The ASA is Listening to us

[BLADEMDA]

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Cricoid Pressure During Rapid Sequence Induction: Since its introduction by Sellick in 196P to prevent the passive regurgitation and aspiration of gastric contents, no randomized controlled study has ever been performed to prove that cricoid pressure has reduced mortality. A meta-analysis of 184 clinical trials failed to show any reduction in the incidence of pulmonary aspiration of gastric contents following rapid sequence induction.6 In countries where it is rarely used, the pulmonary aspiration rate is lower.7 Its disadvantages include an impairec view of the larynx, difficult intubation, laryngeal fracture anc esophageal rupture. Cricoid pressure is also associated witl an increased rate of failed intubation.8 Of note, in the patien with an unstable cervical spine, the recommended applicatioi of 40 Newtons of pressure may be dangerous. Furthermore radiological studies have shown that in over 50 percent of cases the esophagus is displaced laterally, allowing reflux to occur Application of cricoid pressure also causes reflex relaxation c the lower esophageal sphincter and may provoke vomiting, which is not reversed by the administration of metoclopramide. In many situations, cricoid pressure has to be released in ordt to permit tracheal intubation, thus negating the very benei













John H. Pennant, MB.B.S., F.R.C.A. Dallas, Texas

Girish RJoshi, MB.B.S., M.D., F.FA.R.C.S. Dallas, Texas







American Society of
Anesthesiologists

10

April 2009 • Volume 73 • Nurnbc



it is purported to offer. Perhaps it is time to re-evaluate this maneuver and instead induce our patients in a head-up position to prevent regurgitation of gastric contents.12

 

[BLADEMDA]

I am extremely encouraged that the leadership at the ASA is listening to us at SDN. I have NO DOUBT they now realize the potential threat the AANA poses to this specialty.

The articles in our Journals and Newsletters have NEVER BEEN BETTER in terms of clinical focus. Again, these are great signals that our leaders are in tune these days with the real world issues.👍👍

Thank You,
Blade

 

[BLADEMDA]

Demonstrating the ability to ventilate before administration of muscle relaxants: Many training programs teach that neuromuscular-blocking drugs should not be administered before it has been demonstrated that it is possible to ventilate with a face mask. If ventilation is impossible, the recommendation is to awaken the patient. However, this is usually unrealistic before profound hypoxemia has ensued, and in most cases, face mask ventilation becomes easier following muscle relaxation. In a preliminary double-blind, randomized, prospective study, Szabo et al. assessed the difficulty of mask ventilation with or without neuromuscular blockade and found ventilation to be significantly more effective after paralysis.13 Their findings suggest that muscle relaxation may be advantageous when managing the unexpected difficult airway and should lead to a re-evaluation of airway management protocols. In Kheterpal's prospective study of 22,660 patients, mask ventilation was impossible in 37 cases, 36 of whom were intubated following the administration of muscle relaxants.14 In contrast, the ability to ventilate with a face mask before relaxation does not always translate into easy ventilation following paralysis, particularly in obese patients with redundant soft tissue that prolapses into the airway when its supporting musculature has been paralyzed. Curiously, in cases requiring rapid sequence induction of anesthesia, it is taboo to attempt face mask ventilation before relaxants are administered, in case gastric insufflation and ensuing regurgitation should occur. The focus of the anesthesiology community in the recent past has been to issue algorithms for predicting and managing difficult or failed intubation, while remaining silent on failed face mask ventilation. The more logical and safer approach in all patients would be to administer neuromuscular blockers at the earliest opportunity without having to demonstrate face mask ventilation beforehand.15'16 However, in those cases where obvious difficulty with mask ventilation or intubation is suspected, awake intubation or the use of regional anesthesia might be a safer option.
Similar to the above-mentioned issues, several other controversies exist where a demonstrated advantage of a specific perioperative clinical intervention in a subset of patients has been shown. Its widespread adoption in all patients has occasionally been deleterious (e.g., tight glycemic control and routine perioperative beta-blockade). We should proceed cautiously and with a healthy skepticism when guidelines from health care organizations are thrust upon us in the absence of a sound scientific basis.

 

[ChrisA]

That research was done years ago by an ER doc named Levitan (both of them). Im not sure why the authors are suggesting its new, he has been presenting it forever and its also apart of his airway class.

 

[BLADEMDA]

That research was done years ago by an ER doc named Levitan (both of them). Im not sure why the authors are suggesting its new, he has been presenting it forever and its also apart of his airway class.

My point is that the STUDIES showing Cricoid pressure is Junk Science/B.S. were published years ago. I have discussed this many times with peer reviewed evidence. However, I prefer to have the blessing of the ASA prior to abandoning what many still consider "standard of care." Unlike militant CRNAs I believe the ASA should set the guidelines for Anesthesia Practice in the USA (e.g. ASA classification, recommended monitors, etc.).

 

[jetproppilot]

it is purported to offer. Perhaps it is time to re-evaluate this maneuver and instead induce our patients in a head-up position to prevent regurgitation of gastric contents.12

I can't count the number of times in the last 5 years, on this website, I've refuted the Sellick maneuver and suggested reverse Trendelenberg for true-RSIs.

 

[dfk]

I am extremely encouraged that the leadership at the ASA is listening to us at SDN. I have NO DOUBT they now realize the potential threat the AANA poses to this specialty.

The articles in our Journals and Newsletters have NEVER BEEN BETTER in terms of clinical focus. Again, these are great signals that our leaders are in tune these days with the real world issues.👍👍

Thank You,
Blade

i'm sorry, but i cannot find the correlation betw/ the title of the thread and your spout about the AANA.
in any event, as i recall, no studies show great positive effect of cricoid pressure during RSI. i too am a fan of HOB up.

 

[BLADEMDA]

i'm sorry, but i cannot find the correlation betw/ the title of the thread and your spout about the AANA.
in any event, as i recall, no studies show great positive effect of cricoid pressure during RSI. i too am a fan of HOB up.

That is because you are a CRNA and support the AANA agenda (if not entirely then at least partly).

The ASA is listening to its core membership and our issues. That is the title of this thread. Does anyone except YOU doubt the AANA is one of those issues?

 

[BLADEMDA]

You need to start worrying DFK because they are getting the message loud and clear at the ASA.


Thus, our claims that anesthesiology is the practice of medicine are rooted more firmly in the past. It was not until the late 1800s (1870s to 1890s) that nurses began administering ether and other anesthetics to provide surgical anesthesia.
In more recent history, we have seen nurse anesthetists claim that the care they provide is no different than ours, that they have a similar education and clinical learning experience. We have argued that they are not doctors, that their education and training is quite different and less encompassing than ours. They have responded by designing programs to graduate Doctors of Nursing Practice so that they can truly say to patients that they are Doctor So and So. We probably all agree that even if they were not trying to work toward independent practice, calling themselves "Doctor" in the hospital setting is a form of identity theft.
Your ASA has long been fighting these scope-of-practice issues that are brought forward each year by the nurse anesthetists
American Society of
Anesthesiologists

April 2009

 

[fakin' the funk]

That is because you are a CRNA and support the AANA agenda (if not entirely then at least partly).

The ASA is listening to its core membership and our issues. That is the title of this thread. Does anyone except YOU doubt the AANA is one of those issues?

Dude, are you drunk? I was wondering the same thing as dfk was: what does the title of the thread have to do with potentially-myth-busting articles being published in the ASA's journal and the AANA?!

 

[BLADEMDA]

Dude, are you drunk? I was wondering the same thing as dfk was: what does the title of the thread have to do with potentially-myth-busting articles being published in the ASA's journal and the AANA?!

Since you have little experience in Medicine I will SPELL IT OUT FOR YOU.

The ASA and I know that Clinical Issues and POLITICAL ISSUES are important to its Core Membership base. Hence, the title of this thread "The ASA is Listening to us."

The "us" means those that are dues paying members and have a stake in this game.

What good are the Clinical Issues if the AANA succeeds in ERADICATING ANESTHESIOLOGY as a Medical Specialty?

In this field Politics matter because the AANA are the Marines of Nursing and we are ground Zero. Like it or not those are the facts.

 

[dfk]

D.F.K.= Dumb... Fu.....Kid

dude... whatever.
and FWIW, you're losing street cred by the day...
i'm no doc, nor anesthesiologist, but i can ASSURE you i'm no
DFK as you like to put it...
thanks for being a team player.
blade---- go to sleep, please.

 

[BLADEMDA]

dude... whatever.
and FWIW, you're losing street cred by the day...
i'm no doc, nor anesthesiologist, but i can ASSURE you i'm no
DFK as you like to put it...
thanks for being a team player.
blade---- go to sleep, please.

Then stop acting like one. Stop pretending that the AANA agenda is beneficial for either patients or the Medical Specialty of Anesthesiology.
It has the potential to kill both.

Now, stop arguing with me over the AANA. Please use the midlevel forum for that purpose. This thread was to point out with PROOF that the ASA is listening to us on our core issues (both clinical and political).

 

[Bertelman]

Then stop acting like one. Stop pretending that the AANA agenda is beneficial for either patients or the Medical Specialty of Anesthesiology.
It has the potential to kill both.

Now, stop arguing with me over the AANA. Please use the midlevel forum for that purpose. This thread was to point out with PROOF that the ASA is listening to us on our core issues (both clinical and political).

That's ridiculous. You mentioned the AANA, so anyone should be free to argue that point.

 

[BLADEMDA]

That's ridiculous. You mentioned the AANA, so anyone should be free to argue that point.

You of all people know I am more than willing to argue over the AANA. However, I am trying to limit comments/debate about the AANA in the main forum. Out of respect to our SDN hosts let us try limit those discussions in this section.

 

[ChrisA]

Blade, you are in serious need of some sortof psych eval. You go further over the edge every post...

 

[BLADEMDA]

Blade, you are in serious need of some sortof psych eval. You go further over the edge every post...

Why are you posting that type of comment here? I respectfully request that ChrisA refrain from making derogatory comments about me in the public forum. I am an ASA member and a loyal supporter of our PACS. ChrisA is a militant CRNA whose agenda is anything but supportive of this specialty.

By allowing ChrisA to "discredit me" you are helping his agenda. My posts are accurate and truthful.

Why should I bother posting Clinical threads if ChrisA can continue such disparaging remarks?

 

[ChrisA]

Oh my..

So THIS is a clinical thread?

Listen blade, I generally dont comment on anything your write as the vast majority of it is not worth my effort and just ramblings or repetitive pastes. However, for you to suggest I am the one making derogatory remarks after everything you say about me, my website and CRNAs is the pot calling the kettle black bud.

Your posts are about as 'accurate and truthful' as Nixon was.

Why are you posting that type of comment here? I respectfully request that ChrisA refrain from making derogatory comments about me in the public forum. I am an ASA member and a loyal supporter of our PACS. ChrisA is a militant CRNA whose agenda is anything but supportive of this specialty.

By allowing ChrisA to "discredit me" you are helping his agenda. My posts are accurate and truthful.

Why should I bother posting Clinical threads if ChrisA can continue such disparaging remarks?

 

[coprolalia]

Your posts are about as 'accurate and truthful' as Nixon was.

Blade's posts may go a little heavy-handed on the "doom and gloom" stuff, and he is often a broken record, but he's not far off. After all, this is a forum and, just like you and everyone else, he's free to express his opinions provided he doesn't overstep the bounds of the TOS.

-copro

 

[ProRealDoc]

Blade's posts may go a little heavy-handed on the "doom and gloom" stuff, and he is often a broken record, but he's not far off. After all, this is a forum and, just like you and everyone else, he's free to express his opinions provided he doesn't overstep the bounds of the TOS.

-copro

Second that.

 

[BLADEMDA]

Oh my..

So THIS is a clinical thread?

QUOTE]

That was my plan. But, the CRNA trolls like yourself took ONE comment and blew it our of proportion to this thread. I was going to discuss pertinent everyday private practice issues and anesthesia dogma but not anymore. I will put those in the private forum.

 

[BLADEMDA]

"Listen blade, I generally dont comment on anything your write as the vast majority of it is not worth my effort and just ramblings or repetitive pastes" ChrisA


Well, right now there is a very good clinical thread underway here on SDN. I believe many think that the hundreds of CLINICAL posts I have made over the past two years do have value. Why not go back to your Militant Website where you belong? I will continue my ramblings here on SDN. The readership here is well-educated and can decide the "truth" for themselves.

Blade

 

[Bertelman]

You of all people know I am more than willing to argue over the AANA. However, I am trying to limit comments/debate about the AANA in the main forum. Out of respect to our SDN hosts let us try limit those discussions in this section.

I know you typically limit those discussions to the appropraite forum, but by mentioning the AANA, you left this thread open to that discussion. You could have made the same point without mentioning the AANA.

 

[BLADEMDA]

I know you typically limit those discussions to the appropraite forum, but by mentioning the AANA, you left this thread open to that discussion. You could have made the same point without mentioning the AANA.

Lesson Learned. Even ONE comment feeds the trolls. You notice that they rarely add any clinical content of value? The ad-hominem attacks by the trolls though are really an attempt to discredit the author more than debate the statement. If you can do the former you don't need facts to do the latter.

 

[Impromptu]

I am fairly new to the ASA, but have been pretty impressed with their newsletters of late. I especially enjoyed the article on how to better "market" ourselves. I would love to start seeing anesthesiology groups advertising on television in a way that promotes both their own groups and the entire field of anesthesiology. Maybe the ASA can start a few advertising campaigns.

 

[fakin' the funk]

The ad-hominem attacks by the trolls though are really an attempt to discredit the author more than debate the statement.

That is because you are a CRNA and support the AANA agenda (if not entirely then at least partly).

🙄

 

[2win]

"Listen blade, I generally dont comment on anything your write as the vast majority of it is not worth my effort and just ramblings or repetitive pastes" ChrisA


Well, right now there is a very good clinical thread underway here on SDN. I believe many think that the hundreds of CLINICAL posts I have made over the past two years do have value. Why not go back to your Militant Website where you belong? I will continue my ramblings here on SDN. The readership here is well-educated and can decide the "truth" for themselves.

Blade

👍👍👍👍

 

[BLADEMDA]

Dude, are you drunk? I was wondering the same thing as dfk was: what does the title of the thread have to do with potentially-myth-busting articles being published in the ASA's journal and the AANA?!

If and when you finish Residency in Anesthesiology we will see if your view about ChrisA and the AANA remains the same.

The ASA has become much more staunch in opposition to the AANA. Many of us recognize there won't be a specialty of Medicine in this field by the time you complete your training unless STRONG counter-measures are taken against the AANA and militant CRNAs like ChrisA.

The ASA is listening to us and FINALLY has awoken to this threat to YOUR FUTURE my friend. The irony is that you should be taking the lead on this very serious issue as ChrisA wants your (future) job.

While Politics are a MAJOR part of defending this Specialty so you have a
job in 4-5 years I will refrain from mentioning the most evil, militant Nursing Union in the USA on public forum again.😉

Blade

 

[hoyden]

Dude, are you drunk? I was wondering the same thing as dfk was: what does the title of the thread have to do with potentially-myth-busting articles being published in the ASA's journal and the AANA?!

Dude, you haven't read the newsletter yourself, or did you? 😀
BLade is absolutely right, though a little dramatic ( just IMHO)

 

[ozzie20]

I'll agree with Blade as well, the ASA is doing a good thing by taking a stance against CRNA practices. We will always need people like Blade to take a very loud and vocal stance against the AANA, just as there are loud and vocal people on the other side as well.

 

[BLADEMDA]

I'll agree with Blade as well, the ASA is doing a good thing by taking a stance against CRNA practices. We will always need people like Blade to take a very loud and vocal stance against the AANA, just as there are loud and vocal people on the other side as well.

You almost got it right. The "other side" wants your job, your career and the profession itself. The threat is both real and imminent. The ASA recognizes that fact and is taking action. Ours is not an offensive war as the other side would have you believe; no, we are simply defending the Medical Specialty of Anesthesiology from becoming irrelevant in the operating room.

The ASA and I believe large scale SOLO CRNA practices have the potential to do great harm to the surgical patients in the USA.

Blade