Jet's TOP TEN

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jetproppilot

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10) you don't need to be sterile to place an A line.

9) giving an asymptomatic asthma patient a breathing treatment pre op is a waste of time.

8) Using etomidate for induction because you're scared to use propofol because of hemodynamic instability has no basis in fact....actually, etomidate has been shown to INCREASE mortality....moral of the story? USE PROPOFOL. Just use less. Or if the situation is that dire, use scopolamine or midazolam.

7) There is only ONE situation where I'd want a pulmonary artery catheter intraoperatively so WHY ARE YOU PUTTING SO MANY IN?

6)Giving blood? Yes. You can mix it with Lactated Ringers. Yeah I know. Doesn't matter. Academic, perpetuated dogma.

5) Combined spinal epidural for OB analgesia is superior to, and safer than current day accepted epidural care.

4) There exists no superior laryngoscopy blade. The best blade is the one you yield THE FORCE with.

3) If you're coming off bypass and you experience asystole or a brady arrhythmia, give 2mg atropine IMMEDIATELY.

2) Don't accept OBSTRUCTIONALISTIC NURSE BEHAVIOR. Move past it. Use your status to keep the OR moving.

AND THE NUMBER ONE JET TOP TEN:

1) Don't wait for ventilation to give succinylcholine. Give it as soon as the patient is unconscious. If the chips are down, assuming you are giving an appropriate dose, waiting to ventilate is burning precious seconds off your airway clock. This by far is one of the stupidest dogmas perpetuated by the "doctors" teaching you.

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Good list. Except, coming off bypass, I'd check the pacing wire connections and capture before the 2 mg of atropine.

10) you don't need to be sterile to place an A line.

9) giving an asymptomatic asthma patient a breathing treatment pre op is a waste of time.

8) Using etomidate for induction because you're scared to use propofol because of hemodynamic instability has no basis in fact....actually, etomidate has been shown to INCREASE mortality....moral of the story? USE PROPOFOL. Just use less. Or if the situation is that dire, use scopolamine or midazolam.

7) There is only ONE situation where I'd want a pulmonary artery catheter intraoperatively so WHY ARE YOU PUTTING SO MANY IN?

6)Giving blood? Yes. You can mix it with Lactated Ringers. Yeah I know. Doesn't matter. Academic, perpetuated dogma.

5) Combined spinal epidural for OB analgesia is superior to, and safer than current day accepted epidural care.

4) There exists no superior laryngoscopy blade. The best blade is the one you yield THE FORCE with.

3) If you're coming off bypass and you experience asystole or a brady arrhythmia, give 2mg atropine IMMEDIATELY.

2) Don't accept OBSTRUCTIONALISTIC NURSE BEHAVIOR. Move past it. Use your status to keep the OR moving.

AND THE NUMBER ONE JET TOP TEN:

1) Don't wait for ventilation to give succinylcholine. Give it as soon as the patient is unconscious. If the chips are down, assuming you are giving an appropriate dose, waiting to ventilate is burning precious seconds off your airway clock. This by far is one of the stupidest dogmas perpetuated by the "doctors" teaching you.
 
10) you don't need to be sterile to place an A line.

9) giving an asymptomatic asthma patient a breathing treatment pre op is a waste of time.

8) Using etomidate for induction because you're scared to use propofol because of hemodynamic instability has no basis in fact....actually, etomidate has been shown to INCREASE mortality....moral of the story? USE PROPOFOL. Just use less. Or if the situation is that dire, use scopolamine or midazolam.

7) There is only ONE situation where I'd want a pulmonary artery catheter intraoperatively so WHY ARE YOU PUTTING SO MANY IN?

6)Giving blood? Yes. You can mix it with Lactated Ringers. Yeah I know. Doesn't matter. Academic, perpetuated dogma.

5) Combined spinal epidural for OB analgesia is superior to, and safer than current day accepted epidural care.

4) There exists no superior laryngoscopy blade. The best blade is the one you yield THE FORCE with.

3) If you're coming off bypass and you experience asystole or a brady arrhythmia, give 2mg atropine IMMEDIATELY.

2) Don't accept OBSTRUCTIONALISTIC NURSE BEHAVIOR. Move past it. Use your status to keep the OR moving.

AND THE NUMBER ONE JET TOP TEN:

1) Don't wait for ventilation to give succinylcholine. Give it as soon as the patient is unconscious. If the chips are down, assuming you are giving an appropriate dose, waiting to ventilate is burning precious seconds off your airway clock. This by far is one of the stupidest dogmas perpetuated by the "doctors" teaching you.

Just finished the 5-hour repeat C/S from hell. At one point the OB attending looked over the drape and said "thank goodness for CSEs." Amen to that.
 
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Just finished the 5-hour repeat C/S from hell.

You must be joking. 5-hour CS with the patient lying 'still' on the table??????
 
1) Don't wait for ventilation to give succinylcholine. Give it as soon as the patient is unconscious. If the chips are down, assuming you are giving an appropriate dose, waiting to ventilate is burning precious seconds off your airway clock. This by far is one of the stupidest dogmas perpetuated by the "doctors" teaching you.
I am eager for wisdom, so please share your reasons. So, you are saying knowing you are able to ventilate is not a requirement for the administration of paralytics? I have done it both ways as my attendings are often the ones pushing the induction agents, but I was taught a very specific order of things and sux comes after you have succesfully mask ventillated. Of course, that seems to go out the window when the BMI is high, the neck is thick and the jaw is not able to open very wide...
 
I am eager for wisdom, so please share your reasons. So, you are saying knowing you are able to ventilate is not a requirement for the administration of paralytics? I have done it both ways as my attendings are often the ones pushing the induction agents, but I was taught a very specific order of things and sux comes after you have succesfully mask ventillated. Of course, that seems to go out the window when the BMI is high, the neck is thick and the jaw is not able to open very wide...

From the BJ of A

Confirmation of the ability to ventilate by facemask before administration of neuromuscular blocker: a non-instrumental piece of information?

R. H. Broomhead, R. J. Marks and P. Ayton

Background. Our aim was to determine whether anaesthetists routinely confirm their ability to ventilate a patient’s lungs by a facemask before the administration of a neuromuscular blocker and the rationale for this practice.
Methods. An online survey of trainee and non-trainee anaesthetists working in hospitals forming part of the Central London School of Anaesthesia collected 136 complete data sets over a 3 month period.
Results. Seventy-eight of 136 (57%) routinely checked they could ventilate by the facemask (‘checkers’). The reasons given for this varied, though the most common was the ability to ‘enable escape wake-up’. The practice was most commonly adopted by anaesthetists with less experience. In a hypothetical ‘cannot ventilate’ scenario, the use of succinylcholine was advocated by the majority of respondents, both ‘checkers’ and ‘non-checkers’.
Conclusions. Despite the lack of firm evidence to support the practice of confirming the ability to ventilate the lungs before administering a neuromuscular blocking drug (NMB), we found strongly held views that supported the practice and equally strongly held views that opposed it. However, in a hypothetical emergency situation where ventilation by the facemask after induction of anaesthesia was impossible, the majority of respondents (including ‘checkers’) would administer a neuromuscular blocker. This apparent paradox can be explained by wellrecognized psychological mechanisms. We suggest that in checking the ability to ventilate by
the facemask, some anaesthetists are seeking information that may be relevant but not instrumental in deciding when to administer an NMB.
Br J Anaesth 2010; 104: 313–17
 
I am eager for wisdom, so please share your reasons. So, you are saying knowing you are able to ventilate is not a requirement for the administration of paralytics? I have done it both ways as my attendings are often the ones pushing the induction agents, but I was taught a very specific order of things and sux comes after you have succesfully mask ventillated. Of course, that seems to go out the window when the BMI is high, the neck is thick and the jaw is not able to open very wide...

Editorial on the subject.

Anaesthesia, 2008, 63, pages 113–115

Could ‘safe practice’ be compromising safe practice? Should anaesthetists have to demonstrate that face mask ventilation is possible before giving a neuromuscular blocker?

A common instruction to trainee anaesthetists in the UK is that they should establish that face mask ventilation (FMV) is possible, before administering neuromuscular blocking drugs (NMBs). As far as we know the ‘no NMBs until FMV has been demonstrated’ rule is not evidence-based. The earliest reference to this policy we have found is in the chapter on tracheal intubation by Professors Gal and White in the third edition of the textbook Anesthesia [1]. Professor Gal has told us that they did not base their recommendation on published work, and did not intend to make failed FMV an absolute contraindication to NMBs (Gal TH, personal communication, 2007). Nevertheless, this policy seems to have become firmly entrenched in the minds of our trainees. This is curious, since it is barely mentioned in two standard UK texts on anaesthesia [2, 3], not mentioned in one other text [4], nor in texts dealing with airway management [5, 6]. Kheterpal and colleagues have reported recently on a study of 22 660 attempts at FMV[7], and their results suggest to us that it is time that the anaesthetic community discussed this issue.

At first sight the ‘no NMB before FMV’ rule seems an admirably sensible concept, but we perceive at least five possible defects.

Firstly, the theoretical advantage of the rule is not fulfilled in practice. Our trainees tell us that the advantage conferred is that a patient in whom FMV is impossible after induction can be woken up and an alternative technique applied. However, in real life this does not appear to be what happens. In both Kheterpal et al.’s study [7] and a previous, smaller one by Langeron et al. [8], no patient was woken. It may be that when a patient has an obstructed airway it is not feasible to await awakening; something has to be done to ventilate the lungs before catastrophic desaturation occurs. This is a different scenario to that obtaining after failed intubation when oxygenation can be performed by FMV. It is interesting that considerable attention has been given to the development of algorithms to aid the anaesthetist in decision making after failed intubation, but not to what the response to difficulty with mask ventilation before an attempt at intubation should be.

Secondly, it to some extent places anaesthetists on the horns of a dilemma. On the one hand enough anaesthetic must be given to permit FMV, but on the other hand the dose must allow a reasonably rapid return of consciousness should FMV prove impossible. It is conceivable that suspicion that a patient may need to be woken up might lead to under-dosing with induction agents, which could of itself result in difficulty with FMV due to an insufficient depth of anaesthesia. We have no evidence that the existence of the ‘no NMB before FMV’ rule leads anaesthetists to underdose patients, but it is possible that the existence of the rule might lead an inexperienced anaesthetist to be fearful of administering adequate doses at induction. In our experience, more difficulty with FMV is encountered when the patient is too lightly anaesthetised than when too deeply anaesthetised.

Thirdly, it is our experience that in patients in whom FMV is initially awkward, FMV becomes easier once the NMB has been given. While it might be claimed that this observation is related to the deepening of anaesthesia after induction, rather than to the developing neuromuscular blockade itself, our view is supported (albeit anecdotally) by the observation that this improvement in ease of FMV seems to be related to the speed of onset of the NMB used. We do accept, though, that our claim is difficult to support with evidence, partly because of the difficulty of translating the ‘feel’ of the reservoir bag during FMV into an objective measurement [9]. So our suspicion is that trainees’ reluctance to give a NMB in case FMV proves to be difficult is more likely to result in FMV that is difficult, compounding any difficulty resulting from a relatively low dose of induction agent.

Fourthly, should difficulty occur then the absence of neuromuscular blockade may hinder rescue of the situation. In the report by Kheterpal et al. of 22 660 attempts at FMV [7], there were 313 patients in whom FMV was difficult (1.4%), and 37 in whom it was impossible (0.16%). Of the latter 37, tracheal intubation after direct laryngoscopy was successfully performed in 36 (10 were noted to have been ‘difficult’ intubations) and one patient required surgical cricothyrotomy. All 37 were given NMBs, either before FMV was found to be impossible or to aid intubation [10]. In an earlier study by Langeron et al. of 1500 patients, FMV was reported as difficult in 75 (5%) and impossible in one (0.07%) [8]. One can only speculate on the likely success of rescue techniques such as tracheal intubation in the absence of NMBs, in such cases. There is a considerable body of evidence to support the proposition that NMBs make intubation easier [11–14]. A conclusion that could be drawn from Kheterpal et al.’s report is that, if tracheal intubation is planned in a patient in whom difficulty with FMV is a possibility, the safest tactic is to give NMB drugs as soon as possible, so that conditions for intubation are optimised. A logical extension of this is to suggest that since not all such patients can be identified in advance, NMBs should be given routinely immediately after induction.

Fifthly, the rule might inhibit practitioners in situations where FMV is impossible but NMBs are unarguably a correct treatment, such as opioid induced rigidity and laryngospasm from other causes [15].

Unfortunately, the work of Kheterpal and Langeron does not provide us with a template that we can apply to suspect patients in order accurately to identify the difficult-FMV ones. It seems that obesity is the background problem (BMI > 30 kg.m)2), and other factors that are associated with difficult FMV include beards, thick neck, age > 57 years, a history of snoring or obstructive sleep apnoea, poor mandibular protrusion, poor Mallampati grade and a thyro-mental distance of less than 6 cm [7]. However, the presence of one or a combination of these factors does not increase the likelihood of difficult FMV to an extent that makes decision making straightforward.* Of course, in ‘ivory tower theory land’, where all anaesthetists are competent endoscopists, there are no economic restrictions and all patients are cooperative, we could simply perform awake intubations on all such patients, but in the real world we would not necessarily end up with a better outcome, as awake fibreoptic intubation itself has morbidity and mortality [16].

Anaesthetists will increasingly be presented with grossly obese patients who require general anaesthesia. It is this group that seems to be most at risk of difficult FMV, but we can take some comfort from the findings of Kheterpal et al. that, in most of them, tracheal intubation was possible after direct laryngoscopy. An LMA does not seem to have been tried in Kheterpal et al.’s investigation [7]. We suspect that many UK anaesthetists encountering very difficult FMV would attempt to ventilate via an LMA before direct laryngoscopy, and would certainly do so if laryngoscopy did not permit intubation. Another option is to leave a tube in the pharynx, inflate the cuff and seal the mouth and nose [17]. These tactics will only be successful if the glottis is open. In our opinion neuromuscular blockade is the most certain way to ensure glottic patency, so that administration of NMBs is more likely to be helpful than not in this dire situation.

So should anaesthetic instructors perform a volte-face and tell their trainees to give NMBs before demonstrating successful FMV? Our experience and Kheterpal et al.’s findings suggest to us that such a policy is more logical than the current one. However, we cannot point to conclusive evidence. Anaesthetists should consider their own abilities and the patient’s characteristics and opt for awake intubation or a regional technique when they believe that to be the best course. We are not suggesting that it is acceptable for anaesthetists to give NMBs to patients in whom it is obvious that FMV and intubation are going to be impossible. However, if general anaesthesia is (or has to be) the choice, we are concerned that the current rule may lead to half-hearted anaesthesia. Practitioners who believe that the administration of a NMB might help when difficulty with the airway is encountered should be able to exercise their judgement without fear of criticism. If anaesthetists hesitate to give NMB agents when necessary, this will be a retrograde step in patient safety. It may be that in the future we will be able to reverse the effects of NMBs promptly, so that everyone will feel comfortable with their early administration [18].

I. Calder
Consultant Anaesthetist
Department of Anaesthesia
The National Hospital for Neurology and Neurosurgery
 
Interesting editorial. Admittedly, I generally achieve FMV prior to NDMBs, be it with a mask or LMA (we get a lot of ZZ top beards here), but if I'm using succ I'll give it with induction. I agree that waking up a morbidly obese, unmaskable, desaturating patient after an induction dose of propofol (particulular if adjuncts like opiates and benzos were included) is pretty unrealistic. I'd add that the right-sided tail of apneic periods after 1 mg/kg of succ stretched up to 9 minutes (saw this paper in residency in Anesthesiology, but didn't take the time to look it up again), suggesting that the traditional dose of succ for RSI may not achieve the desired effect of "wearing off before they get hypoxic."

I think the important aspect is to assess the airway and history with an eye toward 1) whether they'll be difficult to mask (kheterpal's paper is a great read for this), and 2) whether they'll be difficult to intubate so that you can have a plan in place before having to make a decision when you induce and learn that they're tough to mask.

That and get comfortable with "awake" intubations (FOB, glide, AND DL). I do lots and I've never regretted one.
 
Interesting editorial. Admittedly, I generally achieve FMV prior to NDMBs, be it with a mask or LMA (we get a lot of ZZ top beards here), but if I'm using succ I'll give it with induction. I agree that waking up a morbidly obese, unmaskable, desaturating patient after an induction dose of propofol (particulular if adjuncts like opiates and benzos were included) is pretty unrealistic. I'd add that the right-sided tail of apneic periods after 1 mg/kg of succ stretched up to 9 minutes (saw this paper in residency in Anesthesiology, but didn't take the time to look it up again), suggesting that the traditional dose of succ for RSI may not achieve the desired effect of "wearing off before they get hypoxic."

I think the important aspect is to assess the airway and history with an eye toward 1) whether they'll be difficult to mask (kheterpal's paper is a great read for this), and 2) whether they'll be difficult to intubate so that you can have a plan in place before having to make a decision when you induce and learn that they're tough to mask.

That and get comfortable with "awake" intubations (FOB, glide, AND DL). I do lots and I've never regretted one.

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Of course the drummer (the guy in the middle) is named Frank Beard.
 
Love em, especially 1,2,4, and 8, although we all know a MAC 3 is the best ;) for gravid fire ants.

Respectfully (of course) agree to disagree on #5 though. Nearly 20k deliveries a year in our system and nary a CSE to be found.
 
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Respectfully (of course) agree to disagree on #5 though. Nearly 20k deliveries a year in our system and nary a CSE to be found.

I would have agreed with you JWK until I went to my current gig. Now I have to say the CSE is da bomb. But it's not necessarily better. How's that for confusing? I like it cuz it I can leave he room as soon as the catheter is placed. No need to stay and assess the situation.
 
I would have agreed with you JWK until I went to my current gig. Now I have to say the CSE is da bomb. But it's not necessarily better. How's that for confusing? I like it cuz it I can leave he room as soon as the catheter is placed. No need to stay and assess the situation.

How long do you monitor the BP after the spinal dose?
 
How long do you monitor the BP after the spinal dose?

I have the nurse take a BP before I start while she is sitting up and then every 5 min after that. Th next BP is after the IT dose and then one more as I'm walking out of the room. I am typically in the room less than 15-20 minutes. I haven't been called back in years.
 
I have the nurse take a BP before I start while she is sitting up and then every 5 min after that. Th next BP is after the IT dose and then one more as I'm walking out of the room. I am typically in the room less than 15-20 minutes. I haven't been called back in years.

What's your intrathecal dose? Do you co-load with 500mL? We do the 500, dose for multip/nullip>4cm is 2.5 mg 0.5% Bupivicaine/15 mcg FTL, nullip<4cm is 25 mcg of FTL. We are instructed at minimum to stay until the blood pressure stabilizes, threshold to treat I'm sure varies, not sure the frequency at which I need to treat with something other than fluid, seems rare.
 
I'm a big fan of the labor CSE and it's all I do now.

I use 1 mL 0.25% bupiv + 15 mcg fentanyl, and ALMOST never see any hypotension afterwards ... I do think you still need to make sure patients have had at least some fluid bolus, especially the pre-e ones who may be dry. I've thought about changing to a fentanyl only IT dose but I'm not sure the itching would be worth getting rid of the local.
 
What's your intrathecal dose? Do you co-load with 500mL? We do the 500, dose for multip/nullip>4cm is 2.5 mg 0.5% Bupivicaine/15 mcg FTL, nullip<4cm is 25 mcg of FTL. We are instructed at minimum to stay until the blood pressure stabilizes, threshold to treat I'm sure varies, not sure the frequency at which I need to treat with something other than fluid, seems rare.

Why are you guys making it so difficult?

I tell the OB to have the nurse call when the bolus is in. I don't care what the bolus is really. Then I Do a one size fits all ( sort of like a crna with a general anesthetic) bupiv 2.5 mg and Fent aprox 20mcg.
 
I would have agreed with you JWK until I went to my current gig. Now I have to say the CSE is da bomb. But it's not necessarily better. How's that for confusing? I like it cuz it I can leave he room as soon as the catheter is placed. No need to stay and assess the situation.

Agreed. I haven't done a single CSE in private practice because our OB volume is low and so there's never a rush. But in residency where we did about 12000 deliveries a year and 95% got epidurals...I had to put CSEs in everybody because by the time I got LOR on one epidural, they'd be paging me about the next one...
 
I'm a big fan of the labor CSE and it's all I do now.

I use 1 mL 0.25% bupiv + 15 mcg fentanyl, and ALMOST never see any hypotension afterwards ... I do think you still need to make sure patients have had at least some fluid bolus, especially the pre-e ones who may be dry. I've thought about changing to a fentanyl only IT dose but I'm not sure the itching would be worth getting rid of the local.

With the 25mcg of fentanyl people frequently complain about itching while I'm finishing the charting. It's tempting to ask if it's worse than the prior discomfort? Do you think the intrathecal dose sets up high expectations? The pure fentanyl ones rarely seem to complain(re doses, etc), but the ones that get the 2.5 mg of bupivicaine + 15 mcg fentanyl end up having more complaints of pain and that 'it isn't as good as it was at first.'

The blood pressure usually consistently drops with our full dose, people vary in threshold for treating, RN concern vs <100 SBP vs symptomatic etc.
 
With the 25mcg of fentanyl people frequently complain about itching while I'm finishing the charting. It's tempting to ask if it's worse than the prior discomfort? Do you think the intrathecal dose sets up high expectations? The pure fentanyl ones rarely seem to complain(re doses, etc), but the ones that get the 2.5 mg of bupivicaine + 15 mcg fentanyl end up having more complaints of pain and that 'it isn't as good as it was at first.'

The blood pressure usually consistently drops with our full dose, people vary in threshold for treating, RN concern vs <100 SBP vs symptomatic etc.

It all depends on your nursing staff.
 
what I dislike about CSEs is getting a patient comfy for 90 minutes with the spinal and then finding out after that the epidural catheter blows and can't keep them comfy. If I'm going to have to redo the epidural, I'd rather find out within 15 minutes than 90 minutes later when they are potentially significantly more uncomfortable and it becomes a more difficult task.

The only time I do a CSE is if I think there is a decent chance the patient will deliver before the spinal wears off.
 
what I dislike about CSEs is getting a patient comfy for 90 minutes with the spinal and then finding out after that the epidural catheter blows and can't keep them comfy. If I'm going to have to redo the epidural, I'd rather find out within 15 minutes than 90 minutes later when they are potentially significantly more uncomfortable and it becomes a more difficult task.

The only time I do a CSE is if I think there is a decent chance the patient will deliver before the spinal wears off.

Agree completely. I usually just place my epidural, then inject the remaining 3 cc of test dose lido and add 5 cc of pump solution (usually .2% ropi w/fent or .125% bupi). I stick around for 5 minutes to finish my paperwork and by the time I'm done the pt is nice and comfy.
 
Agree with every item on the list especially the one about not wasting precious time on attempting ventilation before giving SUX.
I am not sure why people don't understand that the ability to ventilate before sux does not mean you will be able to ventilate after SUX and also that sometimes when you cant ventilate before Sux ventilation becomes possible after Sux.
Basically proving that you can ventilate before giving SUX does not prove anything it only wastes precious time.
 
Agree with every item on the list especially the one about not wasting precious time on attempting ventilation before giving SUX.
I am not sure why people don't understand that the ability to ventilate before sux does not mean you will be able to ventilate after SUX and also that sometimes when you cant ventilate before Sux ventilation becomes possible after Sux.
Basically proving that you can ventilate before giving SUX does not prove anything it only wastes precious time.

Exactly plank. Especially that last part.

To be honest... I hardly ever test ventilation... and in most cases I give the ROC and the Propofol in the same syringe... but only if they have a narcotic load upfront + some lido as ROC also burns.

For me, it's prop/roc or prop/sux then tube w/o testing for ventilaiton OR Awake fiberoptic/glidescope/DL or mask induction.

As mentined... ventilation more often than not improves after muscle relaxation.

Of course there are the head and neck radiation cases, tracheal stenosis, mediastianal and AW masses, facial trauma, AW burns... these require critical thinking and are case dependant. Mask inductions with preservation of SV vs Prop/sux/tube vs trach vs. awake FO or the like.


Good to see you posting jet. :thumbup:
 
That's a good top ten, but I place my a lines with sterile technique. Chlorhex bath, sterile gloves. The drape is optional, though policy requires it. If the fellow is struggling on one side, I usually don't drape the other, maybe one drape to put the wire on. Shhh, don't tell.;)
 
To be honest... I hardly ever test ventilation... and in most cases I give the ROC and the Propofol in the same syringe...
How are you dosing the Roc, .6mg/kg or 1.2mg/kg?

In the surgery center for shorter cases, we often use a small dose of Roc and mask the patient down with Sevo for ~90 seconds. Clearly ventilation is tested that way, but your points regarding not testing ventilation are well made.

At what point do you typically tape the eyes? The corneal abrasion thread had me wondering what common practice is elsewhere as I will not even mask the patient until their eyes are taped (urgent circumstances excepted)...
 
How are you dosing the Roc, .6mg/kg or 1.2mg/kg?

In the surgery center for shorter cases, we often use a small dose of Roc and mask the patient down with Sevo for ~90 seconds. Clearly ventilation is tested that way, but your points regarding not testing ventilation are well made.

At what point do you typically tape the eyes? The corneal abrasion thread had me wondering what common practice is elsewhere as I will not even mask the patient until their eyes are taped (urgent circumstances excepted)...

You are not testing ventilation if u already gave the paralytic. Mask inductions are fine, but prop inductions are more predictable, nicer and faster for adults. Kids are by far the exception.
My roc dose depends on the case. Spine case gets full dose and then some. Lap chole = much smaller, but also depends on comorbid conditions and age. I tape the eyes after the tube is in. I've never had a corneal abrasion.
 
Mask inductions are fine, but prop inductions are more predictable, nicer and faster for adults.
We do propofol inductions, we just mask with Sevo while the small dose of roc takes effect which is ~90 seconds
 
We do propofol inductions, we just mask with Sevo while the small dose of roc takes effect which is ~90 seconds

You describe a standard induction. If you are going with a smaller dose of roc, turning on the sevo while the paralytic takes effect is wise as it takes longer to get adequate relaxation. (bigger dose of propofol +/- fent accomplishes the same thing).

You get negative style points if the patient bucks or gags during laryngoscopy. ;)
 
At what point do you typically tape the eyes? The corneal abrasion thread had me wondering what common practice is elsewhere as I will not even mask the patient until their eyes are taped (urgent circumstances excepted)...

Right after I push the drugs. But not because I care about abrasions with a mask. Mostly because otherwise I will sometimes forget. Plus I've got plenty of time to do so while the relaxant takes effect.

And I probably used to do it to piss my attendings off just a little bit, like "Here I am taping the eyes shut- don't worry I'll mask 'em in just a second!"
 
You are not testing ventilation if u already gave the paralytic. Mask inductions are fine, but prop inductions are more predictable, nicer and faster for adults. Kids are by far the exception.
My roc dose depends on the case. Spine case gets full dose and then some. Lap chole = much smaller, but also depends on comorbid conditions and age. I tape the eyes after the tube is in. I've never had a corneal abrasion.

You guys do MEPs at all? Or even with your larger doses is it absent by the time you go prone/prep/etc?
 
Some of our surgeons do. The surgeon I worked with today during a five level percutaneous fusion uses mep's/ssep's 40% of the time. Another one uses it 100% of the time. Always on scoliosis cases.
 
Why are you guys making it so difficult?

I tell the OB to have the nurse call when the bolus is in. I don't care what the bolus is really. Then I Do a one size fits all ( sort of like a crna with a general anesthetic) bupiv 2.5 mg and Fent aprox 20mcg.


In terms of the intrathecal(opioid vs LA/opioid) based on source of pain, visceral vs somatic pain, and the rate of progression thru the visceral component into the somatic.

In terms of the co-loading...I thought one thing but because of your points I started looking into it and now am not so sure...so thank you.
 
3) If you're coming off bypass and you experience asystole or a brady arrhythmia, give 2mg atropine IMMEDIATELY.

]

I'm curious about the physiologic basis for this one. Too much vagal stimulation coming off bypass?
 
I havent decided yet if I like CSE vs epidural for labor better yet. We rotate through 2 hospitals, one everyone gets an epidural only, the other, CSE for all. The nurse calls after the pt has received a fluid bolus. Every pt gets 1mg of bupivicaine + 15mcg fentanyl. As a resident, i like the CSE because it sometimes confirms im in the right space. Occasionally i get a not so great loss, and if my spinal needle returns csf, im more confident im the right space, and if it doesnt...ill likely replace the touhy. On the other hand, like it was said above, it might take 90 minutes before i realize my catheter isnt working. And they are heading back for a section. blergh.
 
10) you don't need to be sterile to place an A line.

9) giving an asymptomatic asthma patient a breathing treatment pre op is a waste of time.

8) Using etomidate for induction because you're scared to use propofol because of hemodynamic instability has no basis in fact....actually, etomidate has been shown to INCREASE mortality....moral of the story? USE PROPOFOL. Just use less. Or if the situation is that dire, use scopolamine or midazolam.

7) There is only ONE situation where I'd want a pulmonary artery catheter intraoperatively so WHY ARE YOU PUTTING SO MANY IN?

6)Giving blood? Yes. You can mix it with Lactated Ringers. Yeah I know. Doesn't matter. Academic, perpetuated dogma.

5) Combined spinal epidural for OB analgesia is superior to, and safer than current day accepted epidural care.

4) There exists no superior laryngoscopy blade. The best blade is the one you yield THE FORCE with.

3) If you're coming off bypass and you experience asystole or a brady arrhythmia, give 2mg atropine IMMEDIATELY.

2) Don't accept OBSTRUCTIONALISTIC NURSE BEHAVIOR. Move past it. Use your status to keep the OR moving.

AND THE NUMBER ONE JET TOP TEN:

1) Don't wait for ventilation to give succinylcholine. Give it as soon as the patient is unconscious. If the chips are down, assuming you are giving an appropriate dose, waiting to ventilate is burning precious seconds off your airway clock. This by far is one of the stupidest dogmas perpetuated by the "doctors" teaching you.

Great

to see such interest!

We've got a lot to talk about.

I encourage all pre meds, med students, residents, attendings:


Let it out man.

There's soooooooooo many
VOYEURS OUT THERE
dudes.
Chime in.
I wanna hear from the
Scared med students
the
Humble residents
the
Quiet Attendings
out there
I've quoted some s h it I've learned over the last sixteen years of my private practice life.

Here's the thing:

ITS OK TO LIKE OR DISLIKE

A.K.A. tell Jet to go €#€k himself


It's

all ok man.

Here's what I've learned:

I've learned that anesthesiology is a practice of medicine where you can do

ONE THING

Several different ways so it is


IMPORTANT TO LISTEN TO EVERY BODY ELSE.

That includes

You, Slim.

Show me whatcha got. :D
 
Good list. Except, coming off bypass, I'd check the pacing wire connections and capture before the 2 mg of atropine.

No man. I'm talking about
WAYYYyYYYYY ahead of pacing
I'm suggesting that aggressive atropine use in the presence of bradyarrythmia
during that immediate moment can


Make pacing unneeded.

2mg.

Atropine.

Seriously.

Try it next time during separation where you see bradycardia

Slam in 2mg atropine and wait a cuppla minutes.

You can always pace.

I'm suggesting that atropine at the right time can make pacing unnecessary.
 
No man. I'm talking about
WAYYYyYYYYY ahead of pacing
I'm suggesting that aggressive atropine use in the presence of bradyarrythmia
during that immediate moment can


Make pacing unneeded.

2mg.

Atropine.

Seriously.

Try it next time during separation where you see bradycardia

Slam in 2mg atropine and wait a cuppla minutes.

You can always pace.

I'm suggesting that atropine at the right time can make pacing unnecessary.

Is pacing a bad thing?
 
Is pacing a bad thing?

Indeed not.

If you come off pacing, tho, and it doesn't work, where do you go?

You go back on bypass.

You have no safety net.

That's why I'm suggesting exhausting your pharmacologic armamentarium before pacing.

Because you are leaving yourself a safety net.

If you're able to separate from bypass without pacing,

you've got another weapon in your holster if things go awry.

Being ahead of the game pays dividends.

Use everything you know when doing a difficult case.

I've done the Atropine trick many times, dudes.

I wouldn't suggest it if it didn't work.

Volume coming in, venous line clamped, bradycardia,

BOOM.

Atropine 2mg.

A lotta times pacing unneeded.

I don't have time to make a randomized double blinded study.
 
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Agree with every item on the list especially the one about not wasting precious time on attempting ventilation before giving SUX.
I am not sure why people don't understand that the ability to ventilate before sux does not mean you will be able to ventilate after SUX and also that sometimes when you cant ventilate before Sux ventilation becomes possible after Sux.
Basically proving that you can ventilate before giving SUX does not prove anything it only wastes precious time.

Cool thanks for these teaching points -

Can you guys explain why giving sux doesn't make ventilating easier? It just seems to me that once sux is given and all the muscles are relaxed, resistance to ventilation is now lower. So it would logically follow that if you are able to ventilate them when they aren't paralyzed yet, you should definitely be able to afterwards
 
Cool thanks for these teaching points -

Can you guys explain why giving sux doesn't make ventilating easier? It just seems to me that once sux is given and all the muscles are relaxed, resistance to ventilation is now lower. So it would logically follow that if you are able to ventilate them when they aren't paralyzed yet, you should definitely be able to afterwards

I hope an attending will follow up this post to correct my errors and omissions, but in the spirit of Jet mentioning pre-meds and med students do some thinking here as well...I'll take a stab here based upon reading everyone's prior sux posts on SDN and time having my ears open in the OR...

Nooblet, I don't think anyone said that sux doesn't make ventilating easier per se. I think the (I said I think twice so I know I'm outta my league but still, I think, I can answer this. 3X) idea is that testing ventilation without sux is not necessary/time wasting etc. I think (4x) what's being argued here is, "Why test ventilation prior to giving a muscle relaxant, when, if you cannot easily ventilate, you are going to use a muscle relaxant anyway...so why not a) give the muscle relaxant and NOW see where things stand, or, don't, find out that you cannot ventilate without it, and then give it." Point is, somewhere along the line you may use sux, so, what use carrying out an experiment that is really not giving you any pertinent information?

I think it is safe to say (for me at least, and I stopped counting I thinks) that sux will make the patient easier to ventilate. It's kind of the whole point why you wouldn't test ventilate prior to its use.

In other words, scenario 1: patient induced, you mask ventilate, it's not happening...(I imagine the algorithm brings you to) using a muscle relaxant. So what was the point of testing before sux? You're here now anyway... Testing ventilation without sux is a test to see if you can do something without all the ingredients of what you will ultimately use in case you fail (your test). scenario two: you mask ventilate after using sux/roc, ventilation not happening so, a) TOTAL GUESS - you give more sux to make sure they are fully relaxed? b) instead of using sux in the first place you used (past tense) a non-depolarizing relaxant so you reverse and back out, but why would you do that because you want to facilitate ventilation, with nice relaxed muscles, preferably muscles that weren't relaxed by hypoxia, so TOTAL GUESS, can you give sux after Roc? (If not actually, patient is still relaxed, so, we're theoretically where sux would get us). All of the above get you to: having used sux, which I think is the quickest, most effective paralytic (as it's used in RSI). So why test without it, if, should the HITSAY hit the ANFAY, you're going to use it anyway?

I don't know if I thought through this out loud well enough, so I do hope an Attending will follow up with what I'm missing! :thumb up:

Applying flame ******ant as we speak...

D712
 
what I dislike about CSEs is getting a patient comfy for 90 minutes with the spinal and then finding out after that the epidural catheter blows and can't keep them comfy. If I'm going to have to redo the epidural, I'd rather find out within 15 minutes than 90 minutes later when they are potentially significantly more uncomfortable and it becomes a more difficult task.

The only time I do a CSE is if I think there is a decent chance the patient will deliver before the spinal wears off.

CSE is my default. Maybe I'm in minority, but I am MORE CONFIDENT about an epidural with CSE than without. The only thing better than LOR to confirm epidural space is to advance a spinal needle through the tuhoy and get CSF back. The spinal will have kicked in by the time you taped in the catheter and laid the patient back down. A study out of Brigham showed dural puncture (without drugs) results in more symmetric block and better sacral spread of epidural analgesia. As for "spoiling" the patient with the spinal, it's all about setting reasonable expectation. I tell all of them that after the more dense block wears off, they are going to feel more, but that doesn't mean something is wrong. They just need to be checked and most likely the baby is coming soon.

A randomized trial of dural puncture epidural technique compared with the standard epidural technique for labor analgesia.

Cappiello E, O'Rourke N, Segal S, Tsen LC.
Source

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.

Abstract

BACKGROUND:

We designed this prospective, double-blind, randomized study to examine whether a dural puncture without intrathecal drug administration immediately before epidural drug administration would improve labor analgesia when compared to a traditional epidural technique without prior dural puncture.
METHODS:

Eighty nulliparous parturients with cervical dilation less than 5 cm were randomly assigned to receive a standardized epidural technique, with or without a single dural puncture with a 25-gauge (G) Whitacre spinal needle. After successful placement of the needle(s) and the epidural catheter, 12 mL of bupivacaine 2.5 mg/mL was administered through the epidural catheter and a patient-controlled epidural infusion of bupivacaine 1.25 mg/mL + fentanyl 2 mug/mL was initiated. The presence of sacral analgesia (S1) and pain scores were compared between groups.
RESULTS:

In demographically similar groups, parturients with prior dural puncture had more frequent blockade of the S1 dermatome (absolute risk difference [95% confidence interval] 22% [6-39]), more frequent visual analog scale scores <10/100 at 20 min (absolute risk difference 20% [1-38]), and reduced one-sided analgesia (absolute risk difference [95% CI] 17% [2-330]). The highest median sensory level (T10) was no different between groups.
CONCLUSIONS:

Dural puncture with a 25-G spinal needle immediately before the initiation of epidural analgesia improves the sacral spread, onset, and bilateral pain relief produced by analgesic concentrations of bupivacaine with fentanyl in laboring nulliparous patients.
 
CSE is my default. Maybe I'm in minority, but I am MORE CONFIDENT about an epidural with CSE than without. The only thing better than LOR to confirm epidural space is to advance a spinal needle through the tuhoy and get CSF back. The spinal will have kicked in by the time you taped in the catheter and laid the patient back down. A study out of Brigham showed dural puncture (without drugs) results in more symmetric block and better sacral spread of epidural analgesia. As for "spoiling" the patient with the spinal, it's all about setting reasonable expectation. I tell all of them that after the more dense block wears off, they are going to feel more, but that doesn't mean something is wrong. They just need to be checked and most likely the baby is coming soon.
.

So in my previous post i agreed with you. However, i just placed a CSE. I used LOR with saline, got a fantastic loss. Placed my spinal needle, no pop, no CSF. So now, rather than making me feel confident, i am unconfident (is that a word?). So I ended up advancing the touhy like 3/4 of a centimeter, and then i finally got csf. but it made me uneasy! Anyways, now i am concerned it went intravascular. Aspiration was negative, but we dont give a test dose with our CSE's. I guess ill find out soon enough. blergh.
 
So in my previous post i agreed with you. However, i just placed a CSE. I used LOR with saline, got a fantastic loss. Placed my spinal needle, no pop, no CSF. So now, rather than making me feel confident, i am unconfident (is that a word?). So I ended up advancing the touhy like 3/4 of a centimeter, and then i finally got csf. but it made me uneasy! Anyways, now i am concerned it went intravascular. Aspiration was negative, but we dont give a test dose with our CSE's. I guess ill find out soon enough. blergh.

There's a good diagram in Chestnut that illustrates reasons you might not get CSF even with good loss, one of which being the spinal needle isn't long enough to reach the dura or just dents the dura.

Another alternative being you're at an angle and you're sliding the needle past the CSF, which I think had happen to me on a particularly difficult CSE.

On the flip side, if you do get CSF, I do feel like that's pretty good reinforcement that the Tuohy's in the epidural space.
 
Indeed not.

If you come off pacing, tho, and it doesn't work, where do you go?

You go back on bypass.

You have no safety net.

That's why I'm suggesting exhausting your pharmacologic armamentarium before pacing.

Because you are leaving yourself a safety net.

If you're able to separate from bypass without pacing,

you've got another weapon in your holster if things go awry.

Being ahead of the game pays dividends.

Use everything you know when doing a difficult case.

I've done the Atropine trick many times, dudes.

I wouldn't suggest it if it didn't work.

Volume coming in, venous line clamped, bradycardia,

BOOM.

Atropine 2mg.

A lotta times pacing unneeded.

I don't have time to make a randomized double blinded study.

Why are you giving such a large dose of atropine? That's double the code dose. You ever get a brisk response >100?

Also, you have any thoughts on what you're treating? I'm concerned that acute bradycardia immediately after separation may be from air down the RCA.

I'm all for trying out various techniques to get me to the ICU, but if we have an issue coming off pump, I want to make sure that pacer is working. If it's not, you've got to troubleshoot that, especially if the patient has demonstrated a tendency to brady down. Atropine or not, you gotta get that **** working.

You ever use ephedrine coming off?
 
I am also going to come down against the CSE for labor.

While I agree that the analgesia from a standard labor epidural is second best as compared to a CSE. An ("A" grade versus "A+"). As someone who supervises residents and CRNAs who place these catheters. (I would add that we typically supervise 3-4 rooms). I have seen more than one patient get comfortable with the intrathecal injection. Never activate the epidural catheter. Roll back for a STAT C-sec only to find out that the epidural s*cked. Two times on a challenging airway that we struggled on. I have since modified my belief on why epidural catheters get placed in my practice:
Providing outstanding labor analgesia as opposed to very good labor analgesia is a secondary priority compared to making certain that I have a quick, reliable method of administering regional anesthesia for a Csec. If I placed all the catheters myself or only supervised very experienced CRNAs that I have complete confidence in, my opinion would probably be different.
 
I am also going to come down against the CSE for labor.

While I agree that the analgesia from a standard labor epidural is second best as compared to a CSE. An ("A" grade versus "A+"). As someone who supervises residents and CRNAs who place these catheters. (I would add that we typically supervise 3-4 rooms). I have seen more than one patient get comfortable with the intrathecal injection. Never activate the epidural catheter. Roll back for a STAT C-sec only to find out that the epidural s*cked. Two times on a challenging airway that we struggled on. I have since modified my belief on why epidural catheters get placed in my practice:
Providing outstanding labor analgesia as opposed to very good labor analgesia is a secondary priority compared to making certain that I have a quick, reliable method of administering regional anesthesia for a Csec. If I placed all the catheters myself or only supervised very experienced CRNAs that I have complete confidence in, my opinion would probably be different.

I've done them both ways. CSE or standard. Yes, the CSE is faster but in my hands it works out to about 3-4 minutes longer for a standard Epidural and I don't nick the dura.
By the time I finish the paperwork and leave the room the patient is comfortable plus I know the Epidural is fully functional.

The CSE is a great technique and it may even improve the quality of the Epidural block itself; but, I still prefer my old fashioned standard epidural where I avoid puncturing the dura.
 
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