Optimal Anesthesia by RENNY

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 oxygen in ar...

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...

Overview and Key Learning Objective Definition: NIDP uses neuromuscular blocking agents (NMBAs) to achieve profound skeletal muscle relaxation (TOF = 0)  without  endotracheal intubation. Goal: absolute surgical immobility while maintaining spontaneous or assisted ventilation. Requirements: modern pharmacology, airway-support tools (e.g., HFNC), and quantitative neuromuscular monitoring. Key learn...

Introduction Managing anesthesia for a 7-year-old, 30 kg male with congenital talipes equinovarus (clubfoot) undergoing bilateral tendo-Achilles lengthening presents specific challenges related to age, anatomy, and the surgical plan. This discussion outlines a resident-level anesthesia approach for a planned 90-minute procedure. The approach is described using the analogy of conducting a symphony:...

Mastering Airway Management: Handling a Defective Pilot System in an Endotracheal Tube Airway management is a cornerstone of anesthesia practice. While most challenges are anticipated and managed with established protocols, rare but serious complications demand special attention. One such event is a defective pilot system in an endotracheal tube (ETT). The pilot system—comprising the pilot balloon...

Introduction: A Lesson I’ll Never Forget I still remember a moment early in my training that reshaped how I think about cardiac function. We were discussing a patient scheduled for non-cardiac surgery with an ejection fraction (EF) of 35%. My teacher turned to me and asked: “What do you think is an acceptable EF for surgery?” I replied confidently: “I think anything above 50% should be acceptable....

Perioperative Management of a High-Risk Cardiac Patient for Laparoscopic Anterior Resection Patient Overview A 78-year-old male, weighing 50 kg and 160 cm tall (BMI 19.5), with a history of prior percutaneous coronary intervention and moderate left ventricular dysfunction, was scheduled for a 4-hour laparoscopic anterior resection. His baseline vitals showed a heart rate of 62 beats per minute and...

Introduction In clinical anesthesia, the success of our practice is not determined only by drugs, monitors, or machines, but by how well we establish  contact , maintain  communication , and build  connection —not just with patients, but with their  biology . Every anesthetic encounter is a dialogue between human physiology and our interventions. This article reframes routine anesthetic practice a...

Case Overview A 22-year-old, 55 kg male presents for tibial interlocking surgery 10 days after sustaining a head injury with pneumocephalus and an open tibial fracture. He was ventilated for 3 days, extubated 6 days ago, and has a history of seizure disorder, untreated for 10 years. He is currently maintained on levetiracetam (Levipil) for seizure control. Despite receiving both a buprenorphine pa...

Clinical Snapshot A 45-year-old male with end-stage renal disease (ESRD) due to IgA nephropathy, body mass index (BMI) of 26, was scheduled for renal transplantation. His main preoperative concern was persistent hyperkalemia greater than 5.4 mmol/L. The nephrologist prescribed salbutamol nebulization every six hours to reduce serum potassium. Heparin exposure likely contributed to type IV renal tu...

Case Presentation A 73-year-old male, 14 years post-liver transplant for hepatitis B-related hepatocellular carcinoma, presented for elective bilateral transabdominal preperitoneal (TAPP) inguinal hernia repair. He had normal liver function tests, a bifascicular block on ECG with a PR interval of 120 ms, and a normal echocardiogram. Current Medications Tacrolimus (Pangraf) 1 mg morning, 0.5 mg eve...

Introduction Empagliflozin is a sodium–glucose cotransporter-2 (SGLT2) inhibitor used to treat type 2 diabetes, heart failure with reduced ejection fraction (HFrEF), and chronic kidney disease (CKD). It confers important cardio-renal benefits but introduces unique perioperative considerations. This guide summarizes when to stop and restart empagliflozin and how to manage its perioperative risks. P...

Summary of Case Patient: 59-year-old male, weight 45 kg, underwent gastrectomy. Postoperative course: On postoperative day 2 he developed supraventricular tachycardia (SVT). Key clinical data: Recent transthoracic echocardiogram (23 June 2025): moderate systolic dysfunction (EF 20–40%), global left ventricular hypokinesia, grade I LV diastolic dysfunction, and mild pulmonary arterial hypertension...

Introduction Succinylcholine chloride remains a cornerstone of anesthetic practice, especially for rapid-sequence induction and emergent airway control. Its ultrashort duration and depolarizing mechanism make it uniquely suited to these scenarios, but safe, reliable clinical performance depends on appropriate storage. Understanding the chemical and physical stability of succinylcholine, the hazard...

Case Scenario A 58-year-old male with alcohol-related cirrhosis (Child-Pugh B, MELD 18) is scheduled for arthroscopic rotator cuff repair in the beach-chair position. Pertinent findings: Mild ascites. INR 1.6, platelets 72,000/µL. Serum albumin 2.6 g/dL, total bilirubin 2.3 mg/dL. Occasional evening confusion consistent with Grade I hepatic encephalopathy. Medications: lactulose, spironolactone, f...

Sympathetic Crashing Acute Pulmonary Edema (SCAPE) – An Anesthesia Perspective Sympathetic Crashing Acute Pulmonary Edema (SCAPE) is a rapidly progressive form of decompensated heart failure triggered by a neurohormonal surge. Unlike volume-overload heart failure, SCAPE is primarily an  afterload mismatch syndrome , characterized by preserved or elevated cardiac output, sudden pulmonary edema, and...

CASE HISTORY A 53-year-old male with known intestinal B-cell lymphoma, previously treated with chemotherapy, presented with an acute abdomen characterized by generalized peritonitis, fever, and altered sensorium. CT imaging of the abdomen revealed an ileal perforation with approximately five liters of free ascitic fluid. On arrival his heart rate was 122 beats per minute, blood pressure 86/48 mmHg...

Clinical Background A 51-year-old male with type 2 diabetes mellitus and a recent Frey’s procedure for chronic pancreatitis was admitted to the ICU with a liver abscess, which was drained via pigtail catheter. His course was complicated by septic shock and multiorgan dysfunction syndrome (MODS). He required vasopressor support, ventilator assistance, and had evidence of renal, hematologic, and met...

Anesthetic Considerations for Orchidectomy Across Age Groups Introduction Orchidectomy is a definitive surgical intervention performed for a variety of urological conditions, including testicular torsion, trauma, and as part of hormonal therapy for advanced prostate cancer. For the anesthesia resident, it is important to approach such cases with an integrated understanding of segmental neuroanatom...

Oxytocin is a cornerstone drug in obstetric anesthesia. It is used primarily during cesarean delivery to promote uterine contraction and reduce the risk of postpartum hemorrhage (PPH). Because oxytocin given rapidly as an intravenous (IV) bolus can produce important systemic and hemodynamic effects, dosing must be precise. Lower, slower doses usually achieve the desired uterotonic effect while red...

Case Overview A 36-year-old, 65 kg male patient presented with multiple traumatic injuries. He had sustained a flail chest involving ribs 4–8, which was surgically fixed a week earlier. Additional injuries included pulmonary contusion, L-spine fracture, multiple long bone fractures, and a Grade IV splenic laceration. At baseline, his heart rate was 98 beats per minute, blood pressure was 170/110 m...

Case Summary A 55-year-old male, one day after renal transplantation, developed sudden dyspnea with oxygen saturation falling to 55%. Chest X-ray showed pulmonary edema. Echocardiography revealed a fall in ejection fraction from 50% preoperatively to 35%, consistent with stress cardiomyopathy. BNP was elevated at 687 pg/mL while troponin I remained normal. Fluid balance was neutral, with intake ma...

Clinical Context An 85-year-old female with hypertension (blood pressure 170/85 mmHg) undergoes open reduction and internal fixation (ORIF) of a distal humerus fracture. A pneumatic tourniquet inflated to 200 mmHg fails to fully suppress arterial bleeding. This clinical scenario highlights the interaction of vascular physiology, tissue mechanics, molecular signaling, and neurohumoral reflexes in d...

Every time you administer a local anesthetic, give succinylcholine, or correct potassium levels, you are manipulating ion gradients. The Nernst concept explains how these ion gradients create electrical forces that control nerve conduction, muscle activity, and cardiac rhythm. In anesthesia we rarely write the equation at the bedside, but we observe its effects in every case. A solid conceptual gr...