What approach should be taken for an anesthesia interview for a patient with a history of pre-existing conditions, allergies, and previous surgeries, who is currently on medications and has undergone relevant laboratory tests, undergoing surgery at a hospital?

Pre-Anesthesia Interview Approach for Patients with Complex Medical Histories

A systematic, structured pre-anesthesia interview must prioritize identification of allergy history (particularly latex and drug allergies), previous anesthetic complications, current medications requiring perioperative adjustment, and airway assessment to prevent life-threatening intraoperative reactions. 1, 2

Critical First Steps: Allergy Assessment

Document allergy status before any medications are administered, as one-third of patients with previous perioperative allergic reactions will experience recurrence if the culprit agent is not identified. 2

Specific Questions to Ask:

• Previous anaphylactic reactions during anesthesia or surgery - if positive, obtain detailed records of the event and all drugs administered before collapse 3
• Latex exposure symptoms: Ask specifically about reactions to balloons, condoms, or latex gloves causing itching, rash, or angioedema 3
• Fruit allergies: Banana, chestnut, or avocado allergies suggest latex cross-reactivity 3, 4
• Egg, soya, or nut allergies: While propofol contains egg phosphatide and soya-bean oil, manufacturing likely removes allergenic proteins; however, exercise caution 3, 5
• Multiple previous surgeries (especially in children with spina bifida) - up to 75% develop latex allergy 4
• Healthcare worker status or occupational latex exposure 3, 4

High-Risk Latex Allergy Groups Requiring Heightened Vigilance:

• Patients with atopy 3
• Children with spina bifida or genitourinary abnormalities 4
• Healthcare professionals 3, 4
• Patients with severe hand dermatitis 3
• Industrial workers using protective gear 3

If latex allergy is confirmed or suspected, document it in case notes AND on the patient's wrist bracelet, schedule as first case, prepare operating room the night before with only latex-free products, and use only synthetic gloves for all equipment preparation. 3, 2

Previous Anesthetic History Review

Review previous medical records specifically for airway difficulty, cardiovascular problems during anesthesia, and any cardio-respiratory collapse. 1

If Previous Anesthetic Reaction Occurred:

For elective surgery: Refer for specialized allergy testing (latex-specific IgE or skin prick testing with 75-90% sensitivity) before proceeding 3, 2

For emergency surgery without prior investigation: 3

• Exclude latex allergy through detailed history or provide latex-free environment
• Avoid ALL drugs given during previous anesthetic before collapse onset (except inhalational agents)
• If neuromuscular blocking drug was given before collapse, avoid ALL neuromuscular blockers due to common cross-sensitivity
• Avoid chlorhexidine preparations (allergy more common than povidone-iodine)
• Avoid histamine-releasing drugs like morphine
• Consider regional/local anesthesia (amide local anesthetics are extremely safe)

Medication Review and Perioperative Management

Document current medications with careful review for inappropriate dosing, potential drug interactions, and medications requiring perioperative adjustment. 1

Key consideration: 20% of patients aged >70 take more than five medications, increasing adverse drug reaction risk 1

Cardiac Device Assessment:

For patients with pacemakers/ICDs, establish device type, determine pacemaker dependency, and assess device function before surgery. 1

Airway and Physical Examination

Evaluate nasopharyngeal characteristics, neck circumference, tonsil size, tongue volume, and musculoskeletal abnormalities (osteoarthritis, kyphoscoliosis, fixed flexion deformities). 1

Obstructive Sleep Apnea Screening:

Ask about: 1

• Snoring and apneic episodes
• Frequent arousals during sleep
• Morning headaches
• Daytime somnolence
• Measure baseline oxygen saturation
• Consider overnight saturation measurement or formal sleep study if severe OSA suspected

Laboratory Testing Based on Risk Stratification

Obtain CBC for patients with diseases increasing anemia risk, history of anemia, or anticipated significant blood loss. 1

• Pre-operative anemia occurs in approximately 40% of hip fracture patients 1
• Consider transfusion if Hb <9 g/dL, or Hb <10 g/dL with ischemic heart disease history 1

Perform electrolyte and creatinine testing for patients with chronic disease and those taking medications predisposing to electrolyte abnormalities. 1

Random glucose testing for patients at high risk of undiagnosed diabetes. 1

Reserve coagulation testing (PT, aPTT, platelet count) for patients with bleeding history, coagulopathy-predisposing conditions, or anticoagulant use. 1

Documentation Requirements

Record the following in multiple locations: 1, 2

• Allergy status (particularly latex and drug allergies) in case notes and wrist bracelet
• Cardiac rhythm management device information and perioperative plan
• Sickle cell disease diagnosis (if applicable) so all teams are aware
• Previous anesthetic complications with detailed description

Common Pitfalls to Avoid

Do NOT proceed with elective surgery if allergy history is incomplete or suggests previous perioperative reaction without specialized testing. 2

Do NOT perform your own skin testing without specialist training - results are technique-dependent and require expert interpretation 3

Do NOT use H2-blocking drugs for anaphylaxis management - no evidence supports this 3

Do NOT use rapid bolus propofol induction - use slow rate of approximately 20 mg every 10 seconds (0.5-1.5 mg/kg total) to avoid cardiorespiratory depression 5

Do NOT assume egg/soya allergy absolutely contraindicates propofol - while caution is appropriate, no published evidence mandates avoidance 3