General anesthesia

General anesthesia in patients undergoing diagnostic or therapeutic procedures.

1. Indication

  • Abdominal and thoracic procedures
  • Head and neck soft tissue procedures
  • Lateral decubitus and prone procedures
  • Procedures in morbid obesity
  • Emergency procedures in patients at risk for aspiration (RSII - rapid sequence induction and intubation)

2. Contraindication

  • None

3. Required

  • Detailed informed consent discussion
  • Physical examination and history
  • Possibly additional studies (e.g., lab panel, chest films, cardiological studies)
  • Patient informed consent

4. Workflow description

  • Device check by the nurse anesthetist
  • Nursing staff premedicates patient at least 30 minutes before surgery is started, with midazolam oral syrup dosed as suggested below:

> 65 years: 0.1 mg/ kg
≦ 65 years: 0.15 mg/ kg
≦ 45 years: 0.2 mg/kg

Upon transfer of patient to nurse anesthetist

  • Check name of patient
  • Check surgical field
  • Ask patient if fasting
  • Attach leads for monitor, ECG, NIBP, pulse oximetry
  • IV access and infusion
  • Document baseline measurements in anesthesia record
  • Prepare induction medication and materials needed for ventilation
  • Position patient on OR table
  • Anesthesiologist reviews the documents and checks them for completeness
  • Preoxygenate the patient with 100% oxygen via face mask
  • Administer opiate observing blood pressure and time to onset
  • Administer hypnotic until blink reflex lapses
  • Bag-valve-mask ventilation, possibly with an oropharyngeal airway
  • Check BVM ventilation and relax patient
  • Open mouth and check teeth
  • With the laryngoscope and by patient positioning adjust the oral, pharyngeal and laryngeal axes for best view of the glottis
  • Intubate trachea, under direct vision if possible
  • Check black marking on tube
  • Block tube
  • Ventilate and auscultate
  • Secure tube and oropharyngeal airway
  • Transport patient into OR
  • Hook up patient to ventilator in the OR
  • Check capnometry
  • Adjust flow, FiO2 and concentration of anesthetic gas
  • Hook up patient to monitor units
  • Check patient position
  • After checking for possible allergies administer antibiotics
  • Insert central venous and/or arterial catheter
  • Maintain patient's core body temperature
  • Administer medications to maintain anesthesia
  • Release patient to OR team
  • Prepare preemptive analgesia protocol

5. Intraoperative monitoring

  • Single-channel ECG
  • NIBP
  • Pulse oximetry
  • Capnometry
  • Check ventilation settings
  • Measure end-expiratory CO2 concentration
  • Measure inspiratory and expiratory anesthetic gas concentration
  • Measure inspiratory and expiratory oxygen concentration
  • Measure urinary excretion
  • Neuromuscular monitoring
  • Temperature

6. Emergence

  • Check retained relaxation
  • Check opiate overhang
  • Wash out anesthetic gas through high-flow setting
  • Prepare suction unit
  • Restore patient's spontaneous breathing
  • Extubate in presence of protective reflexes
  • Oral or endotracheal suction
  • Observe patient's respiration after extubation
  • Test vigilance
  • Inform recovery room

7. Hand over to recovery room

  • Hand over patient to nursing staff of recovery room
  • Check drains
  • Check vigilance
  • Hook up to monitor units
  • Administer oxygen if needed
  • Anesthesiologist discharges patient from recovery room

Author: Prof.C. Diefenbach, MD Head, Department of Anesthesiology and Surgical Intensive Care

St. Katharinen-Hospital Frechen GmbH, Germany