Jet's TOP TEN

[thegasman]

Nobody else likes bolusing through the Tuohy then infusing through the catheter? Kinda like a single shot epidural followed immediately by a continuous epidural without the need to place the needle twice. Kinda like a cse without the need to puncture the dura?
I know it isn't popular these days, but it works well and works fast with no pdph and no wasting time wasting narcotics and no itching.
I know, I know...

YES. I like this a lot. Learned it from some of my older partners, would be a big no no at my residency program. I give 8-10 cc bolus through the tuohy and then another 8 cc through the catheter after test dose. Placed at L4/5 3 cm into the space I never get called back and it sets up fast. Nurses frequently tell me that what a great epidural and sometimes ask me to turn it down because the patients are "too numb" What? I run 12 cc/hr.

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[Noyac]

YES. I like this a lot. Learned it from some of my older partners, would be a big no no at my residency program. I give 8-10 cc bolus through the tuohy and then another 8 cc through the catheter after test dose. Placed at L4/5 3 cm into the space I never get called back and it sets up fast. Nurses frequently tell me that what a great epidural and sometimes ask me to turn it down because the patients are "too numb" What? I run 12 cc/hr.

I did it this way for years back when I had crnas babysitting the epidurals in house. Now that I don't work with those trolls I do the CSE. But for those of you criticizing the CSE bc you feel the catheter is an unknown better not be doing this technique since your catheter is unknown here as well.

 

[Precedex]

1) Don't wait for ventilation to give succinylcholine. Give it as soon as the patient is unconscious. If the chips are down, assuming you are giving an appropriate dose, waiting to ventilate is burning precious seconds off your airway clock. This by far is one of the stupidest dogmas perpetuated by the "doctors" teaching you.

Editorial just published on this (attached).

 

[TheSweetness]

Given the fact that if someone is impossible to mask ventilate and once you have wasted your time checking this noninstrumental piece of information (Broomhead - British Journal Anes 2009) then if you did decide to switch from roc to sux, there goes the valuable time needed for the sux to wear off and wake the patient back up. If there are multiple risk factors for impossible mask ventilation (Mal 3-4, Male, OSA, history of radiation to the neck, beard - Kheterpal, Anesthesiology 2009) and you are not comfortable that you will be able to bag mask ventilate, I'd give a short acting paralytic up front (without checking) for it to possibly wear off in time. But, if there is significant neck radiation I would look strongly into an awake fiberoptic. If diff airway to not be able to intubate, I'd have advanced airway equipment and plan appropriately...

 

[pgg]

If there are multiple risk factors for impossible mask ventilation (Mal 3-4, Male, OSA, history of radiation to the neck, beard - Kheterpal, Anesthesiology 2009) and you are not comfortable that you will be able to bag mask ventilate, I'd give a short acting paralytic up front (without checking) for it to possibly wear off in time.

Say wha ...

But, if there is significant neck radiation I would look strongly into an awake fiberoptic.

That's a better plan.

 

[TheSweetness]

From earlier in this thread:

Interesting editorial. Admittedly, I generally achieve FMV prior to NDMBs, be it with a mask or LMA (we get a lot of ZZ top beards here), but if I'm using succ I'll give it with induction. I agree that waking up a morbidly obese, unmaskable, desaturating patient after an induction dose of propofol (particulular if adjuncts like opiates and benzos were included) is pretty unrealistic. I'd add that the right-sided tail of apneic periods after 1 mg/kg of succ stretched up to 9 minutes (saw this paper in residency in Anesthesiology, but didn't take the time to look it up again), suggesting that the traditional dose of succ for RSI may not achieve the desired effect of "wearing off before they get hypoxic."

I think the important aspect is to assess the airway and history with an eye toward 1) whether they'll be difficult to mask (kheterpal's paper is a great read for this), and 2) whether they'll be difficult to intubate so that you can have a plan in place before having to make a decision when you induce and learn that they're tough to mask.

That and get comfortable with "awake" intubations (FOB, glide, AND DL). I do lots and I've never regretted one.

I'm just quoting the literature as previously has been done. I recommend reading the two quoted articles if you do not understand or disagree. They are very good articles. I do not agree with "checking". What is your preference and rationale? What do you not understand ?
I listed the 5 independent risk factors from that study. Once there are 3 or more the chance of impossible mask ventilation goes up dramatically, esp for history of neck radiation.

 

[pgg]

What is your preference and rationale? What do you not understand ?

I give muscle relaxant with induction. I never test mask ventilation before paralyzing.

What I objected to was your statement

If there are multiple risk factors for impossible mask ventilation (Mal 3-4, Male, OSA, history of radiation to the neck, beard - Kheterpal, Anesthesiology 2009) and you are not comfortable that you will be able to bag mask ventilate, I'd give a short acting paralytic up front (without checking) for it to possibly wear off in time.

The problem here, IMO, isn't that you're giving a short acting paralytic with induction, but that you're inducing a patient with "multiple risk factors for impossible mask ventilation" in the first place.

Maybe there's a typo or a missing "not" in your post? I don't understand why you'd consider inducing and paralyzing a patient like that. If there's anyone who deserves an AFOI, it's this person.

 

[TheSweetness]

I meant 2-3 out of those five .. Not all 5 and not neck radiation . Haha Those are the five to pick from ..

 

[Bertelman]

I meant 2-3 out of those five .. Not all 5 and not neck radiation . Haha Those are the five to pick from ..

I think what he is getting at, and what I wondered as well, is the wisdom of pushing paralytic if you "suspect you may not be able to mask ventilate", to paraphrase your earlier post. At best, a paralytic may not improve your ability to mask ventilate. At worst, you are committing yourself to an airway disaster, and definitive trach if you are "fortunate".

Drawing on my personal experience, if I truly suspect I may not be able to mask, that's a clear indication for an awake FOI.