Ink & Air by Optimal Anesthesia

Case Summary Patient Profile 78-year-old female Frail, 40 kg Hypertensive Advanced chronic kidney disease (CKD) Baseline Status Renal function: Creatinine 4 mg/dL, Urea 70 mg/dL, urine output 800 ml/day Hemodynamics: HR 55/min, BP 130/84 mmHg, echocardiogram shows preserved EF Hematology: Hemoglobin 9 g/dL, microcytic normochromic anemia Surgical Course Procedure: Hip arthroplasty under general an...

Case Overview A 32-year-old female with genetically confirmed Alport syndrome, who underwent renal transplantation 5 months ago for end-stage renal disease, presents for bilateral hip core decompression due to probable steroid-induced avascular necrosis. Comorbidities:  Mild bilateral sensorineural hearing loss, no visual complaints, no airway symptoms. Medications:  Tacrolimus, predniso...

Patient Profile Age/Sex:  32-year-old male Procedure:  Arthroscopic Bankart’s repair Background:  Competitive bodybuilder Supplements:  Creatine monohydrate and whey protein daily Laboratory Findings Serum creatinine:  1.4 mg/dL (mildly elevated; reference 0.6–1.2 mg/dL) BUN:  40 mg/dL (upper-normal; reference 7–20 mg/dL) Urine output:  Normal Electrolytes: &nbsp...

Functional Endoscopic Sinus Surgery (FESS) is performed in one of the most anatomically compact and delicate regions of the body. For anesthesiologists, every millimeter of this surgical field carries significance, not only because of its proximity to critical structures but also due to the array of reflexes that may be triggered and the need to balance surgical visibility with patient safety. Ana...

Case Context A 39-year-old male is scheduled for microlumbar discectomy (MLD) at the L3–L4 level in the prone position. Why Spinal Cord Perfusion Matters Although the surgical site lies below the conus medullaris, which typically terminates at L1–L2 in adults, adequate blood flow to the cauda equina and lower cord segments remains crucial. These regions are dependent on segmental arterial supply....

Anesthetic Considerations in a 21-Year-Old Female Undergoing High-Grade L4–S1 Spondylolisthesis Decompression and Fusion A 21-year-old female (BMI 18) presented for high-grade L4–S1 spondylolisthesis decompression and fusion under general anesthesia. The airway was secured in the supine position with a 6.5 mm North Pole nasal RAE tube inserted via the left nostril to minimize oral tube–related sof...

Introduction This chapter describes an anesthetic strategy for a 78-year-old man with Mobitz type II second-degree atrioventricular (AV) block who is scheduled for channel transurethral resection of the prostate (TURP) for an 88-mL prostate. Because of his conduction disease, reduced left ventricular function and diastolic dysfunction, advanced age, and the hemodynamic stresses of TURP, the plan u...

NSAIDs versus Corticosteroids: Renal Safety in Perioperative Care Introduction Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are both frequently employed for pain management and anti-inflammatory purposes in perioperative care. However, their renal safety profiles differ significantly, especially in at-risk populations such as the elderly, diabetics, and patients with pre-exist...

Introduction: Why This Chapter Matters Obesity affects more than 650 million adults worldwide, with its prevalence continuing to rise according to the World Health Organization in 2020. In anesthesia practice, obesity introduces multifaceted challenges such as altered drug metabolism, difficult airway management, and cardiovascular instability. These difficulties are further compounded by common c...

Introduction Vagus Nerve Stimulation (VNS) is a neuromodulation therapy used in patients with treatment-resistant conditions such as epilepsy and depression. The anesthesiologist’s role is central to ensuring safe perioperative management, given the vagus nerve’s complex anatomy and physiology. This chapter reviews anesthetic considerations, with emphasis on differences between right- and left-sid...

BIS 95 at MAC 1.2 — awareness or artifact? In this episode, we cut through the noise with a stepwise framework to decode BIS anomalies and sharpen safe decision-making. 👉 Support & read more:  buymeacoffee.com/optimalanesthesia/tuning-into-bis-truth-unraveling-static-anesthesia-monitoring

Patient Profile 51-year-old female undergoing surgery. Anesthesia maintained at MAC 1.2, corresponding to 1.2 times the alveolar concentration of an inhalational anesthetic such as sevoflurane. Intended depth: sufficient to prevent movement and maintain unconsciousness. Monitoring Data (Philips IntelliVue System) BIS: 95 (expected 40–60 under general anesthesia). SQI: 56 (normal >70). EMG: 37 (...

Vocal cord assessment after surgery is critical in anesthesia, as intubation and airway management can affect vocal cord integrity. This review integrates anatomy, physiology, clinical practice, and diagnostic tools, emphasizing diverse patient populations and resource-limited settings. Anatomy and Physiology of the Vocal Cords Vocal Cord Structure Mucosal folds covering the thyroarytenoid muscles...

The Day Begins: Pre-Anesthesia Clinic The pre-anesthesia clinic is bustling with preparations for a diverse surgical roster, including orthopedic joint replacements, oncologic resections, and cardiac procedures. Regional anesthesia (RA) offers significant advantages—opioid-sparing analgesia, faster recovery, and reduced hospital stays. However, many patients are on antithrombotic therapy, which ra...

Kaplan’s Lesion: Why a Wrist Block Alone Is Inadequate Introduction Kaplan’s lesion is a rare but surgically complex traumatic injury involving disruption of digital neurovascular bundles and flexor tendons, often on the volar aspect of the index finger or hand. Because repair requires precise exposure and neurovascular reconstruction, the anesthetic plan must be comprehensive. A wrist block alone...

Introduction Glomus tumors are rare, benign neoplasms arising from the  glomus body , a neuro-myo-arterial structure specialized for thermoregulation. They are typically  exquisitely painful , particularly when located in subungual or digital regions. Surgery often requires meticulous anesthetic planning due to: High vascularity Neuropathic pain profile Potential need for reconstructive...

Introduction Central venous catheter (CVC) placement is essential in perioperative and critical care for hemodynamic monitoring, fluid therapy, and drug delivery. The procedure carries potential complications, notably cardiac arrhythmias arising from mechanical irritation of cardiac structures. Arrhythmias commonly result from contact with the coronary sinus and right heart due to the anatomical r...

Part 1: Case Presentation and Systems Breakdown Case Snapshot Imagine a 55-year-old man facing an urgent mission: emergency surgery to clean infected wounds on both lower limbs, with the possibility of amputation looming. His body is a battleground of complex conditions. He’s got acute-on-chronic liver disease with grade 3 ascites—think of his belly swollen like an overfilled water balloon, tapped...

Introduction The success of fistula surgery depends on two critical goals: Eradication of the fistula tract Preservation of continence Both rely on accurate preoperative anal sphincter assessment, particularly in complex or recurrent cases. For anesthesiologists, knowledge of how anesthetic agents alter sphincter tone, reflex arcs, and the depth of anesthesia is essential. This understanding ensur...

Perioperative Glycemic Management in Hepatobiliary Surgery: An Integrated Approach Introduction Perioperative glycemic management is crucial in diabetic patients undergoing major hepatobiliary surgery. The liver plays a central role in glucose homeostasis and insulin clearance. Poor glycemic control is linked with higher morbidity and mortality. This article integrates molecular biology, anestheti...

In this episode of  Ink & Air , we confront one of anesthesiology’s most unsettling events: intraoperative awareness. Through a clinical case of a patient who — on postoperative day one — vividly recalls hearing conversations, feeling pressure, and being unable to move, we walk listeners step-by-step through what happened, why it matters, and what clinicians should do next. This is a clin...

Biomarkers in Anesthesiology Biomarkers are objectively measurable characteristics that indicate normal or pathogenic biological processes, or responses to pharmacological interventions. In anesthesiology, they extend beyond traditional vital signs and laboratory tests, providing molecular insights into real-time patient physiology. Types of Biomarkers in Anesthesia Diagnostic Identify the presenc...

Introduction Substance use disorders (SUDs) affect a significant portion of the surgical population. Addiction is now understood as a chronic, relapsing disorder with strong genetic underpinnings—accounting for approximately 40–60% of individual vulnerability. Genetic influences not only determine the risk of addiction but also affect perioperative analgesic needs, opioid responsiveness, and withd...

Introduction Postoperative hypoxemia is common in anesthesia practice. The  A–a gradient  helps identify why oxygen transfer is impaired. A widened gradient indicates inefficient oxygen movement from alveoli to blood. Understanding this concept requires basic physics, physiology, and clinical application. Basics What Is the A–a Gradient? Difference between oxygen in alveoli (PAO₂) and ox...

Introduction NSAIDs are commonly used for perioperative pain management. In cirrhotic patients, their use must be reconsidered due to: Altered pharmacokinetics and pharmacodynamics Fragile homeostasis Risk of renal, gastrointestinal, and bleeding complications Understanding these mechanisms at the molecular level improves safe anesthesia care. Pathophysiology Renal Hypoperfusion and Prostaglandin...