When the patient arrives on the day of surgery, he or she is escorted to the preoperative holding area, where the anesthesia provider introduces himself or herself to the patient, completes a focused evaluation, explains what the patient should expect, and answers any questions.

A patient’s medications should be reviewed carefully because of anesthetic or surgical complications that may arise as a result of direct, pharmacodynamic, or pharmacokinetic effects of certain drugs. Drugs that produce adverse effects must be altered or discontinued before surgery. Conversely, drugs that have desirable therapeutic effects should be taken throughout the perioperative period.

Cardiac related and antihypertensive medications should be continued on the morning of surgery. Exceptions may include loop diuretics (eg, furosemide). Withdrawal of antihypertensive medications can exacerbate intraoperative hypertension and hypotension. Beta blockers, in particular, have been shown to Reduce the risk of adverse cardiac events in patients who undergo major noncardiac surgery.

Chronic corticosteroid use can lead to secondary adrenal insufficiency with resultant hypotension when a patient is surgically stressed. In all patients who have had as little as 7 days of supraphysiologic corticosteroid dosing over the last year, stress dose steroids should be considered to prevent adrenal crisis. Hydrocortisone, 100 mg IV, given preoperatively is an accepted prophylaxis. Recent studies have shown that patients with secondary adrenal insufficiency do not experience hypotension and tachycardia caused by inadequate glucocorticoid levels when given only their daily dose of steroids for surgical procedures. This ?nding suggests that the level of glucocorticoids required for stress may be lower than previously believed.

Antihyperglycemic medications must be held preoperatively to prevent hypoglycemia in the perioperative period. Many protocols exist for altering a diabetic patient’s insulin or oral medication regimen. A patient can hold the morning dose of insulin regular and take half the usual morning dose of insulin NPH before surgery. A patient can continue all oral antihyperglycemic medications through the night before surgery and then hold them the morning of surgery. A blood glucose reading should be obtained before and at the end of surgery. During surgery, the patient is given an IV ?uid that contains 5% dextrose. The patient should be scheduled for the earliest surgical time slot to prevent an extended period of fasting.

Herbal medications should be discontinued 2 weeks before elective surgery because of the number of adverse e'ects and drug interactions attributed to their use. Direct side effects of herbal medications include bleeding from garlic, ginkgo, and ginseng; cardiovascular instability from ephedra; and hypoglycemia from ginseng.

Pulmonary aspiration of gastric contents is a recognized risk of anesthesia. Adults who present for outpatient surgery have been shown to be at risk for aspiration pneumonitis because of a significant percentage found to have gastric contents of 25 mL or more with a pH of 2.5 or less. The authors routinely provide prophylactic treatment for potential aspiration when patients undergo general anesthesia.

The combination of a histamine2 receptor antagonist and metoclopromide has been shown to be effective in raising gastric pH and decreasing gastric volume. Histamine2 receptor antagonists inhibit function of gastric parietal cells and reduce hydrogen ion concentration. Metoclopro mide reduces gastric emptying time and increases lower esophageal sphincter tone. The adult dosing regimen that the authors use is as follows: nizatidine, 150 mg orally, and metoclopromide, 10 mg orally, 1 hour before surgery.

To decrease further the risk of aspiration, adult patients are routinely instructed not to eat or drink anything for at least 6 to 8 hours before surgery (or after midnight). Some practitioners advocate a more liberal fasting policy and allow adult patients to have clear liquids (tea, co'ee, gelatin) until 3 to 4 hours before surgery. This approach is taken because literature shows that gastric volume is reduced and gastric pH is increased when patients are allowed to take liquids before surgery.