Anesthesia, Resuscitation, and ICU: Q&A

Scott Allen10 said:I know a few of them... honestly, the only thing that really eats at them is the fact that succinylcholine isn't used anymore—not that you could even get your hands on it if you wanted to.🙂

How can you say there isn't... we have it right here in the States. 🙂
I mean, hand on heart—if I had my way, I’d definitely prefer having more Esmeron on hand. 🙂

That's true, though side effects from succinylcholine aren't actually all that common. I don't see why they would use it more frequently in developed Western nations than we do here. For instance, we still rely heavily on thiopental quite often, whereas they seem to use propofol for everything, which is a bit frustrating...
It can't even be compared to halothane.... And while I personally prefer Esmeron, succinylcholine still has its place...

Look, guys, most of these cases are pretty much cut from the same cloth. If you've got a healthy patient and the surgery isn't overly intense, you could jokingly say you could run the anesthesia on autopilot. We're talking about 80-90% of our patients right there. In my book, the absolute best anesthetic technique is simply the one you've mastered, and the best drug is the one you actually have experience with. Once things get complicated, everyone starts overthinking which drug is "better" than the other. Honestly, every single agent has its pros and cons, and they all still have their specific niche and timing in the OR (well, obviously excluding the ones that aren't even on the market anymore).
The reason we see anesthesiologists being stingy with heavy-duty opioids for pain management usually boils down to one frustrating thing: freshly operated patients get sent to surgical wards where they just don't get the level of monitoring they need. Most of our big-shot surgeons have already headed home or moved on to the next case, and frankly, some just don't care—they've done their cuts and stitches, and as far as they're concerned, their job is done. That leaves poor patients at the mercy of the nurses, who are mostly wonderful people, but there just aren't enough of them to keep up with everyone physically. (In our hospitals, it’s often the nurses doing the heavy lifting while doctors just write the orders and check if they worked. It’s a sad reality, but true. Doctors prescribe the meds, but anesthesiologists are the only ones who seem to have that innate "caregiver gene" baked into their DNA from day one!) So, you end up with someone screaming in pain, yet somehow breathing fine—but if that pain relief doesn't kick in, they could stop breathing because of the lingering effects of the anesthesia. It's a well-known fact that people rarely die from pain, but they definitely die from respiratory failure. Why is it like this in our hospitals?!
Will it ever get better? "We'll see!" shouted the blind!

A quick question for our dear expert, though I won't say who... 😁 how many hospitals in the US actually have a PACU? Feel free to wing it if you don't have the exact numbers...

Sam Hall15 said:A question for our dear resident expert—not that I’d name names... 😁 how many hospitals in the US actually have a dedicated PACU? Feel free to roast me if you don't have the exact numbers handy...

Well... look, I’m certainly no expert, but I can take a stab at this. At my hospital, we have a proper recovery room, and honestly, it caught me off guard when I realized some places don't even have that. In our PACU, there are always at least two nurses or techs on duty.

As for Lystenon / Lepotosukcin... even though it comes with its own set of contraindications, I’ve chatted with quite a few veteran anesthesiologists who were unanimous on one thing: if you actually understand the nuances of when to use it, you aren't going to run into trouble.

There’s actually a little "green box" in the latest edition of Morgan that mentions a non-depolarizing relaxant being developed under the code AV430... I did a bit of digging and found it finally has a name: Gantacurium.

http://en.wikipedia.org/wiki/Gantacurium_chloride

It’s still in the clinical trial phase, but the potential is promising... Some aspects are frankly brilliant—a faster onset than Esmeron, a very short T1/2, and no need for a separate reversal agent to handle decurarization. If you just let metabolism do its job, strength returns in about 2-3 minutes; however, if you administer cysteine as an antidote, you're looking at full recovery in about 45 seconds.

Sam Hall15 said:Well, yeah—but let's be honest, side effects from succinylcholine aren't exactly something you see every day. Why would we use it more often in a developed, Western nation? Though, I have to say, it does grate on my nerves a bit how much we still lean on thiopental while they seem to use propofol for absolutely everything over there...
it’s not even in the same league as halothane... and while I personally prefer Esmeron, succinylcholine still has its place in the toolkit, I suppose...

It’s funny how everyone loves to trash halothane—constantly bringing up halothane hepatitis and arrhythmias—when the actual truth is a little more nuanced. Personally, I’ve never actually worked with halothane, but the veteran anesthesiologists always mention that it wasn't nearly as bad an anesthetic as the pharmaceutical industry wants us to believe.
If there aren't any glaring contraindications for using halothane (say, neurosurgery, NYHA Class III patients, or pheochromocytoma), then there’s really no reason to shy away from it. The real reason they’re shoving sevoflurane down everyone's throats everywhere is simply because it’s obscenely more expensive than halothane. *Sapienti sat.*

urbanscout50 said:In emergency surgical cases, the anesthesiology assessment is performed rapidly, right before the procedure begins.

I ended up needing emergency surgery, and after the nurse wheeled me over to the anesthesia clinic, the anesthesiologist actually refused to see me. Consequently, I found myself on the operating table without having had a single word with the anesthesiologist beforehand. I do know, however, that particular specialist wasn't the one who eventually handled my case, because I was moved straight into the OR immediately after.

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?

Alexander Wright said:Honestly, the real reason they're pushing sevoflurane everywhere is just because it costs a fortune compared to halothane. It's pretty obvious if you know anything about it.

Yeah, that’s definitely the big driver behind it all. Both Iso and Sevo are way more expensive to deal with.

Sam Hall15 said:Well yeah, for now, succinylcholine is pretty much the only short-acting relaxant that kicks in fast, and honestly, people blow the side effects way out of proportion. As long as you're keeping an eye on potassium levels and watching out for MH, most other stuff like intraocular pressure doesn't really move the needle that much. Esmeron isn't exactly your go-to if you need a quick RSI on a floor or in the ER where things could go south and you might have to scramble for a difficult airway protocol... though, then again, maybe you shouldn't be giving a relaxant at all in those spots, but that's a whole different conversation...

Regarding the PACU, Alexander Wright, do you and the anesthesiologists stay present there, or is there at least someone designated who's always nearby?

A little off-topic here...
Man, Sam Hall15, chill out with the acronyms for a second... 😉...I know what PACU is, but I'm guessing "difficult airway conditions" is what you meant by the English bit, and I assume RSI on a ward means some kind of emergency before someone dies, but I'm still lost on what you mean by MH... 🤷...and look, if I don't get it even after bouncing around anesthesia and ICU for 15 years, I bet a lot of other people are struggling too... 😉...

Back to the topic...
The PACU—which we’d just call the recovery room at my hospital—has to have an anesthesiologist present if it exists, and I’m pretty sure every major US hospital has one. If nothing else, how is a tech supposed to know when it's safe to send a patient back to their home unit once they wake up? 🙂

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...

Sam Hall15, you mentioned the "crap" that can happen when repeating anesthesia... what exactly are we talking about here?

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.

Sam Hall15 said:Regarding the PACU—Alexander Wright, do you and the anesthesiologist stay on-site, or is there at least someone specific always hovering nearby?

We certainly do; our surgical suite is designed such that you can get from the most remote OR to the recovery room in under 15 seconds—which, honestly, is probably for the best when things go sideways. 🙂

Sam Hall15 said:.... and MH is malignant hyperthermia...
My bad if my last post was a bit fuzzy, sorry about that

No worries on my end at all...😉...

As for the whole MH situation... I’ve actually got some firsthand experience with how scary this stuff gets, though indirectly—I once saw a case where an induction with succinylcholine went south fast because of malignant hyperthermia, and honestly, even tossing Dantrolene at it didn't help much since things moved way too quickly for anyone to react...😢....

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?

I've got some stuff regarding the JIL... I'll shoot you the details via DM shortly...

Quick question for someone who’s had to go under for a bronchoscopy here in the States... does anyone know if they typically use anesthesia for it? I don't really care about the cost or anything, just wondering how they actually do it—is it more like a light sedation or a full deep sleep?

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.

Scott Allen10 said:In the JIL... I'll send the details via PM shortly...

Understood, thank you. I look forward to hearing more...