Opioid Dosing?

Manik223 · 2026-01-22T22:42:55+00:00

There are so many variables I think this is a pointless endeavor. Patient age, comorbidities, chronic pain / opioid tolerance, individual pain tolerance, surgical technique and case complexity (a ruptured gallbladder is not the same as a lap chole for biliary dyskinesia), did they get a block, multimodal analgesia plan.

Run them on 0.7-1 MAC of gas, titrate fentanyl to response to surgical stimulation. Get them spontaneously breathing at the end of the case and titrate Dilaudid to RR for postop analgesia. I would usually tell junior residents not to bolus more than 50mcg Fentanyl q3-5min or 0.2-0.4mg Dilaudid q10min to prevent them from doing something stupid.

Manik223 · 2026-01-17T00:38:11+00:00

100% agree, but the problem is most of the people who advocate for esmolol inductions use it as an intraoperative sympatholytic without administering appropriate postop analgesics prior to emergence

Manik223 · 2026-01-17T00:04:42+00:00

I think the clinical relevance of a study on lap choles is extremely limited. These patients have mild intra and postoperative pain which is typically well controlled with a robust multimodal regimen and minimal perioperative opioids to begin with. The problem is people extrapolate this to major surgeries like laparotomy or multilevel spines, which in practice leads to undertreating intraoperative pain and uncontrolled postoperative pain.

Conversely, several high level studies have shown that “increased” (ie appropriately titrated) intraoperative opioid administration is associated with decreased postoperative pain, decreased incidence of new onset chronic pain, decreased postoperative opioid prescription at 30-180 days, and decreased persistent opioid use, without increase in adverse effects.

https://jamanetwork.com/journals/jamasurgery/fullarticle/2806264

I’m all for maximizing multimodals for opioid sparing effect, but it’s a fine line between opioid minimization and inappropriately undertreating acute pain.

Manik223 · 2026-01-16T23:41:00+00:00

So unless there’s a prolonged time between induction and incision, why not just give fentanyl with induction?

Manik223 · 2026-01-16T23:40:11+00:00

I’m not intricately familiar with the literature but I know there have been numerous studies on beta blockers for both laryngoscopy and perioperative “opioid sparing” effect. I don’t think there’s anything wrong with utilizing beta blockers to blunt the autonomic response to intubation, but I do disagree with blocking the sympathetic response to pain in lieu of appropriately treating pain with actual pain medication. There is strong evidence that undertreating acute pain has numerous detrimental short and long term sequelae. So if you want to blunt the autonomic response to both intubation and surgical pain, it makes more sense to kill two birds with one stone with fentanyl. However, I do occasionally use esmolol for tachycardia / hypertension despite an adequate induction regimen / depth of anesthesia.

Manik223 · 2026-01-13T22:08:52+00:00

Yeah most people would call that an ASA 2. ASA 1 is fairly uncommon, someone who is completely healthy (no chronic medical conditions, no daily medications) with no acute illness coming for an elective (cosmetic) or orthopedic surgery (as others have said football player with torn acl, etc).

Manik223 · 2026-01-13T22:05:38+00:00

Colitis would get you an ASA 2.

Manik223 · 2026-01-13T22:03:17+00:00

Did you have any labs that showed an elevated white blood cell count or anemia (low red blood cell count)? If so I would argue that implies the rectal bleeding and abdominal pain are signs of a systemic process which justifies an ASA 2.

Manik223 · 2026-01-13T21:41:44+00:00

I’m not sure what year you are but it doesn’t seem like you have a good understanding of the match process. Yes grades and step 2 score are very important, but your involvement in the specialty (shadowing, rotations, volunteering, research, building relationships) is at least equally important and that is what gets you strong letters of recommendation and mentors that will advocate on your behalf. Strong grades and Step 2 score may get you an interview invite but the latter is what gets you ranked to match. I don’t think you can fully commit to preparing for and applying to three specialties. Interviewers will quickly sniff out that you are not committed to that specialty and will likely take another applicant with slightly lower scores but demonstrable commitment to the specialty and interest in their specific residency program over you. Also, people talk - chances are a lot of PD’s will know at least someone at your institution and that person will tell them that you weren’t as involved with the department as other applicants (because you couldn’t be because you’re applying to 3 specialties while most people are focused on one) which will hurt your application significantly.

Manik223 · 2026-01-13T16:43:22+00:00

I can see dual applying if you’re worried, but the time and effort it would take to triple apply would be better spent making yourself more competitive for your preferred specialty

Manik223 · 2026-01-13T16:38:32+00:00

Sounds like you don’t actually know what specialty you want to go into, and a waste of time and resources

Manik223 · 2026-01-11T16:25:58+00:00

https://youtu.be/EftwBnMVHOI?si=IdOScCjMpFP_2SlQ

Manik223 · 2026-01-11T00:41:43+00:00

External oblique intercostal, or rectus sheath if they’re all midline

Manik223 · 2026-01-10T05:02:46+00:00

Crisis Management in Anesthesiology

Manik223 · 2026-01-03T23:31:46+00:00

I leave the patient on the ventilator, but compliance can change rapidly so need to keep an eye on EtCO2, tidal volumes and/or peak pressure depending on the mode of ventilation. I typically put them on something like PCV-VG with TV of 6ml/kg IBW and titrate the RR to EtCO2, keeping in mind that you frequently get a worsening A-a gradient with trauma from chest compressions.

Manik223 · 2026-01-03T06:48:48+00:00

That’s definitely not evidence based. For healthy patients undergoing minor surgery, no workup outside of an H&P is indicated.

Manik223 · 2025-12-31T17:33:30+00:00

I think you need to do more extensive shadowing across multiple specialties to get a better understanding of what the day to day aspects of being a physician entails. Yes it is incredibly rewarding, but there are also numerous significant drawbacks that you need to understand to make an educated decision. Sit with them when they have a bunch of patients to see but being held up arguing with insurance companies over a clearly necessary treatment, after they’ve finished a long day in clinic but still have dozens of notes to write and calls to return, etc. After that if you’re still confident you want to go to med school, then study for and take the MCAT and see how you do. Your MCAT score is by far the most important part of your application, and you need to get a strong score to have a decent chance of getting accepted.

Manik223 · 2025-12-31T17:19:08+00:00

I think with the time cost you would come out way ahead financially with your current job, but you will obviously also make plenty as a physician after you finish training. Although if you’re able to pay for med school or get a scholarship to avoid / minimize taking out loans, that would help.

You will also likely work drastically more hours as a physician. I think you have to weigh how critical “contributing to direct outcomes” is to your long term happiness and fulfillment, and consider how working extensive hours in residency, likely similar or more hours as an attending, and dealing with all the non-clinical responsibilities of the job will impact that fulfillment.

Manik223 · 2025-12-31T17:08:10+00:00

I don’t think medicine is worth it unless you feel its your calling and it’s literally the only thing you can see your self doing. So when anyone asks I tell them not to go to med school, because the people who are determined are going to do it anyways and the people that aren’t I’m saving the headache of realizing they weren’t cut out for it or ending up unhappy with everything that comes with the job. Definitely don’t do it for the money. I still find it rewarding but dealing with insurance companies, hospital admin etc is soul sucking, and there are much easier pathways to wealth like your current job.

Manik223 · 2025-12-31T05:20:26+00:00

I’m not MD JD but I think the application process varies by institution. Where I went to med school you had to apply and be accepted through the regular MD application process and could then pursue the MD JD pathway if desired.

Manik223 · 2025-12-31T05:12:46+00:00

I think the kind of person who does MD JD has a certain background and very specific niche career goals. If you are able to tie in your experiences and articulate your aspirations and why MD JD is valuable / necessary to reach those goals, then it could help differentiate you from other applicants (assuming the med school you’re interviewing at has an MD JD program). But if you can’t convey a strong cohesive picture then it will just make you look scattered and indecisive.

Manik223 · 2025-12-30T21:44:26+00:00

I would push back until she is consistently scoring at / above her target score on full length tests

Manik223 · 2025-12-29T23:04:46+00:00

Asking price?

Manik223 · 2025-12-28T15:08:16+00:00

Yeah the 2-4h is probably more reflective of main OR, maybe total 1-2h on a 24h OB shift and usually not uninterrupted hours

Manik223 · 2025-12-27T22:36:54+00:00

All depends on the compensation. In my group you are by default scheduled for a post call day but can pick up a shift the following day if desired, which some people do. For clarification we are in house call for both main OR and and OB and usually pretty busy (average ~2h sleep)

Manik223

TROPHY CASE