What are the stages of anesthesia in patients undergoing surgical procedures?

Stages of Anesthesia

Anesthesia recovery is divided into three distinct phases: first-stage recovery (immediate post-anesthesia until airway reflexes return), second-stage recovery (mobilization until discharge readiness), and late recovery (full physiological and psychological recovery). 1

First-Stage Recovery

This phase lasts until the patient is awake, protective airway reflexes have returned, and pain is controlled. 1

• Must be undertaken in a recovery area with appropriate facilities and staffing 1
• Modern drugs and techniques may allow early recovery to be complete by the time the patient leaves the operating theatre 1
• Patients undergoing surgery with local or regional anesthetic blocks can bypass this stage entirely (fast-tracked) 1
• For obese patients, reversal of neuromuscular blockade should be guided by nerve stimulation, with the aim to restore motor capacity before waking 1
• Patients should have return of airway reflexes and be breathing with good tidal volumes before tracheal extubation, which should be performed with the patient awake and in the sitting position 1

Key Monitoring Parameters in First-Stage Recovery:

• Return of consciousness 1
• Protective airway reflexes 1
• Pain control 1
• For obese patients: oxygen saturation levels, with CPAP therapy reinstated if needed 1
• Observation for signs of hypoventilation, specifically episodes of apnea or hypopnea with associated oxygen desaturation 1

Second-Stage Recovery

This phase begins when the patient steps off the trolley and ends when the patient is ready for discharge from hospital. 1

• Takes place in an area adjacent to the day surgery theatre 1
• Must be equipped and staffed to deal with common postoperative problems (nausea/vomiting, pain) as well as emergencies (hemorrhage, cardiovascular events) 1
• The anaesthetist and surgeon should be contactable to deal with problems 1
• Nurse-led discharge using agreed protocols should be the standard pathway 1

Specific Criteria for Spinal Anesthesia Mobilization:

Nursing staff must follow strict criteria before allowing safe mobilization: 1

• Return of sensation to the peri-anal area (S4-5) 1
• Plantar flexion of the foot at pre-operative levels of strength 1
• Return of proprioception in the big toe 1

Discharge Readiness for Obese Patients:

The patient is safe to return to the ward only when: 1

• Routine discharge criteria are met 1
• Respiratory rate is normal with no periods of hypopnea or apnea for at least one hour 1
• Arterial oxygen saturation returns to pre-operative values with or without oxygen supplementation 1

Common Issues Not Requiring Delayed Discharge:

• Voiding is not always required, though high-risk patients (prolonged bladder instrumentation) should be identified 1
• Mild postoperative confusion in the elderly is usually insignificant and should not influence discharge provided social circumstances permit 1

Late Recovery

This phase ends when the patient has made a full physiological and psychological recovery. 1

• Extends beyond hospital discharge 1
• Patients and their carers should be provided with written information that includes warning signs of possible complications and when to seek help 1
• Protocols should exist for the management of patients who require unscheduled admission 1

Critical Pitfalls to Avoid Across All Stages:

• Do not extubate obese patients without confirming adequate neuromuscular recovery using quantitative monitoring 2
• Do not discharge patients after spinal anesthesia without ensuring all three mobilization criteria are met (sensation, motor function, proprioception) 1
• Do not overlook the need for an analgesic plan for patients having spinal or regional anesthesia, otherwise significant pain will occur when the block wears off 1
• Do not force patients to void before discharge unless they are at particular risk 1
• Do not hospitalize elderly patients with mild confusion after minor surgery; avoidance of hospitalization is preferred 1