A Case From Start to Finish

Putting it all together — an illustrative case.

You're assigned a 30-year-old woman for an urgent laparoscopic appendectomy. Your H&P: no past medical history, normal vitals, 70 kg, ate one hour ago. Exam: Mallampati I, good thyromental distance and neck extension, heart/lungs normal, negative pregnancy test, an 18-gauge IV already in.

Plan: ASA 1E, general anesthesia with rapid sequence induction (full stomach). She's at higher PONV risk (female, non-smoker, motion sickness) — build prevention in. This single case touches nearly every other guide in the Playbook.

Set up the room with [PMS-MAIDS](/playbook/setting-up-your-room): positioning fine, machine checked, suction on, monitors on, airway (Mac 3 + 7.0 cuffed ETT), IV ready, drugs drawn and labeled, no special needs. Draw your rescue pressors (phenylephrine, ephedrine) too.

Induction (RSI): midazolam pre-op → monitors + a fresh baseline BP → pre-oxygenate → wait for the attending. Then, in quick succession: fentanyl, lidocaine (blunt the propofol burn), propofol, and succinylcholine. Wait for the fasciculations to stop, intubate, and confirm with fog in the tube, bilateral breath sounds, and sustained EtCO₂. Secure the tube, start the ventilator, and place a bite block.

Dial in your volatile (e.g., desflurane, increased slowly to avoid tachycardia), turn the fresh-gas flows down, and once twitches return give a non-depolarizing relaxant. Give dexamethasone for PONV and place an OGT to empty the stomach.

As the patient is prepped — full anesthetic on board, no surgical stimulation yet — the BP starts to drift down with a high HR. Reach for the [BP equation](/playbook/troubleshooting): a small phenylephrine 50 mcg dose raises SVR, the BP comes up, and the reflex slows the heart. Through the case, treat rises in HR/BP (from stimulation) with small fentanyl boluses.

As the surgeons close, plan your landing. Give ondansetron (PONV). Let the EtCO₂ rise (lower the rate/tidal volume) so she starts to breathe; suction and remove the OGT; dial down the vapor. With the fascia closed and at least one twitch back, give full reversal (neostigmine + glycopyrrolate). Titrate analgesia (e.g., morphine) to a respiratory rate around 10, turn the vapor off, and let the rest blow off. When she's awake, swallowing, and following commands, deflate the cuff and extubate — then to PACU with a report.