Standard Operating Procedure: Clinical Anaesthesia Administration

This Standard Operating Procedure (SOP) outlines the mandatory clinical workflow for the safe administration of anaesthesia. Its primary objective is to ensure patient safety through rigorous pre-anaesthetic evaluation, precise equipment verification, and systematic intraoperative monitoring. Adherence to this protocol is compulsory for all clinical staff to minimize the risk of adverse events, airway complications, and drug errors. All procedures must be conducted in strict alignment with the World Health Organization (WHO) Surgical Safety Checklist.

1. Pre-Anaesthetic Evaluation and Preparation

• Confirm patient identity using three points of verification (Full name, DOB, Medical Record Number).
• Verify the Informed Consent document is signed and the surgical site is marked.
• Review NPO (nil per os) status to ensure the patient has adhered to fasting requirements for solids and clear liquids.
• Document comprehensive medical history, specifically focusing on airway anatomy (Mallampati score), history of malignant hyperthermia, and allergies.
• Perform a baseline assessment of vital signs: Blood Pressure (BP), Heart Rate (HR), Oxygen Saturation ($SpO_2$), and Electrocardiogram (ECG).

2. Equipment Verification (The "MACHINE" Check)

• Manifold/Gas Supply: Ensure oxygen and medical air supplies are pressurized and functional; verify backup cylinders are full.
• Airway Equipment: Confirm laryngoscope light intensity, availability of multiple blade sizes, endotracheal tubes (ETT) with cuff integrity check, and suction apparatus functionality.
• Circuit/Ventilator: Perform a leak test on the breathing circuit and verify the ventilator settings are calibrated.
• Hardware/Monitors: Ensure all monitors (Capnography, Pulse Oximeter, BP cuff) are synced and displaying real-time data.
• Infusion/Drugs: Verify emergency crash cart contents, resuscitation drugs (Atropine, Epinephrine), and planned induction agents.
• Nitrous Oxide/Waste Gas: Confirm waste gas scavenging system is active and functioning correctly.
• Emergency/Back-up: Verify the presence of an Ambu bag and difficult airway cart in the immediate vicinity.

3. Induction and Maintenance

• Initiate pre-oxygenation (denitrogenation) with 100% $FiO_2$ for 3–5 minutes.
• Administer induction agents as per weight-based dosing protocols; perform the "Check of Consciousness" before proceeding to neuromuscular blockade.
• Maintain airway patency via ETT or Laryngeal Mask Airway (LMA) and confirm placement via gold-standard capnography ($EtCO_2$ waveform).
• Secure the airway and confirm bilateral breath sounds upon auscultation.
• Transition to maintenance phase using inhaled anesthetics or Total Intravenous Anaesthesia (TIVA), maintaining hemodynamic stability within 20% of baseline.

4. Emergence and Post-Anaesthetic Handover

• Assess for reversal criteria: spontaneous breathing, adequate tidal volume, and ability to follow commands.
• Perform suctioning of the oropharynx before extubation.
• Extubate in a controlled environment once protective reflexes return.
• Conduct a formal handover to the Post-Anesthesia Care Unit (PACU) nurse using the SBAR (Situation, Background, Assessment, Recommendation) format.

Pro Tips & Pitfalls

• Pro Tip: Always practice the "Closed Loop Communication" method when administering medication; have the assistant repeat the drug name and dose back to you before injection.
• Pitfall - The "Hidden" Hypoxia: Do not rely solely on pulse oximetry. Capnography is the most reliable indicator of tube displacement or respiratory depression; if the trace flattens, act immediately.
• Pitfall - Drug Errors: Never leave unlabeled syringes on the tray. Use standardized color-coded labels for all induction agents to prevent accidental administration of neuromuscular blockers as induction agents.

Frequently Asked Questions (FAQ)

Q: What is the most critical step if the capnography waveform is lost? A: Immediately assume a dislodged airway. Disconnect the circuit, manually ventilate with 100% oxygen using an Ambu bag, confirm tube placement via laryngoscopy, and listen for breath sounds.

Q: How often should the anesthesia machine be checked? A: A full "MACHINE" check must be completed before the first case of the day, with abbreviated checks performed between every subsequent case to ensure circuit integrity.

Q: When should I deviate from this SOP? A: This SOP provides a baseline for standardized care. In life-threatening emergencies (e.g., cardiac arrest, anaphylaxis), clinical judgment takes precedence, and you should pivot immediately to the relevant ACLS/advanced resuscitation algorithms.