Anesthesia Dogma

[Noyac]

Advertisement - Members don't see this ad

I thought it might be time to talk a little about some of the things we do because we were taught to do it a certain way. For instance, must we demonstrate ability to ventilate b/4 giving muscle relaxants?

 

[ProRealDoc]

I thought it might be time to talk a little about some of the things we do because we were taught to do it a certain way. For instance, must we demonstrate ability to ventilate b/4 giving muscle relaxants?

I guess staying up until 1am reading the newsletter pays off. 😀

 

[Planktonmd]

No, We don't need to demonstrate ability to ventilate before giving muscle relaxants because:
There are patients who you can ventilate before muscle relaxants that become difficult or impossible to ventilate after, and there are patients who you can't ventilate but they become easy to ventilate after relaxants.
So, deomnstrating ability to ventilate before muscle relaxants has very little correlation with how easy they will be to ventilate after.

 

[Planktonmd]

Here is another dogma example:
Do we really need to avoid doing C sections under GA at any price??

 

[ProRealDoc]

Ok I will play along. what about the cricoid pressure dogma?

 

[proman]

Ok I will play along. what about the cricoid pressure dogma?

I like how cricoid pressure activates the swallow reflex and actually relaxes the LES. Oops.

 

[mstudent12345]

On the flip side if you have a pt where you are worried about the airway and you can't ventilate will you push the vec???

maybe, maybe not

No, We don't need to demonstrate ability to ventilate before giving muscle relaxants because:
There are patients who you can ventilate before muscle relaxants that become difficult or impossible to ventilate after, and there are patients who you can't ventilate but they become easy to ventilate after relaxants.
So, deomnstrating ability to ventilate before muscle relaxants has very little correlation with how easy they will be to ventilate after.

 

[geauxg8rs]

agreed on the cricoid, stole my idea.

how about "cant use LMA" because of x,y,z comorbidity

 

[Planktonmd]

On the flip side if you have a pt where you are worried about the airway and you can't ventilate will you push the vec???

maybe, maybe not

If you have doubts about the airway there are more elegant ways to approach it than just induce GA and see if you can ventilate.

 

[Noyac]

On the flip side if you have a pt where you are worried about the airway and you can't ventilate will you push the vec???

maybe, maybe not

Maybe. Maybe I'll push sux. Maybe I'll wake em up. More times than not, you will be able to ventilate once muscle relaxants are working.

 

[Noyac]

I guess staying up until 1am reading the newsletter pays off. 😀

Actually, I'm on-call and currently don't have any cases. Its spring break and our usual Thursday surgeons are out of town. 😉

There are a few other topics as well in that newsletter but they should be reserved for other threads.

 

[Planktonmd]

Actually, I'm on-call and currently don't have any cases. Its spring break and our usual Thursday surgeons are out of town. 😉

There are a few other topics as well in that newsletter but they should be reserved for other threads.

I just read that news letter you guys were talking about!
What a pleasant tranformation the ASA is experiencing.
👍

 

[urge]

How about PP guys being slicker than workhorse academic guys?

 

[Breezee]

What about squeezing the bag as you are extubating? Makes no sense to me.

 

[pushthesux]

This is probably not universal, but I was taught by multiple people to NEVER let go of the wire when doing a CVL....like it could get sucked in and cause a wire embolus.😱

 

[ChrisA]

got to it before me...

What about squeezing the bag as you are extubating? Makes no sense to me.

 

[2ndyear]

This is probably not universal, but I was taught by multiple people to NEVER let go of the wire when doing a CVL....like it could get sucked in and cause a wire embolus.😱

Actually this is pretty true. Never let go of that damn thing. People preach this one because it really does happen. One of my co-interns let go, bad things happened.

 

[Noyac]

How about PP guys being slicker than workhorse academic guys?

Not necessarily slicker, just different.

 

[Arch Guillotti]

giving nebs to an asthmatic preoperatively when they have clear lungs

 

[Planktonmd]

Not necessarily slicker, just different.

Different in a good way though 😎

 

[radslooking]

Actually this is pretty true. Never let go of that damn thing. People preach this one because it really does happen. One of my co-interns let go, bad things happened.

me too. saw it happen with less than stellar results. i'd believe that one.

 

[Arch Guillotti]

stress dose steroids all the time

 

[dhb]

I'm doing a presentation on this topic next month, apart from the above here's what i have:

Opiods and thoracic rigidity (thx epiduralman)
high BMI and difficult intubation
Reading and vigilance
CVP/Swan monitoring
Mastectomy and Lymphedema
Cerebral autoregulation
Cristalloids & Blood 3 to 1 ratio
Blood & FFP 5 to 1 ratio

I have to look into the gum chewing 😀

 

[Fastrach]

What about squeezing the bag as you are extubating? Makes no sense to me.

The idea as I've been told is, you're filling up their lungs before you extubate them, that way when the tube comes out they exhale before inhaling, and theoretically this decreases the odds of them aspirating on that first non-intubated breath. Makes some sense to me...

 

[SleepIsGood]

The idea as I've been told is, you're filling up their lungs before you extubate them, that way when the tube comes out they exhale before inhaling, and theoretically this decreases the odds of them aspirating on that first non-intubated breath. Makes some sense to me...

Bingo...

I wish there was a way to do this and 'deep extubate'...and be smooth. As in extubate the pt w/o the surgeon even knowing it and be done. Cant have it all.

 

[Breezee]

The idea as I've been told is, you're filling up their lungs before you extubate them, that way when the tube comes out they exhale before inhaling, and theoretically this decreases the odds of them aspirating on that first non-intubated breath. Makes some sense to me...

I don't buy it. With the cuff deflated, I doubt if you are really giving a good positive pressure breath that would give sufficient lung inflation. If anything, I think you are blowing whatever junk is in the tube back into the trachea and onto the vocal cords as the tube comes out. Can we say laryngospasm?

 

[thegasman]

I don't buy it. With the cuff deflated, I doubt if you are really giving a good positive pressure breath that would give sufficient lung inflation. If anything, I think you are blowing whatever junk is in the tube back into the trachea and onto the vocal cords as the tube comes out. Can we say laryngospasm?

What I remember reading about this is that you are preventing any secretions that were sitting on the cuff from falling into the airway.

 

[ChrisA]

so you blow in air with the PPV and pull the tube... then, then very next thing they do is take a deep breath.... seems to me it does nothing..

Good suctioning then just take the tube..

 

[Planktonmd]

so you blow in air with the PPV and pull the tube... then, then very next thing they do is take a deep breath.... seems to me it does nothing..

Good suctioning then just take the tube..

I don't think it has ever been studied so your guess is as good as anyone's: it might work or it might be BS.
There are things we do that are not really rigid dogma but just a question of personal style.
Example to this would be the different ways for taping a tube or different ways for taping the eyes, every one does it differently and everyone thinks that their way is the best way.

 

[ChrisA]

too true plank, too true!

I don't think it has ever been studied so your guess is as good as anyone's: it might work or it might be BS.
There are things we do that are not really rigid dogma but just a question of personal style.
Example to this would be the different ways for taping a tube or different ways for taping the eyes, every one does it differently and everyone thinks that their way is the best way.

 

[Licoricestick]

How about not giving cephalosporins to people with type 1 hypersensitivity?

I confess I used this dogma the other day because it was my first experience of remote supervision (consultant present for induction, then left to go home). Pt had a (good) history of type 1 reaction to penicillin and the gynae consultant wanted cephazolin. I refused to give any ceph, mainly out of fear of anaphylaxis 5 min after my boss left the hospital, rather than using the evidence base that I know. Interesting what prompts us to avoid using EBM 😳

 

[huktonfonix]

How about not giving cephalosporins to people with type 1 hypersensitivity?

I confess I used this dogma the other day because it was my first experience of remote supervision (consultant present for induction, then left to go home). Pt had a (good) history of type 1 reaction to penicillin and the gynae consultant wanted cephazolin. I refused to give any ceph, mainly out of fear of anaphylaxis 5 min after my boss left the hospital, rather than using the evidence base that I know. Interesting what prompts us to avoid using EBM 😳

Uh, actually thats one I agree with. The cross reactivity is very low, but if I have a patient that had a previous anaphylactic reaction then thats not really something Im gonna mess with. The Gyns only want cephalosporins cause they dont know the alternatives. Ask em what they want to cover and offer an alternative.

 

[OB1🤙]

Yesterday I learned that people who take chronic methadone 10 BID have delayed gastric emptying and that an LMA is contraindicated for a half hour procedure, even if their last (tiny) meal was 24 hours ago, and even if they also happen to have short gut syndrome and are mostly TPN dependent.

 

[nutmegs]

here's mine: avoiding betadine/iodine/etc in people with shellfish allergy.

 

[PMPMD]

test dose abx: giving 1/10th the dose IV (e.g. 100mg of cefazolin) a few minutes prior to giving the rest of the dose.

 

[coprolalia]

Yesterday I learned that people who take chronic methadone 10 BID have delayed gastric emptying and that an LMA is contraindicated for a half hour procedure, even if their last (tiny) meal was 24 hours ago, and even if they also happen to have short gut syndrome and are mostly TPN dependent.

Think about how much smarter and how much better of a practitioner you are now for that wisdom that was bequeathed upon your head.



-copro

P.S. Did you show them an LMA Supreme?

 

[OB1🤙]

Did you show them an LMA Supreme?

I would have loved to, but the answer was too easy to anticipate... "Supreme or regular, that's an unsecured airway, and the risk of aspirating gastric contents remains...." so I Bowed My Head and intubated the poor gutless woman.

 

[ProRealDoc]

How about not putting ipsilateral IVs on patients who have had breast surgery for fear of arm swelling?

Seems to me that if make sure you place the IV in the vein rather than in the tissue then you should be OK.

 

[Planktonmd]

How about not putting ipsilateral IVs on patients who have had breast surgery for fear of arm swelling?

Seems to me that if make sure you place the IV in the vein rather than in the tissue then you should be OK.

This is not anesthesia dogma it is a nursing urban legend.

 

[ProRealDoc]

This is not anesthesia dogma it is a nursing urban legend.

Well, some attendings I've worked with have actually followed such dogma, if you can believe it.

I laugh every time a patient comes to the OR with a big sign taped to the head of the bed that reads "No IV's, venipuctures in left arm". Worst part is that even the patient refuses to have IVs placed on the 'affected' arm.

 

[pjl]

The best is after a prophylactic bilateral mastectomy, when you have to either go for the foot IV or the neck. At our place you can't even put a BP cuff on the affected side, so they get art lines or leg cuffs

 

[joshmir]

I'm doing a presentation on this topic next month, apart from the above here's what i have:

Opiods and thoracic rigidity (thx epiduralman)
high BMI and difficult intubation
Reading and vigilance
CVP/Swan monitoring
Mastectomy and Lymphedema
Cerebral autoregulation
Cristalloids & Blood 3 to 1 ratio
Blood & FFP 5 to 1 ratio

I have to look into the gum chewing
------------------------------------------------

Can you please post the presentation you gave after you give it?

Thanks man!

also, what are folks absolute, and grey-area contraindications for an LMA placement? when does a ProSeal change that?

 

[tracheatoedoc]

How about not putting ipsilateral IVs on patients who have had breast surgery for fear of arm swelling?

Seems to me that if make sure you place the IV in the vein rather than in the tissue then you should be OK.

The risk in sticking an appendage that's had a lymph node dissection is lymphangiitis (theoretically) not infiltration. I have a friend who used a BP cuff on the arm post mastectomy and this case resulted in chronic edema and a slamdunk lawsuit. I think she should have been worked up for an axillary vein thrombosis, but she wasn't.

 

[epidural man]

I love this place.....

It's been a while since I discovered facebook. I was coming by to look for those references that show that etomidate - even in single doses increases mortality - I hate the drug so I need references to back me up.

Anyway, I found this thread and I want to play.

So myths...

I agree with the above the pushing on the bag while extubating is ******ED. So now you are blowing a bunch of crap in the lungs as the tube is removed. A MUCH better way to actually accomplish what you are trying to do - is set you pop-off to 30ish, let the patient take a deep breath, he won't be able to exhale against the 30, or just wait till the pressure arises to 30, then extubate. Air and everything comes out with the tube. Also, this allows you to have both hands on the patient where they belong.

Here are some other myths/dogma that I think are interesting -

1. Lidocaine blunts laryngoscopy - really? How come all the papers that have tried to show this have failed? Strange that so many people use a stick of lidocaine for this reason.....

2. OSA patients are more susceptible to opioids. Really? Where is that data - and by the way, Benumof writing an ASA guideline is not data. Bottom line - there is no great data and for a REALLY interesting article, take a look at Chris Bernards recent article on remifentanyl infusions, OSA patients, and apneic episodse, etc. I think you will be surprised.

3. Preloading spinals makes a difference in the amount or frequency of hypotension. Hmmmm....depends if you believe dogma or data.

4. Of course my favorite - and many of you have been engrained in this dogma - droperidol is BAD. That is this biggest crap of all. Just so you know, there is not ONE case report in the peer reviewed literature at the PONV doses that have shown an adverse cardiac arrythmia - yet there are MANY of case reports of the 5-HT3s causing severe cardiac problems. Try this - next time, tell your staff "I am going to give the much SAFER drug droperidol, instead of this literature proven dangerous drug zofran" How do you think that truth will go over? Dogma is strong....(you should also note that the NNT for droperidol is higher than for 5-HT3s - and droperidol increases efficacy with increasing dose, unlike those others)

 

[epidural man]

The risk in sticking an appendage that's had a lymph node dissection is lymphangiitis (theoretically) not infiltration. I have a friend who used a BP cuff on the arm post mastectomy and this case resulted in chronic edema and a slamdunk lawsuit. I think she should have been worked up for an axillary vein thrombosis, but she wasn't.

Well, they should write the case up because I have been unsuccesful at finding anything in a textbook or literature that would back this silliness up. I can't believe he lost the lawsuit - he must of had a horrible lawyer.

 

[dhb]

removing dentures of edentulous patients :

http://www.anesthesia-analgesia.org/cgi/content/full/105/2/370

 

[Bertelman]

removing dentures of edentulous patients :

http://www.anesthesia-analgesia.org/cgi/content/full/105/2/370

Unbelievable that was published.

I ask all mine to take them out. I'd prefer to place an oral airway than to reach in and retrieve them during induction. I take measures to avoid placing my fingers in patient's mouths at all costs, even the edentulous ones. Besides, some of those are stuck on pretty hard.

Having said that, there was a lady this last week that I wish still had them in. Required a two-hand seal to mask because her cheeks were so floppy.

 

[Bucknut]

Unbelievable that was published.

I ask all mine to take them out. I'd prefer to place an oral airway than to reach in and retrieve them during induction. I take measures to avoid placing my fingers in patient's mouths at all costs, even the edentulous ones. Besides, some of those are stuck on pretty hard.

Having said that, there was a lady this last week that I wish still had them in. Required a two-hand seal to mask because her cheeks were so floppy.

My thoughts exactly...This is one piece of dogma that I don't mind. I'm glad all of our patients leave their dentures with the pre-op nurse. I have no interest in being in charge of making sure some old lady gets her false teeth back after surgery.

 

[periopdoc]

Why bother taking full dentures out? It is not as if they are going to disappear into the trachea. If they somehow loosen and occlude the airway just reach in and get them with your fingers. If your hands are too dainty to get them with fingers, use forceps. I leave them in for induction and intubation. I then grab the front and wiggle. If they drop out easily I will hand them to the circulator. If they are firmly attached I see no reason to try to get them out.

The method I use for masking patients is much easier to accomplish with teeth or dentures in. Open the mouth slightly then pull the jaw forward with two hands. Close the mouth thereby engaging the teeth. Use light cephalad pressure with the ring and little finger of the left hand to keep teeth engaged. Hold mask on lightly with first three fingers of left hand and mask in the usual fashion or to be really elegant turn on the vent to free your right hand for other tasks. Since the teeth are taking the brunt of the work one can do this for a while without fatiguing the left hand.

Not recommended for individuals with really bad teeth.

I can't remember the last time I needed an oral airway for a dentulous patient, but it was about a year and a half ago. If I can get away without blindly cramming hard plastic into soft pharyngeal tissue, I am much happier.

I do however remove all removable partials and "flappers" as they are too small and I can see the potential of them disappearing into places that would require more than direct laryngoscopy to remove.

- pod

 

[SaintFrances]

This is probably not universal, but I was taught by multiple people to NEVER let go of the wire when doing a CVL....like it could get sucked in and cause a wire embolus.😱

Have you guys actually seen a wire embolus? I also used to think you shouldn't let go till I did an ICU rotation with this old school doc who was amazingly deft with CVL's. He ALWAYS lets go of the wire and claims it never moves an inch in or out when he isn't holding onto it. I mean its like what... 8 or so inches of wire sticking out beyond the skin - it would take some crazy venous pressure to suck it all the way in, right?