OSA screening, frailty, and informed consent

S — Snoring loudly? T — Tired during the day? O — Observed apneas? P — high blood Pressure (treated)? B — BMI >35? A — Age >50? N — Neck circumference >40 cm? G — Gender male? Score 0-2 = low risk. 3-4 = intermediate. ≥5 = high risk. Undiagnosed OSA + opioids + sedatives → post-op respiratory arrest. High-risk patients get heightened monitoring (continuous SpO2 + capnography in PACU), opioid-sparing analgesia, head of bed up. Home CPAP comes to hospital and is continued post-op.

Frailty is decreased physiological reserve and increased vulnerability to stressors — distinct from age. An 80-year-old who walks 3 miles daily is not frail; a 65-year-old recovering from cancer who can't stand up without using arms IS. Tools: Clinical Frailty Scale (1-9, ≥5 is frail), Edmonton Frail Scale, or the get-up-and-go test. Frail patients have 2-3× higher post-op mortality, more delirium, more functional decline, longer LOS. Prehabilitation (exercise + nutrition 4-6 weeks before elective surgery) reduces complications.

Four elements: (1) CAPACITY — understand information, weigh options, communicate decision. (2) DISCLOSURE — material risks, benefits, alternatives (including no anesthesia / no surgery). (3) UNDERSTANDING — teach-back. (4) VOLUNTARINESS — no coercion. Documented in the chart. For minors: parent/guardian. For incapacitated adults: advance directive → surrogate (typically spouse > adult children > parents > siblings, per state law).

Capacity is a CLINICAL determination made bedside by a physician. Competency is a LEGAL determination made by a court. A patient may lack capacity (intoxicated, encephalopathic, sedated) but still be legally competent. If capacity is in question, document specifically: 'Patient was asked to summarize the procedure and major risks — was able to articulate the plan and the major risks, verbalized understanding and consent.'

True IgE-mediated anaphylaxis is rare (~1:5000 to 1:20,000 anesthetics) but fatal. Most reported 'allergies' are NOT — they're histamine release (morphine itching, vancomycin red-man), non-IgE reactions, or expected side effects (PONV). Take history: what symptoms, how soon after exposure, epinephrine needed? True anaphylaxis → AVOID. Histamine release → consider alternatives but not absolute. ~90% of self-reported penicillin allergies are not true; cephalosporin cross-reactivity is ~1% (not the old 10%). Latex allergy: screen with rubber-glove / balloon / dental-dam questions.