 payments for a value of 
$475,000,000. The most frequent type of payment to physicians was for 
food and beverage. The total value of the different types of payments 
varied by and within specialties.93
 � RESEARCH
Research has potential financial and nonfinancial conflicts of interest, 
such as the desire for advancement, prestige, and obtaining grants.94 
Research misconduct, one effect of potential conflicts of interest, occurs 
throughout the research cycle and includes fabricating or falsifying 
data, changing the design of the study to assuage the funding source, 
and hiding undesirable results.95,96 In 2009, an anesthesiologist fabri-
cated clinically influential data supporting the use of cyclooxygenase 2 
inhibitors for multimodal pain therapy.97,98 The anesthesiologist was a 
paid speaker for industry and received financial support for research. 
Supporting the benefits of oversight, irregularities found in a routine 
audit initiated the revealing comprehensive evaluation. Management of 
potential conflicts of interest may include disclosure of financial inter-
est, independent review of research, and prohibiting relationships that 
create the potential for conflicts of interest. Disclosure is an inadequate 
remedy.99 Physicians do not accurately disclose payments from industry 
during presentations of research, and it is unrealistic for clinicians to 
assume they can properly appreciate the influences of payments or 
other secondary gains.100-103
 � SAFETY AND QUALITY CARE INITIATIVES
Individualclinicians need to recognize that they have limited perspec-
tive, knowledge, and experience regarding potential medical errors.104 
Patient care obligations require clinicians to incorporate into practice 
hospital safety and quality care initiatives, even if they do not under-
stand or support them. Anesthesia providers, as frontline clinicians, are 
also obligated to speak out. If a policy seems harmful, these clinicians 
should inform the appropriate individuals. Routinely bypassing the 
problem by ignoring the policy prevents policy remediation and hinders 
the effectiveness of implementing policies in general.
 � THE ETHICS CONSULTATION SERVICE
The discipline of medical ethics encompasses recognizing, analyzing, 
and managing ethical dilemmas. Ethics consultants identify relevant 
facts, facilitate communication, apply principles of ethical analysis, 
define precise ethical questions, and discover alternative, more palatable, 
solutions.105,106 The law and medical ethics have different responsibilities. 
By defining boundaries of behaviors, the law prescribes what must be 
done. Medical ethics works within these boundaries to help determine 
what ought to be done, to recognize when to challenge boundaries, and 
to provide guidance in areas not governed by law.
Ethics consultations are typically performed by an individual, a small 
group, or a full committee. Ethics committees seek to have a heteroge-
neous membership that spans the hospital and may include physicians, 
nurses, social workers, chaplains, administrators, and laypeople. There 
are burgeoning attempts to develop and use a quality assessment tool for 
ethics consultants.107 Most ethics consultation services permit patients, 
families, and those participating in the care of the patient to request a 
consultation. The standard of care is that ethics consultation services 
have no formal authority and are only advisory. Outcome data are 
sparse; most research is being used to develop evaluation 
instruments.108
Ethics consultation is helpful with questions about informed consent, 
decision-making capacity, and resuscitation decisions and resolving 
disagreements among patients, families, and caregivers.
 � PROFESSIONAL OBLIGATIONS
Anesthesiologists have overlapping professional obligations to patients, 
the local community, anesthesiology, and societal health (Table 4-4).109-113 
It is fashionable to bemoan the financial and clinical fate of physicians. 
Among other legitimate and illegitimate complaints are these: Physi-
cians are paid too little and work too hard, are forced to assume unten-
able loans, and are being treated like technicians. These issues are 
irrelevant in terms of the physician’s obligation to fulfill the social con-
tract. Society invested limited resources to develop the medical infra-
structure of education, materials, expertise, and opportunities that 
enables physicians to practice. Despite these concerns, medical practice 
still provides significant compensation, official authority, unofficial 
influence, and the exquisite privilege of making a difference in individu-
als and society. In exchange for these considerable privileges, the implicit 
social contract calls for physicians to use their professional skills altruis-
tically to better society.
Anesthesiologists are obligated to “own” the advancement and advo-
cacy of all things anesthesiology.114
Longnecker_Part01_p0001-0034.indd 32 05/05/17 3:48 PM
CHAPTER 4: Ethics and Conflicts of Interest in Anesthesia Practice 33 
TABLE 44 Obligations of Anesthesiologists
Physicians are obligated to their communities. Community may be considered broadly to be a physical location, a type of patient, or groups with whom physicians electively associate. 
Here is one perspective of communities to which anesthesiologists are obligated. Individual anesthesiologists are not expected to fulfill every obligation. Units of anesthesiologists such as 
private practice groups, academic departments, and state societies should fulfill these obligations collectively.112-114
Patient Community Local Community
• Treat every patient with the grace and consideration you would want for 
your family
• Tailor the perioperative experience to the individual
• Respond to problems that may harm patients (eg, impaired colleagues)
• Practice mindfulness and critical self-reflection
• Actively engage in continuing medical education
• Foster patient safety
• Participate in surveillance data collection
• Comply with policies intended to improve care
• Seek best practices
• Participate in collaborative care
• Participate in hospital governance
• Build hospital systems that improve patient care (eg, sedation services, preoperative clinics,
pain management services)
Society Anesthesiology Community
•	 	Be	politically	active
•	 	Participate	in	social	advocacy	of	an	area	of	choice	(eg,	tobacco	use,	socioeconomic	
disparities in general and in health care, health care delivery)
•	 	Support	national	and	international	health	care	missions
•	 	Teach,	do	research,	or	support	teaching	and	research
•	 	Participate	in	professional	organizations	related	and	unrelated	to	anesthesiology
•	 	Prepare	future	generations	through	mentoring,	creating	opportunities,	and	designing	practice	
styles that encourage participation
•	 Lewis-Newby M, Wicclair M, Pope T, et al. An official American 
Thoracic Society policy statement: managing conscientious objec-
tions in intensive care medicine. Am J Respir Crit Care Med. 2015; 
191(2):219-227. doi:10.1164/rccm.201410—1916ST.
•	 Quill TE. “I wish things were different”: expressing wishes in 
response to loss, futility, and unrealistic hopes. Ann Intern Med. 
2001;135(7):551. doi:10.7326/0003—4819—135—7-200110020-.
•	 Sarwar U, Nicolaou M. Fraud and deceit in medical research. J Res 
Med Sci. 2012;17(11):1077-1081.
•	 Shafer SL. Tattered threads. Anesth Analg. 2009;108(5):1361-1363. 
doi:108/5/1361[pii]10.1213/ane.0b013e3181a16846.
KEY REFERENCES
•	 Berwick DM. What “patient-centered” should mean: confessions 
of an extremist. Health Aff. 2009;28:w555-w565.
•	 Bosslet GT, Pope TM, Rubenfeld GD, et al. An official ATS/
AACN/ACCP/ESICM/SCCM policy statement: responding to 
requests for potentially inappropriate treatments in intensive care 
units. Am J Respir Crit Care Med. 2015;191(11):1318-1330. 
doi:10.1164/rccm.201505-0924ST.
•	 Fleming DA. The moral agency of physician organizations: meet-
ing obligations to advocate for patients and the public. Ann Intern 
Med. 2015;163(12):918-921. doi:10.7326/M15—2527.
•	 Greene NM. Familiarity as a basis for the practice of anesthesiol-
ogy. Anesthesiology. 1976;44:101-103.
•	 Greene NM. The 31st Rovenstine lecture. The changing horizons 
in anesthesiology. Anesthesiology. 1993;79:164-170.
•	 Halpern SD. Toward evidence-based end-of-life care. N Engl J 
Med. 2015;37321(19):2001-2003. doi:10.1056/NEJMp1509664L.
REFERENCES
Complete references are available online at www.LongneckerAnesthesiology 
.com.
Longnecker_Part01_p0001-0034.indd 33 05/05/17 3:48 PM
http://www.LongneckerAnesthesiology.com
http://www.LongneckerAnesthesiology.com
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35
Overview of Preoperative 
Assessment and 
Management
Rebecca M. Gerlach 
Bobbie Jean Sweitzer 
KEY POINTS
1. Anesthesiologists function as perioperative consultants when the entire spec-
trum of perioperative care is examined, not solely the intraoperative period, 
and interventions are implemented to improve overall outcome.
2. Risk assessment tools are used to quantify risk and provide a common language 
for communication with patients and colleagues.
3. The medical history and physical examination are the cornerstones of preanes-
thetic assessment. Preoperative investigations are indicated to diagnose disease 
based on known risk factors or to evaluate the current state of an existing disease.
4. “Routine” or “screening” preoperative tests are not indicated,as they are costly 
and seldom provide useful information.
5. At-risk patients are best assessed prior to the day of surgery to allow adequate 
time for assessment and implementation of indicated risk reduction strategies. 
At-risk patients may include those with
a. Cardiovascular disease: hypertension, ischemic heart disease, coronary 
stents, valvular disease, heart failure, rhythm disturbances, cardiovascular 
implantable electronic devices
b. Respiratory disease: reactive airways disease, chronic obstructive pulmo-
nary disease, pulmonary hypertension, upper respiratory tract infection, 
smokers, obstructive sleep apnea
c. Significant systemic disease: obesity, diabetes mellitus, renal disease, hepatic 
disease, anemia, neurologic disease, cancer, thromboembolic disorder
d. Substance abuse
e. Anesthesia-specific concerns
f. Ambulatory surgery
6. Consultation with other physicians should seek specific advice regarding the 
diagnosis and status of a patient’s condition or the creation of a clinical risk 
profile. “Preoperative clearance” is seldom helpful and should not be requested.
7. Evidence-based practice guidelines minimize cancellations or delays on the 
day of surgery resulting from individual practice variation. Liberalized fasting 
guidelines permitting consumption of clear fluids until 2-3 hours preopera-
tively are safe and minimize patient discomfort.
8. Preanesthetic assessment in clinic by an anesthesiologist prior to surgery 
improves patient satisfaction and alleviates anxiety; avoids medicolegal 
culpability resulting from inadequate assessment or unnecessary testing; 
and is economically beneficial by minimizing preoperative testing and 
avoiding case cancellations or delays.
THE ANESTHESIOLOGIST AS PERIOPERATIVE 
CONSULTANT
As the practice of medicine becomes increasingly outcomes driven and 
cost conscious, the role of the anesthesiologist as a perioperative consul-
tant continues to evolve. No other specialty is more uniquely positioned 
or well suited to coordinate overall perioperative care than anesthesiol-
ogy. The cornerstone of perioperative management is the preanesthetic 
assessment, a snapshot of a patient’s overall physical status that allows 
for risk assessment for an upcoming surgical procedure and implemen-
tation of risk reduction strategies. Whether performed weeks in advance 
of the procedure or immediately prior, this information-gathering ses-
sion serves to detect and evaluate disease through the medical history, 
physical examination, and review of investigations and findings. Certain 
at-risk populations will benefit from intensive planning and therefore 
may benefit from assessment in advance of the procedure to allow for 
time to implement management strategies. Perioperative patient man-
agement may include consultations with other physicians, application of 
relevant practice guidelines, discussion of appropriate fasting recom-
mendations, providing instructions for medications, and postoperative 
disposition planning. The evolving role of the anesthesiologist demands 
attention to the entire continuum of perioperative care, not solely the 
intraoperative period, with the aim of improving overall outcome for the 
patient’s surgical procedure. The concept of a perioperative surgical 
home has existed in many forms for several decades; however, it has only 
recently become a focus of attention as a way to streamline costs and 
improve operating room efficiency.1-4 The consultant anesthesiologist, 
working through a centralized perioperative medicine clinic, is a key 
player in this process.
Not all patients require assessment in a perioperative clinic in advance 
of surgery. To ensure effective resource utilization, patients may be tri-
aged based on American Society of Anesthesiologists (ASA) physical 
status, comorbid conditions, screening questionnaires, or procedure 
complexity. Factors that are considered in triaging complex patients 
likely to benefit from assessment in a perioperative clinic include the 
following:
1. Screening and management of comorbid conditions in at-risk 
populations.
2. Assessing the need for surgical risk assessment.
Preparing for Anesthesia
5
C H A P T E R
2
PA R T
Longnecker_Part02_p0035-0290.indd 35 05/05/17 4:47 PM
36 PART 2: Preparing for Anesthesia
3. Identifying patients requiring special anesthetic techniques or post-
operative care, including specialized pain management strategies.
4. Establishing a baseline for anesthetic planning.
5. Educating patients and families about expectations surrounding 
anesthesia care.
6. Obtaining informed consent.
7. Facilitating timely care and avoiding day-of-surgery cancellations by 
managing anesthesia workflow.
8. Determining patient appropriateness for ambulatory surgical facili-
ties or remote locations.
9. Motivating patients to stop smoking, lose weight, or commit to other 
preventive care.
Table 5-1 outlines the criteria and medical conditions of patients 
likely to benefit from evaluation in a perioperative medicine clinic 
before the day of surgery.
Whether occurring in a perioperative medicine clinic or immediately 
prior to surgery, the ASA has indicated in a practice advisory that a 
preanesthetic assessment should include the following content5:
1. Readily accessible medical records
2. Patient interview
3. A directed examination (including an assessment of the airway, 
lungs, and heart, at a minimum)
4. Preoperative tests when indicated
5. Other consultations when appropriate
Effectively triaging patients for assessment in clinic and ensuring 
adequate evaluation improves patient satisfaction with anesthesia, 
avoids unnecessary medicolegal culpability (see Medicolegal Culpability 
section), and improves operating room efficiency and economics (see 
Economics section). In addition, perioperative medicine clinics provide 
opportunities for behavioral modification intervention at a “teachable 
 TABLE 51 General Criteria and Medical Conditions for Which Preoperative Evaluation Is Recommended Before the Date of Surgery
Medical Condition Criteria
General
 Normal activity inhibited
 Monitoring or medical assistance at home within 2 mo
 Hospital admission within 2 mo
 Obesity > 140% ideal body weight
Cardiovascular
 Coronary artery disease
 Arrhythmias
 Poorly controlled hypertension
 Systolic blood pressure > 180 mm Hg or diastolic blood pressure > 110 mm Hg
 Heart failure
Respiratory
 Asthma requiring daily medications
 Chronic obstructive pulmonary disease (COPD) with symptoms
 Exacerbation or progression of COPD within 2 months
 Previous airway surgery
 Unusual airway anatomy
 Airway tumor or obstruction
 Home ventilatory assistance or monitoring
Endocrine
 Diabetes
 Adrenal disorders
 Active thyroid disease
Neuromuscular
 Seizure disorder
 Central nervous system disease (eg, multiple sclerosis)
 Myopathy or other muscle disorders
Hepatic
 Active hepatobiliary disease or compromise
Renal
 Renal insufficiency or failure
Musculoskeletal
 Kyphosis or scoliosis compromising function
 Temporomandibular joint disorder limiting mouth opening
 Cervical or thoracic spine injury/disease
Oncology
 Chemo- or radiotherapy within last 2 months
 Significant physiologic compromise from disease or treatment
Age
 >75 y, unless surgery is minor (eg, cataract, cystoscopy) and under monitored 
anesthesia care
Language
 Patient or parent/guardian cannot hear, speak, or understand English
Anesthesia related
 Patient or family has had previous difficult intubation or elevated temperature during 
anesthesia, is allergic to succinylcholine, has had malignant hyperthermia or pseudocholines-
terase deficiency or paralysis or nerve damage during anesthesia
Procedure related
 Intraoperative blood transfusion likely
 ICU admission likely
 High-risk surgery
Pregnancy
 Patient is pregnant (unless the procedure is termination)
Adapted with permission from Pasternak LR: Preoperative evaluation of the ambulatory surgery patient, Ambulatory surgery. AnesthesiolRep. 1990;3(1):8.
Longnecker_Part02_p0035-0290.indd 36 05/05/17 4:47 PM
CHAPTER 5: Overview of Preoperative Assessment and Management 37 
moment,”6 when patients may be more receptive to change due to an 
upcoming surgical procedure.
RISK ASSESSMENT AND REDUCTION
Perhaps the simplest, yet surprisingly robust, measure used by anesthe-
siologists today in risk stratifying patients prior to surgery is the ASA 
physical status (ASA-PS) classification system (Table 5-2). Initially pro-
posed by representatives of the ASA in 1941, the ASA classification 
indicates a patient’s preoperative fitness and provides both a metric for 
communicating among colleagues and a stratification system for 
research. Simply put, on a scale of 1 through 6, the ASA-PS denotes how 
“sick” the patient is in the preoperative period with the addition of the 
letter E denoting emergency surgery. The system does not incorporate 
type of anesthesia or surgery into the classification and therefore was not 
intended as a tool for predicting likelihood of perioperative morbidity or 
mortality. Despite this, higher ASA-PS classification has been correlated 
with increased mortality and morbidity, unanticipated intensive care 
unit (ICU) admission, longer hospital stays, procedural complications, 
and adverse cardiopulmonary outcomes.7-15
Responding to the need to provide accurate patient and procedure 
specific surgical risk assessments, the American College of Surgeons 
(ACS) has developed an online resource (http://www.riskcalculator.
facs.org/RiskCalculator/) for this purpose.16 Using clinical data from 
over 1.4 million patients in the National Surgical Quality Improvement 
Program (NSQIP) database, the web-based tool incorporates 21 preop-
erative patient factors (including ASA-PS classification) and the 
Current Procedural Terminology (CPT) code for almost all specialty and 
subspecialty surgical procedures. Predicted risk of eight patient-specific 
outcomes are reported in graphical format and compared with the 
expected outcome for the procedure to aid in surgical decision-making. 
The ACS NSQIP tool is not designed to provide perioperative recom-
mendations, yet it is valuable in providing a common language for 
communication about risk with the patient and perioperative team and 
may guide more intensive interventions for prevention of the most 
likely adverse outcomes.
In contrast to the universal approach of the ACS NSQIP risk assess-
ment tool, organ system–specific risk assessment and management tools 
inform perioperative management and risk reduction focusing on spe-
cific body systems. Perhaps the most well established of these is the 
American College of Cardiology/American Heart Association (ACC/
AHA) guideline related to the perioperative cardiovascular evaluation 
and management of patients undergoing noncardiac surgery,17 most 
recently updated in 2014. Figure 5-1 provides a simple cardiac evaluation 
for noncardiac surgery for patients with a history of or risk factors for 
coronary artery disease (CAD). In addition to providing evidence-based 
guidelines on the preoperative management of specific cardiac condi-
tions (see Heart Disease section and Chapter 9 for detailed discussion), 
decisions regarding risk assessment and preoperative cardiac testing for 
CAD are guided by the Revised Cardiac Risk Index (RCRI) or the ACS 
NSQIP Myocardial Infarction and Cardiac Arrest (MICA) calculator 
(http://www.surgicalriskcalculator.com/miorcardiacarrest).17 The RCRI 
is a simple validated index to predict major cardiac adverse events after 
surgery, incorporating six criteria: (1) presence of ischemic heart disease, 
(2) history of heart failure (HF), (3) history of cerebrovascular disease, (4) 
diabetes mellitus (DM) treated with insulin, (5) creatinine 2 mg/dL or 
greater, and (6) intrathoracic, intra-abdominal, or suprainguinal vascular 
procedures.18
The Society of Neuroscience in Anesthesiology and Critical Care also 
published consensus guidelines in 2014 to help guide risk assessment 
and reduction for perioperative stroke in noncardiac and nonneuro-
logical surgery.19 While informing certain practice patterns, such as 
appropriate use of antiplatelet agents and bridging anticoagulation, 
these guidelines also identify ongoing areas of clinical equipoise, such 
as the optimal timing of surgery after stroke and prospective identifica-
tion of risk factors for postoperative stroke19 (see Neurologic Disease 
section).
Unfortunately, no unifying guidelines have been developed for risk 
assessment of postoperative pulmonary or renal injury. Several risk pre-
diction or classification tools exist for postoperative pulmonary compli-
cations20-24 and acute kidney injury,25-27 but there are no specific 
perioperative consensus guidelines.
Perioperative risk assessment is critical to the assessment for several 
reasons. It informs the discussion with the patient about the risks and 
benefits of surgery and anesthesia. Detection of increased risk may alter 
the plan for specific anesthesia techniques, care providers with particu-
lar skills, a change in operative procedure (eg, a less-invasive approach), 
intra- and postoperative monitoring to allow for early detection and 
management of complications, decision to perform surgery in a different 
venue (eg, hospital), or even a decision to not operate.17 Most important, 
preoperative intervention strategies may be undertaken to minimize 
risk. As these strategies may take time to implement, these decisions are 
best made in advance of the day of surgery.
 � TIMING OF ASSESSMENT
In determining the potential benefit of assessment in advance of the day 
of surgery, consensus guidelines from the ASA Task Force on Preanes-
thesia Evaluation consider the severity of patient illness, patient 
TABLE 52 American Society of Anesthesiologists Physical Status Classification System
Definitiona Examples, Including, But Not Limited To
ASA I A normal, healthy patient Healthy, nonsmoking, no or minimal alcohol use.
ASA II A patient with mild systemic disease Mild diseases only without substantive functional limitations. Examples include (but not limited to) current smoker, social 
alcohol drinker, pregnancy, obesity (30 < BMI < 40), well-controlled DM/HTN, mild lung disease.
ASA III A patient with severe systemic disease Substantive functional limitations; one or more moderate to severe diseases. Examples include (but not limited to) 
poorly controlled DM or HTN, COPD, morbid obesity (BMI > 40), active hepatitis, alcohol dependence or abuse, implanted 
pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, premature infant 
PCA < 60 weeks, history (>3 months) of MI, CVA, TIA, or CAD/stents.
ASA IV A patient with severe systemic disease that is 
a constant threat to life
Examples include (but not limited to) recent (<3 months) MI, CVA, TIA, or CAD/stents; ongoing cardiac ischemia or severe 
valve dysfunction; severe reduction of ejection fraction; sepsis; DIC; ARDS; or ESRD not undergoing regularly scheduled 
dialysis.
ASA V A moribund patient who is not expected to 
survive without the operation
Examples include (but not limited to) ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass 
effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction.
ASA VI A declared brain-dead patient whose organs 
are being removed for donor purposes
Abbreviations: DIC = disseminated intravascular coagulation; ESRD = end-stage renal disease; TIA = transient ischemic attack; ARDS = acute respiratory distress syndrome; PCA = post-conceptual age; BMI = body 
mass index; CAD = coronary artery disease; COPD = chronic obstructive pulmonary disease; CVA = cerebrovascular accident; DM = diabetes mellitus; HTN = hypertension.
aThe addition of “E” denotes Emergency surgery: An emergency is defined as existing when delay in treatment of the patient would lead to a significantincrease in the threat to life or body part.
Data from the ASA website: http://www.asahq.org.
Longnecker_Part02_p0035-0290.indd 37 05/05/17 4:47 PM
http://www.riskcalculator.facs.org/RiskCalculator/
http://www.riskcalculator.facs.org/RiskCalculator/
http://www.surgicalriskcalculator.com/miorcardiacarrest
http://www.asahq.org
38 PART 2: Preparing for Anesthesia
demographics, and invasiveness of the procedure to be important.5 For 
greater surgical invasiveness or more advanced disease, ASA members 
and consultants who were surveyed for the guidelines favored assess-
ment in advance of the day of surgery. For less-invasive operations or 
less-severe levels of disease, assessment may be done on or before the 
day of surgery. This is consistent with the concept that low-risk patients 
having ambulatory surgery likely will not benefit from assessment in 
advance of surgery. For low severity of disease but greater surgical inva-
siveness, the guidelines favor assessment in advance of surgery. For 
medium severity of disease and low-to-medium invasiveness, the assess-
ment may be completed on or before the day of surgery. Each patient 
must be considered on a case-by-case basis.
 � DETECTING AND EVALUATING DISEASE
In diagnosing disease, the medical history and physical examination are 
a clinician’s most valuable guides, whereas investigations ordered with-
out a high pretest probability are seldom helpful. The concept of “screen-
ing” or “routine” preoperative tests is not supported by evidence due to 
the low probability of discovering relevant findings and the potential that 
such approaches lead to further unnecessary patient investigations.5,28-36
Tests ordered with no specific indication or purpose may also lead to 
medicolegal culpability resulting from overtesting (see the Medicolegal 
Culpability section). In a general medical clinic, 56% of correct diagno-
ses were made with the history alone, and this increased to 73% when 
adding the physical examination.37 In patients with cardiovascular dis-
ease, the history may establish the diagnosis 66% of the time, and the 
physical examination may contribute to 25% of diagnoses. Routine pre-
operative screening investigations, such as chest radiography and elec-
trocardiography (ECG), assist with only 3% of diagnoses, and special 
tests, mainly exercise ECG, assist with 6%.37 Diagnostic accuracy in 
clinical examination is the result of pattern recognition when listening 
to a patient’s story. The diagnostic acumen of the physician is the result 
of assimilating information and developing an overall impression, rather 
than just reviewing a compilation of facts.
Medical History Common problems in medical history taking include 
variability in methods of symptom inquiry, interpretation of history, and 
recording of patient responses. When taking a history for a medical 
condition in which abstract medical terminology is commonly used, 
such as diagnosis of a transient ischemic attack, a checklist in simple 
language that is free of medical jargon or local or specialty-specific ter-
minology improves interobserver agreement concerning the diagnosis.38
Standardization of the preanesthetic record used within a department 
will help ensure that assessments are thorough, precise, and easily 
understandable among practitioners.
A determination of the patient’s functional capacity is essential for 
guiding additional preanesthetic evaluation and predicting outcome and 
perioperative complications.17,39,40 Exercise ability, or work activity, can 
be quantified using the metabolic equivalent of task score (METs), 
which refers to the volume of oxygen consumed during an activity.41 The 
inability to exercise due to poor mobility, neuromuscular disorder, or 
chronic pain may preclude a true assessment of cardiopulmonary fit-
ness. However, patients who are able to achieve greater than 4 METs of 
activity without symptoms are unlikely to have significant cardiorespira-
tory disease and may proceed to surgery without further cardiac 
testing.17 Common activities indicating greater than 4 METs of activity 
include climbing a flight of stairs or walking a hill (5.50 METs), doing 
yardwork like raking leaves, weeding, or pushing a lawnmower (4.50 
METs).40
In addition to functional capacity, a detailed review of systems and 
surgical history must be elicited to complete the assessment. A patient 
questionnaire can be helpful in gathering this information, such as the 
• YesIs this an emergency procedure?
Is this an acute coronary syndrome?
• ≥ 4 METs
What is the patient's functional
capacity?
• < 4 METs
or
unknown
• No
• No
Proceed with surgery; risk reduction
intra- and postoperatively
• Yes
• Low risk
• (<1% or <2 RCRI)
• Yes • Abnormal
• Normal• No
Proceed to surgery according to guideline-directed medical therapy
OR
consider strategies other than surgery
What is the perioperative risk of MACE?
(determined by RCRI or risk calculator)
• Elevated risk
• (≥1% or ≥2
RCRI)
Proceed with surgery
Proceed with surgery
Manage and treat according to clinical
practice guidelines
Manage and treat
according to clinical
practice guidelines
Pharmacologic
stress testing
Will further testing impact decision-making
OR perioperative care?
FIGURE 5-1. Simplified cardiac evaluation for noncardiac surgery for patients with history or risk factors for coronary artery disease. MACE, major adverse cardiac event; METs, metabolic 
equivalent of task score.
Longnecker_Part02_p0035-0290.indd 38 05/05/17 4:47 PM
CHAPTER 5: Overview of Preoperative Assessment and Management 39 
example given further in the chapter. This can be completed by the 
patient in person, via telephone interview with preoperative screening 
nurses, or electronically. The patient’s medical problems, past surgery, 
previous anesthesia-related complications, allergies, and use of tobacco, 
alcohol, or illicit drugs should be documented. Rarely is a simple nota-
tion of diseases or symptoms such as hypertension (HTN), DM, CAD, 
shortness of breath (SOB), or chest pain sufficient. The severity, extent 
of disease, adequacy of control, and the activity-limiting nature of iden-
tified problems should be explored during the interview.
An important component of preoperative evaluation is identification 
of risk factors for difficult airway management. If the potential for dif-
ficult airway management is identified before the day of surgery, special 
equipment or personnel with advanced training and skills in airway 
management can be available without delaying or postponing proce-
dures or compromising patient safety.42 Difficult direct laryngoscopy is 
to be suspected in patients with the following history:
 • Reported history of difficult intubation, aspiration pneumonia after 
intubation, or dental or oral trauma following intubation
•  Obstructive sleep apnea (OSA) or snoring
•  Previous head/neck radiation, surgery, or trauma
•  Congenital abnormalities
•  Rheumatoid arthritis (RA)
•  Down syndrome
•  Scleroderma
•  Cervical spine disease or previous surgery
Equally important is identification of characteristics independently 
associated with difficult mask ventilation43:
 • Age older than 55 years
•  Body mass index (BMI) greater than 26 kg/m2
•  Lack of teeth
•  A beard
•  Snoring history
Patients with Down syndrome or RA are at risk for atlantoaxial insta-
bility (AAI), and flexion/extension cervical spine radiographs should be 
ordered, especially in the presence of documented neurologic deficits or 
long-standing, severely deforming disease. Imaging may not be possible 
to obtain in the patient with Down syndrome, depending on coopera-
tiveness of the patient. A careful history may elicit neurologic deficits or 
neck and shoulder pain, or patients may be asymptomatic. The parents 
of a patient with Down syndrome may report gait abnormalities, limited 
neck mobility, or sensory deficits if AAI is present.
Previous anesthetic records should be obtained if featuresof difficult 
intubation are present. Patients with oral piercings should be counseled 
to remove all jewelry on the day of surgery and about the potential risks 
if piercings are not removed.44 (See Physical Examination, next, for com-
ponents of the airway examination.) Chapter 32 discusses the evaluation 
of the patient with a difficult airway.
Physical Examination At a minimum, the preanesthetic examination 
includes vital signs; height and weight measurements for BMI calcula-
tion; cardiac and pulmonary examinations; and an airway assessment. A 
change in vital signs during assessment may be the only clinical indica-
tion of an altered state of health, and particular attention must be paid 
to significant changes between those obtained during an earlier periop-
erative assessment and those obtained on the day of surgery. Extremes of 
blood pressure may require additional management prior to surgery (see 
Hypertension). Because obesity is a risk factor for perioperative compli-
cations, notation of patient height and weight is helpful in planning 
anesthesia care (see Obesity for further discussion). Increased BMI, 
combined with HTN and large neck circumference, is associated with 
OSA (see Obstructive Sleep Apnea). BMI can be calculated by the fol-
lowing formulas:
Imperial formula:
×




×BMI =
Weight in pounds
(Height in Inches) (Height in Inches)
703
Metric formula:
×




BMI =
Weight in kilograms
(Height in meters) (Height in meters)
On cardiac examination, the discovery of a new murmur poses sev-
eral questions: (1) What is the cause? (2) Is the murmur clinically signifi-
cant? (3) Does it require investigation? If the murmur occurs in diastole, 
the patient has a poor functional status, age is greater than 55 years, or 
symptoms of valvular disease are present in the history, there is a greater 
likelihood that the murmur is pathologic (see Valvular Disease for fur-
ther discussion). Patients with clinically suspected moderate or severe 
valvular regurgitation or stenosis who have not had an echocardiogram 
in the last year or have had a change in functional status, should undergo 
preoperative echocardiography.17
Three valvular lesions are particularly relevant to anesthesia planning: 
aortic stenosis (AS), mitral stenosis (MS), or subaortic stenosis of hyper-
trophic cardiomyopathy. In assessing for AS, the cardinal symptoms of 
severe disease are angina, HF, and syncope, although patients are much 
more likely to complain of a decrease in exercise tolerance and exertional 
dyspnea. AS causes a systolic ejection murmur that is best heard in the 
right upper sternal border, which often radiates to the neck. In contrast, 
MS causes a rumbling middiastolic murmur best heard at the point of 
maximal impulse of the heart and may also have an opening snap. Patients 
with hypertrophic cardiomyopathy may not present with a murmur or 
may have a murmur elicited only with Valsalva maneuver. If present, this 
murmur may sound similar to AS. In addition to auscultation, inspection 
for peripheral edema and palpation of the pulses can be informative.
The pulmonary examination includes auscultation for wheezing, 
decreased or abnormal breath sounds, notation of cyanosis or clubbing, 
and effort of breathing. Observing the patient walking up one or two 
flights of stairs assesses fitness and may indicate the need for further 
diagnostic testing, such as pulmonary function tests (PFTs), echocar-
diography, or noninvasive cardiac stress testing, if the patient is limited 
by symptoms.17,39,45,46
A detailed airway examination must be done before the initiation of 
anesthesia care. Though not exhaustive, the following elements of the 
airway should be assessed47:
 • Length of upper incisors
•  Relationship of maxillary and mandibular incisors during normal jaw 
closure
•  Relationship of maxillary and mandibular incisors during voluntary 
protrusion of mandible
•  Interincisor distance
•  Visibility of uvula
•  Compliance of mandibular space
•  Thyromental distance
•  Length of neck
•  Thickness of neck
•  Range of motion of head and neck
Because of the possibility of dental injuries during anesthesia, particu-
larly in the presence of poor dentition or dental work, thorough docu-
mentation of preexisting tooth and gum abnormalities is advisable. 
Either a tooth number chart (Figure 5-2) or standard nomenclature 
(eg, right upper central incisor, left lower lateral incisor, or right lower 
bicuspid) can be used.
Discussion of potential dental risks is especially important in the pres-
ence of poor dentition.48 A good time to discuss airway management 
with patients, including possible awake fiber-optic intubation when 
necessary, is after examination of the airway. Findings from the airway 
examination may predict difficult intubations.47,49 When a challenging 
airway is identified, advance planning ensures that necessary equipment 
and skilled personnel are available, and it forewarns the patient of poten-
tial dental or oral injury.
Testing and Investigations Results from the history and physical 
examination determine the pretest probability of disease, which guides 
Longnecker_Part02_p0035-0290.indd 39 05/05/17 4:47 PM
40 PART 2: Preparing for Anesthesia
test selection and interpretation. Preoperative testing is performed both 
to evaluate existing medical conditions and to diagnose conditions 
based on known risk factors for particular diseases. Testing is indicated 
not only when a patient has a likelihood of an abnormal result, but also 
when an abnormal result will have an impact on management of the 
patient or direct further testing. For example, the hemoglobin (Hb) 
value is often slightly abnormal in otherwise-healthy patients, but it 
seldom has an effect on management prior to minor ambulatory surgery 
because the risk of blood loss is low. As a guide to selecting tests, certain 
medical conditions have a higher likelihood of abnormal test results. 
Table 5-3 contains recommendations for testing based on specific medi-
cal conditions for patients undergoing intermediate- to high-risk proce-
dures. Guidelines in this table are not intended for all patients with those 
conditions, but to aid in diagnosing or improving management of a 
disease if that is needed preoperatively.
As noted previously, preoperative tests without specific indications 
lack clinical usefulness and may actually lead to patient harm because 
of unnecessary interventions, delay of surgery, anxiety, and even inap-
propriate therapies.50 In addition, the evaluation of abnormal but insig-
nificant results is costly.51-53 Despite this, the practice of “routine 
preoperative testing” by some physicians persists, with over half of all 
surgical patients receiving at least one unnecessary test at a US institution.54
This can likely be attributed to “practice tradition, belief that other 
physicians want tests done, medicolegal worries, concerns about surgi-
cal delays or cancellation, and lack of awareness of evidence or guide-
lines.”55 Because many unnecessary tests are ordered based on assumed 
beliefs of what is expected by other physicians, greater communication 
of consensus guidelines and evidence-based testing practices are 
required to minimize the incorrect assumption that routine testing is 
expected.
The ASA practice advisory on preanesthetic evaluation includes rec-
ommendations for selection and timing of preoperative testing.5 This 
advisory synthesizes available data and expert opinion from consultants 
and specialty society members. The focus on efficient use of preop-
erative testing by anesthesiologists is evident when comparing testing 
initiated by anesthesiologist assessment rather than standard preop-
erative orders or surgeon-initiated testing. Anesthesiologist-directed 
testing decreases the number and cost of preoperative investigations.34,54 
Anesthesiologists were 53% less likely to order unnecessary tests 
than their surgical colleagues.54 Still, uniformimplementation of 
existing preoperative testing guidelines is difficult to achieve, as evi-
denced by the disparity in preoperative testing practices among 
anesthesia providers.56
The benefits of disease-indicated testing versus batteries of screening 
tests are numerous, and even disease-indicated testing may be unneces-
sary in certain situations. In ambulatory surgery patients with stable or 
mild disease, no increase in perioperative adverse events was detected 
when disease-based complete blood cell count (CBC), electrolytes, 
blood glucose (BG), creatinine (Cr), ECG, and chest radiograph (CXR) 
tests were eliminated.35 Few abnormalities detected by nonspecific test-
ing result in changes in management and rarely have such changes had 
a beneficial patient effect.57 In one hospital, only 0.4% of tests omitted 
would have provided useful clinical information in retrospect, when a 
selective protocol for test ordering was instituted.57 Approximately 1 in 
2000 preoperative screening tests results in patient harm from pursuit of 
abnormalities detected by those tests, while only 1 in 10,000 is likely to 
benefit the patient.58 In children, for example, screening urinalysis may 
result in unnecessary cancellation of surgery because of clinically insig-
nificant or false-positive results.50
 TABLE 53 Preoperative Diagnostic Testing Order Form for Intermediate- to 
High-Risk Procedures by Disease and Therapy-Based Indicationsa
□ AST/AlkP
Alcohol abuse; exposure to hepatitis; hepatic disease; 
history of bleeding
□ β-hCG Possible pregnancy
□ BUN/Cr Cardiovascular, hepatic, or renal disease; diabetes; poor 
exercise tolerance; systemic lupus; use of digoxin, diuretics, 
steroids; procedures with radiographic dye
□ CBC w/plt Alcohol abuse, anemia; cardiovascular, pulmonary, or renal 
disease; malignancy; malnutrition; history of bleeding; proce-
dures with significant blood loss
□ CXR Active, acute symptoms especially with cardiovascular or pul-
monary disease; rheumatoid arthritis, systemic lupus; smoking 
> 40 pack-years; radiation therapy
□ ECG Alcohol abuse; cardiovascular, cerebrovascular, intracranial, 
peripheral vascular, pulmonary, or renal disease; diabetes; 
morbid obesity; poor exercise tolerance; rheumatoid arthritis; 
sleep apnea; smoking > 40 pack-years; systemic lupus; radia-
tion therapy to chest or breasts; use of digoxin
□ Electrolytes Intracranial or renal disease; diabetes; malnutrition; use of 
digoxin, diuretics
□ Glucose Intracranial disease; diabetes; morbid obesity; steroid use
□ PT Alcohol abuse; hepatic disease; malnutrition; personal history 
of bleeding; use of anticoagulants
□ aPTT Personal or family history of bleeding, heparin use
□ Thyroid tests Thyroid disease; use of thyroid medications
□ T&S Procedure with significant blood loss potential
□ Urinalysis Suspected urinary tract infection
Abbreviations: AST/AlkP = aspartate transaminase/alkaline phosphatase; β-hCG = β-human chorionic 
gonadotropin; BUN/Cr = blood urea nitrogen/creatinine; CBC w/plt = complete blood cell count with 
platelets; CXR = chest x-ray; ECG = electrocardiogram; PT = prothrombin time; aPTT = activated 
partial thromboplastin time; T&S = type and screen.
aGuidelines are not for routine testing in all individuals with stated conditions but are only indicated if 
the medical condition is newly diagnosed, evolving, or unstable or results will alter anesthetic management. 
Guidelines may not apply for low-risk procedures where testing is rarely indicated except in situations when 
the patient’s medical condition is significantly deranged. With the exception of β-hCG for pregnancy, all tests 
are valid for 2 months before surgery unless abnormal or patient’s condition has changed.
Permanent 
maxillary
right first
molar
Permanent 
mandibular
right third
molar
Permanent maxillary
left second premolar
Permanent 
mandibular
left canine
Primary teeth
Primary 
maxillary
right first
molar
Primary maxillary
left second molar
Primary mandibular
left canine
Primary 
mandibular
right lateral
incisor
1
10
11
12
2
13
3
4
5
6
7
8 9
14
15
16
17
18
19
20
21
22
23242526
27
28
29
30
31
32
A
B
C
D
E F G
H
I
J
K
L
MNOPQ
R
S
T
Permanent teeth
P
l
P
m
le
Primary teeth
y
st
P
lear
1
1010
11
212
2
131
3
4
55
6
77
14
15
16
17
18
19
02
21
2222
23242526
2727
28
29
30
31
32
A
B
C
D
E F G
H
I
J
K
L
MNOPQ
R
S
T
FIGURE 5-2. Dental chart. [Reproduced with permission from Tintinalli JE, Kelen GD, 
Stapczynski JS: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 6th ed. New York: 
McGraw-Hill; 2004.]
Longnecker_Part02_p0035-0290.indd 40 05/05/17 4:47 PM
CHAPTER 5: Overview of Preoperative Assessment and Management 41 
Preoperative ECGs are one of the most frequently ordered and costly 
noninvasive tests. Occult heart disease is common in the middle-aged 
population and increases with advancing age, but the ASA Task Force 
for Preanesthesia Evaluation has stated “that age alone may not be an 
indication for an electrocardiogram (p. 527).”5 A resting ECG is not a 
discriminating screening tool for CAD, as abnormalities are observed in 
4.6% to 44.9% of unselected patients and in 11% to 78.8% of selected 
patients.5 In a prospective observational study in patients 50 years or 
older having moderate- to high-risk noncardiac surgery, abnormalities 
on preoperative ECGs were common (45% of patients), yet even the 
identification of bundle branch blocks added no value over clinical risk 
factors to the prediction of postoperative myocardial infarction (MI) 
and death.59 In a retrospective study of 23,036 patients undergoing low- 
to intermediate-risk noncardiac surgery, those with abnormalities on 
their preoperative ECG had only a 0.5% increase in cardiovascular mor-
tality as compared with cohorts with normal ECGs.60 Only 2% of 
patients undergoing routine preoperative ECG have abnormalities that 
are considered significant in the perioperative period (new Q waves and 
arrhythmias).61 Patients with known severe CAD requiring coronary 
artery bypass grafting (CABG) are the only patient group where preop-
erative ischemic findings on continuous ECG monitoring significantly 
predicted intraoperative ischemia compared with patients with normal 
ECG (33% vs 7%) in an observational study.62 However, even in these 
patients, the added benefit of a single preoperative ECG for predicting 
clinical risk is unclear. Because of poor predictive value of abnormalities 
and the greater discriminating ability of clinical assessment in predicting 
risk of ischemic heart disease, the ACC/AHA perioperative guidelines 
do not advise consideration of ECG abnormalities in deciding on further 
cardiac testing.17 Clinical evaluation and further cardiac testing recom-
mended in the ACC/AHA guidelines have been validated for predicting 
cardiac risks, and screening ECG adds little to the assessment.
While not useful as a screen for CAD, there are diseases for which 
preoperative ECG may be a useful diagnostic test (see Table 5-3). Diag-
nosis of arrhythmias such as atrial fibrillation (AF) in the presence of an 
abnormal pulse, progression of previous conduction abnormalities, and 
assessment of electrolyte disturbances or medication therapy all have a 
potential impact on perioperative management. However, simply order-
ing an ECG as a “baseline” for comparison with intraoperative or postop-
erative findings is likely not helpful, as a preoperative 12-lead ECG is 
rarely comparable with intraoperative ECG monitoring due to varying 
lead placement. Anesthetic drugs, position, and volume changes affect 
the ECG. If concerns for the development of intraoperative ischemia, 
arrhythmias, long QT, or significant electrolyte disturbances exist, a bet-
ter baseline assessment can be obtained once the patient is in the operat-
ing room with five-lead ECG in place. Immediately before induction of 
anesthesia, rhythm strips of various leads can be printedfor later com-
parison, most importantly leads II, V4, or V5. A more sensitive detection 
mode for ischemia, if available, is transesophageal echocardiographic 
monitoring for regional wall motion abnormalities.63 Preoperative base-
line ECG for comparison with postoperative ECG for ischemia monitor-
ing is similarly unhelpful. An increased troponin level within 48 hours of 
surgery, but not ECG changes, predicts death at 1 year and is a superior 
measure of identifying ischemia or MI.39 Postoperative ECG as a sole 
measure to screen for ischemia adds little to the diagnosis in most cases.
Preoperative Hb measurement is indicated in patients at risk of pre-
operative anemia if a procedure associated with significant blood loss is 
planned or if significant blood loss or intraoperative transfusion is 
anticipated in an otherwise-healthy patient. In otherwise-healthy or 
nonselected patients, preoperative Hb levels are frequently abnormal 
(up to 65.4% of patients), but physicians rarely change management 
(only 2.4% to 28.6% of cases).5 Abnormal Hb level is an independent 
predictor of postoperative complications and mortality.64-67 This increase 
may be related to the severity of preoperative disease or a result of com-
plications of blood transfusions required perioperatively. Preoperative 
interventions to manage anemia prior to elective surgery, such as iron 
supplementation or identification of occult sources of blood loss, can 
decrease perioperative transfusion requirements and subsequent com-
plications.68 If the discovery of anemia will lead to an alteration in surgi-
cal plans or prompt further evaluation for disease or the correction of 
anemia, then testing is warranted.
Coagulation studies (platelet count, prothrombin, or activated partial 
thromboplastin time [aPTT]) are not recommended unless the clinical 
history indicates a bleeding disorder, history of thrombosis, significant 
renal or hepatic disease, or use of an anticoagulant. If none of these are 
present, the cost of screening coagulation tests before surgery outweighs 
the benefit. Conditions that affect prothrombin time (PT), such as liver 
disease, malnutrition, or warfarin use, are readily identified by history, 
making routine screening of PT unnecessary. A platelet count is indi-
cated in patients who have received recent chemotherapy that suppresses 
bone marrow, those with liver disease, petechiae, or an undiagnosed 
bleeding disorder. An aPTT is indicated to detect an acquired anticoagu-
lant (eg, lupus anticoagulant) in patients with a history of unprovoked 
thrombosis or a reduced level of a contact activation factor (eg, von Wil-
lebrand disease or factor VIII, IX, XI, or XII deficiencies) in those with 
undiagnosed history of bleeding. A short aPTT may be equally as 
important as a prolonged aPTT. A short aPTT is associated with hyper-
coagulable conditions and increases the risk of postoperative 
thromboembolism.
Despite frequent laboratory abnormalities in elderly patients, age 
alone is not an indication for laboratory testing.32 No correlation has 
been established between age alone and abnormalities in Hb, serum 
chemistries, radiographs, or PFTs, independent of coexisting disease, a 
positive history, or findings on physical examination.50,69,70 CXRs are 
indicated only in patients with pulmonary signs or symptoms of unde-
termined cause or severity.21
Mandatory preoperative pregnancy testing for women of childbearing 
age, particularly in adolescents, is a debated issue.5,71-74 Past survey of 
anesthesiologists reported 30% of practitioners performed routine pre-
operative pregnancy testing out of concern for potential harm to the 
fetus and medicolegal implications, combined with the unreliability of 
the history to determine the likelihood of pregnancy, especially in ado-
lescents.72,75,76 Currently, the ASA recommends that “pregnancy testing 
may be offered to female patients of childbearing age and for whom the 
result would alter the patient’s management (p. 526).”5 Routine preg-
nancy testing before elective surgery is not mandatory and when per-
formed in dependents, raises important questions of what to do with 
positive results and who to inform. When minors are pregnant, their 
privacy is generally governed by state laws. One must be familiar with 
local statutes and how unexpected positive pregnancy results will be 
handled. With the high reliability of urine testing, it is best to delay test-
ing until the day of surgery instead of testing earlier in the preoperative 
clinic unless the patient suspects pregnancy or the menstrual period is 
delayed. This immediate preoperative testing will avoid missing a diag-
nosis of a recent pregnancy.
Even though routine testing is generally not recommended, there are 
several conditions for which a specific preoperative test is indicated, 
such as a procedure that involves the injection of contrast media (eg, 
serum creatinine) or a patient with DM (blood glucose on the day of 
surgery). These are summarized in Table 5-4.
In summary, preoperative tests are recommended only if the results may
 • Change, cancel, or postpone the surgical procedure
•  Change anesthetic and medical management
•  Change monitoring or intra- or postoperative care
•  Establish a diagnosis in a patient who has not been adequately 
prepared
Many facilities have developed diagnostic testing guidelines to improve 
patient care, standardize clinical practice, improve efficiency, and reduce 
costs. With implementation of guidelines, one facility reduced the cost of 
preoperative testing per patient by 63% without affecting clinical out-
comes.52 A cost-to-benefit analysis of routine urinalysis for those under-
going knee procedures that did not involve a prosthesis would require the 
expenditure of $1.5 million to prevent 1 wound infection.76 Interestingly, 
one study found 50% more routine ECGs and 40% more CXRs were done 
in a fee-for-service practice versus a prepaid practice.77 In the current era 
of cost-conscious medical care, appropriate testing based on medical his-
tory and physical examination rather than routine protocol may repre-
sent an area of significant cost savings.
Longnecker_Part02_p0035-0290.indd 41 05/05/17 4:47 PM
42 PART 2: Preparing for Anesthesia
APPROACH TO THE ATRISK PATIENT
Presented here is a review of common diseases that require perioperative 
evaluation and intervention. The reader is referred to other chapters in 
this text for more detailed discussion of specific diseases. The conditions 
discussed in this section are best managed before the day of surgery to 
allow ample time for thoughtful evaluation, consultation, and planning.
� HEART DISEASE
Cardiovascular complications are the most common serious adverse 
event perioperatively. Cardiac issues that are likely to be encountered in 
the preoperative clinic include the patient with HTN, ischemic heart 
disease, coronary stents, valvular disease, HF, rhythm disturbance or 
abnormal ECG, or cardiovascular implantable electronic devices (CIEDs). 
Chapter 9 provides a comprehensive review of cardiovascular disease.
Hypertension Hypertension is defined by two or more measurements 
of blood pressure greater than 140/90 mm Hg. In the United States in 
2010, the prevalence of HTN was 30.5% in men and 28.5% in women, 
but only 40.3% of these men and 56.3% of women achieved adequate 
control of their blood pressure.78 These findings are concerning because 
the extent of end-organ damage correlates with the duration and severity 
of HTN. Ischemic heart disease, HF, chronic kidney disease (CKD), and 
cerebrovascular disease all result from hypertensive end-organ damage.
Extreme elevations in preoperative blood pressure may lead to peri-
operative ischemia, arrhythmias, and labile hemodynamics. Increasing 
severity of baseline HTN (taken as an average measurement, not isolated 
preinduction HTN) is an independent predictor for postoperative myo-
cardial injury/MI or 30-day mortality.79Hypertension is statistically 
related to adverse perioperative outcomes (odds ratio of 1.35).80 Elective 
surgery should be delayed for severe HTN (diastolic blood pressure 
> 110 mm Hg; systolic blood pressure > 180 mm Hg). Mean arterial blood 
pressure should be kept above 65 mm Hg to prevent adverse events. 
Even tighter control is advisable if severe end-organ damage is already 
present.80 Severely increased blood pressure should be lowered over 
several weeks, rather than aggressively, if possible.
Effective lowering of risk may require 6 to 8 weeks of therapy to allow 
regression of vascular changes. Current (2014) guidelines for long-term 
treatment of HTN recommend initiation of one or a combination of 
thiazide-type diuretic, angiotensin-converting enzyme inhibitor (ACEI), 
angiotensin receptor blocker (ARB), or calcium channel blocker for 
most patients.81 Two groups require special consideration: patients who 
are black, for whom only thiazide-type diuretics or calcium channel 
blockers are recommended initially, and patients with CKD, for whom 
ACEI or ARB is the initial recommendation.81 The initiation of 
β-blockade in the immediate preoperative period may increase the risk 
of cerebrovascular accident, even while decreasing the risk of myocar-
dial ischemia, so it should be started before the day of surgery.17,39,81-83
Perioperative continuation of preexisting β-blocker treatment is strongly 
recommended.17,39,83 ACEI or ARB medications may be held the morn-
ing of surgery if significant intraoperative hypotension is anticipated 
(Table 5-5). If an ACEI or ARB is used in patients with CKD or cardiac 
disease, the risks of holding these classes of medications may outweigh 
the benefits. See Chapter 40 for further discussion.
Ischemic Heart Disease The 2014 guidelines for cardiac evaluation 
before noncardiac surgery published by the ACC/AHA are the current 
standard of care in the United States and Canada and similar guidelines 
exist in Europe.17,39,84 Figure 5-1 presents a simplified approach to the 
evaluation of patients at risk of ischemic heart disease before noncardiac 
surgery. The complete ACC/AHA algorithm is found in Chapter 9. The 
goal is to identify patients with ischemic heart disease who have a sig-
nificantly increased risk of perioperative major adverse cardiac events 
(MACEs), not simply to find patients with mild or stable CAD. 
Increased risk is determined using one of the ACS NSQIP risk calcula-
tors (http://www.riskcalculator.facs.org/RiskCalculator/ or http://www.
surgicalriskcalculator.com/miorcardiacarrest) or using the RCRI 
criteria.17,18,39 For patients with two or more RCRI or if risk of MACE is 
elevated above 1% and functional status is less than 4 METs or unknown, 
then additional testing is indicated if it will change management.
Preoperatively, the premise is not simply to diagnose CAD but rather 
to focus on how the test results will affect perioperative care. Patients 
with stable, chronic disease rarely will benefit from further testing pre-
operatively. Optimization of medicines and anesthesia plans can be 
based on clinical risk assessment in most circumstances. Coronary 
revascularization is never indicated simply to lower perioperative risk. 
In the unusual situation where revascularization before noncardiac sur-
gery is necessary, CABG is superior to percutaneous coronary interven-
tions (PCIs). There is no role for PCI for stable CAD before noncardiac 
surgery.17 Not included in the ACC/AHA guidelines are conditions such 
as chronic inflammatory diseases (eg, RA, systemic lupus erythema-
tous), chronic steroid use, and chest irradiation, which either alone or 
associated with more traditional risk factors identify patients at risk for 
CAD and cardiac complications.85-87
Anesthesiologists who apply the ACC/AHA recommendations and 
develop practice guidelines (Figure 5-1) are well positioned to initiate 
evaluation with stress tests. Results may obviate the need for a cardiac 
consultation or be available at the time of consultation. Exercise tread-
mill testing is indicated for patients who can exercise. However, ECG 
stress tests are associated with a high rate of false-positive or -negative 
tests; therefore, imaging should be combined with exercise. Pharmaco-
logic tests, such as dobutamine stress echocardiography (DSE) or 
nuclear perfusion imaging, are necessary for those unable to exercise. 
Abnormal test results may prompt cardiology consultation.
Even if inducible ischemia occurs on stress testing, routine coronary 
revascularization is not recommended solely to reduce perioperative 
risk.17,39,88 Revascularization is indicated before noncardiac surgery if it 
would otherwise be indicated (eg, severe three-vessel disease, significant 
left main disease).17 Even then, the urgency of the noncardiac surgery 
must be considered (eg, resection for cancer, threatened limb ischemia, 
carotid endarterectomy after stroke) and weighed against the potential 
long-term benefits of revascularization. Noncardiac surgery within 4 
weeks of revascularization (bypass grafting and PCI with or without 
stents) is associated with increased rates of perioperative cardiac mor-
bidity and mortality.89 Coronary revascularization may offer only mod-
erate protection in patients undergoing elective vascular surgery.90
Patients who have had PCI, especially with newer drug-eluting stents 
(DESs), require several months, if not a lifetime, of antiplatelet therapy 
to avoid restenosis or acute thromboses (see Coronary Stents). These 
patients must be identified in the preoperative period and managed in 
collaboration with a cardiologist. Since most perioperative MIs occur in 
the distribution of noncritical coronary stenoses, intensive medical 
management is helpful and may account for the lack of benefits of pre-
emptive revascularization.88,91 Decisions regarding cardiac revasculariza-
tion prior to noncardiac surgery should be made only after evaluating 
the risk of perioperative cardiac adverse events, the options for risk 
reduction, the risk of the coronary revascularization, the benefits of the 
noncardiac surgery, and the patient’s preferences. A multidisciplinary 
case conference with all involved parties is beneficial. Because cardiac 
 TABLE 54 Basic Preoperative Testing Guidelines
Procedure/Patient Type Tests
Injection of contrast dye Creatininea
Potential for significant blood loss Hemoglobin/hematocrita
Likelihood of transfusion requirement Type and screen
Possibility of pregnancy Pregnancy testb
End-stage renal disease Serum potassiumc
Diabetes Blood glucose on day of surgeryc
Active cardiac condition (eg, decompensated heart 
failure, arrhythmia, chest pain, murmur)
Electrocardiogram
aResults from laboratory tests within 3 months of surgery are acceptable unless major abnormalities are 
present or a patient’s condition has changed.
bA routine pregnancy test before surgery is not recommended before the day of surgery. A careful history 
and local practice determine whether a pregnancy test is indicated.
cThere is no absolute level of either potassium or glucose that precludes surgery and anesthesia. The benefits 
of the procedure must be balanced against the risk of proceeding in a patient with abnormal results.
Longnecker_Part02_p0035-0290.indd 42 05/05/17 4:47 PM
http://www.riskcalculator.facs.org/RiskCalculator/
http://www.surgicalriskcalculator.com/miorcardiacarrest
http://www.surgicalriskcalculator.com/miorcardiacarrest
CHAPTER 5: Overview of Preoperative Assessment and Management 43 
TABLE 55 Preoperative Medication Guidelines
Continue on Day of Surgery Discontinue on Day of Surgery
Antidepressants, antianxiety, and psychiatric medications 
(including monoamine oxidase inhibitors)a
Antihypertensives
Generally to be continued
Antihypertensives
Consider discontinuing angiotensin-converting enzyme inhibitors or angiotensin receptor blockers 12-24 hours before 
surgery if taken only for hypertension; especiallyif:
 Lengthy procedures, significant blood loss or fluid shifts, use of general anesthesia, multiple antihypertensive 
medications, well-controlled blood pressure; hypotension is particularly dangerous
Aspirinb
Patients with known vascular disease
Patients with vascular stents
Before cataract surgery (if no bulbar block)
Before vascular surgery
Taken for secondary prophylaxis
Aspirin
Discontinue 5-7 days before surgery:
 If risk of bleeding > risk of thrombosis
 For surgeries with serious consequences from bleeding
 Taken only for primary prophylaxis (no known vascular disease)
Asthma medications Atypical Anticoagulantsc
Rivaroxaban: Discontinue for 24 hours, longer if creatinine clearance < 30 mL/min
Dabigatran: Discontinue for 72 hours, longer if creatinine clearance < 50 mL/min
Autoimmune medications
Methotrexate (if no risk of renal failure)
Autoimmune
Methotrexate (if risk of renal failure)
Etanercept (Enbrel), infliximab (Remicade),
Adalimumab (Humira): Check with prescriber
Birth control pills
Cardiac medications
Clopidogrel (Plavix)
Patients with DES < 6 months if placed for stable CAD; 
< 12 months if placed for ACS
Patients with bare metal stents < 1 month
Before cataract surgery (if no bulbar block)
Clopidogrel (Plavix)
Patients not included in group recommended for continuation
Cox-2 inhibitors COX-2 inhibitors
If surgeon concerned about bone healing
Diuretics
Triamterene, hydrochlorothiazide
Diuretics
Potent loop diuretics
Eye drops
Estrogen compounds
When used for birth control or cancer therapy
Estrogen compounds
When used to control menopause symptoms or for osteoporosis
Gastrointestinal reflux medications Gastrointestinal reflux medications (Tums, Maalox, or other particulate antacids)
Herbals and nonvitamin supplements
7-14 days before surgery
Hypoglycemic agents, oral
Insulin
Type 1 diabetes: take about a third of intermediate- to long-
acting (NPH, lente) insulin
Type 2 diabetes: up to half long-acting (NPH) or combination 
(70/30) preparations
Glargine (Lantus): decrease if dose is ≥ 1 unit/kg
If insulin pump delivery, continue lowest nighttime basal rate
Insulin
Regular insulin (exception: insulin pump, continue lowest basal rate, generally nighttime dose)
Discontinue if blood sugar level < 100
Narcotics for pain or addiction Nonsteroidal anti-inflammatory drugs
48 hours before day of surgery
Seizure medications
Statins Topical creams and ointments
Steroids (oral or inhaled) Viagra or similar medications
Discontinue 24 hours before surgery
Thyroid medications Vitamins, minerals, iron
Warfarin
Cataract surgery, no bulbar block
Warfarinc
Discontinue 5 days before surgery
Abbreviations: DES = drug eluting stents; CAD = coronary artery disease; ACS = acute coronary syndrome.
aNeed consultation for planning ahead of day of surgery.
bExcept when the risk or consequences of bleeding are severe (generally only intracranial, posterior eye procedures).
cBridging may be necessary; check with prescribing physician.
Longnecker_Part02_p0035-0290.indd 43 05/05/17 4:47 PM
44 PART 2: Preparing for Anesthesia
complications are the leading cause of perioperative morbidity and mor-
tality, anesthesiologists must be current on the latest evidence-based 
recommendations and be active in decision-making and patient advo-
cacy to ensure the best outcome.
Aspirin and statins decrease the risk of MACE when taken periopera-
tively. Choosing to continue aspirin perioperatively requires analysis of 
the benefit of continuation (primary vs secondary prevention), the likeli-
hood of intraoperative bleeding, and the anticipated consequence of 
bleeding. For example, if aspirin is used for primary prevention (ie, in the 
absence of known disease), the risk of bleeding likely outweighs the ben-
efit of continuing of aspirin. However, if aspirin is administered for known 
vascular disease of any kind (ie, secondary prevention) and the patient is 
having nonneurologic surgery, the benefit of continuation likely out-
weighs the risk. Figure 5-3 shows one example of a simplified algorithm 
to aid in the decision-making surrounding aspirin use and surgery.
However, there are still some unanswered questions regarding the 
balance of risks and benefits with aspirin use and whether risk of bleed-
ing outweighs potential cardiac risk.92,93 The POISE-2 trial was con-
ducted to answer this question and its authors concluded that aspirin use 
in major noncardiac surgery raised the risk of bleeding without a benefi-
cial effect on death or nonfatal MI.92 However, the trial had a compli-
cated perioperative approach to initiation or continuation of aspirin and 
included few patients with stents (<5%) or even CAD (<23%). Two-
thirds of patients had no history of vascular disease, and simply being 
older than 70 years with HTN having major surgery qualified as an 
inclusion criteria. If risk of bleeding is acceptable and aspirin is taken for 
secondary prophylaxis (ie, known vascular disease), continuation of 
aspirin is likely best.
A less-controversial issue is the perioperative use of statin medica-
tions, which decreases risk of MACE with few side effects, so these 
medications should be continued perioperatively.17 In patients at risk of 
MACE, initiation of a statin perioperatively is reasonable if the patient is 
having vascular surgery and should be considered if having other ele-
vated-risk surgery.17
Coronary Stents Millions of patients receive coronary stents each 
year, and many of them later present for surgery. Many patients are 
treated with DES instead of bare metal stents (BMS) to prevent the 
development of neointimal hyperplasia and restenosis of coronary 
arteries that can occur with a BMS. The downside to slower endothe-
lialization of DES surfaces is the occurrence of late thrombosis, result-
ing in myocardial ischemia, a frequently fatal complication.94 
Thrombosis of either type of stent is more common if antiplatelet 
therapy is interrupted. Dual antiplatelet therapy with aspirin and a 
Stop 7 d before
operation as needed
Stop clopidogrel
Maintain aspirin
Intracranial
neurosurgery
Primary
prevention
Risk of bleeding
in closed space***
Secondary prevention after 
myocardial infarction, 
acute coronary syndrome, 
stent, stroke, 
peripheral arterial disease
High-risk situations:
<12 months after DES placed for ACS
<6 months after DES placed for stable CAD****
High-risk stent*
Low-risk
 situations**
All
surgery
Only vital
surgery
All
surgery
Patients with aspirin (75-100 mg day–1)**** + Clopidogrel (75 mg day–1)Patients with aspirin (75-100 mg day–1)****
Operation under continuous treatment
FIGURE 5-3. Algorithm for preoperative management of patients taking antiplatelet therapy. ACS, acute coronary syndrome; BMS, bare metal stent; DES, drug-eluting stent; MI, myo-
cardial infarction; PAD, peripheral arterial disease; PCI, percutaneous coronary intervention. ∗High-risk stents: long (>36 mm), proximal, overlapping, or multiple stents, stents in chronic total 
occlusions, or in small vessels or bifurcated lesions. ∗∗Examples of low-risk situations: more than 3 months after BMS, stroke, uncomplicated MI, PCI without stenting. ∗∗∗Risk of bleeding in closed 
space: intracranial neurosurgery, intramedullary canal surgery, posterior eye chamber ophthalmic surgery. In these situations, the risk-to-benefit ratio of upholding versus withdrawing aspirin 
must be evaluated for each case individually; in case of aspirin upholding, early postoperative reinstitution is important. ∗∗∗∗Modification to reflect updated recommendations from Levine GN, 
Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease. A Report of the American College of Cardiology/
American Heart Association Task Force on Clinical Practice Guidelines. 68(10):1082-1115. [Modified with permission from Chassot PG, Delabays A, Spahn DR: Perioperative antiplatelet therapy: 
the case for continuing therapyin patients at risk of myocardial infarction. Br J Anaesth. 2007 Sep;99(3):316-328.]
Longnecker_Part02_p0035-0290.indd 44 05/05/17 4:47 PM
CHAPTER 5: Overview of Preoperative Assessment and Management 45 
thienopyridine (typically clopidogrel) should not be interrupted for at 
least 1 month after BMS placement and 12 months after DES insertion94
(see Table 5-6 and Figure 5-3).
In 2016, the ACC/AHA published a guideline focused update on dura-
tion of dual antiplatelet therapy in patients with CAD. If emergent or 
urgent surgery is required, aspirin therapy should be continued through-
out the perioperative period and the thienopyridine restarted as soon as 
possible after the surgery95 (see Tables 5-5 and 5-6 and Figure 5-3).
Valvular Disease Aortic stenosis is the most common valvular lesion 
in the United States, affecting 2% to 4% of adults older than 65 years of 
age. Severe stenosis can result from calcific changes or a bicuspid valve, 
but either is associated with an elevated risk of MACE.17 For patients in 
whom indications for intervention for severe AS exist, repair or replace-
ment before elective surgery decreases perioperative risk.17 If emergent 
or urgent surgery must take place prior to intervention, having an accu-
rate assessment of severity and planning advanced perioperative moni-
toring may reduce risk.
Aortic sclerosis, which also causes a systolic ejection murmur similar to 
that of AS, is present in 25% of adults 65 to 74 years of age and almost half 
of those older than 84 years of age.96 Aortic sclerosis is associated with a 
40% increase in the risk of MI and a 50% increase in the risk of cardiovas-
cular death in the absence of any hemodynamic effects.96 Sclerosis is likely 
a marker of underlying occult CAD. Current guidelines recommend echo-
cardiography every 6 months to 1 year for patients with severe AS, every 1 
to 2 years for moderate stenosis, and every 3 to 5 years for mild stenosis.97
Mitral stenosis is much less common than AS and is usually associ-
ated with a history of rheumatic heart disease. MS causes a diastolic 
murmur and should always be further evaluated with ECG and echocar-
diography. Patients with severe, symptomatic MS can decompensate 
quickly during surgery if they develop AF, tachycardia, or hypovolemia, 
and the ability to correct these perturbations quickly is essential for 
management. Severe MS may be treated preoperatively with percutane-
ous balloon commissurotomy if morphology is favorable and indica-
tions for valve intervention exist, which may decrease cardiac risk.17
Regurgitant lesions, such as mitral regurgitation (MR) and aortic 
regurgitation (AR), are generally better tolerated during anesthesia. 
Although severe MR and severe AR confer greater risk of mortality, the 
risk is still acceptable to proceed with elective surgery, providing ade-
quate hemodynamic monitoring is in place.17 The presence of coexisting 
decreased left ventricular ejection fraction (LVEF) confers additional 
risk, and consideration should be given to monitoring with echocardiog-
raphy and postoperative ICU admission.17
Heart Failure Heart failure affects 4 to 5 million people in the United 
States and is a significant risk factor for postoperative adverse events 
(10% risk vs 3% risk with CAD). Asymptomatic left ventricular dysfunc-
tion predicts cardiovascular events at 1 month and long term in patients 
having open procedures for vascular surgery.98 The goal in the preopera-
tive period is to identify and minimize the effects of HF. Recent weight 
gain; complaints of dyspnea, fatigue, orthopnea, paroxysmal nocturnal 
dyspnea, edema, and recent hospitalizations; and changes in manage-
ment are all significant. Physical findings focus on examination for third 
or fourth heart sounds, crackles, jugular venous distension, ascites, 
hepatomegaly, and edema. Classifying the patient’s medical status 
according to the New York Heart Association’s (NYHA’s) categories is 
useful for risk stratifying:
 • Class I: no limitation of physical activity; ordinary activity does not 
cause fatigue, palpitations, or syncope
•  Class II: slight limitation of physical activity; ordinary activity results 
in fatigue, palpitations, or syncope
•  Class III: marked limitation of physical activity; less-than-ordinary 
activity results in fatigue, palpitations, or syncope; comfortable at rest
•  Class IV: inability to do any physical activity without discomfort; 
symptoms at rest
Diastolic dysfunction may be as common as systolic dysfunction and 
predicts a poor prognosis outside the perioperative period. The signifi-
cance of diastolic dysfunction for anesthesia and surgery is less well 
defined. In a study of patients undergoing major vascular surgery, iso-
lated diastolic dysfunction diagnosed preoperatively by echocardiogra-
phy was an independent predictor of postoperative HF.99
An objective measure of LVEF and ventricular performance is helpful, 
especially in patients with NYHA class III or IV HF. Normal LVEF is 
greater than 50%; mildly diminished, 41% to 49%; moderately dimin-
ished, 26% to 40%; and severely diminished, less than 25%. Patients with 
LVEF less than 30% are at highest risk. Patients with systolic dysfunction 
are at greater risk than those with diastolic dysfunction and a preserved 
ejection fraction, but those in the latter group are at more risk than those 
without any HF.17 Patients with class III or IV HF should be evaluated by 
a cardiologist before undergoing general anesthesia or any intermediate 
or high-risk procedure. Very minor procedures under monitored anes-
thesia care can proceed as long as the patient’s condition is stable.
Rhythm Disturbances and Electrocardiographic Abnormalities 
Arrhythmias and conduction disturbances are common in the periop-
erative period. Supraventricular and ventricular arrhythmias are associ-
ated with a greater risk of perioperative adverse events than atrial 
arrhythmias due to both hemodynamic compromise from the arrhyth-
mia itself and the underlying disease of which the arrhythmia may be a 
marker, such as myocardial ischemia, cardiomyopathy, drug toxicity, or 
metabolic derangement. Patients with preexisting paroxysmal AF who 
progress to persistent AF have worse outcomes due to increases in major 
cardiovascular events.100
New-onset AF, symptomatic bradycardia, or high-grade heart block 
(second or third degree) identified preoperatively may indicate struc-
tural heart disease and warrant postponement of elective procedures and 
referral to cardiology for further evaluation.84 Left bundle branch blocks 
and right bundle branch blocks (RBBBs) discovered on preoperative 
ECG have been shown to predict major cardiac morbidity and mortality 
but do not in and of themselves require additional investigation if the 
clinical history is unremarkable.59 If the history and physical do not sug-
gest significant pulmonary or congenital heart disease, no further evalu-
ation is warranted because of an isolated RBBB. However, an RBBB with 
ST segment elevation in the right precordial leads is suggestive of Bru-
gada syndrome, a congenital disease associated with a risk of sudden 
death and lethal arrhythmias. If congenital heart disease or Brugada 
syndrome is suspected, a cardiology consultation is indicated. RBBB in 
a patient with significant pulmonary disease is suggestive of right ven-
tricular (RV) strain or failure that warrants a pulmonary evaluation and 
echocardiography if an intermediate- or high-risk operation is planned. 
Prolonged QT intervals prompt an evaluation of electrolytes, magne-
sium, and calcium and a cardiology referral.
Cardiovascular Implantable Electronic Devices: Pacemakers and 
Implantable Cardioverter-Defibrillators It is estimated that more 
TABLE 56 Recommendations for Perioperative Management of Patients With 
Coronary Stents Who Are Receiving Antiplatelet Therapy
•   Premature discontinuation of thienopyridine (eg, clopidogrel or ticlodipine) therapy 
haspotentially catastrophic consequences. Health care providers should discuss 
strategies for peri-procedural antiplatelet therapy with the patient’s cardiologist prior 
to discontinuation.
•   Elective procedures requiring discontinuation of thienopyridine therapy should be 
deferred until 1 month after placement of bare metal stents (BMS)
•   Elective procedures requiring discontinuation of thienopyridine therapy should be deferred 
until 6 months after placement of a drug eluting stent (DES) if placed for stable coronary 
artery disease, or until 12 months after DES if placed for acute coronary syndrome (ACS) or 
in other high risk situations (eg, multiple stents, small stents, recent in-stent stenosis)
•   Proceeding with urgent surgery within 3-6 months following DES placement may be 
considered if the risk with delayed surgery is greater than the stent thrombosis risk.
•   Patients with either a BMS or DES should continue aspirin if at all possible throughout 
the procedure. The recommended daily dose is 81 mg (range 75-100 mg) as the bleed-
ing risk is lower and with comparable ischemic protection.
Data from Grines CL, Bonow RO, Casey DE Jr, et al. Prevention of premature discontinuation of dual 
antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart 
Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, 
American College of Surgeons, and American Dental Association, with representation from the American 
College of Physicians. J Am Coll Cardiol. 2007 Feb 13;49(6):734-739.
Longnecker_Part02_p0035-0290.indd 45 05/05/17 4:47 PM
46 PART 2: Preparing for Anesthesia
than 100,000 new CIEDs, which include both pacemakers (PMs) and 
implantable cardioverter-defibrillators (ICDs), are implanted yearly in 
the United States. Perioperative complications can occur when electro-
magnetic interference (EMI) from monopolar cautery (eg, Bovie cau-
tery), radio-frequency ablation, magnetic resonance imaging, or 
radiation therapy interfere with appropriate sensing and pacing func-
tions. In addition, patient monitors and ventilators may interfere with 
the rate-modulation function of many modern PMs (denoted by the 
letter R in the fourth position of the PM code, eg, DDDR). Dangerously 
rapid pacing rates can occur unless the rate modulation function is deac-
tivated. Interference is particularly problematic in patients who are PM 
dependent or who are both paced and have an ICD. Also, if patients have 
neglected regular follow-up, older CIEDs may have insufficient battery 
life to sustain function throughout surgery, which cannot be determined 
without interrogating the device. The battery life can be estimated by 
noting a slowing of the preset magnet mode.
Although use of a magnet intraoperatively to deactivate an ICD or to 
force a PM into asynchronous mode may be appropriate for emergency 
surgery, use of a magnet does not always provide the desired effect. A 
magnet placed on an ICD will have no effect on the pacing function of 
the device, and in a pacer-dependent patient, EMI may still cause over-
sensing and lack of adequate pacing. An ICD must be reprogrammed to 
allow appropriate pacing in PM-dependent patients when EMI is antici-
pated. Depending on PM settings, the preset asynchronous rate in 
response to a magnet may be faster than desired for hemodynamic sta-
bility over a sustained time period (eg, 90-100 beats per minute). If 
electrocautery will be below the umbilicus there is no need to use a 
magnet or reprogram the CIED as no interference will occur.
When time permits, communication with the cardiologist or electro-
physiology service is optimal for patients with CIEDs preoperatively. 
Battery life, response to magnet placement, and underlying patient 
rhythm should be determined. When EMI is likely (eg, required use of 
monopolar cautery or surgical site close to PM), guidelines recommend 
that the PM be reprogrammed to the desired asynchronous rate, rate 
modulation disabled, and antitachycardia function deactivated.101 Dur-
ing periods when the ICD is deactivated, patients must be in a moni-
tored setting with defibrillation capabilities until the device is 
reactivated.101 Appropriate device-specific interrogator and trained per-
sonnel must be available when considering patients in a free-standing 
surgery center.
 � RESPIRATORY DISEASE
Despite the frequency with which postoperative pulmonary complica-
tions occur (as many as 5% of patients having nonthoracic surgery), a 
consensus guideline for the preoperative evaluation and intraoperative 
management of at-risk patients does not exist.21,24,102 This is in stark con-
trast with established risk assessment tools for cardiac complications, 
which have existed for many decades. As many as one in four deaths 
occurring within a week of surgery are pulmonary related, making it the 
second-most-common serious morbidity after cardiovascular adverse 
events.102 Established risk factors for an increased risk of pulmonary 
complications include the following21,103:
 • Advanced age
•  Functionally dependent physical status
•  Heart failure
•  ASA-PS scores greater than 2
•  Chronic obstructive pulmonary disease (COPD)
•  High-risk surgical type (head and neck, thoracic, upper abdominal, 
aortic, neurologic, vascular, or emergency surgery)
•  Anticipated prolonged procedures (>2 hours)
•  Planned general anesthesia (especially with endotracheal intubation)
As a great number of patients having surgery will have one or more of 
these risk factors, additional disease-specific risks should be considered 
prior to surgery and modified when possible.
Reactive Airways Disease and Chronic Obstructive Pulmonary 
Disease Patients with reactive airways disease (asthma) or COPD 
frequently have arterial blood gas (ABG) analysis or PFTs performed 
prior to surgery; however, results from these tests are notably absent 
from the list of pulmonary risk factors. Of greater significance is the 
degree of preoperative control of these diseases, rather than severity of 
disease. Risk of complications is surprisingly low in well-controlled 
asthma and in patients treated preoperatively with corticosteroids.104
Clinical factors such as recent asthma exacerbations, history of postop-
erative pulmonary complications, recent hospitalizations, or recent 
intubations are better predictors of pulmonary complication risk. Only 
in lung resection surgery are PFTs useful in predicting postoperative 
pulmonary complications, by examining the FEV1 (forced expiratory 
volume in first second of expiration), predicted postoperative (ppo) 
FEV1, DLCO (diffusing capacity of the lung for carbon dioxide), and 
ppoDLCO.105,106 PFT assessment may be useful for differentiating the 
cause of wheezing or SOB, but not for risk stratification in nonthoracic 
surgery.107
Patients with a recent asthma or COPD exacerbation may benefit 
from optimization with additional bronchodilators or steroids, referral 
to a pulmonologist or internist, or delay of surgery in the case of nonre-
solved symptoms. In addition, alternatives to general anesthesia and use 
of epidural pain management should be considered.108
Pulmonary Hypertension Patients with pulmonary HTN are at sig-
nificant risk for perioperative morbidity and mortality due to respiratory 
failure and right ventricular (RV) failure. Perioperative care should be 
coordinated with a pulmonary HTN specialist, and intraoperative care 
may be best delivered by an anesthesiologist with proficiency in 
advanced cardiac monitoring with pulmonary artery catheter or trans-
esophageal echocardiography if general anesthesia is planned. Patients 
with severe disease may present on pulmonary vasodilator therapy, 
which must be continued perioperatively. Prostacyclin analogues, such 
as continuous intravenous epoprostanol, inhibit platelet aggregation and 
must be continued perioperatively to avoid rebound pulmonary HTN.109
Endothelinreceptor antagonists, such as bosentan, can cause hepatotox-
icity and anemia, warranting preoperative investigation. Patients may 
present on anticoagulants, necessitating consideration of bridging anti-
coagulation prior to surgery.
An ECG and echocardiogram may be indicated in patients with 
moderate-to-severe disease to assess RV function. Signs and symptoms 
of disease severity include the following109:
 • Dyspnea at rest
•  Metabolic acidosis
•  Hypoxemia
•  Right HF (peripheral edema, hepatomegaly, jugular venous distension)
•  History of syncope
Upper Respiratory Tract Infection In the past, cancellation of elec-
tive surgery for patients with current or recent upper respiratory tract 
infections (URTIs) was routine, particularly for children. Although 
recent or current URTI does increase airway hyperreactivity for up to 
4 weeks after infection, this does not necessarily preclude patients from 
undergoing general anesthesia. When infection is mild (absence of sys-
temic symptoms or productive cough) in healthy patients, there is little 
risk in proceeding with surgery. However, in patients with severe symp-
toms, especially those with additional underlying respiratory conditions, 
it is advisable to postpone elective surgery for at least 4 weeks. Decisions 
regarding suitability to proceed should be made on an individual basis, 
taking into account severity of disease, need for general anesthesia, and 
the risks and benefits of surgery.110 Risk of airway hyperreactivity can be 
minimized by perioperative use of bronchodilators and avoidance of 
endotracheal intubation when feasible. Chapter 7 discusses the pediatric 
patient with a URTI in greater detail. Chapter 10 discusses the patient 
with pulmonary disease in detail.
Smokers or Secondhand Smoke Exposure Exposure to tobacco, 
directly or through “secondhand” smoke, increases the risk of many 
perioperative complications. Smokers are more likely to experience 
wound infections, respiratory or airway complications (including 
oxygen desaturation), and severe coughing.111 Smoking decreases 
Longnecker_Part02_p0035-0290.indd 46 05/05/17 4:47 PM
CHAPTER 5: Overview of Preoperative Assessment and Management 47 
macrophage function, negatively affects coronary blood flow, causes 
myocardial ischemia, induces vascular endothelial dysfunction, causes 
inflammation, and may cause immunosuppression.112
Although smoking cessation for several weeks to months provides the 
greatest benefits perioperatively, even short-term abstinence may posi-
tively affect outcomes. Within hours to days of smoking cessation, car-
bon monoxide and cyanide levels decrease, improving oxygen delivery 
to tissues and mitochondrial oxidative metabolism. Smoking immedi-
ately prior to surgery can induce rate-pressure product-related ST seg-
ment depression intraoperatively even in patients without a history of 
ischemic heart disease.113
Preoperative smoking cessation interventions significantly decrease 
the risk of surgical site infections, with an odds ratio of 0.43 (0.21-
0.85).114 The US Public Health Service recommends that all physicians 
strongly advise every patient to quit smoking as physician advice 
improves abstinence rates.115 Nearly 70% of smokers want to quit, and 
long-term quit rates can be achieved after even a simple intervention 
introduced in a preanesthetic clinic.116
Effective interventions include medical advice and pharmacotherapy, 
such as nicotine-replacement therapy, varenicline (Chantix), and 
bupropion (Wellbutrin), which are safe in the perioperative period. 
Nicotine patches, gum, and lozenges are available without a prescrip-
tion, while nasal spray, varenicline, and bupropion require prescrip-
tions. Clonidine is also effective. Varenicline, bupropion, or clonidine 
should be started 1 to 2 weeks before a quit attempt, while nicotine 
replacement therapy is effective immediately.6 Many hospitals, insur-
ance companies, and communities offer smoking cessation programs, 
and excellent free resources are available on the Internet and from the 
US government. Advice and guidelines are available online (https://
www.cdc.gov/tobacco/quit_smoking/). Patients can also be referred to 
1-800-QUITNOW.
Obstructive Sleep Apnea Obstructive sleep apnea is the most com-
mon serious manifestation of sleep-disordered breathing. OSA severity 
is measured on the apnea-hypopnea index (AHI), the number of apneic 
and hypopneic episodes per hour of sleep. An apneic episode is charac-
terized by total collapse of the airway with complete obstruction for 
more than 10 seconds, while a hypopneic episode is defined by partial 
collapse of the airway (30% to 99%) associated with at least a 4% arterial 
oxygen desaturation. An AHI greater than 30 defines severe OSA.
Patients with OSA frequently develop cardiovascular disease, includ-
ing HTN, AF, bradyarrhythmias, ventricular ectopy, endothelial dam-
age, stroke, HF, dilated cardiomyopathy, and atherosclerotic CAD.117
They are also at risk for airway complications, including difficult mask 
ventilation, difficult direct laryngoscopy and endotracheal intubation, 
difficult fiber-optic visualization of the airway, rapid oxygen desatura-
tion, and postoperative desaturation events.118
The STOP-Bang Questionnaire is a screening tool that has been vali-
dated for predicting moderate-to-severe undiagnosed OSA.119-121 Preop-
erative sleep evaluation and prescription of continuous positive airway 
pressure (CPAP) therapy, if required, is indicated in patients with STOP-
Bang scores greater than 5. Patients with long-standing untreated OSA 
are at risk of developing HF and pulmonary HTN and may benefit from 
echocardiography evaluation if symptoms are present. Patients should 
be instructed to bring their CPAP devices to the hospital on the day of 
surgery. Chapter 10 discusses OSA in detail.
 � SIGNIFICANT SYSTEMIC DISEASE
Patients who do not have identified cardiac or pulmonary disease may 
still be at increased perioperative risk if other systemic disease is present. 
Any one or a combination of the following conditions may increase 
perioperative risk: obesity, DM, renal disease, hepatic disease, anemia, 
neurologic disease, cancer, or thromboembolic disease/pulmonary 
embolism.
Obesity An estimated two-thirds of adults in the United States are 
overweight or obese, resulting in significant health care expenditures 
due to obesity-related heart disease, HTN, stroke, hyperlipidemia, osteo-
arthritis, DM, and cancer. The formula for calculating BMI was pre-
sented previously in this chapter. An overweight person has a BMI of 25 
to 29.9 kg/m2, while obesity is defined as a BMI of 30 to 39.9 kg/m2. A 
BMI of 40 kg/m2 or larger defines extreme obesity.
Extreme obesity contributes to many perioperative management chal-
lenges, including airway challenges requiring specialized equipment and 
personnel; deep venous thrombosis (DVT) prophylaxis with advanced 
techniques such as inferior vena cava filter placements; special operating 
room tables and gurneys to support excessive weight; and challenging 
venous access and invasive monitoring. Preoperative identification and 
planning for these contingencies will avoid delays on the day of the 
operation. Preoperative evaluation is directed toward coexisting diseases 
(Table 5-3). Chapter 19 discusses this in greater detail.
Diabetes Mellitus Diabetes mellitus affects millions of Americans and 
puts patients at increased perioperative risk. DM increases the risk of 
CAD, HF, and renal disease. DM requiring insulin for treatment is an 
RCRI criterion for calculating perioperative cardiac risk.17,39,122 Figure 
5-1 and Chapter 9 address cardiac evaluation for noncardiac surgery. See 
also Chapter 13 and Renal Disease in this chapter.
Patients with poor preoperative glycemic control are more likely to 
have poor intra- and postoperative control, putting them at increased risk 
for postoperative infections.123 Obtaining a glycosylated hemoglobin 
(HbA1c)concentration value preoperatively can guide glucose manage-
ment with intensification of therapy well before the procedure.123,124 The 
American College of Endocrinologists’ position statement recommends a 
target fasting glucose of less than 110 mg/dL in noncritically ill patients.125
The preoperative assessment focuses on end-organ dysfunction and 
glycemic control. Cardiovascular, renal, and neurologic systems should 
be evaluated. Ischemic heart disease is often asymptomatic in a person 
with DM, so a high index of suspicion is required. The goals of periop-
erative diabetic management include avoidance of hypoglycemia and 
marked hyperglycemia. Table 5-6 has suggestions for perioperative 
medication management.
Renal Disease Chronic kidney disease is a risk factor for adverse car-
diac events, and a creatinine value greater than 2 mg/dL represents a 
factor in the RCRI (Figure 5-1).17,26,39 A normal serum creatinine may 
not be an accurate indicator of renal function, as creatinine does not 
exceed the normal limits until the glomerular filtration rate (GFR) has 
fallen below 50 mL/min. A doubling of serum creatinine from 0.8 to 1.6 
mg/dL represents a halving of the GFR. The preoperative evaluation of a 
patient with CKD focuses on the cardiovascular and cerebrovascular 
systems, fluid status, and electrolytes.
Patients who have end-stage kidney disease have significant risk of 
morbidity and mortality. One study examining 23, 016 patients under-
going cardiac surgery demonstrated that those requiring preoperative 
hemodialysis had an increased 30-day morbidity and mortality equal to 
patients having urgent surgery, valvular surgery, or an ejection fraction 
less than 30%.126 In elective surgery, patients requiring hemodialysis 
should have this performed 24 hours before surgery because both hypo-
volemia and hypervolemia are undesirable perioperatively. Although 
potassium and other electrolyte levels should ideally be in the normal 
range before surgery, mild hyperkalemia in dialysis patients is likely not 
clinically significant.
Patients at risk for perioperative acute kidney injury include those 
with preexisting CKD or DM, especially in combination, and those 
undergoing procedures with the administration of contrast medium.27
Preoperative identification of at-risk patients may change management, 
including preoperative hydration, a change in type of contrast medium, 
maintaining a higher intraoperative blood pressure and avoidance of 
hypovolemia. Chapter 13 has a complete discussion of the patient with 
renal disease.
Hepatic Disease Patients with liver cirrhosis are at elevated periopera-
tive risk due to coagulopathy, respiratory complications from ascites, 
altered glucose metabolism, and alterations in mental status from 
encephalopathy. This is particularly true in Child-Pugh class C cirrhosis, 
for which mortality following extrahepatic surgery approaches 84%.127
Even for a normally uneventful procedure, such as laparoscopic chole-
cystectomy, mortality in patients with cirrhosis and elevated PT greater 
than 2.5 seconds over control is 83%.128 In patients with decompensated 
liver cirrhosis, Child C status or Model for End-Stage Liver Disease 
(MELD) greater than 15, elective surgery should be avoided.129
Longnecker_Part02_p0035-0290.indd 47 05/05/17 4:47 PM
https://www.cdc.gov/tobacco/quit_smoking/
https://www.cdc.gov/tobacco/quit_smoking/
48 PART 2: Preparing for Anesthesia
For patients with compensated cirrhosis, continuing potassium-
sparing diuretics, correcting preoperative coagulopathy with vitamin K, 
and consultation with a hepatologist may be appropriate. Delaying elec-
tive surgery until after an acute episode of hepatitis or an exacerbation 
of chronic disease has resolved is also appropriate. Chapter 14 discusses 
the patient with liver disease in detail.
Anemia Preoperative anemia is associated with an increase in postop-
erative morbidity and mortality, including adverse cardiac events, inde-
pendent of receiving a transfusion.64-67 The goal in the preoperative 
period is to identify nontransfusion interventions that may improve 
anemia and to prepare for anticipated blood loss, considering the extent 
and type of surgery. In 2015, the ASA practice guidelines for periopera-
tive blood management was updated.130 Recommended interventions to 
reduce perioperative blood transfusion requirements in selected patient 
populations include iron supplementation, erythropoietin, discontinua-
tion of anticoagulation or antiplatelet therapy if the risk of thrombosis is 
acceptable, and autologous blood donation if time for erythropoietic 
reconstitution allows.130 Type and screen testing before the day of opera-
tion and planning for the availability of blood will avoid delay of the 
procedure (Table 5-4). Intraoperative blood salvage can be planned, if 
appropriate. A restrictive transfusion strategy is supported, although the 
lower limit of acceptable Hb will be determined by patient-specific 
factors.130 In general, transfusion is rarely indicated when Hb is greater 
than 10 g/dL and almost always is indicated when Hb is less than 6 g/dL.
Sickle cell disease is a special type of anemia due to hereditary hemo-
globinopathy that causes vaso-occlusive complications. Patients may 
have end-organ dysfunction of the heart, lungs, kidneys, liver, spleen, 
and central nervous system as well as chronic pain requiring opioids.131 
Severe disease is best optimized perioperatively in collaboration with a 
hematologist. Chapter 15 discusses in detail the patient with anemia.
Neurologic Disease Patients with neurologic diseases affecting motor 
and respiratory function, such as myasthenia gravis, multiple sclerosis, 
Parkinson disease, previous stroke, or cerebral palsy, require careful 
intra- and postoperative management to minimize aspiration, respira-
tory complications, and exacerbation of their underlying condition. A 
detailed history and basic neurologic examination documenting preex-
isting deficits are helpful in identifying patients who may require more 
intensive postoperative care to prevent complications.
In patients with previous stroke or transient ischemic attack, medical 
management of AF and HTN should be optimized preoperatively. 
Although the optimal timing of surgery following a stroke has not been 
definitively established, considering delaying elective surgery at least 
until the peak of autoregulatory disturbances has passed (1 month) is 
reasonable to decrease risk.19 Risk of MACE remains elevated for as long 
as 9 months after an ischemic stroke, so a longer delay may be 
indicated.132
Routinely ordering tests for serum drug levels of antiseizure medica-
tions is not warranted unless toxicity is a concern in the case of lithium 
or the patient is having breakthrough seizures. Patients with good con-
trol of seizures may have levels outside the therapeutic range, especially 
if drug administration timing confounds results. Chapter 11 discusses 
neurologic diseases in detail.
Cancer Patients Patients with a history of cancer may have complica-
tions related to tumor mass effect, metastases, medications and thera-
pies, metabolic abnormalities, and malnutrition. Preoperative evaluation 
includes assessment of all of these.
There are several specific areas of concern that may be identified on 
history. Previous head and neck irradiation may result in difficult airway 
management, premature atherosclerosis of carotid arteries, or hypothy-
roidism. Auscultation for bruits, thyroid function tests (thyroid-stimu-
lating hormone levels), and carotid Doppler studies may be needed. 
Mediastinal, chest wall, and left breast irradiation may cause cardiac 
disease, such as conduction abnormalities, cardiomyopathy, valvular 
abnormalities, and premature CAD, which may warrant an ECG or 
echocardiogram if symptoms indicate disease. Cardiovascular disease is 
also a common cause of mortality in survivors of Hodgkin disease, espe-
cially if patients weretreated at a young age. Identification of previous 
chemotherapy agents may be important, as many are associated with 
cardiac, pulmonary, hepatic, or renal toxicity. A history of bleomycin 
therapy in the prior 1-2 months is particularly important to identify as 
avoidance of hyperoxia (fraction of inspired air [FIO2] > 30%) periop-
eratively is critical to avoiding acute respiratory distress syndrome.133,134
Patients with cancer may have significant pain associated with their 
primary illness and consequently be receiving chronic opioid therapy in 
large doses. Consultation with a pain specialist is recommended for 
patients in whom difficulty with pain management is anticipated. A 
discussion with the patient should occur preoperatively to help allay 
concerns and fears about inadequate pain control.
Thromboembolic Disorder or Pulmonary Embolism Because 
patients with recent thromboembolic events are at greater risk of recur-
rence with interruption of anticoagulation, elective surgery should pro-
ceed only when the benefits outweigh the risks. The risk of recurrent 
DVT is particularly high in the first month after occurrence, and inter-
ruption of anticoagulation during this period is not advised; waiting for 
3 months is preferable.135 For patients with indefinite elevated risk of 
thromboembolism, such as severe thrombophilia (antiphospholipid 
antibody syndrome, deficiency of protein C or S), multiple episodes of 
DVT, AF with recent stroke or transient ischemic attack, or at-risk 
mechanical heart valve (any mitral prosthesis, caged-ball or tilting disk 
aortic prosthesis), bridging anticoagulation during interruption of anti-
coagulation for surgery is recommended.136,137 In patients with low-risk 
mechanical heart valve or AF or venous thromboembolism at low risk 
for thromboembolism, no bridging is recommended during interrup-
tion of warfarin therapy.136 See the section on medication instructions 
and Table 5-5 for further discussion of warfarin management preopera-
tively. Chapter 15 discusses patients with coagulation disorders.
 � SUBSTANCE ABUSE
Patients who use alcohol to excess or illicit drugs are at risk for myriad 
perioperative complications, including withdrawal, acute intoxication, 
an altered tolerance to anesthetic and opioid medications, difficult intra-
venous access, and complications from end-organ damage. As periop-
erative abstinence from drugs and alcohol for a significant time period 
before surgery is often not achievable in patients with addiction, periop-
erative intervention focuses on risk reduction. If a patient identifies a 
desire for sobriety from drugs and alcohol, referral to a treatment center 
or addiction specialist and delay of elective surgery until treatment is 
complete is recommended. Acute preoperative abstinence in alcoholics 
in the absence of treatment of withdrawal is not recommended and may 
be associated with a poorer outcome postoperatively than if alcohol 
consumption were continued.138 Therefore, adequate treatment to pre-
vent withdrawal is necessary.
Intravenous drug use (IVDU) should prompt an evaluation for car-
diovascular, pulmonary, neurologic, and infectious complications. 
Because intravenous access is often limited in patients involved in 
IVDU, referral to interventional radiology for peripheral access line 
placement may be considered, although discharge from the hospital with 
this line in place may be risky in such patients. Alcohol abuse can cause 
hepatic disease or cardiomyopathy, which needs to be assessed preop-
eratively. Postoperative pain management may be challenging in patients 
with a history of opioid abuse, and consultation with acute pain manage-
ment specialists is helpful. Preoperative testing is guided by findings on 
the history and physical examination. Table 5-3 and Chapter 20 provide 
additional information.
 � ANESTHESIASPECIFIC CONCERNS
Anesthetic complications are identified and investigated during the 
assessment. A personal or family history of pseudocholinesterase (or 
butyrylcholinesterase) deficiency may be identified from previous anes-
thetic records or a reported history of prolonged intubation after anes-
thesia. Patients suspected of having a deficiency are encouraged to 
undergo testing, including determination of a dibucaine number and 
pseudocholinesterase levels. Beyond the relevance to anesthesia, patients 
may suffer respiratory complications if exposed to agricultural organo-
phosphate pesticides, and awareness of the disease is important for 
avoidance.139 A history of malignant hyperthermia (MH) or a suggestion 
of it (hyperthermia, rigidity during anesthesia, or unplanned admission 
Longnecker_Part02_p0035-0290.indd 48 05/05/17 4:47 PM
CHAPTER 5: Overview of Preoperative Assessment and Management 49 
to an ICU following a general anesthetic) in either a patient or family 
member requires clear documentation and arrangements before the day 
of surgery. Chapter 82 provides a comprehensive review of MH and its 
prevention and management.
 � AMBULATORY SURGERY
A significant proportion of surgical procedures are performed on an 
outpatient basis (estimated at 60% to 70%). Despite the presence of 
multiple comorbidities, a patient may still be a candidate for ambula-
tory surgery if coexisting diseases are well controlled and safely man-
ageable in a nonhospital setting (if considered for an office-based 
procedure or surgery center). Examples of coexisting diseases that 
might preclude ambulatory surgery or an out-of-hospital anesthetizing 
location include extreme obesity, presence of CIED or OSA, or risk of 
MH (see relevant previous sections for more discussion). Obese 
patients may require specialized equipment to accommodate their 
weight (if > 500 pounds), with such equipment perhaps not readily 
available in ambulatory facilities. Individuals with CIED may not be 
suitable for surgery in locations where personnel are not available to 
reprogram the devices if needed. Patients with or at risk for OSA may 
benefit from admission overnight for respiratory monitoring or require 
CPAP, depending on their disease severity. Patients with a history or 
family history of MH can be cared for ambulatory settings as long as 
there is dantrolene and point-of-care testing for potassium on site, and 
a pre-established transfer plan with the closest medical center capable 
of managing a patient with acute MH. (http://www.mhaus.org). These 
issues need to be identified in advance to avoid case cancellation and 
patient inconvenience.
Despite ambulatory surgery being typically low risk, adverse events 
do occur, particularly in the elderly. In Medicare beneficiaries older than 
65 years having ambulatory surgery, age older than 85 years, significant 
comorbidity, and type of procedure predicted adverse events.140 Almost 
half of ambulatory surgical procedures are performed in patients 65 years 
and older. Elderly patients often have multiple chronic conditions, poor 
eyesight, and poor hearing and may need assistance with activities of 
daily living, causing additional stress in the postoperative period.
Preparation for ambulatory surgery focuses on returning the patient 
to preoperative function as quickly as possible to avoid unnecessary 
delays in discharge. Multimodal approaches to postoperative nausea and 
vomiting prevention are advised for at-risk patients.141 Multimodal and 
nonopioid-based analgesia should be maximized. Diabetic patients are 
best scheduled as the first case of the day and allowed to resume oral 
intake as soon as tolerated after surgery.142
Cataract Surgery Patients Considerable attention has been paid to 
the management of patients undergoing cataract surgery, largely because 
the procedure is so common and occurs mostly in elderly patients who 
often have extensive comorbid disease. However, the procedure is minor, 
with few expected systemic physiologic disturbances or significant post-
operative pain. Topical anesthesia is commonly used, andgeneral anes-
thesia is rarely required, rendering the procedure truly low risk. Elective 
cataract surgery has enormous benefits to the individual, as the restora-
tion of eyesight allows resumption of daily activities and decreases the 
risk of falls.143
Preoperative testing solely for the purpose of undergoing cataract sur-
gery is not necessary.144 However, some patients may benefit from a 
focused preoperative assessment and optimization of new or uncontrolled 
medical problems. “Routine” or “screening” preoperative testing prior to 
cataract surgery is not indicated (see Testing and Investigations).
Routine medical testing before cataract surgery costs an estimated 
$150 million annually. In a study of more than 18,000 patients randomly 
allocated to no routine testing before cataract surgery or to a battery of 
tests, including ECG, complete blood cell count, and electrolytes, blood 
urea nitrogen, creatinine, and glucose levels, no differences in postop-
erative adverse events were found between the two groups.145 Patients 
who crossed over from the “no testing” to the “some testing” group, 
based on disease-indicated testing, had significantly more coexisting 
illness and poor self-reported health status. In patients who have stable 
mild disease and will undergo cataract surgery under topical or bulbar 
block, no special testing is required. Poorly controlled comorbidities 
should be normalized before surgery. In one center, using a similar strat-
egy, a 90% savings in laboratory costs in a 4-month period was achieved 
by eliminating routine testing for patients for cataract surgery.146
PREOPERATIVE MANAGEMENT AND 
INTERVENTION
Management of comorbid conditions and interventions to reduce risk is 
as important as identification and diagnosis of medical disease. Anes-
thesiologists may either intervene directly to improve new or chronic 
disease states or closely collaborate with primary care physicians, spe-
cialists, and surgeons to optimize patients. Collecting information is 
only useful when processes are in place to follow through with indica-
tions for disease management to achieve the goal of improving patient 
outcome and reducing adverse events.
 � CONSULTATIONS
Collaborative care of patients is often necessary and beneficial. Consul-
tation initiated by the preoperative physician seeks specific advice 
regarding diagnosis and status of the patient’s condition(s). Past investi-
gations have shown there is often disagreement or confusion among 
consultant specialists, surgeons, and anesthesiologists regarding the 
purpose of the consultation.147,148 The goal of consultation is never to ask 
“Is the patient cleared for surgery?” because this does not provide useful 
information from which to design the safest anesthetic or evaluate the 
risk of surgery. Consultations should ask a specific question, such as the 
following: “Is perioperative treatment indicated for this patient’s bleed-
ing diathesis?” “Is intervention indicated for severe AS at this time?” or 
“Is this patient’s COPD under optimal control prior to planned thora-
cotomy with lung resection under general anesthesia?” A summary of 
the patient’s medical problems and current status, medical therapy, and 
results of any recent diagnostic tests should be included. Close coordina-
tion and good communication among the preoperative anesthesiologist, 
surgeon, and consultant are vitally important to avoid adverse events. 
Miscommunication among care providers was central to most reported 
incidents in the Australian Incident Monitoring Study (AIMS) whenever 
preoperative assessment was implicated.42
In patients with preexisting or newly diagnosed cardiac disease, con-
sultation with cardiology is frequently requested by both anesthesiolo-
gists and surgeons. Unfortunately, these consultations often do not result 
in recommendations that translate into changes in management, as only 
17% of anesthesiologists felt obligated to follow the consulting cardiolo-
gist’s recommendations in one survey.147 Forty percent of the consulta-
tions contained only the recommendation to “proceed with the case,” 
“cleared for surgery,” or “continue with current medications,” and recom-
mendations regarding intraoperative monitoring or cardiac medications 
were largely ignored.147 Part of this responsibility lies with the consulting 
physicians (whether surgeons or anesthesiologists) and the long-stand-
ing practice of asking for or receiving cardiac “clearance.” This is a vague 
request, and a response (often scribbled on a prescription pad) simply 
stating “may proceed with surgery” or “cleared for surgery” is meaning-
less and unhelpful. In general, preoperative consultations are sought for 
diagnosis, evaluation, and improvement of a new or poorly controlled 
condition and for creation of a clinical risk profile that the patient, anes-
thesiologist, and surgeon use to make management decisions. Wider use 
of clinical risk prediction tools, such as the ACC/AHA preoperative 
guidelines and the ACS NSQIP calculators (http://www.riskcalculator.
facs.org/RiskCalculator/ and http://www.surgicalriskcalculator.com/
miorcardiacarrest), can help standardize communication among 
professionals.17
Detailed discussion and communication are essential for manage-
ment of complicated patients, and often a face-to-face meeting with 
involved parties accomplishes this most effectively. Chapter 8 has fur-
ther discussion of consultations.
 � PRACTICE GUIDELINES
An important element for a successful preoperative evaluation system is 
a uniform, consistent method for assessment and management. 
Longnecker_Part02_p0035-0290.indd 49 05/05/17 4:47 PM
http://www.mhaus.org
http://www.riskcalculator.facs.org/RiskCalculator/
http://www.riskcalculator.facs.org/RiskCalculator/
http://www.surgicalriskcalculator.com/miorcardiacarrest
http://www.surgicalriskcalculator.com/miorcardiacarrest
50 PART 2: Preparing for Anesthesia
Cancellations, delays, or demands for additional diagnostic testing on 
the day of surgery after a patient has been assessed by the preoperative 
clinic is detrimental on many levels. Thorough chart assessment and 
records gathering, implementation of evidence-based guidelines, and 
agreement among stakeholders on the desired approach can avoid these 
outcomes. Individual judgment is still necessary in implementing guide-
lines and policies, but variation in clinical practice can be minimized for 
the benefit of the patient.
Advance records gathering minimizes the chance of undiscovered 
medical conditions being uncovered on the day of surgery. This includes 
reviewing alternate hospital electronic records or requesting copies of 
patient information, including previous anesthesia records, previous 
diagnostic tests, recent clinic notes, or other data that can verify or fur-
ther elucidate the patient history. Even the best-intentioned, “reliable” 
patient may be mistaken in reporting past medical history or advice 
from other physicians, and vastly different information can be discov-
ered on review of medical records. If records are requested, processes 
must be in place to review the information in advance of surgery and 
take further action if required. It is simply not enough to leave results for 
review by the anesthesiologist on the day of surgery.
Evidence-based practice guidelines improve the process of preopera-
tive evaluation and management and affect surgical outcomes. Guide-
lines minimize variation in clinical practice and make good use of 
resources. They may help to avoid cancellations or delays on the day of 
surgery when the anesthesiologist in the clinic and the one performing 
the anesthetic have differences in opinion about the patient’s fitness for 
operation. This will prevent patient inconvenience and surgeon dissatis-
faction. Guidelines synthesized from the best, most current sources help 
practitioners stay up to date with recommendations and the literature by 
assimilating treatments and diagnosticsinto their practices. Guidelines 
can be as simple as an organization of the type and timing of care deliv-
ered to typical, uncomplicated patients or as complex as instructions for 
dealing with a specific issue expressed by decision trees in branching 
logic format.149 The intent is not to design inflexible standards but to 
provide a consistent, straightforward method to evaluate a particular 
disease such as HTN or CAD, a finding such as a murmur, or a symptom 
such as chest pain. Practice guidelines recommend care based on scien-
tific evidence and broad consensus but leave room for justifiable varia-
tions in practice.
Practice guidelines typically rely on evidence-based medicine that 
examines the data from clinical research. Intuition, personal clinical 
experience, and pathophysiologic rationale are less important. Because 
the practice and teaching of evidence-based medicine may not be intui-
tive, medical trainees benefit from instruction in precisely defining a 
problem and seeking high-quality evidence to answer the clinical 
question.
Algorithms such as in Figures 5-1 and 5-3 and guidelines such as in 
Table 5-4 through Table 5-7, are examples of effective practice 
guidelines.
 � NOTHINGBYMOUTH GUIDELINES
Historically, patients were told to abstain from any oral intake (nothing 
by mouth or nil per os [NPO]) after midnight regardless of the time of 
their procedure to reduce the risk of aspiration. Currently, the ASA 
practice guidelines indicate that healthy patients who will undergo elec-
tive procedures may safely drink clear liquids (eg, water, juice without 
pulp, coffee or tea without cream or milk) until 2 hours before anesthe-
sia; breast milk until 4 hours before anesthesia; and nonhuman milk, 
infant formula, or a light breakfast until 6 hours before procedures 
requiring anesthesia (Table 5-7).150 These guidelines are based on the 
integration of years of clinical research showing that gastric volumes are 
smaller and pH more neutral when patients continue to consume clear 
liquids until 2-4 hours before a procedure. Particularly children, who 
may be more sensitive to preoperative dehydration, should be allowed to 
consume clear liquids beyond the traditional fasting window.151 How-
ever, modified fasting guidelines have not been universally adopted, 
likely out of concern for preventing aspiration in the setting of a patient 
with unexpectedly delayed gastric-emptying time, patient confusion 
over appropriate liquids, or avoiding conflicts in operating room sched-
uling. These concerns lead many departments to maintain a stricter 
fasting policy. These fears are unfounded, however, as in a prospective 
cohort study of over 5000 patients, there were no differences in aspira-
tion, delays, or cancellation of cases between groups who followed tradi-
tional fasting versus liberalized (clear fluids until 2-3 hours before 
surgery) guidelines.152 More liberal nothing-by-mouth guidelines are not 
only safe but also spare patients significant discomfort prior to surgery. 
In fact, encouraging the consumption of carbohydrate-rich fluids until 
2-3 hours prior to surgery not is only safe but also improves early return 
of bowel function and is routinely incorporated into enhanced recovery 
after surgery (ERAS) protocols.153-158
 � MEDICATION INSTRUCTIONS
Although a clear risk or benefit exists for the perioperative use of most 
medications, there are other common medication classes for which deci-
sions regarding use are individualized. Despite commonly encountering 
antihypertensive medications, diuretics, aspirin, and herbal medications, 
perioperative recommendations are not always clear. In general, medica-
tions associated with withdrawal effects (eg, β-blockers, centrally acting 
sympatholytics, benzodiazepines, clonidine, and opioid analgesics) 
should be continued through the preoperative period. See the following 
brief discussion and Table 5-6 and Figure 5-3 for detailed recommenda-
tions for drugs to be continued or discontinued before an operation.
Most antihypertensive medications, with the possible exception of an 
ACEI or ARB, should be taken before surgery.159 Perioperative use of an 
ACEI or ARB is associated with greater risk for hypotension during general 
anesthesia, but no increase in operative mortality or complications.160-163
Unless HTN is poorly controlled, they are often held the morning of 
surgery considering the minimal risk of significant HTN with with-
drawal.164 Patients who will undergo minor procedures with monitored 
anesthesia care and those with poorly controlled HTN, CKD, HF, or 
CAD may be advised to continue these drugs on the day of surgery. The 
ACC/AHA guidelines currently suggest that continuation of these drugs 
perioperatively is reasonable.17
There is no consensus regarding management of diuretics preopera-
tively. Diuretics (eg, hydrochlorothiazide) to treat HTN will likely con-
trol blood pressure when continued on the day of operation. Withholding 
potent loop diuretics (eg, furosemide) on the day of surgery may 
decrease the risk of volume depletion and renal insufficiency.165 Intrave-
nous administration by the anesthesiologist perioperatively is an option.
Medications used by patients with a history of or at risk for heart 
disease, such as β-blockers, digoxin, antiarrhythmics, and statins, should 
not be withdrawn before operation. Not only are they beneficial, but also 
risk may be increased when they are not taken.17 Aspirin, when taken for 
primary prophylaxis of vascular disease or for pain, is generally discon-
tinued before the day of surgery. (See the previous Heart Disease section 
for discussion surrounding aspirin administration.) Aspirin and other 
nonsteroidal anti-inflammatory drugs (NSAIDs) do not need to be dis-
continued for planned neuraxial or regional anesthesia techniques.166 
 TABLE 57 Guidelines for Food and Fluids Before Elective Surgery
Time Before Surgery Food or Fluid Intake
Up to 8 hours Food and fluids as desired
Up to 6 hoursa Light meal (eg, toast and clear liquidsb), infant formula, 
nonhuman milk
Up to 4 hoursa Breast milk
Up to 2 hoursa Clear liquidsb only; no solids or foods containing fat in any 
form
During the 2 hours No solids, no liquids
aThis guideline applies only to patients who are not at risk for delayed gastric emptying. Patients with 
the following conditions are at risk for delayed gastric emptying: morbid obesity, diabetes mellitus, 
pregnancy, a history of gastroesophageal reflux, a surgery limiting stomach capacity, a potentially 
difficult airway, opiate analgesic therapy.
bClear liquids are water, carbonated beverages, sports drinks, and coffee or tea (without milk). The 
following are not clear liquids: juice with pulp, milk, coffee or tea with milk, infant formula, and any 
beverage with alcohol.
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CHAPTER 5: Overview of Preoperative Assessment and Management 51 
If the decision to discontinue these agents is made, aspirin is stopped 
5 to 7 days and other NSAIDs 48 hours before the operation.167-169 Cau-
tion is advised for patients using cold remedies and over-the-counter 
drugs (eg, Alka-Seltzer, Excedrin, and Pepto-Bismol), as many contain 
aspirin.
More potent antiplatelet agents, such as clopidogrel (Plavix), may be 
associated with substantial perioperative bleeding. These drugs are dis-
continued 7 days before the operation if appropriate.17,167,168 Patients with 
a DES placed less than 6 months ago, BMS placed 4 to 6 weeks previ-
ously, or PCIs without stents less than 2 weeks before surgery should 
have only lifesaving surgery, preferably while continuing dual antiplate-
let therapy (Table 5-5 and Figure 5-3).17 Dual antiplatelet therapies 
should not be stopped during these high-risk periods without consulta-
tion with a cardiologist familiar with PCI. Aspirin is continued periop-
eratively in patients with stents regardless of implementation date unless 
the risk of bleeding is veryhigh.17
In at-risk patient populations, perioperative statins reduce strokes, 
renal dysfunction, MI, length of hospital stay, and even death.170-175
Patients having CABG who take perioperative statins have a dose-
dependent reduction in adverse cardiac events.170 Side effects of statin 
therapy are generally mild, including myalgias, and only rarely cause 
more significant side effects, such as rhabdomyolysis or liver dysfunction.174
Statins should be continued in the perioperative period.17 They are con-
sidered for perioperative use in patients at risk for MACE or for long-
term use in patients who have indications independent of surgery.17 
(See Heart Disease for further discussion.)
Oral hypoglycemic agents are held the day of surgery to avoid hypo-
glycemia. Taking small amounts of long-acting insulin on the day of 
surgery presents little risk of hypoglycemia but results in improved 
perioperative control. Patients with types 1 and 2 DM discontinue all 
short-acting bolus doses of insulin on the day of surgery. Patients with 
an insulin pump continue their basal rate only. Patients with type 2 
DM take none or up to one-half dose of long-acting (eg, lente or neu-
tral protamine Hagedorn [NPH]) or combination (70/30 preparations) 
insulin on the day of surgery. Ultra–long-acting insulin (eg, glargine) 
is best continued as scheduled. For patients with type 1 DM, it is essen-
tial that they do not completely cease taking insulin in preparation for 
surgery, as this may precipitate diabetic ketoacidosis. Patients can 
safely take a small amount (usually a third to a half) of their usual 
morning long-acting insulin (eg, lente or NPH) on the day of surgery 
and consume sugar-containing clear fluids until 2 hours preoperatively 
as long as they do not have gastroparesis.142 Patients with brittle type 1 
DM may benefit from consultation with an endocrinologist and the 
initiation of an insulin infusion combined with dextrose-containing 
intravenous fluid while fasting to avoid hypoglycemia.
Even though warfarin is associated with increased bleeding in cer-
tain procedures, there is no consensus on the optimal perioperative 
management of patients on warfarin. If normal coagulation is desired, 
warfarin is withheld for 4 to 5 doses before surgery if the international 
normalized ratio (INR) is 2.0-3.0 to allow the INR to decrease to less 
than 1.5, a level considered safe for surgical procedures and neuraxial 
blockade.166 If the INR is more than 3.0, it is necessary to withhold 
warfarin longer than 4 doses. If the INR is measured the day before 
surgery and remains greater than 1.8, a small dose of vitamin K (1.0-
5.0 mg orally or subcutaneously) can reverse anticoagulation. Substitu-
tion with shorter-acting anticoagulants such as unfractionated or 
low-molecular-weight heparin, referred to as bridging, should be 
individualized to the patient based on their risk of complications, 
although indications for bridging are limited.17,39,136 The decision to 
initiate bridging anticoagulation will depend on the indication for 
warfarin (eg, AF, mechanical heart valve, inferior vena cava filter), and 
consultation with a hematologist or cardiologist is recommended for 
assistance with determining risk of thrombosis. The risk of stopping 
warfarin for minor procedures (eg, cataract surgery, diagnostic endos-
copy) is greater than the risk of bleeding.
Newer oral anticoagulants that inhibit factor Xa or thrombin do not 
require monitoring with laboratory testing, which also makes it more 
difficult to assess their effects on coagulation. Discontinuation for sur-
gery must take into account the pharmacokinetics of the drug. Direct 
factor Xa inhibitors (eg, rivaroxaban, apixaban) do not resemble heparin 
and are safe for use in heparin-induced thrombocytopenia (HIT); how-
ever, the dose is reduced in CKD and hepatic disease because clearance 
is prolonged.176 Rivaroxaban should be held for 24 hours or longer 
(48-72 hours) in the presence of renal disease prior to neuraxial anesthe-
sia. The direct thrombin inhibitor dabigatran, also requires reduced 
dosing in CKD or liver disease, as its effect may be prolonged.176 The 
half-life of dabigatran is significantly longer than for rivaroxaban, so it 
needs to be stopped 72 hours or longer before surgery in renal disease or 
the elderly if neuraxial anesthesia is planned.
Most medications for neurologic and psychological problems are 
continued on schedule in the preoperative period. Antiepileptics; anti-
parkinson medications; antidepressants, including monoamine oxi-
dase inhibitors (MAOIs); antipsychotics; benzodiazepines; and drugs 
to treat myasthenia gravis are best maintained to avoid exacerbations 
of symptoms. Antianxiety and psychiatric medications are continued 
up until the time of the procedure. Communication is crucial to alert 
the surgical anesthesia team because alterations in anesthesia may be 
necessary when caring for patients on these medications, especially for 
patients taking an MAOI.177 Highly active antiretroviral therapy 
(HAART) to treat human immunodeficiency virus requires regular 
dosing to prevent drug resistance. It is important to maintain HAART 
as scheduled. Antibiotics should be taken to complete a prescribed 
course of therapy.
Thyroid replacement drugs are continued on schedule, although 
missing one or two doses is probably of little clinical consequence, as the 
half-life is very long.178 Patients taking steroids regularly take their usual 
dose on the day of operation.179 Patients who have taken more than the 
equivalent of 7.5 mg of prednisone a day for at least 3 weeks within the 
previous year may be at risk for stress-associated adrenal insufficiency, 
although the clinical consequence depends on the nature of surgery and 
the overall yearly dose of glucocorticoid administration.179
Postmenopausal hormone replacement therapies containing estro-
gen increase the risk of perioperative thromboembolic complications 
and should be discontinued before surgery.180 Estrogens must be 
stopped approximately 1 month before surgery to return coagulation 
to baseline. Most modern oral contraceptives have low doses of estro-
gen that minimally increase thromboembolic risk. The risk of unan-
ticipated pregnancy likely outweighs the benefits of discontinuing oral 
contraceptives.
Herbals and supplements may interact with anesthetic agents, alter 
the effects of prescription medications, and increase bleeding.181 Many 
patients do not consider supplements to be medications and will not 
report them unless asked. Gingko biloba, echinacea, garlic, ginseng, 
kava, St John’s wort, and valerian may be associated with increased 
bleeding or altered sensitivity to anesthetic and sedative agents.182 
Herbals and supplements are discontinued 7 to 14 days before the 
operation. The exception is valerian, a central nervous system depres-
sant that may cause a benzodiazepine-like withdrawal when discontin-
ued. If time permits, valerian should be tapered before a planned 
anesthetic.
 � POSTOPERATIVE PLANNING
Surgeon and anesthesiologist assessment of patient risk may differ, and 
therefore the plan for postoperative care of the patient may be diver-
gent. Whether this difference occurs in suitability for ambulatory 
surgery, need for ICU postoperatively, or advanced ventilatory moni-
toring, there are many reasons why a patient may be appropriate for 
less-intensive monitoring from strictly a procedural perspective (eg, 
low-risk surgery) than from an anesthetic perspective (eg, an obese 
patient with a difficult airway and OSA requiring opioids). These 
issues are important to identify during the preanesthesic assessment 
and to communicate with the surgical team. At a minimum, World 
Health Organization (WHO) guidelines for safe surgery emphasize the 
importance of discussion of postoperative concerns prior to the 
patient leaving the operative room.183 While requesting a change in 
postoperative monitoring is usually easyto accomplish before the 
patient leaves the postanesthesia care unit (PACU), unexpectedly rec-
ommending the admission of an outpatient to the hospital usually 
requires patients to alter plans with caregivers and may require transfer 
Longnecker_Part02_p0035-0290.indd 51 05/05/17 4:47 PM
52 PART 2: Preparing for Anesthesia
to an alternate hospital facility. Clearly, this discussion optimally 
occurs prior to proceeding with the case.
Patients with suspected or diagnosed OSA present a particular chal-
lenge for postoperative planning, as respiratory depressants given dur-
ing the perioperative course may increase the risk of postdischarge 
respiratory depression and hypoxic insult.184 However, given the high 
incidence of patients with OSA presenting for surgery, routine admis-
sion to the hospital after ambulatory surgery places a burden on the 
health care system. Recent guidelines from the Society of Ambulatory 
Anesthesia presented an algorithm to aid in the decision to proceed 
with ambulatory anesthesia.184 Patients with optimized comorbid con-
ditions and either ability to use CPAP after discharge or minimal antici-
pated opioid analgesic requirement may proceed with ambulatory 
surgery, whether OSA is diagnosed or only suspected based on the 
STOPBang screening questionnaire.184 Patients with OSA or suspected 
OSA and nonoptimized comorbid conditions or those requiring more 
than minimal opioids and inability to use CPAP are not suitable for 
ambulatory surgery.
CLINICAL MODELS AND MANAGEMENT
With ever-increasing frequency, anesthesiologists are required to assess 
progressively more complex patients for technically challenging proce-
dures. In considering how best to accomplish preanesthetic evaluations 
in a resource- and time-efficient way, various models have been devel-
oped. Some preoperative clinics simply document information provided 
by the patient, the medical record, or others who have seen the patient 
to minimize the documentation burden on the day of surgery. In the 
absence of anesthesiologist-based perioperative medicine clinics, some 
anesthesiologists rely on internal medicine specialists to prepare patients 
for surgery, based on either anesthesia-derived guidelines or not (p. 4). 
Even in the absence of a preoperative clinic, members of the health care 
system are “obligated to provide pertinent information to the anesthesi-
ologist for the appropriate assessment of the invasiveness of the pro-
posed surgical procedure and the severity of the patient’s medical 
condition.”5 This may take the form of the surgical history and physical 
examination, a patient preoperative questionnaire, or availability of 
medical records from outside health care facilities. A preoperative 
checklist for surgeons, such as Table 5-8, documenting requested 
information in the absence of a clinic visit may help to streamline assess-
ment and avoid unnecessary delays on the day of surgery.
Beyond simply improving documentation and workflow, anesthesiol-
ogist-staffed preoperative clinics improve the satisfaction of patients and 
physicians, reduce operating room cancellations and delays, and decrease 
unnecessary testing and costs.185 In expanding the anesthesiologist’s 
routine responsibilities beyond the operating room, educational sys-
tems have had to adapt to train anesthesiologists in perioperative care. 
Concern has been expressed that current anesthesiology training pro-
grams inadequately prepare physicians to evaluate and manage patients 
with complicated medical conditions prior to anesthesia and surgery.186
In the past, honing the cognitive aptitude for preoperative medicine 
was not emphasized during residency training because of the inordi-
nate amount of time anesthesiologists spent in the operating room 
learning technical and procedural skills. Currently, the Accreditation 
Council for Graduate Medical Education (ACGME) requirements for 
training in anesthesiology emphasize perioperative care of patients and 
mandates a minimum of 1 month spent in preoperative assessment and 
the PACU.
Clinics vary widely in services offered and the personnel involved in 
preoperative evaluation. They are staffed by anesthesiologists, internists, 
or physician extenders, such as nurse practitioners, physician assistants, 
registered nurses, or some combination.149 Depending on services that 
are offered, additional staff might include clerks, phlebotomists, ECG 
technicians, administrators, social workers, case managers, and physical 
therapists. Physician diagnostic accuracy and ability to implement man-
agement strategies may actually be improved when a physician assistant 
or nurse practitioner takes a detailed history and compiles informa-
tion.187 Few data exist to guide ideal staffing models.
 � SCHEDULING
Arbitrary standard appointment times and strictly first-come-first-serve 
booking priority for patient appointments result in inefficient use of 
time and inability to adapt to surgical urgency. Scheduling should be 
based on the anticipated requirements of the preoperative visit and the 
general health of the patient. The general health of the patient may be 
estimated by the ASA-PS category or by screening through various 
Internet-based tools, a previsit telephone call, or a patient-completed 
information form sent from the surgeon’s office (Figure 5-4). Facilities 
should consider open-access scheduling that accommodates last-minute 
appointments for those patients traveling long distances to see other 
physicians, who have physical disabilities, or have imminent surgery 
booked to prevent inconveniencing patients with a return appointment. 
Reserving a block of time to coordinate appointments with high-volume 
office visits to surgeons might be useful. Scheduling patients to be seen 
in clinic as far in advance of their surgery as possible allows time for 
ordering tests, improving the patient’s medical condition, and recruiting 
social services without needing to delay procedures. Evening and week-
end hours afford patients the least disruption from work or family 
responsibilities.
Workflow strategies should lessen wait times to improve patient satis-
faction. Scheduling appointments that reflect actual time needed, using 
longer appointment intervals, computerized patient tracking, accepting 
provider idle time, and scheduling breaks between patients will help to 
decrease patient wait time.
 � IMPROVING PATIENT EXPERIENCE WITH PREOPERATIVE 
EVALUATION
A patient’s perioperative experience is greatly improved by a visit with 
an anesthesiologist, as it can reduce anxiety and help in the understand-
ing and retention of information provided about their anesthetic care. 
Particularly during important preoperative risk/benefit discussions or 
description of anesthetic options, the opportunity to absorb information 
and ask questions is important for informed consent. Anesthesiologists 
are required to perform preoperative evaluations, review diagnostic 
studies (often chosen and ordered by someone else), discuss anesthetic 
risks, and obtain informed consent moments before a patient undergoes 
 TABLE 58 Surgeon’s Preoperative Checklist
If the patient has not had an anesthesia consultation before the day of surgery, please 
adhere to the following guidelines:
□ 1. Surgical history and results of physical examination are available on the day 
of the operation.
□ 2. Preoperative Questionnaire (Figure 5-4) is given to the patient with instruc-
tions to complete it and bring it on the day of surgery or fax it beforehand to 
________________________
□ 3. Appropriate diagnostic tests are completed and are available. You are 
responsible for follow-up on any tests that you order (Tables 5-3 and 5-4 and 
Figure 5-1).
□ 4. Medical information from outside our health care system (diagnostic tests, 
blood work, cardiac stress tests, echocardiograms, catheterizations, pulmo-
nary function tests, consultations) is available on the day of the operation.
□ 5.Patient has been given preoperative medication instructions (Table 5-6).
□ 6. Patient has been given guidelines for nothing by mouth (Table 5-7).
□ 7. “Clearance” letters or notes are rarely sufficient to design a safe anesthetic. 
A letter summarizing the patient’s medical problems and condition and 
verifying that the patient’s medical status is optimized is necessary. Surgery 
may be delayed or postponed for patients with chronic medical conditions 
if they have not been evaluated in the Anesthesia Preoperative Medicine 
Clinic (APMC) and necessary information is not available preoperatively, or 
their medical status is not optimized. The staff of the APMC encourage you 
to use the clinic for complex patients or those undergoing major operations 
(Table 5-1).
Longnecker_Part02_p0035-0290.indd 52 05/05/17 4:47 PM
CHAPTER 5: Overview of Preoperative Assessment and Management 53 
a major, potentially life-threatening or disfiguring procedure. The effects 
of extensive disclosure are stressful for patients and families at a time 
when they may be ill prepared to consider the implications rationally. 
Even if a patient does not make a decision about anesthetic options dur-
ing a clinic visit, discussion of options in advance of the day of surgery 
facilitates future decision-making.
A preoperative visit with an anesthesiologist has long been recognized 
as good or better than anxiolytic drugs or techniques at decreasing 
patient anxiety.188 Visits with an anesthesiologist may decrease the 
degree of postoperative pain and improve readiness for discharge.189 An 
opportunity to meet an anesthesiologist preoperatively is important to 
patients. A Canadian survey found that more than 60% of patients 
thought it was important to see an anesthesiologist preoperatively, more 
than 30% thought it was extremely important, and more than half indi-
cated that the visit should be before the day of surgery.190 In another 
study conducted in Canada and Scotland, patients rated meeting the 
anesthesiologist as their highest priority of the preoperative visit, equal 
to or above that of information on pain relief, alternative methods of 
anesthesia, and complications.191
Patients consistently rank good communication as the most impor-
tant aspect of their interaction with their anesthesiologist. Interestingly, 
they rank receiving information about the minor or major discomforts 
of the procedure as far more important than actually easily tolerating the 
side effects themselves.192 Similarly ranked as very important, patients 
desire the anesthesiologist to identify all of their concerns, to talk to 
them as they are being prepared for the anesthetic, and to tell them how 
the surgery and anesthetic went.192 These factors were deemed more 
important than being informed about the rare serious risks and dangers 
with anesthesia, feeling calm and relaxed before anesthesia, or having no 
or few side effects.192
The exact content of the preanesthetic discussion should be tailored to 
the level of information desired by the patient. Too much information, 
especially detailed information about the dangers of anesthesia and sur-
gery, creates anxiety in patients who prefer to cope by avoidance. Patients 
without prior anesthetic exposure may desire more information than 
patients who have had previous anesthetics. Respecting a patient’s feel-
ings, explaining complex issues in a simple manner, and learning effective 
communication skills can improve patient satisfaction.193 Nonverbal 
PATIENT PREOPERATIVE HISTORY
Name___________________________ DOB ______________ Phone #_____________________
Planned operation _________________________________ Date of Surgery __________________
Surgeon ______________________________ Primary Care Phys __________________________
3. Circle TESTS that you have already completed, list where and when you had them. Bring all exis-
 ting reports for your visit. We are NOT suggesting that you require (or need to have) these tests.
1. Please list all previous operations (and approximate dates)
A D
B E
C F
2. Please list any allergies to medications, latex, food or other (and your reactions to them)
A C
B D
A ECG Date:
LOCATION:
B BLOOD WORK Date:
LOCATION:
C ECHO/ULTRASOUND OF HEART Date:
LOCATION:
D STRESS TEST Date:
LOCATION:
E SLEEP STUDY Date:
LOCATION:
F Other Test:
LOCATION:
4. Please list all medications you have taken in the last month (include over-the-counter drugs,
 inhalers, herbals, dietary supplements and aspirin)
Drug Name Dose and How Often? Drug Name Dose and How Often?
FIGURE 5-4. Sample patient questionnaire. TB, tuberculosis; TIA, transient ischemic attack; TMJ, temporomandibular joint.
Longnecker_Part02_p0035-0290.indd 53 05/05/17 4:47 PM
54 PART 2: Preparing for Anesthesia
communication, dress, and avoidance of jargon are also important.193 In 
providing details about anesthesia care, information should be transmit-
ted in layperson language, as approximately half of patients fail to under-
stand at least one technical term during an appointment.194 To help with 
information clarity, videos about anesthesia can be time efficient and well 
received. Written instructions, especially regarding guidelines for noth-
ing by mouth, medications, and when and where to go on the day of 
surgery are essential.
Evaluating current models of preoperative assessment in an anesthetic 
practice through patient satisfaction questionnaires can help to improve 
the process. Examples of important questions to evaluate in such a sur-
vey are as follows:
 • Did the anesthesiologist explain the planned anesthetic in terms you 
understood?
•  How well did the anesthesiologist answer your questions and address 
your concerns?
•  How well did the anesthesiologist explain what you could expect after 
your anesthesia?
•  Did you have to wait long?
•  Was the staff courteous and respectful to you?
•  Overall, how satisfied were you with your preanesthetic visit?
•  How might we improve our services?
 � MEDICOLEGAL CULPABILITY
A thorough and appropriate preanesthetic assessment is important for 
many reasons, one of which is avoiding adverse events due to prevent-
able errors. In AIMS, 3.1% (197 of the first 6271 reports) of adverse 
events were clearly related to insufficient and 11% to inadequate or 
incorrect preoperative assessment.42 More than half of incidents were 
considered preventable. Contributing factors that were deemed insuffi-
cient included poor airway assessment, communication errors when the 
administering anesthesiologist was different from the person perform-
ing the assessment, failure to review previous anesthetic records, inade-
quate blood cross-matched, and inadequate preoperative optimization, 
among others.42 Although inadequate assessment is not typically 
reported as a factor contributing to liability in closed-claims analysis, 
airway misadventure, respiratory depression, and massive hemorrhage 
management are frequently the inciting event for litigation in anesthesia 
management.195-197 Taken together with the findings of AIMS, one 
can only speculate how many of these events may have been avoided 
by greater diligence in the preoperative assessment. In France, a 
Have you or anyone in your family had serious problems with: (Circle all that apply) Nose bleeds,
tooth extractions, bleeding with surgery 
YES NO
Have you had problems with your blood? (Circle all that apply) Leukemia, lymphoma, blood clots,
anemia, sickle cell disease, transfusions
YES NO
Have you had problems with your (Circle all that apply) Liver: Cirrhosis, Hepatitis A,B,C, jaundice.
Kidneys: Stones, failure, dialysis. Digestive system: Frequent heartburn, hiatus hernia, ulcers.
Back, neck or jaws: TMJ, rheumatoid arthritis, herniation. Thyroid problems 
YES NO
Have you ever had: (Circle all that apply) Seizures, TIA, stroke, facial, leg or arm weakness; difficulty
speaking. Cramping pain in your legs with walking.