General anesthesia produces reversible unconsciousness, amnesia, analgesia, and immobility, with control of autonomic reflexes. No single drug does all of this well, so balanced anesthesia combines an IV induction agent, an inhaled or IV maintenance agent, an opioid, and often a neuromuscular blocker.

• IV and inhaled anesthetics mostly enhance inhibitory GABA-A transmission (propofol, etomidate, volatile agents) or block excitatory NMDA receptors (ketamine, nitrous oxide).
• Inhaled agent potency is described by the minimum alveolar concentration (MAC) — the concentration that prevents movement to incision in half of clients; lower MAC = more potent.
• Dexmedetomidine is an alpha₂-adrenergic agonist that reduces sympathetic outflow → sedation that resembles natural sleep with little respiratory depression.

Local anesthetics block voltage-gated sodium channels in nerve membranes so action potentials cannot travel. Small pain and temperature fibers are blocked first, then touch, then motor fibers. They are grouped by chemical link:

• Esters (chloroprocaine, tetracaine, benzocaine) — broken down by plasma cholinesterase; metabolite PABA causes true allergy more often.
• Amides (lidocaine, bupivacaine, ropivacaine, mepivacaine) — metabolized by the liver; true allergy is rare. (Memory aid: amide names contain two letters "i".)
• Epinephrine added to a local anesthetic constricts vessels → longer block, less bleeding, and lower peak blood levels.

Neuromuscular blocking agents (NMBAs) act at the nicotinic receptor of the neuromuscular junction to cause skeletal muscle paralysis. They have no sedative, amnestic, or analgesic effect.

• Depolarizing (succinylcholine): opens the receptor and keeps the membrane depolarized → brief fasciculations, then flaccid paralysis; broken down by plasma (pseudo)cholinesterase.
• Nondepolarizing (rocuronium, vecuronium, cisatracurium): competitively block acetylcholine → paralysis without fasciculation; reversed by sugammadex (rocuronium, vecuronium) or by raising acetylcholine with neostigmine.

US warnings: succinylcholine has a boxed warning — hyperkalemic cardiac arrest in children with undiagnosed myopathies — so it is reserved in children for emergency intubation. The FDA warns that repeated or lengthy general anesthesia (over 3 hours) in children under 3 years and in the third trimester of pregnancy may affect brain development; necessary surgery should not be delayed.

• Malignant hyperthermia susceptibility (personal or family history): no succinylcholine or volatile agents — trigger-free anesthesia (propofol, opioids, nondepolarizing blockers).
• Succinylcholine: avoid after the first day or two following major burns, crush injury, spinal cord injury, stroke with paralysis, prolonged immobility, and in neuromuscular disease and hyperkalemia; caution with open eye injury and raised intracranial pressure.
• Propofol: caution with hypovolemia and shock; disorders of lipid metabolism; the label lists egg and soy allergy, although most clients with egg allergy tolerate it — follow agency policy.
• Ketamine: caution with uncontrolled hypertension, coronary disease, and psychosis.
• Etomidate: avoid repeated doses or infusions (adrenal suppression), caution in sepsis.
• Nitrous oxide: avoid with pneumothorax, bowel obstruction, recent eye gas injection, and B₁₂ deficiency.
• Local anesthetics: true allergy (usually ester); reduce doses in liver disease, heart failure, older adults, and pregnancy; neuraxial blocks — hold per guidelines with anticoagulants (epidural hematoma). Epinephrine-containing solutions have traditionally been avoided in fingers, toes, nose, ears, and penis; current evidence supports careful use in digits in healthy clients — follow the provider and agency.
• NMBA potentiators: aminoglycosides, magnesium, clindamycin, volatile anesthetics, hypokalemia, hypothermia, acidosis, myasthenia gravis (very sensitive to nondepolarizing drugs, resistant to succinylcholine).
• Calcium channel blockers (verapamil, diltiazem) must not be given with dantrolene — hyperkalemia and cardiovascular collapse.
• Sugammadex: clients using hormonal contraception need backup contraception for 7 days.
• CNS depressants (opioids, benzodiazepines, alcohol) add to respiratory depression in recovery.

Listed in priority order.

1. Airway and ventilation
   • Continuous SpO₂, capnography, ECG, and blood pressure during sedation and anesthesia; airway equipment, suction, and reversal agents at the bedside.
   • A paralyzed client cannot breathe — NMBAs are given only with secured airway and mechanical ventilation; set and answer ventilator alarms immediately.
2. Sedation and analgesia before and during paralysis
   • NMBAs do not sedate — always give sedation and analgesia first and continue them; use processed EEG or sedation scales as ordered to prevent awareness.
3. High-alert storage and verification — NMBAs are stored separately with "Warning: Paralyzing Agent" labels and verified before removal from automated cabinets; fatal mix-ups (e.g., vecuronium given instead of midazolam) have occurred. Monitor paralysis depth — peripheral nerve stimulator (train-of-four); in ICU commonly targeted to 1–2 twitches out of 4 per protocol. Before extubation confirm full reversal (sustained head lift, strong grip, adequate tidal volume).
4. Early detection of emergencies
   • Malignant hyperthermia: unexplained rising end-tidal CO₂ (earliest), masseter rigidity, tachycardia, hyperkalemia, late fever → stop triggers, call for help, dantrolene 2.5 mg/kg IV, cool, treat hyperkalemia.
   • LAST: perioral numbness, tinnitus, confusion, seizure, dysrhythmia → stop the injection, airway, benzodiazepine for seizures, 20% lipid emulsion.
   • Hypotension and bradycardia after spinal or epidural block, or with propofol/dexmedetomidine.
5. Protective care of the paralyzed or deeply sedated client — eye lubrication and closure (corneal injury), pressure injury prevention, repositioning, DVT prophylaxis, oral care and ventilator bundle, talk to the client and explain care (hearing is intact).
6. Propofol care — strict asepsis; discard vials and tubing within the product time limit (commonly 12 hours); check triglycerides after about 48 hours of infusion and report values above about 400 mg/dL (4.5 mmol/L); count lipid calories (about 1.1 kcal/mL) in nutrition plans.
7. Recovery — protect the airway until reflexes return; monitor respiratory rate and sedation when opioids are added; manage nausea; for nitrous oxide, give 100% oxygen for 3–5 minutes at the end.

• Tell the team about any personal or family history of problems with anesthesia (high fever, muscle rigidity, prolonged paralysis) — malignant hyperthermia and pseudocholinesterase deficiency are inherited.
• Follow fasting instructions exactly and report any GLP-1 agonist use, herbal products, and anticoagulants.
• After sedation or general anesthesia: no driving, alcohol, or important decisions for 24 hours; have an adult stay with you.
• After a local or regional block: protect the numb area from heat, cold, and injury until sensation returns; do not eat or drink until throat numbness from topical anesthetic is gone (aspiration risk).
• Muscle aches after succinylcholine usually settle in a day or two.
• Clients who received sugammadex and use hormonal contraception: use a backup method for 7 days.
• Parents: do not use benzocaine teething gels for children under 2 years.
• Report severe back pain, new leg weakness or numbness, or loss of bladder or bowel control after an epidural or spinal (possible hematoma).

• NMBAs paralyze but do not sedate or relieve pain — sedate first; the client can hear
• Succinylcholine: hyperkalemia and malignant hyperthermia — avoid in burns, crush injury, immobility, neuromuscular disease
• Earliest sign of MH: rising end-tidal CO₂ → dantrolene 2.5 mg/kg; no calcium channel blockers
• Sugammadex reverses rocuronium/vecuronium; backup contraception for 7 days
• Neostigmine is given with glycopyrrolate to prevent bradycardia
• Aminoglycosides and magnesium prolong neuromuscular blockade; myasthenia gravis is very sensitive
• Propofol: hypotension, apnea, no analgesia, strict asepsis, triglycerides
• Ketamine raises BP and preserves breathing; emergence reactions
• Dexmedetomidine: bradycardia and hypotension, little respiratory depression
• LAST: perioral numbness, tinnitus, seizures, dysrhythmias → 20% lipid emulsion
• Nitrous oxide: give 100% oxygen at the end (diffusion hypoxia)
• Spinal/epidural: hypotension; hematoma risk with anticoagulants