Anesthetic Plan for Surgical Procedure
The optimal anesthetic plan should include regional anesthesia as the primary technique whenever possible, supplemented with appropriate sedation or general anesthesia based on the specific procedure and patient factors. 1
Preoperative Assessment and Preparation
- Airway evaluation: Assess for potential difficult airway, limited mouth opening, neck mobility issues
- Cardiopulmonary status: Evaluate baseline respiratory function, cardiovascular status
- Medication review: Document all current medications, especially anticoagulants, anticonvulsants
- Preoperative fasting: Clear fluids allowed up to 2 hours and solids up to 6 hours prior to anesthesia 1
- Preoperative carbohydrate loading: Should be used routinely unless contraindicated 1
- Premedication: Avoid long-acting sedatives as they delay recovery 1
- Thromboembolism prophylaxis: Ensure compression stockings, consider LMWH based on risk factors 1
Anesthetic Technique Selection
Regional Anesthesia (Preferred)
- Regional anesthesia is preferred over general anesthesia when feasible 1
- Benefits include:
- Reduced postoperative pain
- Decreased opioid requirements
- Earlier mobilization
- Reduced PONV
- Faster recovery
General Anesthesia (When Regional Not Feasible)
- Use a standard protocol allowing rapid awakening 1
- Either volatile anesthetics or total intravenous anesthesia (TIVA) are appropriate, with choice based on factors other than prevention of myocardial ischemia 1
- For induction:
- Propofol: 0.5-1.5 mg/kg (titrated slowly at approximately 20 mg every 10 seconds) 2
- Consider reduced doses in elderly, debilitated patients
- For maintenance:
- Volatile agent (sevoflurane or desflurane preferred for rapid recovery)
- OR propofol infusion (100-200 mcg/kg/min) 2
- Combined with short-acting opioids
Multimodal Analgesia
- Implement preemptive analgesia 1
- Include baseline medications:
- Paracetamol (acetaminophen)
- NSAIDs or COX-2 inhibitors (if not contraindicated) 1
- Consider single intraoperative dose of IV dexamethasone 8-10 mg for analgesic and anti-emetic effects 1
- Regional analgesia techniques when appropriate:
- Peripheral nerve blocks
- Local infiltration analgesia
- Neuraxial techniques for major procedures
- Reserve opioids for rescue analgesia 1
Intraoperative Management
- Positioning: Careful positioning to prevent pressure injuries and nerve damage
- Temperature management: Maintain normothermia with warming devices and warmed IV fluids 1
- Fluid management: Guide fluid administration by flow measurements to optimize cardiac output 1
- Monitoring:
- Standard ASA monitors
- Consider depth of anesthesia monitoring to limit anesthetic load 1
- Neuromuscular monitoring when muscle relaxants used
PONV Prevention
- Implement multimodal PONV prophylaxis for all patients with ≥2 risk factors 1
- Consider dexamethasone 8-10 mg IV at induction
- Add 5-HT3 antagonist (ondansetron) near end of procedure
Postoperative Care
- Ensure complete reversal of neuromuscular blockade before extubation
- Extubate when fully awake with intact protective reflexes
- Continue multimodal analgesia
- Early mobilization and resumption of oral intake
- Remove urinary catheters as early as feasible
Special Considerations
Obese Patients
- Consider ramped position for intubation
- Use short-acting anesthetic agents
- Depth of anesthesia monitoring recommended
- Higher risk of OSA - consider "SDB-safe" anesthetic approach 1
Elderly Patients
- Reduce doses of anesthetic agents
- Avoid long-acting sedatives
- Careful hemodynamic monitoring
- Increased risk of postoperative delirium
Pitfalls to Avoid
- Overreliance on opioids for analgesia
- Inadequate reversal of neuromuscular blockade
- Failure to maintain normothermia
- Delayed recognition of airway problems
- Inappropriate fluid management
This anesthetic plan prioritizes patient safety, early recovery, and effective pain management while minimizing complications that could affect morbidity, mortality, and quality of life.