Most Critical Topics to Learn in Anaesthesia
Mastering airway management, medication safety, pharmacology of anesthetic agents, and patient-specific risk assessment are the foundational pillars of safe anesthetic practice that directly impact patient mortality and morbidity.
Airway Management and Difficult Airway Protocols
Failed intubation management is critical, as the majority of failed intubations occur out-of-hours and in the hands of trainee anaesthetists, making this a high-risk scenario that requires extensive preparation and training 1
Front-of-neck airway access techniques, particularly surgical cricothyroidotomy, are life-saving skills needed in approximately 1 in 60 failed intubations, though providing adequate training is challenging 1
Competence in advanced airway equipment is essential, as expertise may take a significant caseload to develop, and anaesthetists must be proficient with any specialized equipment stocked in their hospital 1
High-fidelity simulation training with practice and feedback can maintain complex procedural skills for at least one year and should be utilized for airway management scenarios 1
Non-technical skills including leadership, decision-making, communication, teamworking, and situational awareness are crucial components of managing airway emergencies 1
Medication Safety and Error Prevention
The five-rights rule (right medication, right dose, right time, right route, right patient) must be applied consistently to prevent medication errors, which are a significant source of anesthetic morbidity 1
International color coding of syringe labels must be carefully read before administration, as this passive safety measure helps prevent substitution errors 1
Medication preparation and administration should be performed by the same person to reduce errors, with extemporaneous preparation preferred over advance preparation 1
High-risk medications including sedatives and vasoactive agents require heightened vigilance, as these are involved in most medication errors in critical care settings 1
Multidisciplinary continuing education using simulation-based tools is particularly effective for teaching risk management and proper use of delivery devices 1
Pharmacology of Anesthetic Agents
Inhaled Anesthetics
Sevoflurane is preferred over desflurane or isoflurane when choosing an inhalational anesthetic with equal clinical benefit, based on environmental and safety considerations 1
Sevoflurane produces dose-dependent decreases in blood pressure during maintenance, and excessive decreases may be corrected by reducing the inspired concentration 2
Low fresh gas flow techniques should be utilized to reduce environmental impact and drug waste while maintaining safe anesthetic delivery 1
Nitrous oxide should not be used when other inhalational anesthetics provide equal clinical benefit, as it has significant environmental impact 1
Monitoring depth of anesthesia in association with end-tidal anesthetic concentration reduces consumption of anesthetic vapors 1
Intravenous Anesthetics
Propofol and total intravenous anesthesia (TIVA) require careful attention to preparation waste, as manufacturing of required syringes and pumps contributes significantly to environmental impact 1
Propofol may cause elevations in serum triglycerides during extended administration, requiring monitoring in patients at risk of hyperlipidemia 3
In neurosurgical patients, propofol should be administered as an infusion or slow bolus of approximately 20 mg every 10 seconds to avoid significant hypotension and decreases in cerebral perfusion pressure 3
Concomitant use of valproate with propofol leads to increased propofol blood levels, requiring dose reduction and close monitoring for increased sedation or cardiorespiratory depression 3
Propofol administration with fentanyl in pediatric patients may result in serious bradycardia, requiring heightened vigilance 3
Drug Interactions and Perioperative Management
Epinephrine administered with sevoflurane increases the risk of ventricular arrhythmias, requiring electrocardiogram monitoring and readily available emergency medications 2
Sevoflurane may lead to marked hypotension in patients treated with calcium antagonists, necessitating close blood pressure monitoring 2
Sevoflurane increases both intensity and duration of neuromuscular blockade induced by nondepolarizing muscle relaxants, requiring dose adjustments similar to those used with isoflurane 2
For endotracheal intubation, the dose of nondepolarizing muscle relaxants should not be reduced, as this may result in delayed onset of suitable conditions or inadequate muscle relaxation 2
Benzodiazepines and opioids decrease the minimum alveolar concentration (MAC) of sevoflurane, with 50% nitrous oxide reducing MAC by approximately 50% in adults and 25% in pediatric patients 2
Patient-Specific Risk Assessment
Medication reconciliation must begin upstream of the procedure with strong involvement of the patient and healthcare professionals to ensure continuity of chronic medications 1
Patient-specific risks must be identified and discussed during the pre-procedural visit, including factors such as professional voice users, coagulopathy, anticoagulant therapy, and immunocompromised state 4, 5, 6
Fluid deficits should be corrected prior to propofol administration, particularly in premedicated, geriatric, or hemodynamically unstable patients 3
In patients with increased intracranial pressure, hyperventilation and hypocarbia should accompany propofol administration to maintain cerebral perfusion pressure 3
Pediatric Neurotoxicity Considerations
Repeated or prolonged use of general anesthetic or sedation drugs in children younger than 3 years may have negative effects on developing brains, requiring discussion of benefits, risks, and timing with parents and caregivers 2, 3
Animal studies demonstrate that anesthetic agents during rapid brain growth cause widespread neuronal and oligodendrocyte cell loss, with the window of vulnerability correlating with the third trimester through approximately 3 years of age in humans 3
Healthcare providers must balance the benefits of appropriate anesthesia in neonates and young children requiring procedures against potential risks suggested by nonclinical data 3
Informed Consent and Documentation
Comprehensive consent must include explanation of the procedure, risks, benefits, alternatives, and potential complications to ensure patients can make informed decisions 4
Anesthesia-specific information including options for regional versus general anesthesia and risks such as post-dural puncture headache and nerve damage must be discussed 4
Clear documentation of the patient's agreement, specific discussions, and any concerns is essential, with consideration of language barriers requiring professional interpreters rather than family members 4, 5, 6
Environmental Sustainability in Practice
Current anesthetic practice should focus on patient needs and established best practices while environmental considerations are incorporated, as scarce lifecycle assessment evidence does not allow definitive conclusions about overall environmental impacts 1
Monitoring depth of anesthesia during both inhalational and intravenous anesthesia reduces consumption of anesthetic drugs and improves resource utilization 1
Target-controlled infusion (TCI) systems should be preferred over manual delivery when available, as automatic delivery improves precision and reduces waste 1