3.1. General Anesthesia

@Chshegolkov_Evhenii

Previous chapter: 3. Anesthetic Management

In our BESS/UBE practice, we usually induce general anesthesia with intravenous propofol and maintain it with sevoflurane, supplemented by opioid analgesia and neuromuscular blockade as indicated. The responsible anesthesiologist determines the specific drugs, concentrations, doses, administration rates, and repeat dosing according to the patient's condition, the extent of the procedure, and monitoring data.

Induction and maintenance of anesthesia

We titrate propofol to clinical effect, taking age, comorbidities, hemodynamics, and other administered drugs into account. We select the sevoflurane concentration individually according to anesthetic depth and monitoring data. The volume concentration of an inhalational anesthetic and age-adjusted minimum alveolar concentration (MAC) are different parameters.

Opioid analgesia

We use fentanyl for opioid analgesia. We determine the need for repeat administration and its dose individually, taking the effect, stage of surgery, concomitant drugs, and the patient's condition into account. Repeat doses are not administered automatically simply because a certain interval has elapsed.

Neuromuscular blockade and emergence

For neuromuscular blockade, we use atracurium besylate (Intuban), an intermediate-acting nondepolarizing muscle relaxant. It is administered under adequate general anesthesia with ventilation provided. The anesthesiologist determines the dose and need for additional administration according to the prescribing information, clinical situation, and neuromuscular monitoring data.

The time to recovery of neuromuscular function varies; the interval since administration of a muscle relaxant does not by itself confirm readiness for extubation. Quantitative neuromuscular monitoring is used. Before extubation, a TOF ratio ≥ 0.9 is confirmed at the adductor pollicis muscle, together with clinical assessment of breathing, consciousness, and the ability to protect the airway. The anesthesiologist determines the need for pharmacological reversal of residual blockade.

Monitoring and patient positioning

Basic monitoring during general anesthesia is required regardless of ASA physical status: ECG, pulse oximetry, blood pressure and heart rate measurement, capnography, and ventilation monitoring. Body temperature is assessed; instrumental temperature monitoring is used when clinically significant changes are expected or suspected. After positioning the patient prone, the position and fixation of the endotracheal tube, patency of the breathing circuit, and ventilation parameters are rechecked.

BIS, cerebral or somatic oximetry, including INVOS, and advanced hemodynamic monitoring are selected according to individual indications rather than as a mandatory set solely because of ASA III–IV status. Blood pressure targets are individualized, prioritizing adequate perfusion of organs and neural structures.

Tranexamic acid

Tranexamic acid may be used as an adjunct to reduce blood loss during BESS/UBE. The anesthesiologist determines the indications, dose, administration rate, and need for a repeat dose according to the local protocol, taking expected blood loss, renal function, contraindications, and individual risks into account. Its use does not replace meticulous surgical hemostasis.

References

1. Thilen SR, Weigel WA, Todd MM, et al. 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology. 2023;138(1):13–41. doi:10.1097/ALN.0000000000004379.

2. American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring. Revision dated 15.10.2025. Official ASA standard.

3. Saugel B, Fletcher N, Gan TJ, Grocott MPW, Myles PS, Sessler DI; PeriOperative Quality Initiative XI Workgroup Members. PeriOperative Quality Initiative (POQI) international consensus statement on perioperative arterial pressure management. Br J Anaesth. 2024;133(2):264–276. doi:10.1016/j.bja.2024.04.046.

4. Upfill-Brown A, Olson T, Adejuyigbe B, Shah A, Sheppard W, Park CW, Heo DH, Park DY. Does the use of tranexamic acid intraoperatively reduce postoperative blood loss and complications following biportal endoscopic lumbosacral decompression? J Spine Surg. 2024;10(1):68–79. doi:10.21037/jss-23-129.

5. Farmak JSC. Intuban® (atracurium besylate 10 mg/mL). Instructions for medical use of the medicinal product. Registration certificate UA/20212/01/01; Order of the Ministry of Health of Ukraine dated 18.10.2023 No. 1808. Sections “Special precautions for use” and “Dosage and administration”.