Anesthesiology Myths

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supahfresh

supahfresh

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Hi folks. I was wondering if any of the bright minds could help me out with my grand rounds talk coming up. I need some ideas for controversial issues in anesthesia. anesthesia myths, if you will. for example: cricoid pressure...not a lot of good data out there, but we do it anyway.

here's what I've been kicking around so far:
1. don't place a BP cuff on the arm the same side as their prior mastectomy

2. APRV

3. timing of tracheotomy

4. timing of pre-incision antibiotics

Any other ideas? I can't do cricoid or timing of NPO because it was done last year.

Thanks!

SF
 
How about the thread I started earlier, "Does position influence epidural spread?" There seems to be some controversy in this area. If you do it, you got to let me know about it and the outcome.
 
supahfresh said:
Hi folks. I was wondering if any of the bright minds could help me out with my grand rounds talk coming up. I need some ideas for controversial issues in anesthesia. anesthesia myths, if you will. for example: cricoid pressure...not a lot of good data out there, but we do it anyway.

here's what I've been kicking around so far:
1. don't place a BP cuff on the arm the same side as their prior mastectomy

2. APRV

3. timing of tracheotomy

4. timing of pre-incision antibiotics

Any other ideas? I can't do cricoid or timing of NPO because it was done last year.

Thanks!

SF
Click to expand...


Research the Cricoid pressure issue. You will finf the only good study (I think Anesthesiology Journal-year 2003) shows it is ineffective 90% of time even when properly applied. But, it is still being taught as effective and the 'standard of care' in our specialty. Bogus.
 
Is cricoid really being taught as effective? As a current resident, it has been made quite clear to me that it probably doesn't work very well but we do it anyway because it doesn't hurt and has a chance of helping.
 
Mman said:
Is cricoid really being taught as effective? As a current resident, it has been made quite clear to me that it probably doesn't work very well but we do it anyway because it doesn't hurt and has a chance of helping.
Click to expand...


It doesn't hurt until someone who doesn't know how to do it messes up your laryngoscopy.
 
VolatileAgent said:
this is a "myth"? hmmm...



isn't this part of the ASA quality incentive initiative (you should read the whole thing, but specifically see page 12)?
Click to expand...


Did you just cite a nursing journal as a reference?????

AACN...is I believe a nursing journal...isn't it? Or does it stand for something that I don't know?
 
VolatileAgent said:
this is a "myth"? hmmm...



isn't this part of the ASA quality incentive initiative (you should read the whole thing, but specifically see page 12)?
Click to expand...

sorry, should have clarified....APRV is not a myth but is it superior to other modes of ventilation. Our SICU puts nearly everyone on it.
 
Noyac said:
How about the thread I started earlier, "Does position influence epidural spread?" There seems to be some controversy in this area. If you do it, you got to let me know about it and the outcome.
Click to expand...

I thought about this one. I asked our top pain doc and he said there is data out there that supports positioning influences spread. I'm going to look for it.
 
militarymd said:
Did you just cite a nursing journal as a reference?????

AACN...is I believe a nursing journal...isn't it? Or does it stand for something that I don't know?
Click to expand...

huh? what's that got to do with anything? the authors are frawley, an Rn, and habashi, an MD. what's the beef? i've done studies which have involved rn's before, and they've gotten credit. i've also cited articles from nursing journals in publications i've written. good data is good data, and you should always judge the merits of a study by itself.

based on your need to point this out i think you're under some mistaken impression based on some faulty inference on your part... which doesn't really surprise me.
 
VolatileAgent said:
huh? what's that got to do with anything? the authors are frawley, an Rn, and habashi, an MD. what's the beef? i've done studies which have involved rn's before, and they've gotten credit. i've also cited articles from nursing journals in publications i've written. good data is good data, and you should always judge the merits of a study by itself.
Click to expand...

you know i've got nothing but respect for you bro, but i would agree that this is a pretty weak source. you have to figure that this article was turned away by every ligitimate peer reviewed journal, and then throw away journals, before it being submited at this level. Even the CRNA's where i work, most of whom are excellent, only seem to read "anesthesia and analgesia".
 
TheSandMan said:
you know i've got nothing but respect for you bro, but i would agree that this is a pretty weak source. you have to figure that this article was turned away by every ligitimate peer reviewed journal, and then throw away journals, before it being submited at this level. Even the CRNA's where i work, most of whom are excellent, only seem to read "anesthesia and analgesia".
Click to expand...

Agreed!
 
VolatileAgent said:
huh? what's that got to do with anything? the authors are frawley, an Rn, and habashi, an MD. what's the beef? i've done studies which have involved rn's before, and they've gotten credit. i've also cited articles from nursing journals in publications i've written. good data is good data, and you should always judge the merits of a study by itself.

based on your need to point this out i think you're under some mistaken impression based on some faulty inference on your part... which doesn't really surprise me.
Click to expand...

ohhh....ok....if that suits you.
 
Bertelman said:
What about periop metformin & acidosis?
Click to expand...

Thanks. I did a brief lit search and found no evidence that metformin caused lactic acidosis. nevertheless, i'm not really excited about presenting this topic because it's not heated enough. I think people will still continue to withold metformin pre-operatively despite the literature.

SF
 
TheSandMan said:
you know i've got nothing but respect for you bro, but i would agree that this is a pretty weak source. you have to figure that this article was turned away by every ligitimate peer reviewed journal, and then throw away journals, before it being submited at this level. Even the CRNA's where i work, most of whom are excellent, only seem to read "anesthesia and analgesia".
Click to expand...

aprv is still considered an "experimental" and proprietary mode of ventilation. it is not a "myth". that was my only point.

"anesthesia and analgesia", while a fine publication, is not the flagship journal of our profession.
 
How about the most controversial topic (at least on this site): improved outcomes (or the lack thereof) of anesthesiologist vs. CRNA care. Might be rather incindiary at a grand rounds....
 
Anyone know of any concrete literature done in advanced mammals..George Bush excluded.
 
You cannot really do a clinical trial on cricoid pressure nowadays. What, you are going to tell pts that they might be randomized to the non cricoid pressure group to see if they aspirate more than the other group? Which IRB is going to approve that? Besides, whats the benefit of such study? Are you going to save millions of dollars by withholding cricoid pressure? Clearly not. It might work or might not but there is little disadvantage in doing it. If it interferes with laryngoscopy, just let it go.
​
 
supahfresh said:
I think people will still continue to withold metformin pre-operatively despite the literature.
SF
Click to expand...

I don't know anyone who witholds metforming anymore.
 
urgewrx said:
You cannot really do a clinical trial on cricoid pressure nowadays. What, you are going to tell pts that they might be randomized to the non cricoid pressure group to see if they aspirate more than the other group? Which IRB is going to approve that? Besides, whats the benefit of such study? Are you going to save millions of dollars by withholding cricoid pressure? Clearly not. It might work or might not but there is little disadvantage in doing it. If it interferes with laryngoscopy, just let it go.​
Click to expand...


Recently published COURAGE trial randomized patients with known CAD to stents versus no stents.

If there is the will, there is a way.
 
militarymd said:
Recently published COURAGE trial randomized patients with known CAD to stents versus no stents.

If there is the will, there is a way.
Click to expand...

Yeah, but thats very different. There is plenty of evidence that stents don't work as well as expected. They might even be placing ps in unnecessary risks. On top of that they cost millions of dollars. There are very good reasons to cary a study like this.

This does not compare to cricoid pressure.
 
urgewrx said:
Yeah, but thats very different. There is plenty of evidence that stents don't work as well as expected. They might even be placing ps in unnecessary risks. On top of that they cost millions of dollars. There are very good reasons to cary a study like this.

This does not compare to cricoid pressure.
Click to expand...

OK...show me one single shred of evidence that cricoid pressure does any good.

There is plenty of evidence to support stent use...leading to ACC guidelines on its use.

Take a look at the "evidence" that exists in ASA's guidelines.

Once you look at the evidence, it ONLY makes sense to do the trial.
 
urgewrx said:
You cannot really do a clinical trial on cricoid pressure nowadays. What, you are going to tell pts that they might be randomized to the non cricoid pressure group to see if they aspirate more than the other group? Which IRB is going to approve that? Besides, whats the benefit of such study? Are you going to save millions of dollars by withholding cricoid pressure? Clearly not. It might work or might not but there is little disadvantage in doing it. If it interferes with laryngoscopy, just let it go.
​
Click to expand...

You could compare the aspiration rates of cases where cricoid pressure is given vs cases where cricoid pressure is not given.

Edit: I dont mean you divide the patients into random groups and run trials. I mean you gather info on as many cases as you can, and compare the rates.
 
I recently did my grand rounds on cuffed vs uncuffed pediatric endotracheal tubes. The myth is that uncuffed tubes are safer. There are a lot of good studies out there on this topic and I can say that none of my staff were aware of the studies or the newer pediatric tubes that have been developed recently. So I think it made for a great topic and is one that you can be the "expert" on for your grand rounds presentation.
 
Also, the use of phenylephrine in OB. Previously regarded as a big NO NO. Now there is evidence of it's safety and has less side effects than ephedrine. You might surprise a few old attendings that don't keep up with times. Although, be careful. There are some hard headed ones that don't want to believe this.
 
pwrpuffgirl said:
There are a lot of good studies out there on this topic and I can say that none of my staff were aware of the studies or the newer pediatric tubes that have been developed recently.
Click to expand...

That's scary.
 
What about allergy to eggs and givin' propofol? I do it and never had a problem. What about allergy to sulfates(SO4) and givin' the sulfite based propofol(SO3)? I give it and never had a problem. How about everybody and their mother with allergies to latex? If they don't have a history of resp. symptoms and/or anaphylaxis with exposure to latex, I treat them as any other pt. Regards, ----Zip
 
supahfresh said:
Hi folks. I was wondering if any of the bright minds could help me out with my grand rounds talk coming up. I need some ideas for controversial issues in anesthesia. anesthesia myths, if you will. for example: cricoid pressure...not a lot of good data out there, but we do it anyway.

here's what I've been kicking around so far:
1. don't place a BP cuff on the arm the same side as their prior mastectomy

2. APRV

3. timing of tracheotomy

4. timing of pre-incision antibiotics

Any other ideas? I can't do cricoid or timing of NPO because it was done last year.

Thanks!

SF
Click to expand...

Theres alotta stuff clinicians do every day thinking they are accomplishing something by instituting it, when in fact there is little to no evidence supporting these actions. Like:

Pre-op reglan/pepcid before inducing a full stomach

Ruling out an LMA for diabetics/GERD patients....I'll use an LMA as long as the GERD pt doesnt have postural symptoms.

Being scared sh*tless to put a parturient to sleep for a C section because of "increased risk"

Pre-op albuterolol tx for an asymptomatic asthmatic/COPDer

Too many pre-op labs/ekgs/cxrs

SWANs

too many A lines/TLCs.....not every ELAP, back, thoracotomy, vascular case needs them

huge thiopental dose in carotids

shunts in carotids...although thats the surgeons call, not ours

avoidance of lmas for all laparoscopic cases.....yes, you can use them sometimes.

too many awake intubations

too many awake extubations

waiting to start a c section because the lady ate a few hours ago

waiting to start an urgent but not emergent case because the pt ate a few hours ago....(closed but serious fractures, appendix, etc)

Intubating every D & C

Starting an IV on a kid having ear tubes put in

Using muscle relaxant on pedi tonsils....yes, you can mask'em down, start the IV, and use volatile agent only. Will save yourself tons of time. Give a little opiod after youve extubated on your way to the recovery room if you want. No more reversal/risk of wasting time for prolonged neuromuscular blockade.


I'm sure we'll add to this list but its a good start.
 
Use of LMAs when pts are in the prone position
 
Well, thanks for all the suggestions everyone. I gave my grand rounds talk on prophylactic antibiotic administration and the 1 hour rule. I also included a few slides on pay for performance. I stirred up a little heat while preparing this talk. very nice.

SF
 
urgewrx said:
Also, the use of phenylephrine in OB. Previously regarded as a big NO NO. Now there is evidence of it's safety and has less side effects than ephedrine. You might surprise a few old attendings that don't keep up with times. Although, be careful. There are some hard headed ones that don't want to believe this.
Click to expand...

urgewrx,

I have heard about the recent use of phenylephrine in parturients. Could you let me know the literature that supports its use? I would very much like to consider using it in many of my patients after epidural placement.

Much thanks...
 
rmh149 said:
urgewrx,

I have heard about the recent use of phenylephrine in parturients. Could you let me know the literature that supports its use? I would very much like to consider using it in many of my patients after epidural placement.

Much thanks...
Click to expand...


Been using NEO for about 6-7 years now. Thousands of cases in OB with no problems. I can't believe anyone is not on board yet. A great study out of an OB program (St. Louis?) years back. I started using it the day after I read the study.

BladeMDA-fighting for the survival of the specialty
 
pratik7 said:
Use of LMAs when pts are in the prone position
Click to expand...

I have an important statement when any attending decides to be cowboy:

"Don't do the crime if you can't do the time."

This means when something goes wrong (and it will) what will your "expert" at Duke, Mayo, MGH, Stanford, Emory, Cleveland Clinic, etc. say about your "care." Was it reasonable? Was it up to the standard of care (whatever that means)?

Every Cowboy gets to deal with this issue sooner or later.

BladeMDA- fighting for the survival of the specialty
 
BLADEMDA said:
Been using NEO for about 6-7 years now. Thousands of cases in OB with no problems. I can't believe anyone is not on board yet. A great study out of an OB program (St. Louis?) years back. I started using it the day after I read the study.

BladeMDA-fighting for the survival of the specialty
Click to expand...

Thanks Blade, I am looking for that study now. Good to hear you have had no problems. I prefer NEO over ephedrine as a first drug of choice. I look forward to now using it with OB patients.
 
Agree with blade. It doesnt make sense. It may work sometimes...but I can almost guarantee it will give you more problems than its worth, including eventually harming a patient. Its so much easier to intubate them and have complete control of their airway than hope everything goes OK.
 
VolatileAgent said:
now you're talking. this is a good topic.
Click to expand...


The primary use of a a Swan is to make the surgeon happy. Echo is a much better tool for assessing the heart and the status of a patient.

Swan's are generally a waste of time and rarely used correctly anyway.

BladeMDA
 
zippy2u said:
What about allergy to eggs and givin' propofol? I do it and never had a problem. What about allergy to sulfates(SO4) and givin' the sulfite based propofol(SO3)? I give it and never had a problem. How about everybody and their mother with allergies to latex? If they don't have a history of resp. symptoms and/or anaphylaxis with exposure to latex, I treat them as any other pt. Regards, ----Zip
Click to expand...


Agree Zippy. Your experience is what makes the difference in understanding the problem.

Latex Sensitivity is NOT latex allergy and one needs to recognize the difference. I have seen full blown latex allergy and this is serious stuff with respiratory involvement. What we see in most adults in latex sensitivity which just requires a few precautions ( if that) and common sense by avoiding exposure to powder in gloves.

If you want to give low dose decadron go ahead. But, there is no need to give high dose Benadryl to a latex sensitive patient and have the patient sleep all day.
 
rmh149 said:
urgewrx,

I have heard about the recent use of phenylephrine in parturients. Could you let me know the literature that supports its use? I would very much like to consider using it in many of my patients after epidural placement.

Much thanks...
Click to expand...


Fck, man. I just taught something to a CRNA. Can somebody shoot me, please.

Mods, please delete this thread. I cannot bare to see this thread again, knowing that I contributed to our doom.

I got to stop posting here. Perhaps I'll just be a lurker. Nah, scratch that. I'll be a "voyeur".
 
pratik7 said:
Use of LMAs when pts are in the prone position
Click to expand...
Why oh why would you do this?
It may be useful to place an LMA in an accidently extubated prone patient to avoid supinating them with their calavarium off, but what could possibly be the advantage of using this as your primary mode of airway management (other than showing off)?
 
Intubate said:
Why oh why would you do this?
It may be useful to place an LMA in an accidently extubated prone patient to avoid supinating them with their calavarium off, but what could possibly be the advantage of using this as your primary mode of airway management (other than showing off)?
Click to expand...

Some people love being a cowboy. I have seen prone LMA's, LMA used for Lap Choley's (like the British do) and spinals done on patients with contraindications. Not me. I am willing to push the envelope just not that far.

Remember, if and when something goes wrong with the case (the law of numbers dicatates it will) you will need to defend your case in court. Your experience and Group's experience counts but it is not the only thing the case rests on. Reasonable and Prudent are the name of the game.

BladeMDA
 
BLADEMDA said:
The primary use of a a Swan is to make the surgeon happy. Echo is a much better tool for assessing the heart and the status of a patient.

Swan's are generally a waste of time and rarely used correctly anyway.

BladeMDA
Click to expand...

I agree, rarely used correctly. We get so darn hung up on the pressures we forget what these are actually useful for. I like the Manny Rivers method. Give me an endpoint. I like SvO2. Cardiac output, now we're getting somewhere. Better than, "hey what's the PA pressure". TEE will never give you a mixed venous.
 
supahfresh said:
Hi folks. I was wondering if any of the bright minds could help me out with my grand rounds talk coming up. I need some ideas for controversial issues in anesthesia. anesthesia myths, if you will. for example: cricoid pressure...not a lot of good data out there, but we do it anyway.

here's what I've been kicking around so far:
1. don't place a BP cuff on the arm the same side as their prior mastectomy
2. APRV

3. timing of tracheotomy

4. timing of pre-incision antibiotics

Any other ideas? I can't do cricoid or timing of NPO because it was done last year.

Thanks!

SF
Click to expand...

Anyone know of any hard data on the no IV/BP cuff issue with mastectomy patients? I know the concern with lymph node dissection, etc. but these pt.'s get signs on the bed at my hospital "NO IV's leftarm" even if the surgery was 20 years ago! Sometimes this is an issue (right arm surgery with hx left mastectomy, etc.). I've asked some of the breast surgeons I know but no one has any good answers...
 
hokie said:
Anyone know of any hard data on the no IV/BP cuff issue with mastectomy patients? I know the concern with lymph node dissection, etc. but these pt.'s get signs on the bed at my hospital "NO IV's leftarm" even if the surgery was 20 years ago! Sometimes this is an issue (right arm surgery with hx left mastectomy, etc.). I've asked some of the breast surgeons I know but no one has any good answers...
Click to expand...

Lymphedema Workshop IV from the National Cancer Institute has guidelines and references
 
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