What is the recommended anesthesia technique for a typical adult patient undergoing a common surgical procedure?

Recommended Anesthesia Technique for Adult Surgical Procedures

For typical adult patients undergoing common elective surgical procedures, regional anesthesia should be prioritized whenever feasible, with general anesthesia reserved for cases where regional techniques are contraindicated or technically impossible. 1

Primary Technique Selection Algorithm

First-Line: Regional Anesthesia

Regional anesthesia (neuraxial or peripheral nerve blocks) should be the default choice because it reduces pulmonary complications, chronic postoperative pain, opioid requirements, and avoids airway-related complications. 1, 2

• Neuraxial blocks (spinal, epidural, or combined spinal-epidural) are appropriate for lower extremity, pelvic, and lower abdominal procedures 3
• Peripheral nerve blocks are ideal for upper and lower extremity orthopedic procedures 3
• Regional techniques reduce postoperative delirium, cardiorespiratory complications, and facilitate faster recovery compared to general anesthesia alone 4

Second-Line: General Anesthesia

When regional anesthesia is not feasible, general anesthesia should follow these principles:

Induction Agents

• Propofol is the standard induction agent for most adults 5
• Reduce induction doses by 30-50% in elderly patients (>65 years) to prevent myocardial depression and hypotension 4, 6
• Remifentanil 0.5-1 mcg/kg/min can be co-administered during induction with a hypnotic agent 6

Maintenance Strategy

Either volatile anesthetics OR total intravenous anesthesia (TIVA) with propofol-remifentanil are equally acceptable; the choice depends on institutional preference and patient-specific factors. 1, 7

• Propofol-remifentanil TIVA is the current standard for ambulatory surgery due to rapid recovery 5
• Volatile agents (desflurane or sevoflurane) are recommended for patients with cardiac disease undergoing major non-cardiac surgery due to cardioprotective effects 2
• Avoid nitrous oxide because it increases postoperative nausea and vomiting 1

Neuromuscular Blockade

• Use reduced intubating doses (1-1.5 times ED95) of rocuronium, atracurium, or mivacurium to accelerate recovery 5
• Mandatory quantitative neuromuscular monitoring and complete reversal before extubation 1, 4
• Avoid succinylcholine except for emergency surgery in non-fasted patients 5

Essential Multimodal Adjuncts (All Patients)

Opioid-Sparing Analgesia

Implement multimodal analgesia to minimize opioid consumption and facilitate recovery: 1, 8

• Dexamethasone 8 mg IV at induction reduces postoperative pain and PONV 1
• IV lidocaine infusion (bolus 1-2 mg/kg, then 1-2 mg/kg/h) for major abdominal, pelvic, or spinal surgery without regional analgesia 1
• Low-dose ketamine (0.5 mg/kg/h maximum after induction, continued intraoperatively) for high-risk pain procedures or opioid-tolerant patients 1
• Local anesthetic infiltration at surgical site whenever possible 4

PONV Prophylaxis

• Dexamethasone 4 mg + ondansetron 4 mg for risk-adapted prophylaxis 5

Depth of Anesthesia Monitoring

• BIS or entropy monitoring is strongly recommended, especially in elderly patients, to prevent overdose and facilitate faster emergence 4

Critical Intraoperative Management

Fluid Management

• Allow clear fluids up to 2 hours preoperatively to prevent dehydration 4
• Target euvolemia with restrictive fluid therapy that replaces losses without causing overload 1, 4

Positioning and Skin Protection

• Comprehensively pad all pressure points before surgery starts and reassess every 30 minutes, particularly in elderly patients at high risk for pressure necrosis 4

Antibiotic Prophylaxis

• Administer IV antibiotics within 60 minutes before incision for contaminated or clean-contaminated procedures 1

Special Population Modifications

Elderly Patients (>65 years)

• Reduce all anesthetic doses by 30-50% from standard adult dosing 4, 6
• Mandatory depth of anesthesia monitoring 4
• Complete end-of-surgery checklist including core temperature, hemoglobin, age-adjusted analgesia doses, and postoperative care level determination 4

Obese Patients (>30% over IBW)

• Calculate remifentanil doses based on ideal body weight, not total body weight 6
• Regional anesthesia is strongly preferred to avoid catastrophic airway complications 9
• If neuraxial technique chosen, use sitting position, extra-long needles, and leave ≥5 cm epidural catheter in space 9
• Mandatory airway management backup plan even when using regional anesthesia alone 9

Common Pitfalls to Avoid

• Do not use standard adult dosing in elderly patients—this causes relative overdose and delayed recovery 4
• Do not extubate without quantitative confirmation of neuromuscular recovery—residual paralysis increases pulmonary complications 4, 8
• Do not neglect positioning checks during long cases—reassess every 30 minutes to prevent nerve injury and pressure necrosis 4
• Do not administer bolus doses of remifentanil to spontaneously breathing patients during monitored anesthesia care—this causes dangerous respiratory depression 6
• Do not calculate local anesthetic or remifentanil doses based on total body weight in obese patients—use lean/ideal body weight to avoid toxicity 9, 6

Monitored Anesthesia Care (MAC) Alternative

For minor procedures under local anesthesia with sedation: 6, 10

• Remifentanil 0.1 mcg/kg/min continuous infusion beginning 5 minutes before local block placement
• Reduce to 0.05 mcg/kg/min after block placement
• Supplemental oxygen is mandatory 6
• Rates >0.2 mcg/kg/min cause respiratory depression (respiratory rate <8/min) 6