I’m not sure I follow your reasoning. There is solid scientific evidence showing that survival rates are higher in ICUs led by intensivists compared to other physician models. Even though we are discussing non-anesthesia populations—and looking primarily at the standards here in North America—I believe having specialists on staff significantly improves patient outcomes. This happens when you have one or more providers who proactively pursue advanced training and stay current, rather than those who don't find critical care particularly engaging. An anesthesiologist trained in intensive care offers a much broader scope of practice; they are essentially ideal for mixed ICUs (combining internal medicine and surgery) and serve as superior consultants in pediatric or neonatal units. Having an intensivist present doesn't diminish the responsibility or the clinical range of the primary attending physician who hasn't subspecialized. In reality, these anesthesiologists can seamlessly manage any ICU setting.
@urbanscout50/">@@urbanscout50 - I agree regarding the patients, though there are likely times when they are actually relieved to have the option of mechanical ventilation—for instance, when a COPD exacerbation or status asthmaticus reaches a point where respiratory support becomes necessary.
I believe this could be resolved if we implemented a streamlined system where anesthesiologists focus specifically on the ICU. Ideally, they would manage their own patients across all departments, coordinating with the on-call ICU specialist during morning rounds to set a clear plan. This way, they’d truly know their patients, making adjustments throughout the day much more seamless. There are surely anesthesiologists out there with intensive care subspecialties—or even those who lean more toward being intensivists anyway... after all, who doesn't love managing mechanical ventilation? 😁
Regularly administering Ketoral and Analgin, along with epidural catheters—which aren't used nearly enough in pain management, especially during major abdominal surgeries—would be a game changer. It would allow patients to be extubated much sooner... 😁
I’ve honestly never seen IV Paracetamol used in practice, nor have I come across it in the literature; I’ll definitely have to do some digging on PubMed. Thanks for pointing that out, colleague. Generally speaking, I don't think poor ventilator synchronization is a valid reason to introduce a relaxant, except in extreme cases.
I am not an advocate for using relaxation protocols in the ICU, even when a patient is agitated, unless it becomes absolutely necessary. It seems far too easy to resort to it, particularly with neurotrauma or similar conditions. Most issues can be managed effectively through proper analgesia combined with light sedation 😁 Starting with Fentanyl and Dormicum usually does the trick; later on, some NSAIDs can be utilized in the ICU as well, though it seems intensivists often overlook the utility of acetaminophen 😁
One more question for our resident anesthesiologist 😁 What is your preferred sedation protocol in the ICU? Especially for patients we hope to extubate quickly, though that’s always such a gamble... Dormicum works fine, but prolonged sedation doesn't seem ideal for someone I want to transition out of the ICU within a few hours or a day or two. During my rotation, I saw them using Propofol constantly, but besides the cost, I've read studies suggesting it might be suboptimal at a cellular level by interfering with oxidation...
It’s easy to dose Propofol when the patient is stable, but things get messy with polytrauma. Small doses can be incredibly tricky; I’ve seen patients crash into severe hypotension with just 50mg of Propofol, which is a nightmare to manage. You end up needing significant volume resuscitation and Phenylephrine, among other things. While it’s technically possible to make it work, I personally wouldn't risk it. In those scenarios, I'd lean toward a lower dose of Etomidate combined with something else—maybe Dormicum, even if it lacks the necessary speed... 😁
How often do you all perform intubations without using a paralytic? Also, how critical do you think preoxygenation really is in stable cases where the patient is well-prepared and has normal cardiopulmonary status? And finally, do you actually trust Sellick?
Alexander Wright said:Regarding induction, which anesthetic do you prefer... personally, I find Diprivan quite agreeable if the patient is hemodynamically stable, mainly because I value its antiemetic properties and how it reduces hypopharyngeal irritability.
By the way... at your hospitals, do you ever administer Reglan or Peptoran during premedication for patients with heart failure... even if they have been fasting?
I wouldn't say Diprivan is my first choice—perhaps because Americans rely on it so heavily—but if the volume status is managed, I might consider it over Thiopental or Etomidate. It seems people are increasingly avoiding the latter, perhaps by exaggerating the side effects. I actually prefer combining multiple agents, even in an RSI scenario, rather than just hitting them with one massive dose as protocols often dictate. Midazolam would be fine, though a bit slow; a little Fentanyl paired with Thiopental works beautifully.
How frequently do you use relaxants during an RSI? When faced with an obvious difficult airway, do you usually opt to administer them, or do you hold off?...
The conduction issues are likely just an incomplete right bundle branch block, which is completely benign... he was right to tell you that everything is fine.
It depends on several variables, including the patient's age, their level of cooperation, and their overall health status—as well as whether sedation or general anesthesia is required. Generally speaking, however, sedation is usually sufficient. Moving to full anesthesia would represent a much more significant undertaking from both a technical and physiological standpoint. The specific type of sedation or anesthesia will be determined on a case-by-case basis, in consultation with the anesthesiologist performing the procedure.
It is possible you are experiencing tenesmus, or perhaps just false urges... Anxiety could certainly be a contributing factor, especially if there aren't any other symptoms present. I would suggest trying some relaxation techniques to see if things improve within a few days...
Painless hyperbilirubinemia... it is never a good sign. One should first rule out any malignant processes, particularly involving the pancreas... best of luck!
That hyperthermia situation was quite something... if you happen to know any of the specifics regarding the case, such as the treatment protocol or whether he passed away in the OR or the ICU?
When a patient wakes up from anesthesia, it’s because their anesthetic concentration has dropped below the threshold required for unconsciousness. However, since these drugs are highly lipophilic, they tend to accumulate in non-target areas—like subcutaneous fat—during induction and maintenance. As blood and brain concentrations fall, the drug can redistribute back into the bloodstream from these peripheral tissues... This may cause a recurrence of anesthesia, which usually manifests as an insufficiently deep plane that might compromise respiration, though this risk increases in patients with underlying health complications.
My apologies for using abbreviations; I was referring to the PACU, which many hospitals don't actually have, leading patients to "wake up" right in the operating room. This is often quite risky due to potential rebound effects, where the anesthesia wears off just enough to cause complications after they seem awake... RSI is the protocol for rapid sequence induction used during emergency intubations, and MH refers to malignant hyperthermia... Please excuse my lack of clarity in the previous post...
It truly warms my heart to see this topic gaining popularity... I see several people here with whom one could have some very wonderful discussions on many different subjects...
True, for now, succinylcholine remains the only short-acting relaxant with a rapid onset. Honestly, the side effects are often quite exaggerated; you just need to monitor potassium levels and be mindful of MH. Other concerns, like intraocular pressure, aren't nearly as significant... Esmeron isn't really the first choice if you're looking for a quick RSI in a ward or the ER, where things can escalate quickly toward a difficult airway protocol. Then again, there are times when you might not even need a relaxant at all, but that’s a different conversation entirely....
Regarding the PACU, Alexander Wright, do you and the anesthesiologists stay present, or is there at least one specialist always nearby?