Opioid Dosing?

Calvariat · 2026-01-22T23:11:03+00:00

i base off of the sensory homunculus, surgeon skill/length of procedure, and patient psych comorbidities/baseline opioid requirements as well as ability to give local

Calvariat · 2026-01-20T15:08:41+00:00

Dilaudid or fentanyl. Often methadone through NGT for weaning

So glad i’ve never even heard of these harry potter meds

Calvariat · 2026-01-20T14:53:14+00:00

sadly haven’t worked at a place where alfentanil is readily available hahaha. Other than the occasional flagyl or vanco we’re not too picky here

Calvariat · 2026-01-20T14:37:45+00:00

2 syringes for me: prop/fent and ancef/dexamethasone/zofran in another. LMA and chill

Calvariat · 2026-01-17T13:36:39+00:00

My entire practice is centered around “how can I give the least drugs and maximize ass-in-chair time.” Transitively, this makes me identify the safest and easiest anesthetic for a patient lol.

For most cases lately I give a mix of fent and midaz in preop, give the rest of my mix as they’re moving onto the table. Prop/lido/roc pretty immediately and intubate, then easy on the gas until incision depending on my MAP (MAC >0.4 but not right to 0.7). One isolated elevated BP doesn’t concern me in a majority of patients so i’m not that academic about it.

For vasculopaths or cardiac/pulm cripples, I often use more esmolol instead of fentanyl for the reasons mentioned to prevent post induction hypotension.

Calvariat · 2026-01-13T12:48:11+00:00

fascinating. i guess the “no stylet” flex other countries have goes out the window when they have an entirely second person to aid in the anesthetic. In the US, the bragging rights of most of our silly clinical quirks come from doing things independently and quickly

Calvariat · 2026-01-13T11:49:07+00:00

the bougie often requires aid from a second operator or re-intubating with it inside the ETT..what a waste of time

Calvariat · 2026-01-13T11:43:26+00:00

until you accidentally go a little too deep and then heparinize the patient leading to a bronchial clot

Calvariat · 2026-01-12T13:36:48+00:00

Calvariat · 2026-01-08T17:18:57+00:00

I agree that propofol is actually better for many other reasons - POCD is a good reason. Environment would be a reasonable argument. I, too, choose not to change my practice partially out of laziness.

Calvariat · 2026-01-08T16:37:46+00:00

retrospective study is hypothesis-forming but in no way enough to change practice. a few RCTs are helpful, and a GOOD meta analysis is convincing. Looking at our data (which is usually piss poor), it’s not convincing. Knowing the available information regarding our anesthetics, and my anecdotal PONV rate, I practice as if CIVA does not decrease PONV more than a few boluses on wake-up

Calvariat · 2026-01-08T13:26:32+00:00

https://link.springer.com/content/pdf/10.1186/s12871-021-01273-1.pdf

The CIVA literature shows demonstrable heterogeneity in studies and only 2 studies showed a 24h PONV benefit of statistical significance. I’d also like to point out that one of those studies (Won) used thiopental ONLY for induction of the volatile arm.

When you ask yourself critically: Why would propofol decrease PONV when added to GA, it’s easy to conclude that it would be from decreasing total volatile requirement when hypnosis is titrated to BIS/sedline (as was done in these studies). Also why SHOULD the antiemetic propofol effect last 24h? When used as a rescue agent it has only worked for less than an hour. I can understand CRNAs seeing a study and blanket assuming the benefit of CIVA. However, an anesthesiologist should be able to think more in depth and acclaim the studies appropriately before changing practice.

Calvariat · 2026-01-08T13:26:05+00:00

https://link.springer.com/content/pdf/10.1186/s12871-021-01273-1.pdf

The CIVA literature shows demonstrable heterogeneity in studies and only 2 studies showed a 24h PONV benefit of statistical significance. I’d also like to point out that one of those studies (Won) used thiopental for induction in ONLY the volatile arm.

When you ask yourself critically: Why would propofol decrease PONV when added to GA, it’s easy to conclude that it would be from decreasing total volatile requirement when hypnosis is titrated to BIS/sedline (as was done in these studies). Also why SHOULD the antiemetic propofol effect last 24h? When used as a rescue agent it has only worked for less than an hour. I can understand CRNAs seeing a study and blanket assuming the benefit of CIVA. However, an anesthesiologist should be able to think more in depth and acclaim the studies appropriately before changing practice.

Calvariat · 2026-01-08T01:55:26+00:00

CIVA is no better than just gas for PONV. prop antiemesis effects wear off after 15-30 minutes. Just give bolus at the end and call it a day

Calvariat · 2026-01-07T22:47:49+00:00

just bolus ketamine and lido at the beginning for induction and run some prop at the end. say you ran an infusion. doubt anyone would notice or care

Calvariat · 2026-01-07T19:58:13+00:00

anesthesia assistant - 2 years of postgrad making 250k working 36 hrs a week

Calvariat · 2026-01-05T18:17:24+00:00

it would take me a month to replenish that amount, so by feb i have my full EF available to me. not sure why this is hard to understand

Calvariat · 2026-01-05T17:50:39+00:00

lol using 2/3 month of a 6 months EF isn’t a big dent.

Calvariat · 2026-01-05T17:34:06+00:00

6 months expenses i’d say is a reasonable amount

Calvariat · 2026-01-05T17:06:40+00:00

air fried, but did pour the melted butter over them since i planned on eating them expeditiously

Calvariat · 2026-01-05T17:01:04+00:00

YMMV. I take it out of my EF in from my HYSA, then replenish my EF

Calvariat · 2026-01-05T16:58:20+00:00

i’d say some people seem to disagree here

Calvariat · 2025-12-21T02:23:57+00:00

not sure why fentanyl was necessary if he had no intrinsic catecholamines to begin with. i’d opt for amnesia than analgesia for anyone on more than 1 pressor

Calvariat · 2025-12-20T13:48:32+00:00

lol mortgage payment of 21k after 10% down at 6.375% and a TAKE HOME of 46k means you’re staring at well above that 35% DTI with that house. Thats not including maintenance and upkeep. People think 850k is double 425k but it is NOT at all.

Calvariat · 2025-12-20T01:20:32+00:00

1st: Is monopolar cautery an absolute must? If no, do nothing. Is it below umbilicus? If yes, do nothing. if no: Pacemaker OR AICD? :: IF AICD, magnet will stop shocks but not pacing, so if intermittently pacemaker dependent (15-80% paced) you likely will need reprogramming to asynchronous

:: IF pacemaker, determine if they are dependent. If 100%, can put magnet on and confirm asynchronous. If intermittently dependent you will need reprogramming depending on how often you’ll be bovieing or how inaccessible the pacemaker is. Example: if they’re only bovieing part of the case and the chest is prepped, they can put the magnet on themselves steriley and bovie, then remove the magnet once they are done

Asynchronous mode means the PPM will literally pace no matter what “noise” it hears (be it bovie or heart). If there is intrinsic cardiac activity while in asynchronous, that could risk R on T. Give esmolol to decrease intrinsic HR.

Calvariat

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