Anesthesia, Resuscitation, and ICU: Q&A

Scott Allen10 said:not much of a difference as far as I'm concerned...😉...

And as for MH... well, for a little while now, I’ve been the proud—though admittedly indirect—owner of a firsthand account involving a fatal induction via Lepotosukcin due to the onset of malignant hyperthermia... even Dantrolen was useless there... practically before you could even turn around...😢....

Whoa, man... I honestly don't know whether to envy you or pity you😱
I only know about MH from textbooks

Regarding crush induction—which anesthetic do you all actually enjoy using? Personally, I’m quite fond of Diprivan (assuming the patient is hemodynamically stable, of course)—mostly because I can't stop thinking about its antiemetic properties and how much it helps dampen that hypopharyngeal irritability.

By the way... in your hospitals, do you still bother giving Reglan or Peporan during premedication for patients with heart failure... even if they’ve already been NPO?

Hey, fellow anesthesiologists—how often do you guys actually run into cases involving a choline esterase deficit?

Michelle Cook83 said:Fellow anesthesiologists—please, tell me, how often do you actually run into cases involving cholinesterase deficiency?

We had a patient like this recently; his serum levels were sitting somewhere around 3,000 units per liter.
It was his first time ever going under the knife, so we had absolutely zero history to go on—no prior surgical issues, nothing at all in the family history, either.

In the end, we just put him on a ventilator, kept him sedated, and managed to extubate him the following day.

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?...

Sam Hall15 said:I don't know—Propofol isn't my first choice, perhaps because Americans seem to overrely on it, but if my volume looks decent, I might consider it over Thiopental or Etomidate—though it seems like everyone has stopped using the latter, which feels like a bit of an exaggeration regarding side effects. Personally, I’d rather combine several drugs, even during RSI, than just hammer them with one massive dose, which is how most protocols seem to go nowadays. Dormicum would be fine, but it's too slow; maybe a little Fentanyl and then some Thiopental—that’s a solid combo.

How often are you guys actually administering relaxants during RSI? And when you're staring down a textbook difficult airway case, do you usually bite the bullet and give them, or do you play it safe?

Dormicum mixed with Nespodal is a solid pairing; if you give 5 mg of Dormicum alongside 150 mg of Nespodal, an 80 kg patient will drift off pretty quickly.
As for relaxants, I stick strictly to Lepto, unless there's a nasty contraindication—then I'll go with Esmeron... honestly, I've seen people use Lepto even with potassium levels above 6, and everything turned out just fine.

Michelle Cook83 said:Hey fellow anesthesiologists, how often do you guys actually run into cases involving a cholinesterase deficiency?

You don't see it all that often, but it definitely happens... honestly, just like someone else mentioned earlier, those patients usually end up stuck with the breathing tube and on the ventilator a bit longer while they wait for things to "kick in"... there isn't really anything crazy about managing them, it's just part of the job.

Alexander Wright said:When it comes to induction, what’s your go-to anesthetic? Personally, I’m a huge fan of Propofol if the patient’s hemodynamics are looking solid, mostly because I can always count on those antiemetic perks and how much it settles down the hypopharynx.

By the way... do you guys see people with heart failure getting Reglan or Peporan during premedication at your hospitals... even if they're already NPO?

If we're talking about a full arrest situation, you usually don't even need to worry about those kinds of drugs... Otherwise, depending on whatever an anesthesiologist prefers, you'll either see the old-school combo of Lepto and Nesdonal, or more modern approaches using Esmeron or Hypnomidate, or just a quick Propofol bolus. For me, Propofol just feels the most elegant—it's easy to dose, clears out fast, and leaves the fewest side effects behind.

To be honest, I haven't really run into that business with Reglan and Peporan before; it seems more like a case-by-case call from the anesthesiologist rather than some standard routine.

Scott Allen10 said:You don't see them all the time, but they definitely pop up... honestly, like someone else mentioned, these patients usually end up stuck on the vent with their tube in a bit longer until things "click"... nothing super crazy about managing them, really.

Yeah, I saw one—the kid was still on the ventilator for another 2 or 3 hours. It was just a tonsillectomy. Turns out the little one had some kind of minor cholinesterase deficit, which is why they stayed intubated longer.

Michelle Cook83 said:Yeah, I saw—the kid was still on the ventilator for another two or three hours. It was just a tonsillectomy. Apparently, the patient had some minor cholinesterase deficiency, which is why they were extubated so early.

Well, it really depends on what kind of deficiency we're talking about—whether it's homozygous or heterozygous.
If it's the homozygous type, you might want to buckle up and plan for at least eight hours before they actually regain any strength.

Though, honestly, trying to get a quantitative reading on serum cholinesterases isn't exactly the gold standard—it’s notoriously unreliable. It would be much more sensible to run a dibucaine test; that way, you can clearly distinguish between the homozygous and heterozygous forms without all the guesswork.

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?

electricpanther82 said:Just one question for a loved one who needs a bronchoscopy. Where in the US is anesthesia typically given for this? Money isn't an issue, but I'm curious about how they handle the anesthesia—is it light sedation or deep anesthesia?

Honestly, if you’re near Washington, D.C., your best bet is probably Jordan. It’s a specialized hospital focused on pulmonary issues, so their pulmonologists and anesthesiologists are basically pros at handling patients specifically for these kinds of procedures. They see this stuff all day long.
Usually, bronchoscopies fall into two categories:
1) Rigid bronchoscopy (using a metal tube to look at the larger airways), which almost always requires general anesthesia. To be totally honest, this is a massive headache for the anesthesiologist. It’s high-stress, and frankly, nobody loves doing it. You often have to relax the patient, but then they struggle to breathe, or the anesthesiologist can't ventilate properly because the scope is in the way, and then the pulmonologist is fighting the anesthesiologist just to get a clear view. In the middle of all that chaos, the patient often ends up looking more blue than pink! While things usually turn out fine, I wanted to give you a realistic picture of what's happening behind the scenes. The teams over at Jordan are definitely the most experienced with this specific setup.
2) Fiberoptic (flexible) bronchoscopy, which is the much more common version. This is typically done without full general anesthesia. If they put someone completely under, they have to intubate them to protect the airway, which makes the whole thing take way longer, keeps the patient in the hospital longer, and requires a full anesthesia team. Instead, they usually use local anesthesia. Basically, the pulmonologist sprays the nose, mouth, and throat with a local anesthetic before sliding the scope in, and then numbs the vocal cords as they move deeper, adding more local anesthetic as they go down into the lungs. Sometimes, they might give the patient some light sedation to take the edge off. In my opinion, pulmonologists actually prefer a cooperative patient because things like whether or not a patient coughs can actually help with the diagnosis. If they *do* decide to go with general anesthesia for a flexible scope, it has to be deep enough to keep the patient perfectly still so they don't make sudden movements that could cause injury during the procedure. Personally, I think doing a flexible bronchoscopy under general anesthesia should really only be reserved for small children, patients who are extremely uncooperative, or those with severe heart conditions where even minimal stress is a huge risk (in those cases, you really have to weigh the benefits against the risks of any "medical heroics").
As for whether you can pay extra somewhere to get it done under general anesthesia? I honestly don't know. Your best move is to call specific clinics directly and ask.
Wishing you and your loved one the very best. I'm rooting for a negative result.

Thanks, urbanscout50! So, she's a friend of mine—she’s actually pretty brave, but she’s just terrified of the whole procedure. She figured she’d rather just sleep through it if possible. She was a heavy smoker for years, and now at 35, she’s dealing with some issues that mean she really needs to get this checked out, but she’s avoiding the big county hospitals. I think it’s mostly people being scared of the discomfort or the pain. Especially when you're facing a new test for the first time, people get so worked up. Honestly, I was a nervous wreck myself during my gastroscopy. I panicked so hard I actually drove all the way from my place out to a specialized clinic just to get sedated. I was just shivering at the thought of the exam. The funniest part is, I've definitely had worse experiences before, like having a permanent tooth pulled without any numbing injection 😢😢😢. Anyway, she’ll probably look into checking out Jordan or one of those private clinics in Washington, D.C.—kind of like how you'd find those high-end clinics in Miami—but there isn't much
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Just wanted to drop another quick shout-out to all the doctors and anesthesiologists hanging out in this thread, whether you’re still grinding through med school or you've already made it to the other side. It’s honestly pretty great being able to get such detailed, spot-on answers from people who actually know their stuff! And look, when it comes to surgeries, everyone seems to go crazy for the surgeons—you know, the ones doing the actual cutting. To me, that feels a little unfair. I mean, sure, the anesthesiologist carries the heavy lifting when it comes to real responsibility, but the surgeon is the one getting the big thank-you gifts, like cash, a nice bottle of bourbon, or a box of chocolates. People always seem to overlook the person who was literally managing their breathing and keeping every other vital function running while they were under. In my book, the anesthesiologist deserves just as much credit, if not more.😍

Man, this discussion is getting deep into some serious territory. Honestly, the most important rule is that there’s no single rule for which anesthetic to use. You pick the drug (type and dose) and the whole technique based on how the patient is doing overall, what kind of surgery it is, the surgeon's skill level, and—let's be real—the anesthesiologist's own experience, knowledge, and personal preferences. All this talk about "I love this drug" or "I hate that one" is pretty pointless; forcing a specific choice just limits our toolkit, which can actually be dangerous depending on the situation.
Take succinylcholine, for instance. Everyone loves to harp on its life-threatening side effects—things like arrhythmias, malignant hyperthermia, or severe bradycardia that's a nightmare to fix in patients on beta-blockers. But nobody ever mentions the one "harmless" side effect that is absolutely miserable for the patient, especially after quick, minor procedures: intense muscle soreness. Every single muscle you didn't even know you had starts aching (trust me, I've been there). So, I have to ask, why put a patient through that? Especially if the procedure is long enough to allow for induction with a different relaxant. And don't even get me started on drug interactions. Why give something if it isn't strictly necessary?

Esmeron. It’s a solid relaxant, and if you go with a higher dose, it gets you intubated within a minute, much like lepto. The catch with Esmeron is that allergic reactions are pretty common. Then there's Norcuron, which is another good relaxant that people seem to ignore. It definitely has its place, particularly for inducing patients with asthma or allergies (assuming Pavulon isn't available), and it actually wears off faster than Esmeron.

Etomidate is a decent drug, but it tends to make patients nauseous more often. It’s usually my go-to for patients with allergies, asthma, or unstable hemodynamics. However, Etomidate can cause such intense tremors that it's almost like they had lepto, which can raise intra-abdominal pressure and trigger vomiting. So, performing an induction on a full stomach becomes a real question mark, doesn't it?

Thiopental—the big pharma industry basically pushed this one out of the market. Still, compared to Propofol, the wake-up period after Thiopental is longer. So, why bother using it for minor cases where you want the patient to head home quickly?

Propofol. Now we're talking. It's a fantastic anesthetic—fast-acting, and patients wake up quickly and lucid (unless, of course, they were also given some Dormicum, Thiopental, or Fentanyl). It shuts down the gag reflex nicely, making it great for intubation without relaxation or using a laryngeal mask. Plus, if they're lucky, they have some pretty pleasant dreams. One huge plus: it doesn't cause nausea. In fact, giving small doses of Propofol toward the end of anesthesia is actually recommended to prevent post-op nausea and vomiting.
Of course, it's not perfect, and you have to keep its downsides in mind. The biggest issue is how it hits the hemodynamics. Propofol drops blood pressure more than almost any other anesthetic, especially if you push it fast. In my book, giving Propofol to a polytrauma patient who's bleeding out, in shock, or severely dehydrated from an ileus is just plain reckless. In those cases, I think Ketalar is the way to go, even though nobody seems to mention it here.

Ketalar. In my opinion, this is the gold standard for patients in shock, hypovolemic, or heavily traumatized. It helps bump up blood pressure and heart rate, which helps prevent a total cardiovascular crash. Another huge perk is the analgesic component. Basically, with one drug, the patient is asleep and pain-free. Once they're hemodynamically stable—whether that's because they recovered or the anesthesiologist and surgeon stabilized them—you can switch to something else or just supplement the Ketalar with smaller doses of other drugs. Just keep in mind that for "cold" procedures, you should probably add something like Norcuron or Dormicum to avoid or dampen those post-Ketalar hallucinations (which are usually more annoying for the people around the patient than the patient themselves).

We could go on forever like this about every single drug. When it comes to other medications or specific maneuvers, you really should follow the established protocols in every situation where they are prescribed, regardless of what the "house style" is or what the old-timers say. Because if everything goes smoothly, great. But if things go south, everyone—including those veteran doctors who set the "house style"—is going to ask, "Why didn't you do this? It was right there in the protocol." At that point, neither the house rules, nor the advice of your seniors, nor your own opinion on a drug's efficacy will save you. You'll be in a massive bind, facing potential lawsuits and a career that's on the line.
In my book, preoxygenation is a must for those cold procedures where you aren't expecting any intubation nightmares. It’s especially vital for the younger, less experienced anesthesiologists out there—I mean, it’s happened more than once where solid preoxygenation basically saved someone's neck with patients who seemed totally routine. You don't have to be all intense about it, jamming the mask onto their face and forcing them to breathe oxygen for several minutes until they feel like they're suffocating. Honestly, you can just run the bypass on the anesthesia machine, hold the mask a few inches away from their face, and tell them to take a couple of deep breaths. That's plenty. You can even just ride those few deep breaths right after you induce them with Thiopental.
Anyway, that's the gist of it.

electricpanther82 said:Thanks, urbanscout50! Yeah, she’s a friend of mine, but she’s just terrified of the whole procedure. She honestly figured she’d rather just sleep through it if possible. She was a smoker for years and now at 35, she's dealing with some issues that mean she really needs to get this done, but she doesn't want to deal with a major hospital setting. I think it's mostly just people being scared of the discomfort and the pain, you know? Especially when it's your first time going in for something like this—people get so worked up. I actually panicked like a total wreck during my own gastroscopy, so I ended up driving all the way out to a different clinic just to get sedated. It's kind of hilarious looking back because I've actually had much worse experiences (like having a permanent tooth pulled without any numbing 😢😢😢). Anyway, she’ll definitely check out that Jordan clinic or some other private facilities in Washington, D.C.—though finding places like that in Miami isn't always easy.

Maybe have her ask around at the hospital in Miami; they might be able to or willing to do a bronchoscopy under anesthesia. It shouldn't cost much, and maybe they can point her in the right direction regarding where else it's offered here in the States.
Best,

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...

Greetings, everyone. I find myself posing a question to this group regarding a matter that has been weighing heavily on my mind. I am curious about the potential cumulative consequences of undergoing frequent surgical procedures combined with various types of anesthesia. To provide some context, I returned home just a week ago from my eighth surgery, which was performed under spinal anesthesia. Looking back at my medical history, I have navigated two instances of general anesthesia, two more involving spinal blocks, one axillary nerve block, and I believe two sessions of local anesthesia. While I haven't encountered any major complications thus far—aside from the typical difficulty with urination following the spinal procedure—I cannot help but feel a sense of apprehension regarding the long-term impact on my system. This concern is amplified by the fact that I am facing at least two more scheduled operations in the near future.

Man, Sam Hall15, what are you even talking about with this cellular oxidation stuff?😁...there’s just no room for those kinds of theories out here...you just work with whatever tools you've got and follow the protocol...if someone started throwing around talk about cellular oxidation and all that high-brow theory, the senior staff would probably kick them straight out of the OR...😁...

Back when I first started out, we mostly did bolus sedation and relaxation. In the real world, that meant every 45 minutes or so, someone was popping an ampule of Pavulon and Dormicum into a vein. We'd go like that until dawn if we had to, sometimes longer...and every now and then, someone would toss in a bit of Apaurin just to keep things steady.
Then infusion pumps finally showed up. That's when someone decided continuous sedation and analgesia was the way to go, adding Pavulon or later Norcuron for relaxation whenever needed.
After that, we moved to a continuous mix of Fentanyl and Dormicum (we'd take 3 ampules of 10ml Fentanyl plus 18ml of Dormicum—totaling 50ml in a syringe—and put it all on the pump).
Then Sufentanyl entered the picture, which we used in pretty much the same combinations with Dormicum.
Honestly, those Fentanyl combos are still being used today, and they seem totally fine to me.

Eventually, Propofol rolled in and slowly became the gold standard for continuous sedation.

Oh, I almost forgot to mention using Thiopental for continuous sedation too. It’s especially common in neurosurgery or when you need to induce a coma. Just load up the Nesdonal on the pump and let it rip!

I should also mention that we sometimes use Anacond. It's this clever method where you basically turn a ventilator into an anesthesia machine. You draw up Sevorane or Forane into a 50ml syringe, hook it to the pump, and connect it via a special applicator directly to the ET tube or cannula. Once you turn the pump on and adjust the flow, the ventilator delivers an inhalation anesthetic with every breath to keep the patient sedated. It’s not super common, though, and doesn't have a massive range of uses.

I really owe a debt of gratitude to the veteran anesthesiologists for all their wisdom... I’ll certainly do my best to make sure some of it actually sticks in my brain 🙂