Workflow of anesthesiology

Premedication

Benzodiazepines are mainstay. Midazolam is most commonly used. However, benzos are less well-
tolerated in older (>65) pts due to risk of delirium. In those cases, pre-medication with alpha 2
antagonist such as dexmetomidine is preferred. However, premedication is not always required

Oxygenation

Goal is to exchange as much N2 in the lung for O2 as possible so that pt can have longer apnea duration.
For typical pt, this does not need to be long. In older pt, diabetic pt, pediatric pt, this is important and
should go for full 3 minutes. Watch end tidal CO2 for monitoring

Anesthesia

Propofol is the default choice here for a few reasons, it is fast acting, and lower BP/blunt vagal response
which is helpful because during intubation there can be vagal stimulation which can increase BP.
However, in pt with risk of hypotension, atomidine is another choice. Prior to propofol, you often want
to give fentanyl or lidocaine for pain. Rocuronium is sometimes given to ensure easier airway. After
anesthesia, you want to give a few more breath to pt to ensure airway

Intubation

If everything is stable, can now intubate. For surgery ~1hr, subglottic airway is viable option. Otherwise
intubate. After intubation, want to check for bilateral lung sound, end tidal CO2, and adequate spO2.
Typical gas anesthetic is sevoflorane, but desflurane is another option. Compared to sevo, desflurane
has more rapid uptake but is pungent, more expensive, and worse for the environment. Desflurane may
worsen asthma and COPD due to its irritation. Target for most gas is MAC = 1.

Additional lines

IV: additional IV is often default. Typical fluid is lactate ringer (less Cl), within 2 hrs. When using
crystalloid to replace blood loss, have to use 3X amount. When using albumin, use 1X. For pts with
diabetes, renal issues etc, the fluid will be goal directed. This means checking to ensure fluid status is
normal via ABG (e.g. hgb is not too dilute, free base is within range) while giving fluid.

Arterial line: this is done for pt > 4hr in the OR. BP goal in anesthesia is >65 mmHg diastole. For pt with
risks of hypotension, e.g. heart disease, diabetes, vasopressors are required. Most common vasopressor
used is phenylephrine. If pt’s BP is too high, then given dilaudid (hydromorphine). For pt with more
persistent hypotension, consider fluid loss, and give albumin.

Paralytic agents: these are often used during surgery for abdominal surgeries. Standard is
succinylcholine or rocuronium. Succinylcholine is more rapid onset, and easier to monitor with
fasciculation following its administration. Rocuronium is better in pt with some renal issues. However, in
pt with really severe renal issues, cistracurium is used because it’s not renally cleared. Cleared via
Hoffman reaction. Reversal is with neostigmine and glycopyrrolate. Can also reverse with sugammadex.

Ventilation modes: there are 4 modes. During anesthesia its either pressure control (preferred in peds)
or volume control (preferred in adults). If doing volume control, then want to ensure pressure is < 40.
20s are usually the sweet spot. If doing pressure control, then want to ensure volume is appropriate.
SIMV is more towards end of case when you want to let pts start getting some of their breathing reflex
back. Pressure support is prior to extubate, want to ensure pt can breath by themselves.

End of anesthesia: as surgery ending, can reduce sevoflurane and add NO. NO is fast on, fast off, but less
potent. It does not go into fat so great for end of surgery. Extubation require stage 2 of anesthesia (pupil
normal rather than constricted, breathing drive)

Drug doses

Phenylephrine 1mg/kg

Benadryl 50mg/kg

Zofran 0.1mg/kg

Dexamethasone 0.5mg/kg

Hydromorphone 0.25mg/kg

Oxycodone 0.1mg/kg