My Residency Journey - First Month Urology

[DrAmir0078]

Dear Fellows,
I hope you are doing well; this post will be special as our Anesthesia residency program schedule is up (The Iraqi Board Residency Program) !
For me, the first month in the next month of October will be Urology!
So please, any highlighted advice about Urology Anesthesia from your experience, any tricks, any (Do or Not to Do), precautions,,, etc will be valuable and helpful !

Love and Peace

Amir

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[vector2]

These kind of threads are much more fruitful for you (and us) if you present them in a case based format and you offer your plan first. For instance, first you post the following things listed below and then we respond with critique and tips. This is what my residents do when they call to discuss a case beforehand, and I usually recommend they read the pertinent sections of a review article (for instance, BJA has very good procedure specific anesthesia articles like this one ) or textbook (baby Miller, Morgan and mikhail, and/or Jaffe) before coming up with a plan.

Type of surgery
Age/sex/Past medical/surgical history
Medication history / pertinent allergies
Pertinent physical exam, labs and studies

Plan:
Pre-medication (if indicated)
Induction
Airway
Second peripheral IV / CVL / arterial line / special monitors (if indicated)
Maintenance of anesthesia
IV fluids / blood transfusion management
Post-op analgesia / PONV prophylaxis

 

[DrAmir0078]

These kind of threads are much more fruitful for you (and us) if you present them in a case based format and you offer your plan first. For instance, first you post the following things listed below and then we respond with critique and tips. This is what my residents do when they call to discuss a case beforehand, and I usually recommend they read the pertinent sections of a review article (for instance, BJA has very good procedure specific anesthesia articles like this one ) or textbook (baby Miller, Morgan and mikhail, and/or Jaffe) before coming up with a plan.

Type of surgery
Age/sex/Past medical/surgical history
Medication history / pertinent allergies
Pertinent physical exam, labs and studies

Plan:
Pre-medication (if indicated)
Induction
Airway
Second peripheral IV / CVL / arterial line / special monitors (if indicated)
Maintenance of anesthesia
IV fluids / blood transfusion management
Post-op analgesia / PONV prophylaxis

Dr. Vector 2,
Thanks for your informative and professional style of writing and explanation of what it is the best way to learn, by presenting a discussion based cases with history and plan, like (sort of) the one I presented in my second post as learned a lot from you doctors.
As I just finished and discharged a case of fistula in ano that required spinal anesthesia approach and I found epinephrine (Adrenaline) and kept next to me as I showing you the picture... As Dr. Pgg said "It is a malpractice not to have vassopressor while performing neuroaxial anesthesia"
I am just wishing and hoping to make my residency enjoyable by sharing, discussing and studying!
Thanks again

 

[Psai]

Dr. Vector 2,
Thanks for your informative and professional style of writing and explanation of what it is the best way to learn, by presenting a discussion based cases with history and plan, like (sort of) the one I presented in my second post as learned a lot from you doctors.
As I just finished and discharged a case of fistula in ano that required spinal anesthesia approach and I found epinephrine (Adrenaline) and kept next to me as I showing you the picture... As Dr. Pgg said "It is a malpractice not to have vassopressor while performing neuroaxial anesthesia"
I am just wishing and hoping to make my residency enjoyable by sharing, discussing and studying!
Thanks again

Please stick around, you are great

 

[shepardsun]

Please stick around, you are great

I agree.

@DrAmir0078 these posts are so awesome and refreshing.

I suspect that we have a lot to learn from you as well- the challenges you face on a daily basis with respect to access to resources and some of the luxuries we take for granted will make you into an excellent anesthesiologist and I have no doubt you will surmount said challenges to provide amazing patient care. Someday I would like to come visit and work with you.

 

[DrAmir0078]

Please stick around, you are great

Thanks a lot Dr.Psai,
I will try my best, and please (all) bear with me, as I am learning from you all.

 

[DrAmir0078]

I agree.

@DrAmir0078 these posts are so awesome and refreshing.

I suspect that we have a lot to learn from you as well- the challenges you face on a daily basis with respect to access to resources and some of the luxuries we take for granted will make you into an excellent anesthesiologist and I have no doubt you will surmount said challenges to provide amazing patient care. Someday I would like to come visit and work with you.

Dr. Shepardsun
What an inspiring words to motivate me further; as I said to Dr. Psai, will try my best!
Me, our 104 residents for both the Iraqi and Arabic Board of Anesthesia and Critical Care residency Class 2022 with our honorable teaching Professors and with the Chairmen of the both programs and without no doubt will welcome this opportunity to learn and exchange knowledge as I feel to be a bridge to have what I am learning here, embedded them into my practice and share the knowledge with my Facebook group that I made exclusively for my class three months ago with the acknowledgement of our Chairmen will help us (we) to make a difference in this growing field!
I would love to work with you too Dr. Shepardsun one day here.
Peace

 

[deleted875186]

Since someone else was discussing LMA in an ORIF, how about LMA in an ermgent sick urology patient. I’ve had several middle aged urology patients that are getting stent changed, or pigtail changed or something, kind of sick looking, NPO for a while but nauseous, urologist wants you to place LMA, says it will be 20 mins, he usually does this with no sedation in the office. What do yoj guys do?

 

[Twiggidy]

Since someone else was discussing LMA in an ORIF, how about LMA in an ermgent sick urology patient. I’ve had several middle aged urology patients that are getting stent changed, or pigtail changed or something, kind of sick looking, NPO for a while but nauseous, urologist wants you to place LMA, says it will be 20 mins, he usually does this with no sedation in the office. What do yoj guys do?

I try whenever I can to use an LMA, especially if the case is short and the patient isn't obese. The level of "sick" doesn't really matter to me. I can titrate narcotics to respiratory rate, I don't need to worry about muscle relaxant, and I treat the hemodynamics as I would if they were intubated.

 

[narcusprince]

A pearl I like is to paralyze patients coming for trans urethral bladder resection with lmas. Especially if they are close to the obturator nerve. Favorable airway not morbidly obese no severe GERD, drop a little roc 30mg. And let the surgeon work, a little suggamadex at the end and your golden. In the days of neo/glyco I shyed away from paralytics and lmas.

 

[narcusprince]

I try whenever I can to use an LMA, especially if the case is short and the patient isn't obese. The level of "sick" doesn't really matter to me. I can titrate narcotics to respiratory rate, I don't need to worry about muscle relaxant, and I treat the hemodynamics as I would if they were intubated.

Cardiac guy who likes lmas......

 

[narcusprince]

Dr. Vector 2,
Thanks for your informative and professional style of writing and explanation of what it is the best way to learn, by presenting a discussion based cases with history and plan, like (sort of) the one I presented in my second post as learned a lot from you doctors.
As I just finished and discharged a case of fistula in ano that required spinal anesthesia approach and I found epinephrine (Adrenaline) and kept next to me as I showing you the picture... As Dr. Pgg said "It is a malpractice not to have vassopressor while performing neuroaxial anesthesia"
I am just wishing and hoping to make my residency enjoyable by sharing, discussing and studying!
Thanks again



View attachment 240068

Not sure if pgg draws up dilute epi for his neuroaxial techniques. No ephedrine or phenylephrine?

 

[DrAmir0078]

Since someone else was discussing LMA in an ORIF, how about LMA in an ermgent sick urology patient. I’ve had several middle aged urology patients that are getting stent changed, or pigtail changed or something, kind of sick looking, NPO for a while but nauseous, urologist wants you to place LMA, says it will be 20 mins, he usually does this with no sedation in the office. What do yoj guys do?

Dr. Dpriman,
I am going to address the use of LMA (if we are not using it, as it is part of my learning), then will put them in my logbook and get a nice paper talking about LMA in short Uro procedure!
Let me see
Thanks

 

[DrAmir0078]

I try whenever I can to use an LMA, especially if the case is short and the patient isn't obese. The level of "sick" doesn't really matter to me. I can titrate narcotics to respiratory rate, I don't need to worry about muscle relaxant, and I treat the hemodynamics as I would if they were intubated.

Interesting!
For like 10 minutes procedure, would you still/like to use succinylcholine as muscle relaxant or Rocuronium?
Thanks Dr. Twiggidy

 

[DrAmir0078]

A pearl I like is to paralyze patients coming for trans urethral bladder resection with lmas. Especially if they are close to the obturator nerve. Favorable airway not morbidly obese no severe GERD, drop a little roc 30mg. And let the surgeon work, a little suggamadex at the end and your golden. In the days of neo/glyco I shyed away from paralytics and lmas.

What is IMAS?

 

[DrAmir0078]

Not sure if pgg draws up dilute epi for his neuroaxial techniques. No ephedrine or phenylephrine?

No epinephrine or phenylephrine handy or available unfortunately!
Thanks Dr. Narcusprince

 

[Twiggidy]

Cardiac guy who likes lmas......

As long as they’re asleep

 

[pgg]

Not sure if pgg draws up dilute epi for his neuroaxial techniques.

I don't, but we have phenylephrine and ephedrine available. Epi is in the cart. He's referring to another thread where we were talking about post spinal hypotension, and my point was that you can't be doing neuraxial anesthetics without a pharmacologic means to correct hypotension. He doesn't have ephedrine, phenylephrine, or norepinephrine, so for him it's epi.

 

[woopedazz]

Interesting!
For like 10 minutes procedure, would you still/like to use succinylcholine as muscle relaxant or Rocuronium?
Thanks Dr. Twiggidy

Depends on how super fast the surgeon is. Sux generally wears off too fast to still be effective when they are near the obturator nerve.

I've done a list recently where my consultant offered the same pearl, however we simply had Rocuronium drawn up in case it was needed; we did not give it pre-emptively due to the cost of reversal in a public/teaching hospital with a finite list with likely under-run.

 

[vector2]

Since someone else was discussing LMA in an ORIF, how about LMA in an ermgent sick urology patient. I’ve had several middle aged urology patients that are getting stent changed, or pigtail changed or something, kind of sick looking, NPO for a while but nauseous, urologist wants you to place LMA, says it will be 20 mins, he usually does this with no sedation in the office. What do yoj guys do?

Middle age urosepsis pt with no other comorbidities I would still likely LMA assuming they haven't been retching for the last three hours and they've gotten fluids and zofran down in the ED. Biggest problem with sick pts is that a large slug of prop is usually needed to get ideal LMA conditions because etomidate is too good at sparing respiratory drive and muscle tone. I use judicious prop + sux or bolus ~100- 200mcg phenylephrine before 2mg/kg prop

 

[deleted162650]

Just keep in mind that every once in a while, a pt who doesn’t look too sick will crump hard once an obstructing stone has been removed and all those evil humors are released into the circulation. 0 to septic real quick, and sometimes it’s the ones you don’t expect.

 

[Twiggidy]

Just keep in mind that every once in a while, a pt who doesn’t look too sick will crump hard once an obstructing stone has been removed and all those evil humors are released into the circulation. 0 to septic real quick, and sometimes it’s the ones you don’t expect.

Yep. Actually saw this recently with a urology patient at our hospital. Low index of suspicion if someone gets unreasonably tachycardic +\- hypotensive after a Stone case

 

[DrAmir0078]

Just keep in mind that every once in a while, a pt who doesn’t look too sick will crump hard once an obstructing stone has been removed and all those evil humors are released into the circulation. 0 to septic real quick, and sometimes it’s the ones you don’t expect.

Will keep that in mind Dr. SaltyDog!
I have worked on Uro cases in the last 15 months of my SHO period.
Most of our stony Uro patients were having spinal anesthesia, especially up to mid ureter, beside Turp!
I got a question :
General Anesthesia vs Neuroaxial Spinal Anesthesia for short Uro procedure, which one you wisely prefer in term of feasibility or consequences?

 

[Twiggidy]

Will keep that in mind Dr. SaltyDog!
I have worked on my Uro cases in the last 15 months.
Most of our stony Uro patients were having spinal anesthesia, especially up to mid ureter, beside Turp!
I got a question :
General Anesthesia vs Neuroaxial Spinal Anesthesia for short Uro procedure, which one you wisely prefer in term of feasibility or consequences?

Typically GA because it can sometimes take longer to do the spinal than to do the actual case

 

[deleted162650]

GA

 

[DrAmir0078]

Typically GA because it can sometimes take longer to do the spinal than to do the actual case

Cool !

So LMA with Muscle relaxants or Spontaneous Ventilation Anesthesia?
Or it depends?

 

[DrAmir0078]

GA

Cool

 

[narcusprince]

I would say. I had a mp4 osa morbidly obese female bmi greater then 40 for a ureteral stent placement. Placed a bupivicaine spinal 1.4ml of .75% told her she may feel the tip of the stent. A few whiffs of fentanyl she tolerated the procedure well. Oftentimes we look at morbidly obese patients as difficult spinals but its worth checking out their back.

 

[DrAmir0078]

I would say. I had a mp4 osa morbidly obese female bmi greater then 40 for a ureteral stent placement. Placed a bupivicaine spinal 1.4ml of .75% told her she may feel the tip of the stent. A few whiffs of fentanyl she tolerated the procedure well. Oftentimes we look at morbidly obese patients as difficult spinals but its worth checking out their back.

As Firefighter rule "Try before you pry" isn't it?

 

[rakotomazoto]

As Firefighter rule "Try before you pry" isn't it?

Exactly! My wife is a former firefighter, I love firefighter sayings. Most of them are pretty vulgar in comparison to this one. Keep the posts coming, it is awesome to read about your experiences.

 

[DrAmir0078]

Exactly! My wife is a former firefighter, I love firefighter sayings. Most of them are pretty vulgar in comparison to this one. Keep the posts coming, it is awesome to read about your experiences.

Thanks Dr. Rakotomazoto
It is indeed !
I will try my best !

 

[Psai]

A pearl I like is to paralyze patients coming for trans urethral bladder resection with lmas. Especially if they are close to the obturator nerve. Favorable airway not morbidly obese no severe GERD, drop a little roc 30mg. And let the surgeon work, a little suggamadex at the end and your golden. In the days of neo/glyco I shyed away from paralytics and lmas.

If you're going to paralyze anyway why not just a tube? I've like tube better than lma because if you don't paralyze sometimes they get real tachypneic during stone manipulation which makes for a crap surgical field especially when you have a junior resident learning. I've never tried lma + paralysis although it makes sense.

I've also wondered how they do lma for bariatrics and c sections in other countries where here it is anathema

 

[DrAmir0078]

If you're going to paralyze anyway why not just a tube? I've like tube better than lma because if you don't paralyze sometimes they get real tachypneic during stone manipulation which makes for a crap surgical field especially when you have a junior resident learning. I've never tried lma + paralysis although it makes sense.

I've also wondered how they do lma for bariatrics and c sections in other countries where here it is anathema

For me
I am truly confused
LMA with paralytics or not?

 

[Twiggidy]

For me
I am truly confused
LMA with paralytics or not?

99% of the time no need for paralytics with an LMA. If your plan is to give paralytic you may as well intubate.

 

[DrAmir0078]

99% of the time no need for paralytics with an LMA. If your plan is to give paralytic you may as well intubate.

Thanks a lot Dr. Twiggidy
So apparently, it is spontaneous ventilation anesthesia, instead (mostly we use here without LMA and sometimes with OPs airway) only putting the LMA for better ventilation?
Isn't it?