The anaesthetic room workflow

Purpose of the anaesthetic room (AR)

• A controlled area to prepare the patient, equipment, drugs, and team before entering theatre.
• Aim: safe induction, stable transfer to theatre, and clear communication with the operating team.
• Not all sites use an AR (some do “in-room” anaesthesia); the same principles apply.

Before the patient arrives: set up your workspace

• Check the anaesthetic machine and breathing system are working (including oxygen supply, ventilator, scavenging, suction).
• Prepare monitoring: ECG, non-invasive BP, pulse oximeter, capnography ready for use once airway is managed; temperature probe available.
• Prepare airway equipment: mask, oral/nasal airways, laryngoscope/video laryngoscope as appropriate, tracheal tubes (sizes), supraglottic airway, bougie/stylet, tape/ties, lubricating jelly.
• Have a difficult airway plan available: know where the difficult airway trolley is; check availability of second-generation supraglottic airway and front-of-neck access kit per local policy.
• Prepare IV equipment: cannulas, flushes, giving set, pressure bag if needed, tourniquet, dressings, sharps bin.
• Prepare drugs with clear labels: induction agent, opioid, muscle relaxant (if planned), vasopressor (e.g., metaraminol/phenylephrine per local practice), antiemetic, local anaesthetic if needed.
• Check emergency drugs and equipment are immediately accessible: oxygen, suction, bag-valve-mask, anaphylaxis box, defibrillator location.
• Confirm theatre readiness: operating list, planned procedure/side, patient position, antibiotic plan, special equipment (e.g., tourniquet, cell salvage).

Team brief and roles

• Introduce yourself to the patient and team; confirm who is the supervising anaesthetist and who is doing what.
• Agree the plan: airway approach, analgesia plan, muscle relaxation plan, and anticipated problems (aspiration risk, difficult airway, haemodynamic instability).
• Clarify when the surgeon wants antibiotics, tourniquet inflation time, and any special requirements (e.g., nerve block before/after induction).
• Make sure help is available: know how to call for senior support and where the emergency buzzer/phone is.

Patient arrival: identity, consent, and baseline safety checks

• Confirm identity using 3 points (name, DOB, hospital/NHS number) and check wristband matches notes.
• Confirm procedure and side/site; check allergies and reaction type; check fasting status and last intake.
• Check key comorbidities and airway history: reflux, OSA, previous difficult intubation, loose teeth, neck mobility.
• Confirm consent is completed for the surgery; for anaesthesia, ensure the patient understands the plan and has had opportunity to ask questions (local process varies).
• Check VTE prophylaxis plan and whether pregnancy test is required/available when relevant.
• Baseline observations and weight (for drug dosing) where possible.

Monitoring and IV access (the basics)

• Apply standard monitoring early: pulse oximeter first if concerned; then ECG and BP cuff.
• Measure BP before induction if possible; set cycling interval (often 3–5 min, more frequent during induction).
• Secure IV access: confirm patency by easy flush and free flow; connect fluids if needed.
• If IV access is difficult: ask early for help, consider ultrasound, warming, topical local anaesthetic, or using a more experienced cannulator.

Pre-oxygenation and induction (routine adult principles)

• Pre-oxygenate: tight-fitting mask, high-flow oxygen; aim for good end-tidal oxygen (if available) or at least 3 minutes of tidal breathing.
• Position: ‘sniffing’ position for most; ramped position for obesity; ensure head and neck supported.
• Induction: give drugs in a controlled sequence; watch for loss of consciousness, airway obstruction, and hypotension.
• Ventilation: confirm you can ventilate with mask before giving muscle relaxant unless a rapid sequence induction (RSI) is indicated.
• After airway device placement: confirm with capnography (continuous waveform), chest movement, and auscultation as appropriate; secure the airway.
• Set ventilator and alarms appropriately; reassess BP and treat hypotension promptly (fluids/vasopressor as per plan).

Rapid sequence induction (RSI): when and what to remember

• RSI is used when aspiration risk is high (e.g., not fasted, bowel obstruction, severe reflux, pregnancy, emergency surgery).
• Key steps: thorough pre-oxygenation, clear plan for failed intubation, appropriate induction agent and fast-acting muscle relaxant per local practice.
• Cricoid pressure: only if trained staff available and per local policy; release if it impedes ventilation or intubation.
• Always confirm tracheal tube placement with capnography; be ready to move to a supraglottic airway and follow the failed intubation algorithm if needed.

Transfer to theatre: safe handover and movement

• Before moving: ensure airway secure, ventilation stable, monitoring attached and visible, IV lines secured, and drugs/infusions safe for transfer.
• Take oxygen supply with you (portable cylinder if needed) and ensure suction availability.
• Move carefully: watch for disconnections, kinking of tubing, and pulling of IV lines; assign someone to manage the airway during transfer.
• On arrival: reconnect to theatre oxygen/ventilator if changing circuits; recheck capnography and vital signs immediately.

Theatre sign-in / WHO checklist: your contribution

• Participate actively in the WHO ‘Sign In’ and ‘Time Out’ processes; speak up if something does not match (patient/procedure/site/allergy).
• Confirm antibiotic given (or planned timing), airway plan, aspiration risk, blood availability if relevant, and any critical events anticipated.
• Document key details: airway device, number of attempts, complications, drugs given, and baseline issues.

Common first-time scenarios and what to do

• Patient anxious: introduce yourself, explain steps simply, consider a calm environment; discuss sedation only with senior agreement and after safety checks.
• Hypotension after induction: check depth of anaesthesia, give fluids if appropriate, use vasopressor per local protocol, reassess frequently.
• Cannot ventilate well with mask: reposition head/neck, use airway adjuncts, two-person technique, increase oxygen flow, consider supraglottic airway early.
• Difficult cannula: stop repeated traumatic attempts; ask for help early; consider ultrasound and alternative sites.
• Allergy history unclear: pause, clarify reaction and timing, check records; if uncertain, discuss with senior before giving antibiotics/agents.