The sequence of anesthetic induction is a well-oiled machine. But small, thoughtful adjustments are necessary to minimize the risk of hemodynamic compromise. It’s also a perfect case study in how habits can take over your critical thinking skills.

Early on, learn to create an induction plan that is tailored to your patient. Don’t just look at the age and weight, consider the procedure, relevant comorbidities, hemodynamic goals, volume status, and the additive effect of medications the patient may already be taking. Even if you’re not the one pushing the drugs, you should have a clear mental map of what you would give if asked to take the lead.

I find that trainees overfocus on the exact dosages of induction agents and underfocus on their specific induction goals. Rather, your plan should focus on specific considerations.

Weak: “I’m planning on 120 mg of propofol and 50 mg of lidocaine.”

Strong: “Since the patient is likely hypovolemic, I will plan to titrate propofol slowly, a few mLs at a time, and supplement with phenylephrine.” OR “I’m concerned about the risk of aneurysm rupture, so I will use propofol and fentanyl to achieve a deep plane of anesthesia prior to laryngoscopy.”

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