A structured approach

Why a structured approach matters

• Reduces missed steps when you’re tired, interrupted, or unfamiliar with the environment
• Improves patient safety: better preparation, earlier recognition of deterioration, clearer escalation
• Helps you communicate clearly with the team (surgeons, ODPs, recovery, ICU)
• Makes “first time” scenarios manageable by breaking them into predictable stages

The core framework (use every case)

• 1) Prepare: patient, team, equipment, drugs, plan A/B/C
• 2) Assess: focused history, exam, investigations, risk, airway assessment
• 3) Plan: technique, monitoring, analgesia, PONV strategy, fluids, postoperative destination
• 4) Deliver: safe induction, maintenance, emergence with continuous reassessment
• 5) Review: handover, documentation, debrief, learning points

Preparation: before you meet the patient

• Know the list: procedure, urgency, expected duration, positioning, likely blood loss, special equipment
• Check the environment: oxygen supply, suction, scavenging, workspace, lighting, access to help
• Machine check: follow local checklist; ensure ventilator, alarms, vapourisers, circuit, CO2 sampling are working
• Airway setup: standard airway kit plus a clear backup plan (e.g., second-generation supraglottic airway, bougie, videolaryngoscope if available)
• Emergency readiness: know where the difficult airway trolley, emergency drugs, defib and malignant hyperthermia kit are kept
• Drugs: draw up and label clearly; confirm concentrations; keep emergency drugs immediately available (e.g., vasopressor, atropine/glycopyrrolate as per local practice)
• Monitoring: ensure ECG, NIBP, SpO2, capnography available; consider temperature and neuromuscular monitoring when relevant

Patient assessment: a safe, focused approach

• Confirm identity, procedure, site/side, allergies, fasting status, pregnancy status when relevant
• History: previous anaesthetics (PONV, difficult airway, awareness), comorbidities, functional capacity, medications, anticoagulants, substance use
• Airway assessment: mouth opening, dentition, neck movement, jaw protrusion, Mallampati (if used locally), signs of obstruction (snoring/OSA)
• Exam: cardio-respiratory baseline, volume status, infection signs, IV access options
• Investigations: review Hb, U&E, ECG, imaging as appropriate to patient/procedure; don’t order tests “by habit”—use local guidance
• Risk discussion: explain plan and common risks in plain language; document key points and consent per local policy

Planning: make Plan A/B/C explicit

• Plan A: primary technique (GA, regional, sedation) and airway approach (e.g., mask/SGA/intubation)
• Plan B: what you will do if Plan A fails (e.g., change device, call for senior help early, wake the patient if appropriate)
• Plan C: emergency pathway (e.g., can’t intubate can’t oxygenate—follow local difficult airway algorithm and call for help immediately)
• Analgesia plan: multimodal (paracetamol, NSAID if appropriate, local/regional techniques, opioids titrated)
• PONV plan: assess risk and give prophylaxis accordingly (use local guideline)
• Fluid/blood plan: access, crossmatch if needed, transfusion triggers per local policy, warming strategy
• Post-op destination: recovery vs HDU/ICU; plan for oxygen, analgesia, antiemetics, and monitoring needs

Team brief and safety checks

• Introduce yourself and clarify roles (who is assisting, who is supervising, who to call)
• Agree key points with surgeon: antibiotics, tourniquet, positioning, expected blood loss, need for paralysis, local infiltration
• Use the WHO checklist properly: sign-in (before induction), time-out (before incision), sign-out (before leaving theatre)
• Speak up early if something doesn’t feel right (missing kit, unclear plan, unstable patient)

Induction and airway: safe basics for new starters

• Pre-oxygenate properly (aim for a good seal and adequate time; use end-tidal O2 if available)
• Positioning: optimise head/neck position; ramp if obese; ensure you can ventilate before committing to paralysis if uncertain
• Always confirm ventilation and oxygenation continuously; capnography is essential for confirming tracheal tube placement
• Have suction on and working before induction
• If difficulty arises: stop, oxygenate, call for help early, and follow a structured airway plan

Maintenance: continuous reassessment

• Monitor trends, not just single numbers (BP, HR, SpO2, ETCO2, airway pressures, temperature, urine output if indicated)
• Treat the cause: hypotension may be depth, vasodilation, hypovolaemia, bleeding, anaphylaxis, arrhythmia, pneumothorax (context matters)
• Ventilation: check chest movement, pressures, ETCO2 waveform; troubleshoot systematically if abnormal
• Temperature management: active warming early; hypothermia worsens bleeding, shivering, and recovery
• Documentation: record key events, drugs, fluids, and any complications clearly

Emergence and transfer: finish safely

• Plan emergence early: analgesia, antiemetics, reversal if needed, suction, oxygen, and extubation criteria
• Extubation is a high-risk moment: ensure patient is stable, oxygenating, and airway is protected; consider senior input if concerns
• Structured handover to recovery: procedure, anaesthetic, airway, analgesia, antiemetics, fluids/blood, antibiotics, issues/complications, ongoing concerns
• Confirm post-op instructions: oxygen requirements, monitoring, escalation plan, and thromboprophylaxis considerations (per surgical team/local policy)

When things go wrong: a simple crisis approach

• Call for help early (don’t wait until you are stuck)
• Use an A–E approach and treat immediately life-threatening problems first
• Oxygenation first: if in doubt, increase FiO2 to 1.0 and ensure ventilation
• Use cognitive aids (local emergency manuals/algorithms) during crises
• Afterwards: document, debrief, and complete incident reporting as required