What is the typical sequence of steps for administering general anesthesia?

Steps of General Anesthesia Administration

General anesthesia follows a standardized sequence: preoperative assessment and preparation, induction, maintenance, emergence, and recovery monitoring, with each phase requiring specific interventions and continuous physiologic monitoring. 1

Preoperative Phase

Conduct a focused assessment targeting cardiovascular risk factors, previous anesthetic complications, medication interactions, and fasting status rather than routine screening protocols. 2, 3

• Review medical history specifically for cardiovascular disease, respiratory conditions, allergies, previous anesthetic reactions, and family history of anesthetic complications 4, 3
• Assess current medications for potential interactions, particularly MAO inhibitors (avoid meperidine/ephedrine), serotonergic agents, and anticoagulants 5
• Verify fasting times: 2 hours for clear liquids, 4 hours for breast milk, 6 hours for formula/light meals, and 8+ hours for fatty foods 1
• Establish baseline vital signs and ensure appropriate monitoring equipment is available (ECG, pulse oximetry, blood pressure, capnography) 2
• Prepare standardized medication trays with single concentrations per drug, proper ISO 26825 color-coded labels, and documentation of preparation time and personnel 6

Induction Phase

Administer induction agents in small incremental doses or by infusion while establishing airway control and initiating continuous monitoring. 1

• Begin continuous monitoring (ECG, pulse oximetry, blood pressure, capnography) before administering any medications 2, 1
• Establish intravenous access and maintain it throughout the procedure until cardiorespiratory depression risk has resolved 1
• Administer induction agents (propofol, ketamine, sevoflurane) in titrated doses, allowing sufficient time between doses to assess peak effect before subsequent administration 1
• Secure the airway through one of three methods: endotracheal intubation, laryngeal mask airway, or maintenance of spontaneous ventilation with airway support 1
• Administer 100% oxygen and ensure adequate ventilation is established 1

Maintenance Phase

Maintain anesthesia depth using inhalational agents or intravenous medications while continuously monitoring vital signs and adjusting to surgical stimulation. 1

• Continue anesthesia with volatile agents (sevoflurane) or intravenous drugs (propofol, remifentanil) either alone or in combination 1
• Record vital signs, oxygen saturation, and expired carbon dioxide values at minimum every 10 minutes in a time-based record 1
• Monitor for signs of inadequate anesthesia depth or excessive depression requiring intervention 1
• Maintain vascular access and ensure immediate availability of reversal agents (naloxone for opioids, flumazenil for benzodiazepines) 1
• Have emergency equipment immediately accessible including suction, bag-valve-mask, supraglottic devices, and resuscitation medications 1

Emergence Phase

Discontinue anesthetic agents and support the patient through return of consciousness while maintaining airway patency and adequate ventilation. 1

• Reduce or discontinue maintenance anesthetics based on surgical completion and patient response 1
• Continue 100% oxygen supplementation and monitor for respiratory depression or airway obstruction 1
• If hypoxemia, hypoventilation, or apnea develops: (1) encourage or physically stimulate deep breathing, (2) administer supplemental oxygen, (3) provide positive pressure ventilation if spontaneous ventilation is inadequate 1
• Administer reversal agents only when airway control, spontaneous ventilation, or positive pressure ventilation is inadequate 1
• Maintain continuous monitoring until the patient demonstrates purposeful response to verbal commands or tactile stimulation 1

Recovery Phase

Observe the patient in a properly equipped recovery area with continuous monitoring until discharge criteria are met. 1

• Transfer to recovery area with functioning suction, capacity to deliver >90% oxygen, positive-pressure ventilation equipment, and age-appropriate rescue devices 1
• Continue vital sign monitoring every 10-15 minutes with continuous oxygen saturation and heart rate monitoring until fully alert 1
• Maintain NPO status for up to one hour after local anesthetic application to the airway due to depressed laryngeal reflexes and aspiration risk 1
• Document cardiovascular and respiratory stability, level of consciousness, and orientation before discharge 1
• Consider extended observation or step-down monitoring for patients receiving long half-life sedatives with re-sedation risk 1

Critical Safety Protocols Throughout All Phases

Implement standardized medication preparation, labeling, and error prevention systems at every step. 6

• Read medication information aloud twice before preparing syringes for neuraxial procedures 6
• Use only colored antiseptics to prevent confusion with injectable anesthetics or saline 6
• Avoid placing antiseptics and injectable anesthetics in similar sterile cups during neuraxial procedures due to high confusion risk 6
• Calculate maximum safe doses of local anesthetics before administration: lidocaine 7.0 mg/kg with epinephrine (4.4 mg/kg without), bupivacaine 3.0 mg/kg with epinephrine (2.5 mg/kg without) 6
• Have direct-acting vasopressors (phenylephrine, norepinephrine) immediately available for hemodynamic management 5

Common Pitfalls to Avoid

• Never administer meperidine to patients on MAO inhibitors due to fatal serotonin syndrome risk 5
• Never use indirect sympathomimetics (ephedrine) in MAO inhibitor patients due to hypertensive crisis risk; use direct-acting agents instead 5
• Recognize that drug combinations (sedatives plus opioids) cause synergistic respiratory depression requiring dose reduction of each component and continuous respiratory monitoring 6
• Do not delay resuscitation to obtain laboratory samples during anaphylactic reactions; obtain mast cell tryptase samples after stabilization 1
• Avoid assuming adequate ventilation based solely on oxygen saturation; capnography is essential for detecting hypoventilation before desaturation occurs 1