Skip to content

Anesthesia Sub-I

Today
Start here
Prepare the room
Airway
Drugs
Learn
Practice
Evaluations

Fictional case · 9 stages

Lap chole: night-before to PACU

Choose what you’d do at each stage, then reveal the teaching points. Adapted from the sub-internship course, with current corrections.

Fictional patient

Teaching scenario only. The supervising anesthesiologist makes every real decision.

Stage 1 of 9

Stage 1

The night before

You’re assigned a 45-year-old for elective lap chole: HTN, OSA (CPAP), GERD, BMI 34. What do you do tonight?

Review the chart in the EHR
Text your resident the patient’s name and history
Text your resident: “What would you like set up for your 7:30?”
Look for prior anesthesia records

Teaching points

Prepare in the EHR; message your resident without identifiers. Prior anesthesia records are gold — a previous difficult airway changes everything.

Stage 2

Airway concerns

What airway issues do obesity and OSA raise?

Harder mask ventilation
Faster desaturation during apnea
Awake intubation is required because BMI > 30
Post-op obstruction risk

Teaching points

Obesity/OSA → harder mask ventilation, less apnea tolerance, post-op obstruction. An awake technique is a team decision based on the whole picture — not BMI alone. Exam: Mallampati, thyromental distance, neck circumference, mouth opening.

Stage 3

Aspiration risk

GERD is listed. What determines whether the team chooses RSI?

Current reflux symptoms and control
Fasting history
GLP-1 agonist use and GI symptoms
The GERD diagnosis alone

Teaching points

GERD + obesity do not automatically mean RSI. Symptom control, fasting, GLP-1 use and the overall aspiration picture inform the team’s choice.

Stage 4

Your proposed plan

Which belong in a reasonable plan to propose?

Ramped position and head-up pre-oxygenation
Propofol, fentanyl, rocuronium (doses per team)
Video laryngoscope available; SGA backup
Lung-protective ventilation (6–8 mL/kg PBW + PEEP)
Ondansetron + dexamethasone for PONV

Teaching points

All reasonable to propose. Also anticipate pneumoperitoneum: ↑ETCO₂ (CO₂ absorption), ↑airway pressures, ↓venous return in reverse Trendelenburg.

Stage 5

Morning setup

You arrive at 7:00. What’s first?

Find your resident and confirm the plan
Run the machine checkout yourself from memory
Suction, monitors, airway, IV, drugs (MSMAIDS)
Draw up drugs before talking to anyone

Teaching points

Confirm the plan, then MSMAIDS with your resident. Machine checkout follows the tech/resident and the machine’s own procedure.

Stage 6

Induction

Your attending says “give 100 of fent.” You say…

“OK.”
“Giving 100 micrograms of fentanyl IV now.”
“How much?”
Push it and tell them after

Teaching points

Closed-loop read-back: drug, dose with units, route — then wait for confirmation.

Stage 7

Maintenance

ETCO₂ climbs from 36 to 46 after insufflation. Most likely?

CO₂ absorption from pneumoperitoneum
Esophageal intubation
Malignant hyperthermia — definitely
Normal — ignore it

Teaching points

Insufflated CO₂ is absorbed; the team increases minute ventilation. Mention it — and keep MH in mind if HR, temperature or rigidity also change.

Stage 8

Emergence

Before extubation the team wants…

Quantitative TOF ratio ≥ 0.9
Awake, following commands
Head lift for 5 s is enough to rule out residual block
Semi-upright positioning for OSA

Teaching points

Measured TOF ratio ≥ 0.9 (sugammadex by depth if rocuronium). Clinical tests like head lift miss residual block. Have an O₂ mask ready.

Stage 9

PACU handoff

What does a good handoff include?

Procedure and anesthetic
Airway grade and device
Opioids, reversal and TOF ratio, antiemetics
OSA monitoring concerns
Your opinion of the surgeon

Teaching points

Structured: patient → procedure → anesthetic → meds → fluids/EBL → events → now → plan/watch-fors → questions.

Finish — more practice

LA General Anesthesia Sub-I
A learning companion for supervised clinical training. Your anesthesia team and current LA General policies guide patient care.

About & contributors
Image credits & licences
Rotation info · Emergencies
QI survey

Curriculum adapted with permission from the sub-internship course by Saumya Shah, DO. Photographs © LA General anesthesia teaching collection.

Today Setup Drugs More

Offline — showing saved pages