In this episode I review the basic medication setup for the operating room including premedication, induction, neuromuscular blockade, antibiotics, reversal and antiemetics. I discuss weight based dosing and comment on a few alternatives to consider once you have the basic setup down. This episode should be useful for new CA-1s getting started in the OR but I would also like to ask senior residents to comment on what their basic setup is and how it may differ from what I’ve mentioned here.
Here is a list of the medications I discuss: Basic med setup w dosing
12 thoughts on “Episode 9: Basic Med Setup”
I also always have a pre-made syringe of atropine and an epinephrine bristojet (100mcg/ml) immediately available. Additionally, even if my plan is to use non-depolarizing neuromuscular blockers on induction, I keep succinylcholine immediately available. I consider it one of my rescue drugs in the event of laryngospasm or for its potentially utility for a challenging airway.
Great points, Stephen, I agree. I put atropine on the sheet that is posted here with this podcast. And yes, succinylcholine should be ready available for the reasons you mention. Thanks.
What is the reason vecuronium is preferred over rocuronium at Hopkins? It appears to me that rocuronium, in combination with sugammadex as a reversal agent, is an ideal neuromuscular blocking agent for most cases.
Great question. Until last week we didn’t have sugammadex at Hopkins so that wasn’t an option. Between vec and roc, the choice was made to use vec as first line because it was somewhat cheaper than roc. Now that we have sugammadex I would imagine we’ll start seeing more rocuronium used. However, I should say that, as you know, sugammadex does a fairly good job of reversing vecoronium as well, just not quite as rapidly as it reverses roc.
Hi Dr. Wolpaw
This is Farah, a resident in University of Toronto.
Thank you so much for the great teachings. It’s been a daily routine for me to listen to your podcasts.
Thanks so much for the comment. I’m so glad you’re enjoying the show. Good luck with the ongoing training!
Hi Dr. Wolpaw,
Just discovered your podcast, and this was my favorite episode yet! I’m a third year med student at OUWB about to finally begin my anesthesia rotations. This episode provides a solid framework for how I can think about the anesthetic medication plan from start to finish. I’ve listened to some more recent episodes as well and it’s cool to see how far along the podcast has come. Keep up the great work!!
What evidence support the claim that intubation does not cause pain? What mechanism/reflex gives a non-painful sympathetic response? Best regards.
First, I think we can probably agree that intubation, while I’m sure uncomfortable, is not the same as being cut with a scalpel. It’s stimulating, probably fairly uncomfortable, but not “painful” the way a surgical incision is painful. Do we have studies to prove that? Not that I’m aware of, but I think it’s a reasonable assumption.
Second, there is sympathetic innervation of the larynx, and it’s discussed in an interesting way in this article: https://anesthesiology.pubs.asahq.org/article.aspx?articleid=1944215. The hard part is trying to tease out whether the sympathetic activation is from direct stimulation or from discomfort caused by that stimulation. Ultimately I’m not sure it matters. The patient who has received an induction dose of propofol is not going to have any conscious experience of pain or discomfort from intubation and so what we are addressing is the hemodynamic response. If we want to prevent the potential for significant tachycardia and hypertension we can give fentanyl but we can also give esmolol. I would argue, and some would disagree, that esmolol is a better choice that more directly addresses the issue and does not have the negative effects of opioids. As we see more of a move toward opioid free or opioid reduced anesthetics this is being used more and more.
I hope that helps!
Do you think there are pitfalls to undercutting your Robinul dose to prevent tachycardia where acetylcholine could cause untoward effects at muscarinic receptors in places other than the heart such as in the Lungs (bronchoconstriction) or bowel (GI cramps) or is the unopposed ACh too low in concentration? Obviously hemodynamic control is a higher priority than the avoidance of GI cramping but in an asthmatic I wonder if you would give a full 1ml to 1ml ratio?
I haven’t seen any adverse reactions like the ones you describe. I think reducing the glyco just gives you balance where 1:1 is actually an overdose of glyco.
Thank you so much for making this podcast!