What are the guidelines for basic surgical anesthesia as a Physician Assistant (PA) or Nurse Practitioner (NP)?

Basic Surgical Anesthesia Guidelines for PAT NPs

As a PAT NP, you must adhere to the Association of Anaesthetists' minimum monitoring standards during all phases of anesthesia, regardless of location or duration, to ensure optimal patient safety and outcomes. 1

Pre-Anesthetic Assessment

Essential Patient Evaluation

• Complete medical history focusing on:
  • Cardiovascular conditions (hypertension, coronary artery disease)
  • Respiratory issues (asthma, COPD, sleep apnea)
  • Metabolic disorders (diabetes, thyroid disease)
  • Current medications and allergies
  • Previous anesthetic experiences and complications
  • Airway assessment (Mallampati score, neck mobility, dentition)

Laboratory Testing

• Selective testing based on patient factors rather than routine panels:
  • CBC for patients with suspected anemia or bleeding disorders
  • Basic metabolic panel for patients with renal disease, diabetes, or on diuretics
  • ECG for patients >65 years or with cardiovascular disease
  • Chest X-ray only for symptomatic patients or those with active pulmonary disease

NPO Guidelines

• Clear fluids: allowed up to 2 hours before elective surgery
• Light meal: prohibited for 6 hours before elective surgery
• Note: Tea or coffee with small amount of milk (up to 1/5 of volume) is considered a clear fluid 1

Intraoperative Monitoring Requirements

Minimum Monitoring for All Anesthesia Cases

• Pulse oximeter with plethysmograph
• Non-invasive blood pressure (NIBP)
• ECG
• Temperature (before anesthesia and every 30 minutes until end of surgery) 1

Additional Monitoring for General Anesthesia

• Inspired and expired oxygen
• Waveform capnography (must continue until artificial airway removal and response to verbal contact re-established)
• Airway pressure, tidal volume, and respiratory rate during mechanical ventilation
• Inspired and end-tidal inhalational anesthetic drug concentration, if used 1

Special Monitoring Situations

• Neuromuscular blockade: Quantitative neuromuscular monitoring throughout all phases of anesthesia until TOF ratio >0.9 confirmed
• TIVA with neuromuscular blockade: Processed EEG monitoring required
• Procedural sedation: Capnography required whenever there is loss of response to verbal contact 1

Regional Anesthesia Guidelines

Block Performance

• Ultrasound guidance recommended for precise local anesthetic placement and reduced total dose
• Optimal ergonomic positioning: minimal trunk/head rotation (<45°), dominant hand for needle insertion 1
• In-plane technique recommended for beginners 2

Spinal Anesthesia for Day Surgery

• Acceptable with low-dose techniques and shorter-acting agents (hyperbaric prilocaine 2%, 2-chloroprocaine)
• Use smaller gauge (25G) pencil-point needles to reduce post-dural puncture headache incidence (<1%)
• Restrict IV fluids to <500 ml to reduce urinary retention risk
• Encourage oral fluid intake postoperatively 1

Patient Discharge After Regional Anesthesia

• Patients may be discharged with residual motor/sensory blockade if:
  • The limb is protected
  • Appropriate support is available at home
  • Written instructions are provided about expected block duration
  • An analgesic plan is in place before block wears off 1

Sedation Management

Midazolam Administration Guidelines

• Titrate slowly with multiple small doses (over at least 2 minutes)
• Allow 3-5 minutes between doses to assess peak CNS effect
• For healthy adults <60 years: Initial dose of 1 mg, maximum 2.5 mg over 2+ minutes
• For adults ≥60 years or debilitated patients: Initial dose of 1 mg, maximum 1.5 mg over 2+ minutes
• Maintenance: Additional doses of 25% of initial effective dose as needed 3

Sedation Safety Requirements

• Continuous monitoring with pulse oximetry
• Immediate availability of resuscitative drugs and appropriate equipment
• Personnel trained in airway management
• For deeply sedated pediatric patients: dedicated individual to monitor throughout procedure 3

Recovery and Discharge

Recovery Phases

1. First-stage recovery: Until patient is awake with protective airway reflexes and controlled pain
2. Second-stage recovery: From transfer off trolley until ready for discharge
3. Third-stage recovery: From hospital discharge until full recovery at home 1

Discharge Criteria

• Nurse-led discharge using agreed protocols is standard
• Voiding not always required except for patients with prolonged bladder instrumentation
• Provide written information about warning signs of complications and when to seek help 1

Common Pitfalls to Avoid

• Inadequate pre-anesthetic assessment: Failure to identify significant comorbidities that may impact anesthetic management
• Insufficient monitoring: Not adhering to minimum monitoring standards for the specific anesthetic technique
• Improper handover: When transferring care to another provider, ensure detailed handover with documentation in the anesthetic record
• Oversedation: Administering subsequent doses of sedatives before peak effect of previous dose is assessed
• Inadequate post-block analgesia: Failing to provide an analgesic plan for when regional blocks wear off
• Poor ergonomics during regional anesthesia: Can lead to block failure and musculoskeletal disorders in practitioners

By following these guidelines, PAT NPs can ensure safe and effective perioperative care for surgical patients while minimizing complications and optimizing outcomes.