Afterthought

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jetproppilot

jetproppilot

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What this forum is current day.
The Truth hurts sometimes.
SAD. NO LEADERS OUT THERE.
SDN ANESTHESIA
USTA ROCK.
Now it
SUCKS.
MilMD checked in not long ago...
looked around...and essentially said
OK YEAH I HAVENT MISSED ANYTHING,

SEE YAH

I haven't seen anything here either.

You residents.....

You attendings....

WTF?

Kinda sad.

SAD that theres

NOT ANY ANESTHESIA MDs OUT THERE THAT CAN

RERAISE

THE GREATNESS

THAT HAPPENED ON SDN ANESTHESIA

not long ago.

SAD that...looking at

ALL OF YOU OUT THERE....

and you can't

COME CLOSE

to the

volumes of anesthesia

we produced.

(DOUBT ME? GOOGLE IT, MUTHERFU&^%$R.)

I LOOK BACK TO THE GREAT DAYS OF THE UNIVERSITY OF MIAMI WHERE NFL DUDES... FROM

THE U

SHOWED UP AND LEAD

THE WEAK.

This SDN Anesthesia forum is seriously

HURTING.

F54CKING BORING MAN.

AND THERE IS NO LEADERSHIP HERE!!!!

Who is speaking to the RESIDENTS with clarity?

Ummmmmmmmm

NO ONE.

And that's sad, dude.

That the

I've matched at HOBOKOE KANSAS, HAVE YOU?

threads thrive.

IS THERE ANYONE OUT THERE BESIDES BLADE?

ANYONE?

This forum was once the dominant forum when it came to ATTENDING presence and interaction.
Younger, naive people may skoff at that, write it off.
This forum once had a plethora of attendings willing to share all the

tricks of the trade.

No such thing exists now man.

What a loss to the upcoming residents.

Sad.
 
jetproppilot said:
What this forum is current day.
The Truth hurts sometimes.
SAD. NO LEADERS OUT THERE.
SDN ANESTHESIA
USTA ROCK.
Now it
SUCKS.
MilMD checked in not long ago...
looked around...and essentially said
OK YEAH I HAVENT MISSED ANYTHING,

SEE YAH

I haven't seen anything here either.

You residents.....

You attendings....

WTF?

Kinda sad.

SAD that theres

NOT ANY ANESTHESIA MDs OUT THERE THAT CAN

RERAISE

THE GREATNESS

THAT HAPPENED ON SDN ANESTHESIA

not long ago.

SAD that...looking at

ALL OF YOU OUT THERE....

and you can't

COME CLOSE

to the

volumes of anesthesia

we produced.

(DOUBT ME? GOOGLE IT, MUTHERFU&^%$R.)

I LOOK BACK TO THE GREAT DAYS OF THE UNIVERSITY OF MIAMI WHERE NFL DUDES... FROM

THE U

SHOWED UP AND LEAD

THE WEAK.

This SDN Anesthesia forum is seriously

HURTING.

F54CKING BORING MAN.

AND THERE IS NO LEADERSHIP HERE!!!!

Who is speaking to the RESIDENTS with clarity?

Ummmmmmmmm

NO ONE.

And that's sad, dude.

That the

I've matched at HOBOKOE KANSAS, HAVE YOU?

threads thrive.

IS THERE ANYONE OUT THERE BESIDES BLADE?

ANYONE?

This forum was once the dominant forum when it came to ATTENDING presence and interaction.
Younger, naive people may skoff at that, write it off.
This forum once had a plethora of attendings willing to share all the

tricks of the trade.

No such thing exists now man.

What a loss to the upcoming residents.

Sad.
Click to expand...

That's because b.tches like your friends b.tch to the mods to have people banned. Then, they get banned and aren't around to stur up the pot.

Where were you when people were getting the hammer on "hot" topics.
 
Ha ha...A self-proclaimed junior resident busting on one of the most helpful posters this forum has ever seen...Jet's been a help to myself as a resident/fellow, something many other people here can attest to as well...

Tell you what, hoss...You contribute something of value to this forum, and then you can begin to consider calling Jet out. Until then, keep your head buried in Miller and your nose up your attending-of-the-days' azz...
 
KCBarbarossa said:
That's because b.tches like your friends b.tch to the mods to have people banned. Then, they get banned and aren't around to stur up the pot.

Where were you when people were getting the hammer on "hot" topics.
Click to expand...

Nah, I'm still here.

D712
 
ive been lurking here for years as a resident and have been an attending for 3 years now. I agree the quality of forum has decreased. I don't know how you guys have te time to consistently post on the forum. between a busy practice and kids I have a hard time finding the time to sort through different posts and follow the discussion. perhaps this has happened to others who were contributing to the forum.
 
ecCA1 said:
Ha ha...A self-proclaimed junior resident busting on one of the most helpful posters this forum has ever seen...Jet's been a help to myself as a resident/fellow, something many other people here can attest to as well...

Tell you what, hoss...You contribute something of value to this forum, and then you can begin to consider calling Jet out. Until then, keep your head buried in Miller and your nose up your attending-of-the-days' azz...
Click to expand...

I never said he wasn't helpful. I'm suggesting that he doesn't practice what he preaches which is supposed freedom of speech andEXPRESSION. Long time lurker here as well, but I recall at least a few instances where he's remained ominously silent. Where's the leadership there??

If you're gonna be a writer you might as well support the 1st Amendment, no?
 
Jet, you are an attending and a member of SDN. You also love to write. So do it. Take the lead and post some $h1t. Start some threads, clinical or otherwise. It is contagious. I know you have done a LOT. But if you love writing, don't quit on us.

Wish I could contribute more but I'm only a med student and I do what I can.
 
I'm an attending and enjoy reading this forum. What do you guys want that I could contribute. I've been working in private practice for a few years now. I enjoy the good cases that I may have not had experience with as I enjoy learning new things.
 
KCBarbarossa said:
I never said he wasn't helpful. I'm suggesting that he doesn't practice what he preaches which is supposed freedom of speech andEXPRESSION. Long time lurker here as well, but I recall at least a few instances where he's remained ominously silent. Where's the leadership there??

If you're gonna be a writer you might as well support the 1st Amendment, no?
Click to expand...

Dude.

Seriously? Learn some respect. If you're gonna call out JPP or any attending, do so in a positive way. This is JPP's way of encouraging folks to contribute. You're not contributing to anything positive for this forum with posts like this.
 
cincincyreds said:
I'm an attending and enjoy reading this forum. What do you guys want that I could contribute. I've been working in private practice for a few years now. I enjoy the good cases that I may have not had experience with as I enjoy learning new things.
Click to expand...

anything you've picked up along the way? maybe even during residency?
 
Doctor4Life1769 said:
Dude.

Seriously? Learn some respect. If you're gonna call out JPP or any attending, do so in a positive way. This is JPP's way of encouraging folks to contribute. You're not contributing to anything positive for this forum with posts like this.
Click to expand...

Fair enough.

I respect the hell out of JPP believe me. He's a big boy, though, and can be challenged from time to time. We need some healthy discourse sometimes.

That being said, you are right. This wasn't the time for that and I jumped the gun.
 
One positive way in which we can ALL contribute to clinical issues is to challenge convention.

This takes some balls though. Perhaps some of the stronger personalities have kept some folks on the sidelines in the past.

Remember (preaching to the choir I know, but for the newer people and students in particular) that often very strong opinions will be held about practices which are NOT black and white. And, frequently, even the best of literature searches may come up contradictory. So, if you are challenged by any number of opinionated attendings or fellow residents, it doesn't mean you are wrong. Just be prepared to support your arguement. Afterall, we're not going to learn by agreeing with one another all the time.
 
Doctor4Life1769 said:
anything you've picked up along the way? maybe even during residency?
Click to expand...

Sure, I'll chime in about a case today. 40 yo with achilles tear. Hx of myasthenia gravis s/p thymectomy 20 years. Currently asymptomatic. Patient refuses spinal. Surgeon wants 0/4 twitches for the case. Would you paralyze this patient. This case is being done in an outpatient center? What are your guys thoughts?
 
BTW, what is it with surgeons and muscle relaxation. I bet if we did a surgeon blinded study they wouldn't be able to tell the difference between 0/4 and 4/4 twitches.
 
cincincyreds said:
Sure, I'll chime in about a case today. 40 yo with achilles tear. Hx of myasthenia gravis s/p thymectomy 20 years. Currently asymptomatic. Patient refuses spinal. Surgeon wants 0/4 twitches for the case. Would you paralyze this patient. This case is being done in an outpatient center? What are your guys thoughts?
Click to expand...

Haven't started anesthesia yet (just finished intern year).

My thoughts:
1. could use a non-depolarizing agent (roc) and go low/slow
2. could you not do a popliteal block? or some sort of local block? or is this a case of the pt refusing all interventions?
3. i dunno what an outpt center may not have compared to being in the hospital OR
 
Doctor4Life1769 said:
Haven't started anesthesia yet (just finished intern year).

My thoughts:
1. could use a non-depolarizing agent (roc) and go low/slow
2. could you not do a popliteal block? or some sort of local block? or is this a case of the pt refusing all interventions?
3. i dunno what an outpt center may not have compared to being in the hospital OR
Click to expand...


patient is fearful of needles, so no blocks.
 
I would avoid any and all NMBD. Once a myasthenic, always a myasthenic. Deep inhaled anesthetic, or go TIVA route. High remi can trick the surgeon into thinking they have 0/4 twitches. Those are my thoughts.

To the upcoming residents, what is the implication of MG and NMBD?
 
I'd just smile and nod at the surgeon who said he needed total relaxation, and just run the patient deep on volatile.

The surgeon's going to put a thigh tourniquet on the patient anyway, so an hour in it's not like there's any point in keeping him at 0/4 as measured at the orbicularis oculi ...


If it's at a free-standing ASC, and if you're going to use muscle relaxant, maybe the case deserves to move to the main hospital. You can start slow with it, but there's a ton of patient-to-patient variability here and however much you give, the patient's still at risk for postop weakness and a longer recovery. Which won't be fun at 4 PM in a free-standing ASC.
 
cincincyreds said:
Sure, I'll chime in about a case today. 40 yo with achilles tear. Hx of myasthenia gravis s/p thymectomy 20 years. Currently asymptomatic. Patient refuses spinal. Surgeon wants 0/4 twitches for the case. Would you paralyze this patient. This case is being done in an outpatient center? What are your guys thoughts?
Click to expand...

A combo popliteal with a saphenous should do it. Then just some sedation.

If not viable for whatever reason, I would explain to the surgeon that MG patients are "exquisitely" sensitive to NDNMB's and that you will need to monitor twitches. Tell him that he'll get plenty of relaxation with 2 twitches and maybe run a Vecuronium infusion.

Now, the induction dose? Not sure about that one. Maybe even use a higher dose of Sux? Or no induction dose....Then a vec infusion? Start the vec infusion at maybe 0.3 mcg/kg/min (random I know but might as well start low and titrate up)

The block would be best once again.
 
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DrBeaker said:
I would avoid any and all NMBD. Once a myasthenic, always a myasthenic. Deep inhaled anesthetic, or go TIVA route. High remi can trick the surgeon into thinking they have 0/4 twitches. Those are my thoughts.

To the upcoming residents, what is the implication of MG and NMBD?
Click to expand...

I hear you but asymptomatic and s/p thymectomy? Not on pyridostigmine? I might be more aggressive.

It's an interesting case.
 
DrBeaker said:
I would avoid any and all NMBD. Once a myasthenic, always a myasthenic. Deep inhaled anesthetic, or go TIVA route. High remi can trick the surgeon into thinking they have 0/4 twitches. Those are my thoughts.

To the upcoming residents, what is the implication of MG and NMBD?
Click to expand...

This is extremely conservative and, though not wrong, is unsupported by current literature which supports judicious use monitored by a nerve stimulator. Obviously one can be lead astray by an inappropriately placed stimulator, which is an important concern. If one is really concerned, one can us nimbex which is more reliably cleared...
 
Alright, just finished the case. I induced with propofol, lidocaine, and fentanyl with some preop versed. I maintained anesthesia with propofol and remifentanil. I used a little larger dose of propofol to make it easier to intubate the patient. I used an ETT over an LMA just for the small chance of laryngospasm I can avoid it with an ETT. Not to say you can get laryngospasm on extubation. I made pretend like there were no twitches. Case went fine. Extubated. Pacu. Surgeon happy.

I avoided gas as gas can cause some muscle weakness which is something I am trying to avoid. He'll be home in an hour.

The patient didn't want a spinal because he is afraid of needles.

Not the most thought provacative case, but it does give you something to think about.
 
seems you went TIVA w/ the remi (similar to Beaker's plan).

(I'm assuming what you used is considered TIVA, anyway).

So, I found that both depolarizing and non-depol NM blocking agents cause post-synaptic blockade. Those with MG will have rapid and marked NM blockade due to the low availability of Ach receptors. The fact is that the pt is not on any medications for MG, so there is no drug-based effect on metabolism of these agents.

Also, I found gases do cause weakness and thus lower doses are used. However, the effects on NM transmission apparently dont extend beyond the discontinuation of the inhaled anesthetic (once shut off, the effects wear off) and it doesn't prolong post-op extubation.

I also found that propofol and lidocaine can potentiate the effects of NM blocking agents, but in this case the paralytics weren't used.

Source:

http://www.ispub.com/journal/the-internet-journal-of-neurology/volume-10-number-2/drugs-which-may-exacerbate-or-induce-myasthenia-gravis-a-clinician-s-guide.html

Very good case, especially for some of us noobs coming aboard.
 
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If you search about forum problems/issues you get a lot of threads, they go back 6+ years. Yet before and after each of these posts over the course of these years there are great threads to be found on every subject possible. Despite many claims that the forum was dead over the years, it still seems to be here producing great knowledge/stories/questions/answers on a plethora of subjects.

Sevoflurane
Bertelman
Periopdoc
Blademda
Noyac
Arch
Pgg
jetproppilot
militarymd(ret.)
Seinfeld
Gern Blansten
PlanktonMD
CChoukal
Dr doze
Idiopathic
ILDestriero
dhb
proman
urge
ProRealDoc

These are all people who I consider strong attendings (not saying others aren't, just listing some for the point), I love the knowledge and experience they provide(d). They are leaders to me. They are rockstars. They speak with clarity. There are attendings I work with who inspire me to be a better physician/person, but the people listed above also do that. I think it is a great testament to the above, that words they type can have that large and reaching of an influence.

As for threads that can overwhelm sometime, and seem less relevant(see matching @HOBOKOE KANSAS). It's relevant to those people. These questions aren't silly to them. They are in a very exciting period in their life from an educational/career standpoint. They can't see the process thru the eyes of people who are far out, they are experiencing it right now with a lot of trepidation. So while people far out from this process might find these threads clutter, for people in the process its as priceless as threads concerning perioperative management of critically ill patients are to me. It's all about what phase you are in. The earliest threads on this forum are questions about residency programs, so it's safe to say this will continue, and should.

Overall, I feel posts calling people out on this forum/criticizing the forum are similar to trying to start a camp fire with a bunch of giant logs and a ton of lighter fluid. You get a massive flame up that burns out quickly and a bunch of dirty looks from the people camping around you. There is a better way to build a fire that will burn strong and into the night.

This is just my opinion though.
 
KCBarbarossa said:
Then a vec infusion? Start the vec infusion at maybe 0.3 mcg/kg/min (random I know but might as well start low and titrate up)
Click to expand...

I don't see any utility to a NMBD infusion (or bolus redosing for that matter) since the tourniquet will prevent any of it from getting to the NMJ of interest.
 
cincincyreds said:
Sure, I'll chime in about a case today. 40 yo with achilles tear. Hx of myasthenia gravis s/p thymectomy 20 years. Currently asymptomatic. Patient refuses spinal. Surgeon wants 0/4 twitches for the case. Would you paralyze this patient. This case is being done in an outpatient center? What are your guys thoughts?
Click to expand...

Here you go--and with a smile: "Hey Joe, I like you. You worry about the surgical repair and let me worry about the anesthesia. We're taking the patient in now"

"Maam, would you like me to use the ultrasound and inject some local after you're asleep?" Propofol, LMA, prone.

"Hey Joe, are you sure you don't want to use the cat gut suture with a flying mattress stitch like those Ortho studs downtown who take care of the pro players?"
 
pgg said:
I don't see any utility to a NMBD infusion (or bolus redosing for that matter) since the tourniquet will prevent any of it from getting to the NMJ of interest.
Click to expand...

Yeah, I guess you're right. Didn't think of that. Thanks. I suppose whatever you had on board on induction would be what you'd be working with.
 
pgg said:
I don't see any utility to a NMBD infusion (or bolus redosing for that matter) since the tourniquet will prevent any of it from getting to the NMJ of interest.
Click to expand...

Aren't there studies out there as well that showed residual neuromuscular blockade was more likely with a NMBD infusion vs bolus of NMBD?

Anyone have the paper/link? I'm still looking.
 
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GypsySongman said:
High dose Sux for intubation.
Click to expand...

not a given, MG patients being treated will have a variable response to sux and prolonged response to nmb. so don't go jumping on the double dose of sux.

go bi dose of fentanyl and propofil and DL.

what antibiotics are not desirable in patients with mg?
 
Skip2myLou said:
not a given, MG patients being treated will have a variable response to sux and prolonged response to nmb. so don't go jumping on the double dose of sux.

go bi dose of fentanyl and propofil and DL.

what antibiotics are not desirable in patients with mg?
Click to expand...

Odds are sux would work at 2/
Prolonged block?... So much the better.
Very prolonged block?... Unlikely with untreated MG.
 
Skip2myLou said:
not a given, MG patients being treated will have a variable response to sux and prolonged response to nmb. so don't go jumping on the double dose of sux.

go bi dose of fentanyl and propofil and DL.

what antibiotics are not desirable in patients with mg?
Click to expand...

my link posts all medications/classes that would not be desirable in pts with MG.
 
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