Supervising junior/semi-experienced residents

[zizzer]

Regarding myalgias, I've always wondered how much of a problem they actually are. Perhaps somebody can chime in. What's the worst case of myalgias you have ever seen? How long did it last? Was it disabling in any way? I have a suspicion that it's similar to how muscles feel a couple of days after an intense weightlifting episode. As a regular weightlifter, this soreness can be pretty intense, and I remember it being a lot more intense the week I was first introduced to resistance exercises. Perhaps this feeling is really distressing for people not accustomed to it, but is it really a problem?

I don't know for sure or anything, I'm just asking. I've never heard a complaint of it, but I would guess some of my patients have had myalgias later.

One reason I don't use SCh much is because I don't want to run into one of those slow metabolizer situations, especially at an outpatient surgery center. The only RSI I really feel strongly about using it for is something like a SBO. To the person who doesn't want to use NDMB because they have to justify sugammadex, so do I. Just enter "deep NMB reversal" in the core Pyxis each time. Nobody has given me trouble at any hospital or surgery center and I haven't used neostigmine in months. I would be well ready for that argument if somebody were to bring it up.

Also, some of y'all's induction practices are bizarre. No, an ASA1 patient doesn't need 5 minutes of preoxygenation, but I can't believe people are arguing against something that barely takes any time and greatly increases safety. Are you guys working with ASA 1 and 2 patients every case with easy airway exams? Even then, you can't be bothered to have a nurse hold the mask and have the patient take four vital capacity breaths while you prepare something else?

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[zizzer]

To answer the original question, micromanaging is fine as long as you're teaching why in a respectful manner. You may have some residents who resent not having more autonomy (I did), but if you teach them why you do things your way they will benefit from that in the long run.

 

[anaesthetic]

Regarding myalgias, I've always wondered how much of a problem they actually are. Perhaps somebody can chime in. What's the worst case of myalgias you have ever seen? How long did it last? Was it disabling in any way? I have a suspicion that it's similar to how muscles feel a couple of days after an intense weightlifting episode. As a regular weightlifter, this soreness can be pretty intense, and I remember it being a lot more intense the week I was first introduced to resistance exercises. Perhaps this feeling is really distressing for people not accustomed to it, but is it really a problem?

I don't know for sure or anything, I'm just asking. I've never heard a complaint of it, but I would guess some of my patients have had myalgias later.

One reason I don't use SCh much is because I don't want to run into one of those slow metabolizer situations, especially at an outpatient surgery center. The only RSI I really feel strongly about using it for is something like a SBO. To the person who doesn't want to use NDMB because they have to justify sugammadex, so do I. Just enter "deep NMB reversal" in the core Pyxis each time. Nobody has given me trouble at any hospital or surgery center and I haven't used neostigmine in months. I would be well ready for that argument if somebody were to bring it up.

Also, some of y'all's induction practices are bizarre. No, an ASA1 patient doesn't need 5 minutes of preoxygenation, but I can't believe people are arguing against something that barely takes any time and greatly increases safety. Are you guys working with ASA 1 and 2 patients every case with easy airway exams? Even then, you can't be bothered to have a nurse hold the mask and have the patient take four vital capacity breaths while you prepare something else?

I’ve had a couple of patients get ahold of me to ask why they’re so sore. It can be debilitating for some.

Also, regarding preoxygenating, of course it’s important (and critically important in certain patient populations). Nobody’s arguing the fact that preoxygenation works. I’m saying not every patient needs a mask jammed in their face immediately upon entering the OR for fear of desaturation on induction. It’s going to be okay.

 

[Radetzky]

Why are we talking about myalgias when the bigger issue with using sux when it’s not required is its large anaphylaxis rate?

 

[deleted1147063]

I disagree. In an RSI I much prefer sux. High dose roc still takes more time to work.

Let's put it this way: if one RSIs with roc and the patient aspirates, guess what will be held up in court as standard of care?

 

[Beeftenderloin]

Let's put it this way: if one RSIs with roc and the patient aspirates, guess what will be held up in court as standard of care?

I don’t think this is necessarily as straightforward as you think it is. EM and crit care are basically all in on high dose roc for RSI, and as you can see (as evidenced by this thread), even in the anesthesia world is relatively split on the topic.

 

[BobLoblaw78]

Just mix the roc with the induction drug. I give it together, wait a few breaths until the patient becomes apneic and intubate. It has literally never failed me. I haven’t used sux for an RSI in at least 10 yrs.

I do the same with 40-50 mg of Roc. What dose do you use bc I know they have lowered recc's? I ask bc I end up waiting 1 minute, and many times they are still not relaxed. Almost never is it a few breaths. (or maybe you use my 'relaxed enough' tech)

 

[vector2]

I don’t think this is necessarily as straightforward as you think it is. EM and crit care are basically all in on high dose roc for RSI, and as you can see (as evidenced by this thread), even in the anesthesia world is relatively split on the topic.

I give a 5-10mg priming dose along with the lido and then when the 95mg goes in after induction med the onset time to intubating conditions is almost as fast as sux

Comparison of intubating conditions between rocuronium with priming and without priming: Randomized and double-blind study

Rocuronium produces faster neuromuscular blockade compared with other neuromuscular blocking drugs. It produces comparable intubating conditions to that of succinylcholine, but does not have the short intubation time of the latter. Hence, it may not be ...

www.ncbi.nlm.nih.gov

 

[drmwvr]

Roc sitting in a drawer for a week is not the same roc right out of the fridge....

 

[abolt18]

I don't mind giving sux, but if I give it, I will do a defasciculating dose of roc a few minutes before (while pre-oxygenating), use a higher dose of sux, and make every effort to administer NSAIDS to the patient. Each one of those reduces incidence of myalgias.

And how is there any anesthesiologist saying they don't pre-oxygenate? That is completely idiotic. There is a reason it is a standard of care. Do all patients need ET O2 of 80%? No. But to suggest not pre-oxygenating at all? Like riding a motorcycle without a helmet.

 

[gunnershow]

I don't mind giving sux, but if I give it, I will do a defasciculating dose of roc a few minutes before (while pre-oxygenating), use a higher dose of sux, and make every effort to administer NSAIDS to the patient. Each one of those reduces incidence of myalgias.

And how is there any anesthesiologist saying they don't pre-oxygenate? That is completely idiotic. There is a reason it is a standard of care. Do all patients need ET O2 of 80%? No. But to suggest not pre-oxygenating at all? Like riding a motorcycle without a helmet.

Yes, a lot of the "slick" anesthetics here sound a lot like my CRNAs who take every shortcut they can and then get burned for it

 

[deleted875186]

I give a 5-10mg priming dose along with the lido and then when the 95mg goes in after induction med the onset time to intubating conditions is almost as fast as sux

Comparison of intubating conditions between rocuronium with priming and without priming: Randomized and double-blind study

Rocuronium produces faster neuromuscular blockade compared with other neuromuscular blocking drugs. It produces comparable intubating conditions to that of succinylcholine, but does not have the short intubation time of the latter. Hence, it may not be ...

www.ncbi.nlm.nih.gov

I dislike this technique. I’ve tried the 5-10 mg roc priming dose, some patients feel it. If your concerned enough about aspiration to do an RSI, makes sense to me to not give anything that might compromise the airway or reflexes before induction.

For me, bolus of prop, or titrate dose to unconsciousness if not stable along with vasopressors, bolus of sux, ready in 30 seconds, simplifies my life.

 

[vector2]

I dislike this technique. I’ve tried the 5-10 mg roc priming dose, some patients feel it. If your concerned enough about aspiration to do an RSI, makes sense to me to not give anything that might compromise the airway or reflexes before induction.

For me, bolus of prop, or titrate dose to unconsciousness if not stable along with vasopressors, bolus of sux, ready in 30 seconds, simplifies my life.

I still use sux 99% of the time. And i've heard of ppl having an issue with the priming dose pt complaints but anecdotally I've never seen it.

 

[BobLoblaw78]

And how is there any anesthesiologist saying they don't pre-oxygenate? That is completely idiotic. There is a reason it is a standard of care. Do all patients need ET O2 of 80%? No. But to suggest not pre-oxygenating at all? Like riding a motorcycle without a helmet.

This reminds me of the "macho intubator." That guy that thinks can get every airway when others fail. I must confess that I struggle not to be this person.

I am going to guess that everyone preoxygenates, or at least believes they should. I guarantee you that if that guy (who doesn't preoxygenate) saw an ER doc intubate w/o preoxygenating then they would proceed to rip the ER doc to shreds.

 

[T-burglar]

I guess you don’t have to pre oxygenate if you do baby anesthesia on ASA 1-2 all day every day

 

[Anestheezee]

Yes, a lot of the "slick" anesthetics here sound a lot like my CRNAs who take every shortcut they can and then get burned for it

The trick is: use your knowledge, experience, and skills to avoid getting burned. Fortunately we have the luxury of handling burn-able situations a lot better than crnas with our deeper understanding. I always tell patients and students that my priority is #1 safety and #2 comfort/efficiency. If in your wisdom and experience as a physician are not thinking about evaluating and limiting extraneous steps you are overprioritizing #1 and missing half the story. Don't f*** around. Move the meat. They came here for the surgery not the anesthetic.

 

[GassYous]

I dislike this technique. I’ve tried the 5-10 mg roc priming dose, some patients feel it. If your concerned enough about aspiration to do an RSI, makes sense to me to not give anything that might compromise the airway or reflexes before induction.

For me, bolus of prop, or titrate dose to unconsciousness if not stable along with vasopressors, bolus of sux, ready in 30 seconds, simplifies my life.

Prop lido roc fent dex push
Sux push
No problem

 

[nimbus]

I do the same with 40-50 mg of Roc. What dose do you use bc I know they have lowered recc's? I ask bc I end up waiting 1 minute, and many times they are still not relaxed. Almost never is it a few breaths. (or maybe you use my 'relaxed enough' tech)

I usually use 40-50 mg in normal size people. 70mg in large men/bariatrics/hearts. I wait until apnea, usually 5-6 breaths….I think that’s less than a minute? Rarely I’ll see a vocal cord quiver weakly. Doesn’t stop me from intubating. Maybe it’s because I use a glidescope 100% of the time and don’t need complete relaxation to intubate.

 

[zizzer]

You all are acting like preoxygenation with 4-5 VC breaths takes so long. It can be delegated to the nurse while you do something else anyway.

At minimum you're adding unnecessary risk for next to zero time saved, and I refuse to believe you all never run into airway challenges you underestimate, even if you only do easy cases in surgery centers.

 

[MirrorTodd]

Also remember this thread is about supervising residents, not what you do solo, so pre-oxygenation is most def a requirement we should be teaching our residents.

 

[Anestheezee]

I have to agree, I never skimp on preo2 no excuse for that. Just not necessary unless you are dealing with a situation where you physically can't perform preo2, e.g. Combative autistic 300lb pt. In those cases getting O2 on them ASAP is as good as you can do.

 

[vector2]

Also remember this thread is about supervising residents, not what you do solo, so pre-oxygenation is most def a requirement we should be teaching our residents.

Ok, now for the love of god, tell me how I can get them to rest the mask on the pt's face before doing anything else.

Doesn't matter how many times I tell them to pre-ox first, inevitably I get called to the room and the pt's just lying there supine on RA slowly derecruiting, circulator is f'ing off in the corner, and mask/circuit are hanging on the tube tree while resident puts all the monitors on, cycles the BP, starts EMR data collection, gets the induction drugs out of pyxis, i.e. does literally everything else but get some O2 into the pt.

 

[coffeebythelake]

I disagree. In an RSI I much prefer sux. High dose roc still takes more time to work.

Slightly longer. But you have longer apnea time with high dose roc. I mostly use roc even for those bowel obstruction cases because I don't like fasiculations and increased intraabdominal pressure from that

 

[coffeebythelake]

Let's put it this way: if one RSIs with roc and the patient aspirates, guess what will be held up in court as standard of care?

I think they will look into how much roc was administered and whether it constitutes a true RSI. 1.2 mg per kg or higher. I mean that is literally defined as an RSI dose. I don't think suxx can be considered the standard of care for RSI, and it hasn't been for some time.

 

[2buckchuck]

I don't think suxx can be considered the standard of care for RSI, and it hasn't been for some time.

Disagree.

 

[MirrorTodd]

Ok, now for the love of god, tell me how I can get them to rest the mask on the pt's face before doing anything else.

Doesn't matter how many times I tell them to pre-ox first, inevitably I get called to the room and the pt's just lying there supine on RA slowly derecruiting, circulator is f'ing off in the corner, and mask/circuit are hanging on the tube tree while resident puts all the monitors on, cycles the BP, starts EMR data collection, gets the induction drugs out of pyxis, i.e. does literally everything else but get some O2 into the pt.

Find a different place to work. I've noticed that academic centers just suck for having people actually help to get **** done.

 

[patriot6]

Find a different place to work. I've noticed that academic centers just suck for having people actually help to get **** done.

"that's not my job," said nearly every circulating RN at my training institution

 

[UscGhost]

I guess I just don't see much use for sux other than RSI situations or very quick 15-30 min cases that need paralysis

Scenario 1: short case (1 hr) that needs relaxation. Are we giving sux to intubate and then a small dose of roc for relaxation (because a large roc dose may not wear off in time for neostigmine and a small roc dose doesn't kick in fast enough) ?

But then you still have to reverse AND you still risk myalgias, allergic reactions, pseudocholinesterase def. Seems easier to just give higher dose roc and then sugammadex at the end. Gives you better surgical relaxation, you can keep gas low and CO2 high for rapid awakening.

Benefit?

For longer cases, sux makes even less sense.

And in regards to myalgias, most patients probably don't make the connection to anesthesia so they won't complain unless asked specifically about it. But the literature reports high rates

 

[2Fast2Des]

"that's not my job," said nearly every circulating RN at my training institution

Oh thanks for the residency reminder days. I love being in a non academic community hospital, everyone pitches in and does what needs to be done. Academia is so slow and toxic...

 

[FiO2@21]

Let's put it this way: if one RSIs with roc and the patient aspirates, guess what will be held up in court as standard of care?

Using roc for RSI is absolutely considered a standard of care.

 

[T-burglar]

A ****load of roc is a way better RSI than sux anyway , that disorganized muscle contraction is Russian roulette with involuntary regurgitation

 

[PpfSuxTube]

I remember some attendings invariably waiting for the EtO2 to be 0.8 prior to pushing meds, even if it meant five minutes of preoxygenating on an ASA1 lap chole. What a joke.

Looking back on the insane practices we had to endure in academics on the behalf of some incompetent OCD 'professor' types its honestly funny...

One guy used to push the ancef 2 mls at a time... it took 20 mins... every single case...
Cause one time, somone somewhere had anaphylaxis... and he took pride in this

As a PP cardiac and intensivist now, those guys would probably kill most of my patients on an average complexity week

 

[FiO2@21]

Looking back on the insane practices we had to endure in academics on the behalf of some incompetent OCD 'professor' types its honestly funny...

One guy used to push the ancef 2 mls at a time... it took 20 mins... every single case...
Cause one time, somone somewhere had anaphylaxis... and he took pride in this

As a PP cardiac and intensivist now, those guys would probably kill most of my patients on an average complexity week

Had an attending at the VA who would make me dilute sugammadex in a 20 cc syringe and push it over 5 minutes. There's a certain amount of creativity with those sorts of people that I appreciated at some level.