Anesthesia, Resuscitation, and ICU: Q&A

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 😁

We usually only pull the trigger on relaxation when it’s absolutely necessary. By "necessary," I mean there are times when an anesthesiologist decides that, given the specific nature of the illness or injury, having a totally relaxed patient is actually better than just having someone who's sedated—even if they seem relatively calm to us.
As for Paracetamol, we use it in the ICU, specifically the IV version called Perfalgan (it comes in those 100ml vials). The reason you don't see it used more often is basically a headache with Medicare coverage; it's not on the standard formulary, so it has to be brought in through special emergency imports. At least from what I can tell, that creates a massive hassle for hospitals and medical suppliers who really don't feel like jumping through hoops for such a small amount.
I'm not entirely sure what you meant by NSAIDs, though I'm guessing you're talking about non-steroidal anti-inflammatories... regardless, we use pretty much everything when it comes to analgesics—Analgin, Paracetamol, Ketoral, Tramal, Dolantin, the Fentanyl I mentioned earlier, even the Tramal and Paracetamol combo known as Zaldiar, and I've even seen people handing out Ibuprofen... honestly, even in the ICU, we're starting to see PCA pumps (patient-controlled analgesia) being used, albeit very sparingly. Plus, if a epidural catheter was placed during the procedure, we usually keep using it for pain management in the recovery period. So yeah, there are plenty of methods available. The bigger issue is that pain management often lacks a personal touch; sometimes a patient is in pain simply because they aren't following a specific doctor's protocol regarding how much analgesia should be handed out... while another patient might not just be pain-free, but they'll be "troublesome" in a different way, sleeping like a baby all day and night...😁....but hey, that's a whole other conversation and I don't want to start a whole new thread here...

urbanscout50 said:So yeah, that's pretty much the gist of it, keeping it short and sweet

😂.....👍....

Hello to all the on-duty professionals here. It’s clear everyone on this forum is incredibly knowledgeable. I recently met the anesthesiologist who handled my heart surgery less than two months ago—a very handsome young doctor.🙂 He was actually quite surprised that I took such an interest in finding out who my anesthesiologist was; in practice, most patients don't really care who administers their anesthesia, nor do they realize how vital that role is. I'm just so glad I got to meet him. I didn't think to ask him directly at the time, so instead, I'll ask you: how long does it typically take for a patient to wake up in the ICU following a procedure like mine (a Bentall procedure)? All I can say about my time in the ICU was 😢😢😢 brrrrrrrrrrrr
Warm regards to everyone,🙂

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.

Scott Bennett4, hey there. I’ve been wondering about this too, honestly. When people claim that getting too much anesthesia is bad for you, what exactly do they mean by that? Like, in what sense is it actually harmful? 🤷

Are you referring to the total number of general anesthesias performed, or the specific dosage of certain drugs?

Chloe Johnson24 said:... how long did I sleep after my surgery (that Bentall aortic root replacement) basically, how long does it take for a patient to wake up in the ICU?

Honestly, if things are looking stable, the ECG looks good, and there isn't crazy drainage coming from the chest tubes... there’s really no reason to keep someone sedated on a ventilator longer than necessary. We just stop the Propofol infusion and wait for them to start "breathing through" it on their own. It’s super individual, though. I’ve seen people start triggering the vent and opening their eyes almost immediately after we cut the Propofol, but then you have others who sleep like a log for hours—to the point where you actually start worrying they might have had a stroke and find yourself checking their pupils and wondering if you need to call a neurologist....😁....

Sam Hall15 said:Generally speaking, I don't think poor ventilator synchronization is much of an excuse to throw in a relaxant, unless things are truly extreme.

Hmm... you know, sometimes that "extreme" can happen way more often than you'd think. It’s true that those stretches aren't super common in the ICU, but honestly, you can't just wish away the chaos. When you're dealing with neurosurgery traumas where you absolutely need "peace in the brain," or major multi-trauma cases—especially those nasty lung contusions or ARDS—you almost always need fully controlled ventilation and regular relaxation, especially during those first few critical days.

I mean, I mostly agree with you. Usually, sync issues with the vent aren't the main culprit. It’s rarely an issue if there's an anesthesiologist on duty who actually knows how to handle pressure-assisted modes—someone who actually understands the nuances of BIPAP, CPAP+ASB, or APRV. But man, when you get some of those "old schoolers" on shift, that's when the "syncing" problems really start, because the older docs usually don't want to bother with the fine-tuning of different ventilation modes; they just want to stick to the basics and say, "just give me CMV or SIMV, set this tidal volume, and crank the frequency to this"... 😁

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? 😁

Sam Hall15 said:Mechanical ventilation—I mean, who doesn't love that? 😁

Patients on ventilators 🙂

Personally, I find myself wondering about the cumulative damage caused by the sheer frequency of general anesthesia versus the various other types out there. At the end of the day, we have to acknowledge that all these substances act as "toxins" in some capacity. It’s why, regardless of which anesthetic is used, you always find yourself being urged to hydrate aggressively—it's a desperate attempt to help the body flush those harmful compounds out of its system as quickly as possible.

Sam Hall15 said:you know, we could probably fix this if we had a solid system where anesthesiologists focused specifically on the ICU—like, instead of just floating around, they’d be assigned to specific patients across all departments alongside the on-call ICU doc, deciding everything during morning rounds for people they actually know, which makes adjusting care throughout the day a breeze. I'm sure there are plenty of anesthesiologists out there who have a subspecialty in intensive care, or even if they don't, they're basically more of an intensivist type anyway, and let's face it, who doesn't love playing around with mechanical ventilation??? 😁

Hmm... I don't think I'm gonna side with you on this one... Joe, no way!.... Personally, I feel like this whole "everyone manages their own patient" setup is a total disaster for any ward, but that's a whole different conversation and I don't want to go down that rabbit hole right now...
As for the ICU specifically, what you're suggesting just wouldn't fly in practice here. In the ICU, the responsibility for a patient lies solely with the attending physician on duty. Nobody else. Once an anesthesiologist moves a patient from the OR or the ER into the ICU, their job is to hand that patient over both verbally and in writing to the ICU doctor, and then it's goodbye... they move straight back to the surgical schedule, and given how fast things move in the ICU, that anesthesiologist won't have anything to do with how that patient is treated after they leave.

When it comes to subspecialties, in this country, it's pretty much a meaningless designation for now. The people taking those subspecialties are usually anesthesiologists who have already been working in the ICU for 10 or 20 years, so they aren't exactly gaining new wisdom... meanwhile, neurologists and internists who try to get into that specialty end up in a bit of a mess because most hospitals won't even bother since we basically lack competent neurological or internal medicine ICU specialists.

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.

Kimberly Edwards38 said:Personally, I'm curious about how much damage the number of general anesthetics—or any other type—actually does. Since they're all essentially "toxins" in some way, isn't it true that after any anesthesia, they push you to drink a lot of fluids just so your body can flush out the harmful substances as quickly as possible?

Anesthetics aren't really any more "toxic" than most other medications, and they generally don't leave lasting consequences. There’s no reason to force excessive fluids right after surgery; in fact, during those first few hours, intake should actually be limited depending on the specific type of anesthesia used.

So, you're telling me there are no lasting consequences? I find that somewhat difficult to swallow, honestly, but if it’s coming straight from the doctor's recommendation, then I suppose I can proceed with the same approach 🙂. Dr. Anthony, I truly appreciate the clarification.

Sam Hall15 said:Why don't you agree? Science shows survival rates are higher in ICUs led by intensivists rather than other types of doctors, and even though we're talking about non-anesthesia populations—and looking at how things work primarily in North America—I still think having them can help treat patients in the ICU if there's someone, or better yet, several people, who take extra training in that field to stay more up to date than, say, those who don't find critical care particularly interesting. An anesthesiologist-intensivist actually has a much broader scope of practice; they’re ideal for mixed ICUs (like internal medicine/surgical units) and make better consultants in pediatric and neonatal ICUs, etc. Having an intensivist present doesn't diminish the responsibility of the on-call doctor who hasn't sub-specialized, nor does it limit their range of action. Honestly, those anesthesiologists can handle any ICU without breaking a sweat.

Hold on a second... I think we might be talking past each other here...🙂....Forget the science, forget North America, and stop looking at ICUs through this theoretical lens....

The reality on the ground here is this:
anesthesiologist = intensivist
Through their residency, an anesthesiologist picks up almost all the knowledge and—more importantly—the hands-on skills needed to manage a patient in the ICU. I mean, what’s the point for an anesthesiologist who’s been pulling ICU shifts for twenty years and knows all the tricks by heart to go through a sub-specialty program just to sit through lectures on stuff they've already been doing for decades? You won't convince me otherwise. What's worse, parts of that sub-specialty training have to be supervised by people who barely even touch critical care. They have no clue. They’re just some big-shot professors in neurology or internal medicine who act tough and toss around "intensive care" titles.

As for the other specialties that should technically cover critical care within their scope—pediatricians, neurologists, and internists—for the vast majority, with maybe a couple of exceptions, they either only dabble in intensive care or don't touch it at all. Most of them just see that part of the job as a massive headache and a total waste of time. So, if one of them actually decides to go for an intensive care sub-specialty, they end up like Alice in Wonderland—they don't really know what they're doing, they can't practice the skills, and most importantly, they aren't going to actually perform intensive care once they head back to their home departments...
I mentioned a few exceptions. Among the non-anesthesia doctors who are actual intensivists, you only see them in:
- the infectious disease ICU at a major hospital like Mayo Clinic
- pediatric/neonatal ICUs at places like Children's Hospital of Philadelphia
- pediatric ICUs in a city like Miami
- parts of the neurological ICU at a major center (though the intubations there are handled by anesthesiologists from Neurosurgery)
and maybe one or two other ICUs in the US
...and that's pretty much it... nothing else...
Every other neuro/internal med/cardio/infectious disease ICU is basically a joke where it's impossible to fully manage a patient's cardio-respiratory needs, which is the whole damn point of an ICU. Regardless of whether someone finished a sub-specialty or not.

I didn't quite catch what you meant about anesthesiologists being in ICUs run by other specialties. I hope you aren't seriously suggesting that an anesthesiologist would work under a neurologist or an internist in an ICU?... Joe, please, don't ever suggest that to anyone...😁...you'll end up getting scalped....🙂

That was simply a suggestion 😁 but from what I’ve gathered through my conversations with anesthesiologists, they aren't particularly keen on the idea. Even at the hospital where I completed most of my clinical rotations, the anesthesiologist is the one who consistently handles consultations for non-surgical JILs.
Another clear sign of the lack of readiness and certain snobbery among other physicians can be seen in difficult intubation and resuscitation scenarios. In those moments, no one seems to think of—or even wants to—call an anesthesiologist. This leads to the patient being intubated only when there is nothing left to lose, followed by the ultimate shrug from internists and pediatricians: "there was nothing we could do." I am not suggesting anesthesiologists are omnipotent, but for any complex resuscitation on any ward, one should consult an anesthesiologist, given their specialization in anesthesia, resuscitation and intensive care.
From my observations, internists and pediatricians struggle to look beyond the narrow scope of their own specialties; they fail to see the patient through the lens of intensive medicine, focusing instead on the primary disease. Consequently, I believe that until significant changes are made to our medical training, the anesthesiologist remains the ultimate authority for all types of JILs, whether surgical or non-surgical. At its core, intensive medicine is the same regardless of the underlying pathology, though many clearly fail to grasp this.
I agree that an experienced anesthesiologist has already mastered their craft and doesn't strictly require additional formal education. However, subspecialization exposes you to more non-surgical JILs, making you more competent. The issue in America is that on those JILs, you are often met by people who actually know less about intensive medicine than you do...

Scott Allen10, let's start a medical revolution in America!!! :P 😁

Honestly, I was pretty surprised to find out there’s no actual harm involved, especially considering all that noise about how anesthesia is supposedly bad for you. My mom was even lecturing me when I needed sedation for a gastroscopy, saying, "Not now, honey, you’re having two different types of anesthesia—oh my, it's dangerous, it leaves lasting effects on your brain." 😂😂😂😂😂😂😂😂 I mean, I haven't exactly heard of anyone actually "damaging" their brain from anesthesia. 😁 I don't really get what the big deal is regarding these compounds being harmful to the body, since they basically just clear out of your system in a couple of days after surgery anyway, right?

electricpanther82, I haven’t actually encountered this theory regarding brain damage before—though perhaps we just haven't collectively realized it yet, 🤷—but I have certainly overheard enough people insisting that every single bout of anesthesia effectively shaves five years off your life expectancy 👎. If that were true, it would mean I don't exactly have a massive reservoir of time left to spend, 😕. So, when the opportunity arose to ask the experts who actually know what they're talking about, I figured, why not? Let's take the risk. In my estimation, while anesthesia is technically just a drug like any other, we aren't talking about micro-doses here; these are significant amounts, so the possibility of side effects remains a valid concern. But honestly, I'll cross that bridge when I come to it. Best,