What are the requirements for general anesthesia (GA) clearance?

From the Guidelines

General anesthesia clearance should be based on a comprehensive preoperative evaluation, including a thorough medical history review, physical examination, and relevant laboratory tests, with a focus on minimizing risks and optimizing patient safety, as recommended by the most recent guidelines 1. To ensure patient safety during surgery, a thorough assessment by an anesthesiologist or primary care physician is crucial, typically within 30 days before surgery. This evaluation should include:

• A complete medical history review, including medication and allergy history
• Physical examination, with a focus on airway evaluation and potential risk factors for complications
• Relevant laboratory tests, such as complete blood count, basic metabolic panel, coagulation studies, and electrocardiogram for patients over 50 or with cardiac risk factors Patients with significant medical conditions, such as heart disease, lung disease, or diabetes, may require additional testing, including:
• Echocardiogram
• Pulmonary function tests
• Hemoglobin A1c Medication management is also crucial, with blood thinners like warfarin stopped 5-7 days before surgery, and aspirin and clopidogrel discontinued 7-10 days prior, unless otherwise directed for cardiac stents. Fasting guidelines should be followed, with a minimum of 8 hours for solids and 2 hours for clear liquids before surgery, as recommended by the American Society of Anesthesiologists 1 and supported by recent studies 1. The comprehensive clearance process helps identify risk factors that could lead to complications during anesthesia, such as difficult airways, medication interactions, or underlying conditions that might affect how anesthetic drugs are metabolized and cleared from the body. Key aspects of anesthesia monitoring, as recommended by the Association of Anaesthetists 1, include:
• Minimum monitoring of ECG, SpO2, NIBP, and capnography during general anesthesia
• Quantitative neuromuscular monitoring when neuromuscular blocking drugs are administered
• Processed electroencephalogram (pEEG) monitoring during total intravenous anesthesia (TIVA) with neuromuscular blockade By following these guidelines and recommendations, patients can undergo general anesthesia with minimized risks and optimized safety.

From the FDA Drug Label

The decision as to when patients who have received injectable midazolam hydrochloride, particularly on an outpatient basis, may again engage in activities requiring complete mental alertness, operate hazardous machinery or drive a motor vehicle must be individualized.

The FDA drug label does not provide a specific clearance time for general anesthesia. The decision to resume activities requiring complete mental alertness should be made on an individual basis, taking into account the patient's response to the medication and their overall medical condition. Key factors to consider include:

• The dose and duration of midazolam administration
• The patient's age, health status, and presence of any underlying medical conditions
• The use of concomitant medications that may interact with midazolam
• The patient's ability to recover from the effects of the medication 2

From the Research

General Anesthesia Clearance

• The decision to continue or discontinue certain medications, such as angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin II receptor blockers (ARB), on the day of surgery is crucial for general anesthesia clearance 3, 4, 5.
• Studies have shown that continuation of ACE-I/ARB on the day of surgery is not associated with increased risk of intraoperative hypotension upon induction and within 15 minutes of general anesthesia in elective noncardiac surgeries 3.
• However, discontinuing ACEIs and ARBs on the day of surgery did not result in a substantively increased incidence of pre- or postoperative hypertension compared with patients who continued these medications on the day of surgery 4.
• It is recommended that patients continue to take beta-blockers and calcium channel blockers on the day of surgery, while the decision to continue or discontinue ACE inhibitors and angiotensin receptor blockers should be made on a case-by-case basis 5.
• A thorough preoperative evaluation is mandatory for all patients undergoing any surgical procedure, including oral surgery, to identify correctable medical abnormalities and understand the residual risk 6.
• In cases where ACE inhibitor-associated refractory hypotension occurs during the perioperative period, vasopressin and methylene blue have been found to be effective treatments 7.