Evaluating the patient—history and physical, airway evaluation, laboratory tests, NPO status—and formulating an anesthetic plan.

Preparing the patient for the OR—obtain consent, type and screen/crossmatch, preoperative medication, and line placement (IV, arterial/central line). Side of IV placement for breast surgery/AV fistula is usually opposite to the side of surgery.

Preparing anesthesia equipment—anesthesia machine, airway equipment, monitors, fluid warmer, and medications.

Basic monitoring—pulse oximeter, noninvasive blood pressure monitoring, and electrocardiogram (rhythm, heart rate). Additional monitors include end-tidal CO₂ monitoring, temperature monitoring (skin/esophageal/other), and urine output (if Foley catheter is inserted).

Specialized monitoring—nerve stimulator (facial/ulnar nerve, if muscle relaxants are used), inspired oxygen monitor, airway pressure monitor, and inhalational agent monitoring.

Arterial line—sites include radial/brachial/femoral/dorsalis pedis arteries. Indications include surgeries associated with significant blood loss and fluid shifts, patients with severe systemic disease, and drawing of repeated samples for blood gas/hematocrit.

Central venous pressure line and pulmonary artery catheter—sites include internal jugular/subclavian/femoral veins (the latter mainly for venous access). Indications include patients with significant systemic disease (cardiac/renal) undergoing major surgery, anticipated large fluid shifts and blood loss, and measurement of central venous pressure/cardiac output.

Transesophageal echocardiogram (TEE)—to evaluate cardiac function in patients undergoing cardiovascular surgery or in patients with reduced cardiac function undergoing major surgery. It can be also used to evaluate volume status in a patient and thus can be used together/instead of a pulmonary artery catheter.

Bispectral index (BIS) monitor—to monitor depth of anesthesia so as to decrease incidence of patient awareness under anesthesia. It processes electroencephalogram (EEG) to give a number (up to 100). The higher the number, the more awake the patient. A number below 60 is aimed for adequate depth of anesthesia.

Techniques of induction—intravenous (used commonly) or inhalational (children, adults without IV access)

Drugs used for IV induction—propofol (1–2 mg/kg), thiopental (5–7 mg/kg), etomidate (0.3 mg/kg), ketamine (1 mg/kg), or midazolam (0.1 mg/kg)

Drugs used for inhalational induction—O₂, N₂O with sevoflurane (nonpungent)

Insertion of laryngeal mask airway (LMA)—different sizes are available by weight/age. It is important to establish an IV access before inserting an LMA, if induction is done via inhalational agents.

Insertion of endotracheal tube (ETT)—once the patient is asleep the patient is ventilated via a face mask. Muscle relaxants are used to facilitate intubation, either succinylcholine (1–2 mg/kg) or a nondepolarizing muscle relaxant—rocuronium (0.6–0.9 mg/kg)/vecuronium (0.1 mg/kg). The next step is to intubate the patient via an appropriate size of ETT using a laryngoscope (Macintosh/Miller blade).

Rapid sequence intubation—patients on full stomach precautions (trauma, bowel obstruction) and acid reflux disease can be intubated via this technique (to prevent pulmonary aspiration). The premedication is omitted (no midazolam/fentanyl), the patient is preoxygenated with 100 % O₂, and the anesthesia is induced with an IV induction agent followed immediately with the administration of succinylcholine. The patient is not given any positive pressure breaths via the face mask, a cricoid pressure is applied gently, and the patient is intubated to secure the airway.

Difficult airway patients—patients with known and anticipated difficult airway may be intubated with the help of specialized intubating equipment (instead of direct laryngoscopy), such as fiber-optic intubation and use of a Glidescope or Airtraq.

Gases—oxygen, nitrous oxide or air, and an inhalational agent (isoflurane, sevoflurane, or desflurane). Nitrous oxide is contraindicated in patients with bowel obstruction, pneumothorax, and tympanoplasty as it leads to dilation of closed air spaces.

Analgesics—narcotics such as fentanyl, morphine, or hydromorphone.

Muscle relaxants—required to provide muscle relaxation for bowel surgery and used in patients who should not move during surgery (cardiac or neurosurgery). Nondepolarizing muscle relaxants, such as rocuronium, vecuronium, or cisatracurium, are used. Cisatracurium is beneficial for patients with renal failure as it is eliminated by Hoffman degradation (not dependent on liver/renal routes for metabolism).

Adjuncts—epidural anesthesia/nerve blocks are commonly used in addition to general anesthesia for intraoperative/postoperative pain management.

Monitor patient’s vital signs and ventilation, assess blood loss, and communicate with the surgeon.

Fluid management—4 ml/kg/h for the first 10 kg of weight, 2 ml/kg/h after first 10 kg up to 20 kg of weight, and 1 ml/kg/h thereafter. When calculating fluid requirements under anesthesia, one needs to consider fluid deficit from NPO status, maintenance fluid requirements, additional fluid requirements secondary to blood loss, and losses through the gastrointestinal and respiratory systems. Replacement of blood loss by crystalloid is done by a ratio of 1:3 and for colloid by a ratio of 1:1. This means that every milliliter of blood loss should be replaced with 3 ml of crystalloid or 1 ml of colloid.

Blood components—blood (packed RBCs), platelets, and fresh frozen plasma. Blood transfusion is required when excessive blood loss leads to hemodynamic instability or a hemoglobin of less than 7 g/dl (note: with rapid blood loss, the measured hematocrit may not be accurate).