20 Steps to Administering General Anesthesia

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Step 1 Preoperative Assessment

(a) Identify the anesthetic considerations for the patient

(b) Ensure that all required consults have been done (e.g. diabetic patients may need an endocrinology consult; patients with myasthenia gravis will need a neurology consult).

(d) Ensure that the consent for the surgery has been completed.

(e) Ensure that any needed blood products are available

Order preoperative sedation, drying agents or other drugs as appropriate.

Step 3 IV Access

Start an intravenous (IV) of appropriate size.

Step 4 Equipment Preparation

Check anaesthesia machine and related equipment, and prepare conventional and emergency drugs.

Step 5 Attach Monitors

Prior to induction the electrocardiogram, blood pressure cuff and pulse oximeter should be attached. After intubation the capnograph, neuromuscular blockade monitor and temperature probe should be attached. Special monitors may also be needed.

Step 6 Give Any Preinduction Drugs

Curare 3 mg IV may be given to prevent subsequent fasciculation from succinylcholine. Small doses of midazolam (eg. 2 mg IV) and/or fentanyl (e.g. 100 mcg IV) may be given to "smooth out" induction.

Step 7 Induce General Anesthesia

Using thiopental, propofol or other IV drugs, render the patient unconscious.

(Use of an inhalation induction would also work, but is less popular)

Step 8 Induce Muscle Relaxation

After the patient is unconscious, as evidenced by loss of lid reflex, use a depolarizing muscle relaxant such as succinylcholine or a nondepolarizing agent such as vecuronium to paralyze the patient in order facilitate endotracheal intubation. (This step is not needed if a face mask or Laryngeal Mask Airway is used).

Step 9 Intubate the Patient (Secure the airway)

Insert a laryngoscope to visualize the glottis and then pass an endotracheal tube (ETT) through the vocal cords. Inflate the ETT cuff to 25 cmH2O pressure (about 5 ml air will usually suffice). Hook up ETT to patient breathing circuit. Check for equal air entry with stethoscope. Check for capnogram. (If an LMA is used this step does not apply).

Step 10 Ventilate the Patient

Tidal volume 10-12 ml/kg. Respiratory rate 8-12/min. (Spontaneous ventilation may also be appropriate in many cases).

Step 11 Dial in Inhaled Anesthetics

Provide maintenance anesthesia with nitrous oxide (N2O) 70%, oxygen 30% and a potent inhaled agent such as isoflurane (e.g. 1%). Adjust as needed.

Step 12 Add Intravenous Anesthetics as Needed

Add fentanyl, midazolam and other anesthetic agents as needed according to your clinical assessment.

Step 13 Add Muscle Relaxants as Needed

Using a neuromuscular blockade monitor add muscle relaxants as needed.

Ensure adequate hematocrit, coagulation intravascular volume and urine output by giving adequate IV fluids and blood products.

Step 15 Monitor Depth of Anesthesia

Using clinical assessment, ensure that the patient is unconscious

Step 16 Prevent Hypothermia

Keep core temperature above 35 Celsius

Step 17 Emergence

When the surgery is nearing completion, discontinue the anesthetic agents and reverse any neuromuscular blockage. Allow spontaneous ventilation to resume.

Step 18 Extubation

Once the patient is awake and obeying commands suction out the oropharynx, remove air form the ETT cuff, and pull out the ETT. Apply 100% oxygen by face mask.

Step 19 Transport to PACU

Don't forget the oxygen tank. Monitor patients breathing visually.

Step 20 Arrange For Postoperative Care

This includes analgesic orders, oxygen orders, antibiotics, feeding orders, fluid orders and postoperative tests such as electrolytes and hematocrit.


	Anesthesia Pearls \| home 20 Steps to Administering General Anesthesia Step 1 Preoperative Assessment (a) Identify the anesthetic considerations for the patient (b) Ensure that all required consults have been done (e.g. diabetic patients may need an endocrinology consult; patients with myasthenia gravis will need a neurology consult). (c) Assess the patient's airway (d) Ensure that the consent for the surgery has been completed. (e) Ensure that any needed blood products are available Step 2 Premedication Order preoperative sedation, drying agents or other drugs as appropriate. Step 3 IV Access Start an intravenous (IV) of appropriate size. Step 4 Equipment Preparation Check anaesthesia machine and related equipment, and prepare conventional and emergency drugs. Step 5 Attach Monitors Prior to induction the electrocardiogram, blood pressure cuff and pulse oximeter should be attached. After intubation the capnograph, neuromuscular blockade monitor and temperature probe should be attached. Special monitors may also be needed. Step 6 Give Any Preinduction Drugs Curare 3 mg IV may be given to prevent subsequent fasciculation from succinylcholine. Small doses of midazolam (eg. 2 mg IV) and/or fentanyl (e.g. 100 mcg IV) may be given to "smooth out" induction. Step 7 Induce General Anesthesia Using thiopental, propofol or other IV drugs, render the patient unconscious. (Use of an inhalation induction would also work, but is less popular) Step 8 Induce Muscle Relaxation After the patient is unconscious, as evidenced by loss of lid reflex, use a depolarizing muscle relaxant such as succinylcholine or a nondepolarizing agent such as vecuronium to paralyze the patient in order facilitate endotracheal intubation. (This step is not needed if a face mask or Laryngeal Mask Airway is used). Step 9 Intubate the Patient (Secure the airway) Insert a laryngoscope to visualize the glottis and then pass an endotracheal tube (ETT) through the vocal cords. Inflate the ETT cuff to 25 cmH2O pressure (about 5 ml air will usually suffice). Hook up ETT to patient breathing circuit. Check for equal air entry with stethoscope. Check for capnogram. (If an LMA is used this step does not apply). Step 10 Ventilate the Patient Tidal volume 10-12 ml/kg. Respiratory rate 8-12/min. (Spontaneous ventilation may also be appropriate in many cases). Step 11 Dial in Inhaled Anesthetics Provide maintenance anesthesia with nitrous oxide (N2O) 70%, oxygen 30% and a potent inhaled agent such as isoflurane (e.g. 1%). Adjust as needed. Step 12 Add Intravenous Anesthetics as Needed Add fentanyl, midazolam and other anesthetic agents as needed according to your clinical assessment. Step 13 Add Muscle Relaxants as Needed Using a neuromuscular blockade monitor add muscle relaxants as needed. Step 14 Fluid Management Ensure adequate hematocrit, coagulation intravascular volume and urine output by giving adequate IV fluids and blood products. Step 15 Monitor Depth of Anesthesia Using clinical assessment, ensure that the patient is unconscious Step 16 Prevent Hypothermia Keep core temperature above 35 Celsius Step 17 Emergence When the surgery is nearing completion, discontinue the anesthetic agents and reverse any neuromuscular blockage. Allow spontaneous ventilation to resume. Step 18 Extubation Once the patient is awake and obeying commands suction out the oropharynx, remove air form the ETT cuff, and pull out the ETT. Apply 100% oxygen by face mask. Step 19 Transport to PACU Don't forget the oxygen tank. Monitor patients breathing visually. Step 20 Arrange For Postoperative Care This includes analgesic orders, oxygen orders, antibiotics, feeding orders, fluid orders and postoperative tests such as electrolytes and hematocrit.