What is a focused pre-anaesthetic checkup (PAC) for emergency surgeries and how does it differ from a normal pre-anaesthetic checkup (PAC)?

Focused Pre-Anaesthetic Checkup for Emergency Surgery

For emergency surgeries, the focused pre-anaesthetic assessment prioritizes rapid evaluation of immediately life-threatening conditions and airway management over comprehensive workup, with the critical difference being time constraint—you must balance minimal scene/preparation time against optimizing the patient's condition for survival, not elective surgical perfection. 1

Core Principle: Time-Critical Assessment

The fundamental difference is urgency versus optimization. 1

• Emergency PAC: Streamlined assessment focusing on immediate threats to life and factors affecting anaesthetic safety, completed in minutes
• Routine PAC: Comprehensive evaluation with time for optimization, specialist consultations, and complete laboratory workup over days to weeks 2, 3

Essential Components of Focused Emergency PAC

Immediate Clinical Assessment (Minutes, Not Days)

Vital parameters measured and recorded every 3 minutes minimum: 1

• Pulse presence, location, and rate
• Respiratory rate and effort
• Blood pressure (non-invasive)
• Oxygen saturation (SpO₂)
• Pupil size and reactivity
• Level of consciousness

Critical History Elements Only

Focus exclusively on factors that alter immediate anaesthetic management: 1

• Last oral intake (aspiration risk—full stomach assumed in emergencies)
• Known drug allergies
• Current medications affecting anaesthesia (anticoagulants, cardiac drugs)
• Significant cardiopulmonary disease (heart failure, severe asthma)
• Previous anaesthetic complications (malignant hyperthermia, difficult airway)

Omit in emergency setting: 4, 3

• Detailed family history
• Smoking history quantification
• Routine systems review
• Elective optimization of chronic conditions

Focused Airway Assessment

Rapid airway evaluation is mandatory: 1

• Mouth opening and dentition
• Neck mobility (especially with trauma—assume cervical spine injury)
• Presence of blood, secretions, or foreign bodies
• Facial trauma or burns

Goal: Identify difficult airway and prepare backup plan immediately 1

Minimal Laboratory Testing

Only order tests that will change immediate management: 2, 4

• Hemoglobin if significant bleeding suspected
• Blood glucose in diabetics or altered consciousness
• Pregnancy test in women of childbearing age (affects drug choice)
• ECG only if cardiac symptoms present

Do NOT delay surgery for: 4, 3

• Routine complete blood counts
• Comprehensive metabolic panels
• Chest X-rays (unless specific indication)
• Specialist consultations (unless immediately available and critical)

Key Operational Differences

Equipment Preparation

Emergency setup uses standardized "kit dump": 1

• Pre-drawn, labeled drug syringes ready
• All airway equipment immediately accessible
• Backup airway devices at hand (supraglottic airway, surgical airway kit)
• Suction functional and tested

Contrast with routine PAC: Equipment checked but not immediately deployed 3

Team Briefing

Verbal challenge-response checklist completed before induction: 1

• Drug doses confirmed
• Failed intubation plan stated
• Team roles assigned (minimum 4 people ideally)
• Backup plans verbalized

Routine PAC: Team coordination occurs but without same urgency protocols 3

Documentation

Emergency documentation is abbreviated: 1

• Manual recording often necessary (electronic systems too slow)
• Focus on vital signs and interventions performed
• Detailed history deferred to post-operative period

Routine PAC requires comprehensive documentation: 5, 3

• 12+ core assessment items recorded
• Pre-printed forms with complete systems review
• Time for thorough record completion

Critical Decision Point: Optimize vs. Operate

The defining challenge in emergency PAC is balancing resuscitation against surgical urgency: 1

• Life-threatening hemorrhage: Minimal delay—proceed to operating room while resuscitating
• Airway compromise: Secure airway immediately, even in suboptimal conditions
• Sepsis/peritonitis: Brief resuscitation (fluids, antibiotics) then proceed
• Stable emergency: May allow 30-60 minutes for targeted optimization

In routine PAC, surgery is postponed until optimal conditions achieved 2, 3

Common Pitfalls in Emergency PAC

Avoid these errors: 1, 4

• Delaying surgery for non-essential tests: If the result won't change immediate management, skip it
• Attempting comprehensive optimization: Accept "good enough" rather than perfect
• Inadequate pre-oxygenation: Even in emergencies, all patients require pre-oxygenation (high-flow oxygen via reservoir mask) 1
• Forgetting full stomach precaution: Always assume recent oral intake in emergencies—use rapid sequence induction
• Inadequate backup airway planning: Failed intubation plan must be verbalized before induction 1

Monitoring Standards

Emergency monitoring must match routine standards where possible: 1

• Heart rate, blood pressure, SpO₂, ECG, capnography (mandatory)
• Waveform capnography required (not just qualitative)
• Temperature monitoring for vulnerable patients (children, burns)
• Alarms set loud enough for emergency environment

The standard is the same; the timeline is compressed 1