Induction

Time(min)

Task

Survey

0:00

10 L/min pre-oxygenation 2 minutes + antibiotic administration

MS Maid Survey M-Machine Confirm O₂ and NO₂ flows, anesthetic/vaporizer settings, and circuit integrity. hand or machine ventilation.

SSuction M-Monitor HR, O₂ sat, ETCO₂, BP, TV, MV, PMAX, PAP.

A-Airway:

Inspect connection of circuit to Endotracheal tube, auscultate lungs, check for functioning laryngoscope.

I-IV Assure adequate flow.

D-Drugs Check that all labeled syringes given

2:00

In Rapid Sequence:

Rocuronium 5 mg Glycopyrrolate 0.2 mg Fentanyl 100 μg Propofol 150 mg Succinylcholine 100 mg BMV until successful ETCO₂ waveform

3:00

Endotracheal intubation attach circuit and bag to confirm ETCO₂ waveform

3:15

10 L/min O₂, sevoflurane 4% or desflurane 6%

3:30

Secure tube, tape eyes, insert oral airway as bite block and to assure presence during emergence.

4:30

Short Cases (<45 minutes): Bag by hand ventilation until return of spontaneous ventilation.

Long Cases (>45 minutes): Rocuronium 30 mg and put on ventilator (if available) at TV 700 mL, respiratory rate of 8 breaths/min, PMAX 40 cm of H₂O as initial settings.

Inspect monitors, circuit and patient

5:00 During preparation for incision

Reduce flows to O₂ 2 L/min and N₂O 2 L/min

Incision

Reduce flows to O₂ 0.6 L/min, N₂O 0.6 L/min

Inspect monitors, circuit and patient

Maintenance

Stages

Tasks

Survey

During case

Continue O₂ and N₂O flows. Maintain blood pressure with fluid boluses or 5 mg boluses of ephedrine as needed. After adequate fluid bolus and 3 doses of ephedrine consider phenylephrine infusion.

Inspect monitors, circuit and patient

Depth of anesthesia

Light: consider “rescue” fentanyl 50 μg or propofol 50 mg or increase concentration of volatile anesthetic Deep: for hypotension unresponsive to fluid and catecholamine boluses, consider reducing concentration of volatile anesthetic

Inspect monitors, circuit and patient

Anticipate Emergence

Watch for bag movement or “clefting” of the ETCO₂ wave as sign of spontaneous respirations

Emergence

Steps

Tasks

Step 1 (At skin closure)

Discontinue N₂O and anesthetic, increase O₂ flow to 10 L.

Step 2

Hand ventilation to maintain physiologic TV and ETCO₂

Step 3

Monitor for signs of awakening: respiratory and abdominal excursions, facial grimacing, grasping for ET tube, spitting out oral airway, eye opening.

If satisfactorily emerged and able to protect airway: deflate ET cuff and extubate.

If not ready for extubation because of weak respiratory effort due to prolonged neuromuscular blockage: 3 mg (3 mL) Neostigmine and 0.4 mg (2 mL) glycopyrrolate for reversal then extubate when able to protect airway and breathe spontaneously.