Basic Anesthetic Planning – Study Notes

• Patient assessed, optimized, and consented.

• Surgical issues considered.

• Time to make a basic anesthetic plan.

Core Components of a Basic Anesthetic Plan

1. Type of anesthesia: GA, regional, or local/sedation.

2. Triad of anesthesia: Hypnosis, analgesia, paralysis.

   • Ask: Do I need paralysis?

   • Ask: ETT or LMA?

3. Monitoring requirements:

   • Standard (pulse oximetry, BP, ECG, EtCO₂).

   • Additional: Art line, CVC, BIS, temperature, NM monitoring, cardiac output, TOE/TTE.

4. Pain management:

   • Pre-medications (paracetamol, NSAIDs).

   • Intra-op opioids.

   • Adjuncts (regional, ketamine, lignocaine, magnesium, pregabalin, PCA, acute pain service).

5. Post-op destination: Ward, HDU, or ICU.

The Anesthetic Triad

• Hypnosis: Patient unaware.

• Analgesia: Pain relief.

• Paralysis: For surgical stillness or airway management.

• All agents carry risks: hypotension, respiratory depression, N/V, etc.

• Thus: combine with antiemetics, antibiotics, DVT prophylaxis, and cardio-respiratory management.

Key Questions

Do I need paralysis?

• Surgical reasons:

  • Critical stillness (neurosurgery, microsurgery).

  • Surgical access (laparoscopy, thoracotomy).

• Anesthetic reasons:

  • Easier intubation (RSI).

  • Facilitate ventilation in lung disease, obesity, asthma/COPD.

Airway: ETT or LMA?

• ETT indications:

  • Airway protection (reflux, high aspiration risk).

  • Shared airway (ENT surgery).

  • Precise ventilation (long cases, neuro, thoracic, severe lung disease, unwell patients).

• LMA indications:

  • Short, uncomplicated cases.

  • No airway risk. (~75% of cases).

Monitors

• Standard: SpO₂, BP, EtCO₂, ECG.

• Extras: Arterial line, CVC, BIS, cardiac output monitors, TOE/TTE.

Pain Plan

• Basic: Paracetamol + NSAIDs + opioids.

• Adjuncts: Regional, ketamine, lignocaine, magnesium, pregabalin.

• Escalation: PCA, acute pain service, continuous blocks.

Post-op Care

• Ward: Uncomplicated cases.

• HDU/ICU indications:

  • Airway, breathing, circulation support.

  • ↓ GCS, renal failure.

  • Complex pain.

  • Complex co-morbidities or nursing needs.

Case-Based Examples

Gastroscopy

• Anesthesia: Sedation (looks like GA).

• Airway: Nasal prongs + bite block.

• Monitors: Standard.

• Pain: Minimal (short-acting fentanyl).

• Post-op: Day case.

Inguinal Hernia Repair (reflux, active)

• Anesthesia: GA.

• Triad: Hypnosis + analgesia + paralysis (aspiration risk).

• Airway: ETT.

• Pain: Multimodal + fentanyl PRN.

• Post-op: Ward/day case.

• Alternative: Regional (spinal).

Laparoscopic Cholecystectomy (asthma, controlled)

• Anesthesia: GA.

• Triad: All three required.

• Airway: ETT (laparoscopy).

• Pain: Fentanyl ± morphine.

• Post-op: Ward.

• Rare alternative: LMA if <15 min, <15° tilt, <15 cmH₂O pressure.

Revision Total Knee Replacement (HTN, prior STEMI, aortic stenosis)

• Anesthesia: GA (preferred over spinal in AS).

• Triad: Hypnosis + analgesia + paralysis (to limit propofol/volatile use).

• Airway: ETT or LMA.

• Monitoring: Art line.

• Pain: Multimodal ± nerve block, PCA, pain service.

• Post-op: Ward or HDU (depends on AS severity).

Laparotomy for Bowel Cancer (70 y/o, restrictive lung disease, chronic opioids)

• Anesthesia: GA.

• Triad: All three (paralysis also for restrictive disease).

• Airway: ETT.

• Monitoring: Art line, consider gases.

• Pain: Multimodal, fentanyl + ketamine + regional ± lignocaine/magnesium.

• Post-op: HDU (lung disease + pain complexity).

Pediatric Nail Bed Foreign Body Removal (3 y/o, well, fasted)

• Anesthesia: Inhalational induction.

• Triad: Sedation + analgesia.

• Airway: Small LMA.

• Pain: Fentanyl + ring block.

• Post-op: Pediatric ward.

Tonsillectomy (18 y/o, Crohn’s, well)

• Anesthesia: GA.

• Triad: Hypnosis + analgesia ± paralysis.

• Airway: LMA (common) or ETT + throat pack.

• Pain: Multimodal ± NSAIDs (check with surgeon re: bleeding).

• Post-op: Ward/day case.

Clinical Pearls

• Paralysis reduces need for high-dose propofol/volatile (less hemodynamic instability).

• LMA ≠ always “gentle” – often requires higher propofol than ETT induction.

• In asthma: steroids (hydrocortisone, dexamethasone) may help but nebs (salbutamol, ipratropium) usually effective.

• In sepsis + low MAP: early fluids + noradrenaline + source control (surgery).