1. EXECUTIVE SUMMARY
Overview: This policy establishes a standardized, evidence-based framework for the pre-procedure assessment and readiness verification of all patients undergoing anesthesia, regional anesthesia, monitored anesthesia care (MAC), or procedural sedation. This comprehensive protocol applies uniformly across all Operating Room (OR) and Non-Operating Room Anesthesia (NORA) environments within the healthcare organization.
Key Objectives: The primary objective is to eliminate preventable peri-procedural harm through rigorous risk identification, physiological optimization, and systematic verification of patient readiness. This policy mandates structured clinical assessments to identify comorbidities, airway difficulties, aspiration risks, and medication interactions prior to the induction of anesthesia or sedation.
Scope Statement: The mandate extends to all licensed independent practitioners, nurses, and technicians involved in the delivery or monitoring of anesthesia and procedural sedation. It encompasses elective, urgent, and emergency procedures performed in surgical suites, endoscopy units, interventional radiology labs, cardiac catheterization labs, and ambulatory surgery centers.
Expected Outcomes: Implementation of this policy is expected to:
- Reduce the incidence of adverse anesthesia events, including aspiration, airway mismanagement, and medication errors.
- Standardize the definition of patient readiness to minimize day-of-surgery cancellations and delays.
- Ensure full compliance with national and international accreditation standards (e.g., CBAHI, JCI) regarding perioperative safety.
- Enhance interdisciplinary communication through mandatory checklists and standardized documentation.
2. PURPOSE AND RATIONALE
2.1 Detailed Purpose
To ensure that every patient receiving anesthesia care or procedural sedation undergoes a rigorous, standardized pre-procedure evaluation. This process is designed to support safe anesthetic planning, facilitate risk reduction strategies, ensure valid informed consent, and verify correct patient/procedure/site identification across all clinical settings.
2.2 Clinical Rationale
Pre-anesthesia assessment is the cornerstone of perioperative safety. Scientific literature consistently demonstrates that inadequate pre-operative evaluation is a contributing factor in a significant proportion of anesthesia-related mortality and morbidity. A structured assessment allows for:
- Risk Stratification: Identification of patients with low physiological reserve who require enhanced monitoring or postoperative intensive care.
- Optimization: Opportunity to manage reversible conditions (e.g., hypertension, anemia, hyperglycemia) to improve outcomes.
- Airway Management Planning: Detection of anatomical predictors for difficult airway management, allowing for the mobilization of advanced airway equipment and personnel.
- Pharmacological Management: Prevention of adverse drug interactions and management of critical medications such as anticoagulants and insulin.
2.3 Patient Safety Imperatives
This policy operationalizes the "Universal Protocol" for preventing wrong-site, wrong-procedure, and wrong-person surgery. Furthermore, it addresses critical safety domains including pulmonary aspiration prevention (NPO guidelines), allergy verification, and infection control integration.
2.4 Regulatory Compliance
This document aligns organizational practice with the standards set forth by:
- CBAHI (Saudi Central Board for Accreditation of Healthcare Institutions): Specifically standards regarding Perioperative Safety (POR).
- ASA (American Society of Anesthesiologists): Basic Standards for Preanesthesia Care and Practice Guidelines for Preoperative Fasting.
- JCI (Joint Commission International): International Patient Safety Goals (IPSG).
3. SCOPE AND APPLICABILITY
3.1 Definition of Scope
This policy applies to all clinical encounters where anesthesia services or procedural sedation are provided. It is not limited by the physical location but is defined by the clinical service provided.
3.2 Covered Procedures
The policy governs the pre-procedure phase for:
- General Anesthesia (GA): All techniques rendering the patient unconscious and/or requiring airway intervention.
- Regional/Neuraxial Anesthesia: Spinal, epidural, caudal, and major peripheral nerve blocks, whether used as the primary anesthetic or for postoperative analgesia.
- Monitored Anesthesia Care (MAC): Anesthesia services where a specific anesthesia provider monitors the patient and administers sedatives/analgesics.
- Procedural Sedation: Minimal, moderate, and deep sedation administered by non-anesthesiologists (e.g., emergency physicians, endoscopists) or anesthesia professionals.
3.3 Covered Locations
| Category |
Specific Locations |
| Operating Rooms (OR) |
Main OR, Day Surgery OR, Obstetric OR, Trauma/Emergency OR. |
| NORA (Non-Operating Room Anesthesia) |
Endoscopy/GI Lab, Interventional Radiology (IR), Cardiac Catheterization Lab (Cath Lab), MRI/CT Suites, Bronchoscopy Suite, Radiation Oncology, ECT Suite. |
| Bedside/Procedural Areas |
Emergency Department (ED), Intensive Care Units (ICU), Dental Clinics, Minor Procedure Rooms. |
3.4 Personnel Roles
This policy is binding for:
- Anesthesia Professionals: Consultants, Specialists, Residents, and Anesthesia Technicians/Assistants.
- Privileged Sedation Providers: Non-anesthesia physicians licensed to administer procedural sedation.
- Proceduralists/Surgeons: Responsible for procedural consent and medical optimization related to the surgical indication.
- Nursing Staff: Pre-operative, peri-operative, and post-anesthesia nurses responsible for verification and readiness checklists.
3.5 Exclusions
This policy does not apply to:
- Analgesia administration for pain control without the intent of sedation (e.g., PCA pumps, oral analgesics on wards).
- Local anesthesia infiltration performed by a surgeon/proceduralist without systemic sedation.
4. DEFINITIONS AND TERMINOLOGY
4.1 Clinical Assessment Terms
- Pre-Anesthesia Assessment: A structured clinical evaluation performed by an anesthesia professional prior to the delivery of anesthesia care. It integrates history, physical exam, and diagnostics to formulate an anesthetic plan.
- Pre-Sedation Assessment: A comparable evaluation performed prior to procedural sedation, focusing on airway risk, sedation depth planning, and rescue capacity.
- Medication Reconciliation: The formal process of creating the most accurate list possible of all medications a patient is taking and comparing it against the physician's admission, transfer, and/or discharge orders.
- Time-Out: An immediate pause by the entire medical team just before the procedure starts (or incision is made) to verify patient identity, procedure, site, and critical safety concerns.
4.2 ASA Physical Status (ASA-PS) Classification
A global standard for categorizing the pre-operative physical fitness of patients. (Detailed classification provided in Section 6.2).
4.3 Difficult Airway Terminology
- Difficult Airway: A clinical situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation, difficulty with tracheal intubation, or both.
- Difficult Mask Ventilation: Inability to maintain oxygen saturation >90% despite 100% oxygen and positive pressure ventilation, or inability to prevent gas flow reversal.
- Difficult Laryngoscopy: Inability to visualize any portion of the vocal cords after multiple attempts.
4.4 NORA (Non-Operating Room Anesthesia)
Administration of anesthesia or sedation in locations outside the traditional surgical suite. These areas often present unique challenges such as limited space, remote location from backup support, potential radiation hazards, and unfamiliar equipment.
4.5 Day Surgery / Ambulatory Surgery
A planned clinical pathway where the patient is admitted, undergoes a procedure, recovers, and is discharged to home on the same calendar day. Success relies on strict patient selection criteria regarding comorbidities and social support.
5. POLICY STATEMENT
The Department of Anesthesia and Perioperative Medicine mandates strict adherence to the following core principles. Failure to comply constitutes a breach of patient safety standards.
- Mandatory Assessment: A documented pre-anesthesia or pre-sedation assessment shall be completed for 100% of applicable patients prior to the induction of anesthesia or administration of sedation.
- ASA Classification: An ASA-PS classification score must be assigned and documented for every patient.
- Airway Evaluation: A focused airway assessment and risk stratification (Easy/Difficult/Uncertain) must be documented, with a specific management plan for any anticipated difficulty.
- Fasting Verification: Compliance with NPO guidelines must be verified. For urgent/emergency cases where fasting is compromised, a risk mitigation plan (e.g., Rapid Sequence Induction) must be documented.
- Medication Safety: Medication reconciliation and allergy verification are prerequisites for transfer to the procedural area.
- Testing Stewardship: Pre-operative testing should be driven by clinical indication and patient history, not by routine protocols.
- Informed Consent: Separate informed consent for anesthesia/sedation is required, distinct from the surgical consent, discussing specific anesthetic risks.
- Standardized Readiness: Patient acceptance into the OR/Procedure room is contingent upon the completion of a "Sign-In" safety check verifying identity, site, and consent.
- Ambulatory Safety: Day-surgery candidates must meet specific physiological and social criteria to ensure safe discharge.
6. DETAILED PROCEDURES AND PROTOCOLS
6.1 Pre-Anesthesia Assessment Protocol
6.1.1 Timing Requirements
- Elective High-Risk/Complex Cases: Assessment should ideally occur in the Pre-Anesthesia Clinic (PAC) 1–14 days prior to surgery to allow for optimization.
- Elective Low-Risk Cases: Assessment may occur on the day of surgery, provided all necessary information is available.
- Inpatients: Assessment should occur at the bedside ideally the day before surgery, or at minimum prior to transfer to the OR.
- Day-of-Procedure Update: Regardless of when the initial assessment was done, an "Immediate Pre-Induction Re-evaluation" must be documented on the day of the procedure to confirm NPO status, vital signs, and any interval changes in health.
6.1.2 Comprehensive Assessment Elements
The pre-anesthesia evaluation must include documentation of:
| Domain |
Required Elements |
| History |
Indication for procedure, allergies/reactions, current medications (dose/freq), past anesthetic history (complications, PONV, difficult airway, malignant hyperthermia), family history, smoking/alcohol/substance use. |
| Review of Systems |
CV: Angina, arrhythmias, exercise tolerance (METs), HTN, CHF.
Resp: Asthma, COPD, OSA (STOP-Bang), recent URI.
Neuro: TIA/CVA, seizures, cognitive status.
GI/Endo: Reflux, diabetes, thyroid, liver disease.
Heme: Bleeding diathesis, anticoagulation. |
| Physical Exam |
Vital signs, Height/Weight/BMI, Airway exam (Section 6.3), Cardiopulmonary auscultation, vascular access assessment. |
| Anesthetic Plan |
Proposed technique (GA/Regional/MAC), monitoring level (standard vs. invasive), pain management strategy, PONV prophylaxis, postoperative disposition (Home/Ward/ICU). |
6.1.3 High-Risk Triggers for Escalation
The following findings require discussion with a Consultant Anesthesiologist or Medical Director before proceeding:
- Active cardiac conditions (unstable angina, decompensated heart failure, significant arrhythmia, severe valvular disease).
- New onset physiological instability (sepsis, shock, hypoxia).
- Malignant Hyperthermia history.
- Anticipated difficult airway in a setting with limited backup (NORA).
6.1.4 NORA-Specific Additions
For procedures in MRI, CT, or IR, the assessment must document:
- Access limitations: Patient positioning preventing airway access during the procedure.
- Environment: Presence of strong magnetic fields (MRI compatibility checks) or radiation.
- Remote location safety: Confirmation that emergency equipment (suction, O2, defibrillator) is immediately available.
6.2 ASA Physical Status Classification
The ASA-PS classification is mandatory for risk stratification and billing purposes. It is a reflection of the patient's pre-operative systemic health, not the risk of the surgery itself.
| Class |
Definition |
Examples |
| ASA I |
A normal healthy patient. |
Healthy, non-smoking, no or minimal alcohol use. |
| ASA II |
A patient with mild systemic disease. |
Mild diseases only without substantive functional limitations. Current smoker, social 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. Poorly controlled DM/HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence/abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, 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. |
Recent (<3 months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis. |
| ASA V |
A moribund patient who is not expected to survive without the operation. |
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. |
Organ harvest. |
Emergency Modifier (E): The addition of "E" denotes emergency surgery (e.g., ASA IIE). An emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part.
6.3 Airway Assessment and Difficult Airway Risk Stratification
6.3.1 Airway History
Review of previous anesthetic records is critical. Specific inquiries must include:
- History of difficult intubation or mask ventilation.
- Dental damage during prior anesthesia.
- History of Obstructive Sleep Apnea (OSA) or CPAP use.
- History of head/neck radiation or surgery.
6.3.2 Focused Physical Examination
The following metrics must be evaluated:
- Mouth Opening: Inter-incisor gap < 3cm (approx. 3 finger breadths) suggests difficulty.
- Mallampati Classification (I-IV): Visualization of faucial pillars, uvula, and soft palate.
- Thyromental Distance: < 6cm (3 finger breadths) suggests poor laryngeal axis alignment.
- Neck Mobility: Ability to extend neck (sniffing position).
- Dentition: Loose teeth, caps, bridges, or dentures.
- Mandibular Protrusion: Ability to protrude lower incisors beyond upper incisors (Upper Lip Bite Test).
6.3.3 Risk Stratification
| Risk Level |
Criteria |
Required Action |
| Low Risk |
No predictors identified. Normal anatomy. |
Standard airway plan. |
| Intermediate Risk |
Single predictor (e.g., Obesity alone, or Mallampati III with good mobility). |
Availability of videolaryngoscope in room. Backup airway (LMA) ready. |
| High Risk / Anticipated Difficult |
Multiple predictors, history of difficult airway, or pathology (tumor/abscess) distorting anatomy. |
AWAKE INTUBATION consideration. Videolaryngoscopy primary plan. Fiberoptic scope available. "Call for Help" designated person. Surgeon present for possible surgical airway (FONA). |
6.4 Pre-Procedure Fasting and Aspiration Risk Management
6.4.1 Standard Fasting Guidelines (Elective Procedures)
The following minimum fasting periods apply to healthy patients undergoing elective procedures to minimize the risk of pulmonary aspiration:
| Ingested Material |
Minimum Fasting Period |
| Clear Liquids (Water, pulp-free juice, black coffee/tea, carbohydrate drinks) |
2 Hours |
| Breast Milk |
4 Hours |
| Infant Formula, Non-human Milk, Light Meal (Toast and clear liquid) |
6 Hours |
| Full Meal (Fatty/Fried foods, meat) |
8 Hours or more |
6.4.2 Aspiration Risk Assessment
Patients are classified as "Full Stomach" / High Aspiration Risk if:
- Fasting guidelines are not met (Emergency/Urgent cases).
- Delayed gastric emptying conditions exist: Severe pain/trauma, Opioid use, Diabetes (gastroparesis), Pregnancy (>18 weeks), Bowel obstruction, GERD with active symptoms.
6.4.3 Risk Mitigation
For patients identified as High Aspiration Risk:
- Rapid Sequence Induction (RSI): Utilization of rapid-onset muscle relaxant (Succinylcholine/Rocuronium) and cricoid pressure (if deemed clinically appropriate) to secure airway rapidly.
- Awake Intubation: If difficult airway is also present.
- Nasogastric Decompression: Consideration for suctioning stomach contents prior to induction in bowel obstruction.
6.5 Medication Reconciliation and Allergy Verification
6.5.1 Reconciliation Process
The anesthesia provider must verify the list of medications taken in the last 24 hours. Discrepancies between the patient's report and the medical record must be resolved.
6.5.2 High-Risk Medication Protocols
- Anticoagulants/Antiplatelets:
- Warfarin: Check INR. Hold 5 days usually.
- DOACs (Apixaban/Rivaroxaban): Hold 48-72 hours depending on renal function and bleeding risk of surgery.
- Aspirin: Generally continued for cardiac patients; surgeon discretion for neurosurgery/spine.
- Diabetes Management:
- Oral Hypoglycemics: Hold on morning of surgery. (Metformin may be held 24h prior if contrast used).
- Insulin: Basal insulin often reduced (e.g., 50-80% of dose) night before/morning of. Short-acting insulin held while NPO.
- GLP-1 Agonists (e.g., Semaglutide): High risk for delayed gastric emptying. Hold for 1 week prior if possible; if not held, treat as "Full Stomach" precaution.
- ACE Inhibitors / ARBs: Often held on the morning of surgery to prevent refractory hypotension under anesthesia, unless used for heart failure control.
6.5.3 Allergy Verification
Specific attention must be paid to:
- Latex Allergy: Requires a latex-safe environment (removal of latex gloves, tourniquets, vial stoppers).
- Antibiotic Allergies: Distinguish between intolerance (nausea) and anaphylaxis/hives to guide prophylaxis choice.
- Propofol/Egg/Soy: Review severity; most patients with egg allergy can tolerate Propofol, but caution is warranted for anaphylaxis history.
6.6 Pre-Operative Testing and Consultation Protocol
Routine testing (panels) without clinical indication is discouraged. Testing guidelines based on NICE (NG45) and ASA recommendations:
| Test |
Indications |
| ECG |
History of CAD, arrhythmia, or significant structural heart disease. Considered for age >65 or >50 with risk factors undergoing intermediate/high-risk surgery. |
| Chest X-Ray |
New or unstable cardiopulmonary symptoms. Not routine for stable COPD/Asthma or smoking unless active infection suspected. |
| CBC (Hemoglobin) |
Procedures with moderate/high bleeding risk, history of anemia, renal disease, malignancy. |
| Coagulation (PT/PTT/INR) |
Anticoagulant therapy, liver disease, history of bleeding diathesis. Not routine. |
| Electrolytes/Creatinine |
Renal disease, use of diuretics/ACE-I/ARBs, diabetes, potential for fluid shifts. |
| Pregnancy Test |
All female patients of childbearing age (menarche to menopause) unless hysterectomy confirmed. Policy: "Opt-out" requires documented refusal after counseling. |
6.7 Informed Consent Process
6.7.1 Separate Anesthesia Consent
Informed consent for anesthesia is a distinct process from surgical consent. It must be documented by an anesthesia professional.
6.7.2 Content of Discussion
The discussion must cover:
- General Risks: Sore throat, nausea/vomiting, dental damage, drowsiness, shivering.
- Serious Risks: Aspiration, anaphylaxis, awareness, organ injury, nerve injury, cardiac arrest, death (rare).
- Regional Anesthesia Specifics: Nerve damage, bleeding/hematoma, infection, failure of block, toxicity (LAST), post-dural puncture headache.
- Blood Products: Consent for transfusion if hemorrhage occurs.
6.7.3 Emergency Exception
In life-threatening emergencies where the patient is incapacitated and no surrogate is available, implied consent applies. This must be documented in the medical record as "Emergency procedure necessary to preserve life/limb."
6.8 Patient Acceptance and Safety Verification
6.8.1 The Checklist Workflow
Implementation of the WHO Surgical Safety Checklist (modified for local context) is mandatory.
- Sign-In (Pre-Induction):
- Patient confirms identity, site, procedure, and consent.
- Site is marked by surgeon (if laterality applies).
- Anesthesia machine and medication safety check completed.
- Pulse oximeter on and functioning.
- Allergies re-confirmed.
- Difficult airway/aspiration risk reviewed.
- Time-Out (Pre-Incision):
- All team members stop.
- Introductions (names and roles).
- Surgeon, Anesthetist, and Nurse verbally confirm patient, site, and procedure.
- Antibiotic prophylaxis confirmed (administered within 60 min).
- Critical imaging displayed.
6.8.2 "Stop the Line" Authority
Any team member (nurse, technician, surgeon, anesthetist) has the authority and obligation to halt the procedure if a safety breach or discrepancy is identified during verification. No retribution shall occur for safety stops.
6.9 Day Surgery Selection and Discharge Planning
6.9.1 Patient Selection (Exclusion Criteria)
Patients are generally NOT suitable for ambulatory/day surgery if:
- ASA Class IV (unstable).
- Morbid obesity (BMI >40 or >35 with comorbidities) with severe OSA and non-compliant with CPAP.
- Infants < 60 weeks post-conceptual age (risk of post-anesthetic apnea).
- No responsible adult escort for discharge.
- Malignant Hyperthermia susceptibility (requires extended observation).
6.9.2 Discharge Criteria (e.g., PADSS - Post Anesthesia Discharge Scoring System)
Patients must score ≥9/10 to be discharged:
- Vital Signs: Within 20% of baseline.
- Ambulation: Steady gait, no dizziness.
- Nausea/Vomiting: Minimal/treated.
- Pain: Acceptable control with oral analgesics.
- Surgical Bleeding: Minimal/consistent with expectation.
7. SPECIAL POPULATIONS AND CONSIDERATIONS
7.1 Pediatric Patients
- Assessment: Focus on recent URI (risk of laryngospasm). URI within 2 weeks may require postponement of elective cases if symptoms are severe (fever, wet cough).
- Fasting: Strict adherence to minimizing fasting times (Clear fluids up to 1 hour allowed in some modern pediatric protocols, but standard policy is 2 hours).
- Consent: Obtained from parent/legal guardian. Assent from older children is encouraged.
7.2 Obstetric Patients
- Physiology: Always considered "Full Stomach" after 18-20 weeks gestation due to hormonal and mechanical factors. RSI required for GA.
- Fetal Monitoring: Pre- and post-procedure fetal heart rate check required for non-obstetric surgery during pregnancy.
7.3 Obstructive Sleep Apnea (OSA)
- Screening: STOP-Bang questionnaire used for all adults.
- Management: High-risk OSA patients should bring home CPAP machine. Opioid-sparing analgesia (Multimodal) is critical. Consideration for extended monitoring (overnight) if apnea episodes occur in PACU.
7.4 Patients with Implanted Devices (CIEDs)
- Pacemakers/ICDs: Device type and dependency must be established. Electrocautery (Bovie) can interfere. Magnet application plan or reprogramming to asynchronous mode (VOO/DOO) may be required.
8. ROLES AND RESPONSIBILITIES
8.1 Anesthesia Professionals
- Conduct comprehensive pre-anesthesia assessment.
- Assign ASA-PS score.
- Formulate and document the anesthetic plan.
- Lead the Sign-In check.
- Ensure safe transfer of care to PACU.
8.2 Privileged Sedation Providers (Non-Anesthesia)
- Must hold current privileges for procedural sedation.
- Perform pre-sedation assessment including airway check.
- Cannot administer sedation to ASA IV patients or anticipated difficult airways without anesthesia consultation.
8.3 Surgeons / Proceduralists
- Order procedure-specific labs and imaging.
- Mark the surgical site.
- Participate actively in Time-Out.
- Remain immediately available for complications during NORA/Sedation.
8.4 Nursing Staff
- Pre-op nurses: Verify documentation completeness, NPO status, and checklist initiation.
- Circulating nurses: Lead the Time-Out, verify sterility and equipment readiness.
- PACU nurses: Monitor recovery using standardized criteria (Aldrete/PADSS).
10. QUALITY ASSURANCE AND COMPLIANCE
10.1 Key Performance Indicators (KPIs)
The department will track:
- Assessment Completion Rate: % of cases with documented pre-anesthesia note prior to induction (Target: 100%).
- Consent Compliance: % of cases with valid separate anesthesia consent (Target: 100%).
- Day of Surgery Cancellation Rate: Cancellations due to inadequate pre-op preparation (Target: < 2%).
- Unplanned Admission Rate: Day surgery patients requiring overnight admission (Target: < 3%).
- Checklist Compliance: Audit of Time-Out performance (Target: >95%).
10.2 Audit and Feedback
Random chart audits will be conducted monthly. Feedback will be provided to individual clinicians. Systematic failures will be addressed through the Morbidity & Mortality (M&M) committee and Quality Council.