Very good question. I think, especially during your formative anesthesia years, that it is very helpful to know what cases you are doing in the morning, for educational purposes. Most of the time, the OR schedule is pretty much finalized in the afternoon, today, for tomorrows cases (did that make sense?), and anesthesia assignments are made. If you've left for the day before the schedule comes out for the following morning, most residents call the on-call resident to find out what they are doing.
Especially in the beginning of your training its helpful to run your anesthetic plan by whatever staff MDA is covering your room so the both of you are on the same page. Many programs encourage, or mandate this.
I think what is so confusing when one first starts in anesthesia is that there is usually no RIGHT way to do a case. The clinician has a plethora of techniques (i.e. GA vs regional) and drugs in his/her armamentarium (sic?).
There is a way to conquer the confusion.
Lets say you're in a room with 4 knee scopes scheduled, all on ASA 1 patients. The night before, pick ONE way to do these cases and do it on every one. The only way to get comfortable with anesthesia is repetition, so if you do something over and over again in the same day, at the end of the day you will feel as if you've learned something, and hey, you'll gain some confidence.
Back to the knee scopes. Like I said, theres many many ways to do knee scopes. Lets assume you're gonna do GAs. Now you've got about 3 choices- you can do a mask case, an LMA, or an intubation. Pick one. Lets say you picked, appropriately in my book, the LMA method. Great. Now pick what drugs you're gonna use. Start easy. Midazolam 2mg, fentanyl 100ug while you're rolling to the room. Monitors on, preoxygenate, propofol 2mg/kg. Wait about 45 seconds, mask a couppla times if you want, then put in the LMA. Now pick a volatile agent, say des or sevo. Presto! You're on the road to learning ONE technique. Now do the same thing on the next 3 cases and you'll feel like a star.
Now the next time you do an LMA case you'll have a protocol in your head.
Once you're real comfortable with that, start varying stuff here and there. This is really where you are starting to understand your craft, and the options available to you. Substitute another opiod, like remifentanyl or sufentanil and try that for a while. Or use no opiods at all, and see if that works. Try des instead of sevo, or vice versa, or try iso. Remember during residency is your opportunity to try different things, and those things will become your knowledge bank for private practice.
I remember getting on a nitrous-morphine-curare kick for big posterior spinal fusions. I'd get'em super groggy on midazolam, usually 5-8mg, push between .5-1.0 mg/kg morphine, and .5mg/kg of curare, bag for a cuppla minutes, intubate, crank on 70% nitrous in oxygen, and just a crack of isoflurane for amnesia purposes (isoflurane-remember this was 1996). Worked great because it exploited the histamine release of morphine, keeping the BP around a mean of 60- rarely was supplemental NTG or increased volatile agent needed. Nitrous-narcotic techniques are really cool- a light technique, so you really have to keep'em paralyzed- but if you time it right, its astounding how awake the patients are when you're ready to pull the tube.
My point is I did the same thing for the big back cases until I got bored with it, then I'd try something else.
Even in the real world we make a plan for in the morning. I'm early today so I'm going home now (1:30 pm) Before I left, my partner Rod and I looked at tomorrows schedule- in holding we'll have to line the heart, put in 2 combined-spinal epidurals for hip replacements, and a central line for a gastric bypass. Bottom line, having a plan is a great habit to get into, whether you are a resident or an MDA in a busy practice.
Look at one of UT's posts and read what he has written at the bottom of each post. Very, VERY wise words from a very wise dude. Nuff said. I'm going to the gym. Its leg day and I'm selling tickets.
