I have to be honest everything about that post made me feel the same.
He didn't even allow comments on his own site.
Very dodgy
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Hip # ga vs spinal
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He didn't even allow comments on his own site.
Very dodgy
Studies also show no difference in postop delirium. Thoughts?
He is also touting exparal for Pacira
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deleted643396
“Nothing can be said to be certain, except death and taxes and old people getting delirium 10 seconds after being admitted to a hospital.” -Benjamin Franklin
Wise man
It’s not the anesthesia, but the neurohumoral response to surgical stress that causes delirium. That delirium happens in the same organ where the anesthesia goes is just a red herring.
I know I’ve said this on here before, but some octogenarian that just fell and broke their hip +/- a mild TBI, in acute pain, anxious, sleep deprived from getting woken up poked/prodded every other hour, thrown out of their routine, missing doses of home meds, getting new meds… more than half are delirious in pre-op. I’m far more surprised when they aren’t.
Surgery/anesthesia is just the icing on the cake. We need to stop owning this problem like it’s ours to fix/prevent. Get ‘em through safely and call it a day.
Edit: maybe don’t give 10 of versed though…
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When I used to teach residents, it would always blow their minds when I would ask them to find a randomized trial in any setting that showed benzodiazepines caused delirium. They’ve never found one.
But 10 is a lot!
On one hand, spinals are fine, blah blah. On the other hand the guy's a zealot with significant financial gain that is not always disclosed (investments, conferences, wife's job... etc) from peddling his questionable conclusions.
I work at an institution that runs 2 #NOF theatres from 0800-2000 every day. I GA 90% of them. Years ago I was supervising a pulmonary HTN case that arrested in the context of missed hypoventilation + hypercapnia with incredibly light sedation and a spinal. That anecdote made me review the literature in more detail. I've also been called to assist in multiple vent/hemodynamic catastrophes in the context of spinal and sedation.
My current practice is if they are sick (most of them) and they will need any sedation at all --> I give them the tube. I've had cement syndrome, air locks, massive haemorrhage, anaphylaxis, etc doing it this way and very good outcomes.
I work at an institution that runs 2 #NOF theatres from 0800-2000 every day. I GA 90% of them. Years ago I was supervising a pulmonary HTN case that arrested in the context of missed hypoventilation + hypercapnia with incredibly light sedation and a spinal. That anecdote made me review the literature in more detail. I've also been called to assist in multiple vent/hemodynamic catastrophes in the context of spinal and sedation.
My current practice is if they are sick (most of them) and they will need any sedation at all --> I give them the tube. I've had cement syndrome, air locks, massive haemorrhage, anaphylaxis, etc doing it this way and very good outcomes.
Reminds me of one of my CV attendings in fellowship. Full professor, been there forever. Not changing. 10 versed and 20 fentanyl was the starting point. The real ‘go getter’ residents would draw up another 10 and 20 without checking. If he saw narcs sitting out, he’d immediately dump them in the buretrol. If the resident pulled more, he’d give that too. I’m convinced he would do this ad infinitum.
It got to the point where his practice was so disparate from the rest of the (increasingly younger) CV anesthesia team that CVICU did an internal QI project looking at time to extubation by anesthesia attending.
There was no difference.
It was really annoying.
Often, the greatest determinant is the nursing and intensivist. Some like to run out the clock and have a quiet shift, extubating right before 6hrs, regardless of the anesthetic. Without a concerted push to earlier extubations, how anesthetic choices affect this will be lost in the weeds.
Had one attending who would regularly give very high dose narcotics and run a patient on maybe 0.1-0.2% iso. For a fellow's "educational benefit" he induced a patient with 100mcg/kg of fentanyl. Now, that guy took a while to wake up in the ICU!
As a secondary measure, I'd be curious if there were other markers affected other than just time to extubation, like incidence of ileus?
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deleted87051
So 7-10mg of fentanyl? 140-200 ml? I trained during a time when 2-3mg (40-60ml) was “normal”. We never cracked open the vaporizer.
How much iso? 1.2cc?
If you can’t get a SAB, what’s your typical GA recipe?
Just curious
Yeah it was 9.3mg. No volatile anesthetic was administered during that case.
How was it done? Really can't imagine 186 ml of (50 mcg/ml) fentanyl. Was it multiple 20cc syringes? The same 20cc syringe over and over? 3 big 60cc syringes? Also, quick infusion? Slowly? How long did it take? How about chest rigidity? And the induction? Just fentanyl (how much?) and neuromuscular blocker? Or any other hypnotic?
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Back in the day they used to induce with 100 cc fentanyl.
You'd think at some point all the receptors are saturated
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deleted87051
I’m not quite that old but in residency we induced with versed 20-25mg, fentanyl 40-60ml, and pancuronium 10mg. I still couldn’t imagine cracking 5x 20ml vials of fentanyl.
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deleted87051
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deleted1183938
What do they do now?
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deleted1130227
50ml vial. 60 ml syringe. Drew it up with needle from a 14g angiocath. Biggest needle in the cart.
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deleted87051
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deleted1130227
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deleted87051
Nice! That’s perfect for 1 case😉
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deleted1130227
On an gorilla or elephant.
Prove it then
Well do u ever do just anesthetizing the spinal cord? No. They always end up getting some sedation on top
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deleted87051
I once gave a spinal for a laser TURP to a 90yo retired surgeon who was the father of a surgeon I worked with. He had a bupiv only spinal and propofol 30mcg/kg/min for sedation during the case. Received no intraop benzos or opioids, no anticholinergics. He was very clear headed in the PACU and the afternoon of surgery. But he sundowned badly later that night and never fully recovered. Died about 6 months later. There is so much happening when a patient has surgery which makes it difficult to attribute POCD to any particular thing.
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Or just being 90 years old?
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deleted87051
Been talking to a guy who does a lot of outpatient joints at a freestanding center and this is what he does. They have heavy bupiv in their kits so that’s what he uses. 0.6ml for fast surgeons and 0.8ml for slower surgeons +GA/LMA.
Spinal and GA?
I’ll leave this here with no comment…
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deleted87051
If it were so freaking critical START with glidescope. First shot best shot.
If you can intubate without glidescope you sure as he'll should be able to intubation ate with.
Feel like this takes a lot of time
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deleted87051
I used to do spinal morphine plus ga for inpatient joints 20-25 yrs ago. It didn’t take much time.
The half dose spinal at the opsc is for postop analgesia and MAC reduction. It wouldn’t be adequate for surgical anesthesia. Full dose spinal would cause long postop stays. The guy says most go home 90-120min postop.
Yeah this video made me lose a lot of respect for Dr. Hadzic unfortunately.
He has quite a few faux pas recently...
The one where he posted that regional/spinal couldn't be equal to GA for #hip despite all the emerging evidence, then disabled comments... I think he likes his position of authority and doesn't want it challenged no matter the evidence
Yea, light spinal for decreased intraop opioids, some postop pain relief and faster discharge. Less bleeding and issues with hypertension. Not full heavy spinal because you want patients moving immediately postop
Many do this just with TIVA and a face mask. LMA makes it simpler.
Guys baby spinals + GA are a nonsense. Show some evidence pls?
Personally:
1: I don't want to sit and talk to a patient during a total joint
2: I don't like half sedated patients
3: when properly sedated I don't like doing chin lifts/jaw thrusts
It's just much easier for everyone in the room to just pop an LMA inside after the spinal and it's a good fail safe if for some reason today's bupivacaine decides to not work. I don't think there's a reason to do awake total joints
This is a pretty ****ty RSI not gonna lie. He keeps saying fast, but they're moving at a snails pace. Also ventilating with cricoid pressure after preoxygenation in a full stomach, wtf is this.
Honestly it's so fake I actually have concerns about it...
Did he allow a patient to desat on purpose, or are the vitals faked?
I highly doubt you are going to find any data because it's silly. Just forgo the spinal and pop in an LMA.
This is like purposefully doing a ****ty brachial plexus block with lidocaine for hand surgery that could have been the primary anesthestic and then popping in an LMA.
Yeah I’ve never heard of doing a “baby spinal” and GA lol wtf is what
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deleted87051
Benumof used to advocate this in the 1990s. “Modified RSI”. I personally don’t mask ventilate 99% of my patients before intubation. Typically mask only if I don’t preoxygenate due to claustrophobia.
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deleted87051
Ever do a shoulder with an ISB+LMA? The quality of those wakeups and recovery are phenomenal.
Modified RSI is an oxymoron
