The Things That Matter

[MoMoGesiologist]

Now that I'm out in the real world doing anesthesia, I'm learning so much from my colleagues that would be unimaginable in residency. So many things that seemed so critical, so vital, now when supervising multiple rooms, really no longer seem to matter. Pre-induction alines for severe valvular disease? Pfft who needs it! OB airways are difficult and avoid GA at all costs? Yea right! Can't do a spinal after a failed epidural? Puh-lease!

However, sometimes it's hard to tell whether I'm concerned about something that was ingrained in me unnecessarily by an ivory tower attending vs maybe the people around me are lackadaisical and I shouldn't pick up their practice patterns. Hence I've come here to ask, what are the things you insist happen in the OR for a safe anesthetic that you feel maybe some other MDs or CRNAs are lax on? I don't want to pick up habits that could compromise patient care...

I'll start first:

If there's someone's airway I'm concerned about, I really want to see good pre-oxygenation, meaning a good seal, and to see TVs and EtCO2 and EtO2>70% on the monitor. Not just place the mask on the patients face and look at me like why I'm not inducing yet...

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[deleted171991]

I have never regretted pre-oxygenating to EtO2 of 80+% (with good TV) even the apparently easiest and thinnest ASA1 MP1 patient. I don't push the induction drugs till the patient gets there. I am sure the CRNAs would roll their eyes if they could, but I don't care (many of them are trained to just let the mask rest on the face, because it's not "comfortable" to push on it). Much more important than a lot of other pre-induction things, e.g. A-lines.

The airway is one of those things where "seconds (can) matter", and a completely unexpected post-induction surprise can be stressful to fix (plus I don't want the CRNA to put air in the stomach - while freaking out at 20 ventilations/min with the pop-off at 30). I couldn't care less if it doesn't look "slick". I'll tell you what it is: SAFE. If you have good LMAs it's less important (because the number of difficult to ventilate patients drops precipitously), but I just love that peace of mind.

 

[PainDrain]

I wouldn’t disregard the need for a pre-induction Aline in critical AS or severe pulmonary HTN. It takes a minute to put in and with proper localization is less painful than an 18g IV. Without it, In the 2-3 minutes while the cuff is cycling, your patient may be starting the spiral into the beyond and you won’t know it. It also makes it more difficult to place one when the patient is hypotensive. Food for thought.


Also, I have never regretted putting a tube in someone. Even if the surgeon says it’s going to be a quick ten minute case.

 

[CopaceticOne]

(Mostly sharing this for my resident collegues)

Pre-induction Aline trick that one of my PP attending's showed me: take the SQ insulin syringe, fill it when 1 cc of the lidocaine 1%, stab down to the target artery, inject as you withdraw the syringe, leaving about 0.25-0.5cc to infiltrate the skin. Most patients don't feel a thing with that numbing approach and the small (31G) needle causes no bleeding. I've had lots of success with even the ornery patients.

Edit: correcting lido concentration

 

[anbuitachi]

(Mostly sharing this for my resident collegues)

Pre-induction Aline trick that one of my PP attending's showed me: take the SQ insulin syringe, fill it when 1 cc of the lidocaine 10%, stab down to the target artery, inject as you withdraw the syringe, leaving about 0.25-0.5cc to infiltrate the skin. Most patients don't feel a thing with that numbing approach and the small (31G) needle causes no bleeding. I've had lots of success with even the ornery patients.

you guys have lidocaine 10%?

My belief is always safety first. If you think about it, a lot of things in anesthesia will go fine most of the time. Even if you do it wrong, it'll likely end up fine. Can you do a 10 hr whipple with a 22G IV and no A line? Yea you can. And you'll probably get thru it fine. the problem is when adverse event is not that common, even if its a high 10%, you'd statistically need to do around 10 of them to see something go wrong.

What if if putting a preinduction arterial line decreases the chance of intra op morbidity from 1% to .5% (made up #s), thats a 50% reduction, but only a .5% absolute reduction, so you'll need to do a good # of cases to even see the effects, and you probably wont see that many severe AS to even notice unless you are cardiac. And i think people often forget after being in ORs non stop all day, that our work intraop has an affect way beyond post op. i think its more than getting the patient thru the case alive, it's about optimizing overall outcome for the patient

 

[Velefunt]

This warms my heart to see others take pre-oxygenation to the degree that I do as well. It really is one of the few things I insist on routinely and patiently allowing time for.

 

[Mman]

pre-oxygenation is like putting your seat belt on. Even the slickest race car drivers in the world wear a seat belt.

 

[vector2]

I still do pre-induction a-line for severe AS and PHTN but nowadays I'm much less likely to do one for CHF with LVEF > 25% or CAD unless it's bad left main or equivalent disease. Most of that stems from the fact that my inductions are pretty damn stable when I give a prophylactic neo bolus, titrate propofol 40mg at a time to effect, and push paralytic with induction so the CRNA isn't decreasing venous return forever with 700cc bagged TVs and the APL closed to 20.

A couple other 'always' things for me: ETT for GI bleed, impactions, SBO. NMB reversal for everyone who received a cumulative full dose of roc within the last 6 hrs. Videolaryngoscope backup in the room for any mandible fx even if they look easy. Using a cook catheter for airway exchange even if the first intubation took one attempt. Pads on and a box in the OR/PACU slot for any pt with magnet who has a high degree of PPM dependence or was recently shocked by their AICD.

 

[CopaceticOne]

you guys have lidocaine 10%?

My belief is always safety first. If you think about it, a lot of things in anesthesia will go fine most of the time. Even if you do it wrong, it'll likely end up fine. Can you do a 10 hr whipple with a 22G IV and no A line? Yea you can. And you'll probably get thru it fine. the problem is when adverse event is not that common, even if its a high 10%, you'd statistically need to do around 10 of them to see something go wrong.

What if if putting a preinduction arterial line decreases the chance of intra op morbidity from 1% to .5% (made up #s), thats a 50% reduction, but only a .5% absolute reduction, so you'll need to do a good # of cases to even see the effects, and you probably wont see that many severe AS to even notice unless you are cardiac. And i think people often forget after being in ORs non stop all day, that our work intraop has an affect way beyond post op. i think its more than getting the patient thru the case alive, it's about optimizing overall outcome for the patient

Fat fingers late at night...1% Lidocaine

 

[DM27]

I am completely on board with pre-oxygenating to > 80%. I have never regretted this, especially when working with a trainee. I agree that pre-induction a-lines, when done well, take little to no time and should be no worse than an IV. Also if you have multiple general anesthesia with ETT starts simultaneously, having the a-line pre-induction is a nice way to stagger those starts assuming you aren't the one doing it.

 

[PainDrain]

and you probably wont see that many severe AS to even notice unless you are cardiac.

I thought this until I entered the real world. You would be surprised at how many people are walking around with severe to critical AS. I had a 60 yo woman coming for a thyroidectomy who was in complete denial. Had an echo showing 0.5cm valve area in December but didn’t bother going to the follow up with cardiologist or surgeon. Came in for the thyroid in April because she had difficulty swallowing. Was in CHF a month prior and surgeon was worried her hyperthyroidism would cause AF again and kill her. Case went fine but lady was oblivious to the severity of her disease.

 

[T-burglar]

Never ever ever **** around with hypoxemia. Prevent it, or fix it right now. Its The most common way healthy people get killed perioperarively.

Other things that actually matter? Arterial lines. I actually put in more arterial lines than in training, and I do most pre-induction. Good sedation and infiltration technique make this painless. I work in a group where a lines are utilized a lot though. It’s like an ETT. You never regret doing it.

You must have not ever seen a critical AS and CAD fibrillate on induction to think that any severe valve disease is safe to anesthetize with no a line, OP. I would be really careful with that, especially if you don’t do a lot of cardiac yourself to have a sense of which valves to be scared of.

 

[narcusprince]

First thing I put on the patients is the oxygen mask strap system to keep mask on the patients face. Then monitors kills 2 birds with one stone. By the time monitors are set and ready to induce 90 seconds have elapsed. Another dogmatic thing I do is unit dose pediatrics. In a pinch its easy to tell the nurse to give the whole syringe.

 

[bigdan]

OP -

It took me a bit to differentiate between two entirely separate things that you address in your post: 1) cutting corners on dogma that might be related to safety, and 2) doing things that effect what other MDs or CRNAs think of you. Those are not the same thing

I have a partner that puts pt's with LVADs to sleep prior to heart transplant without arterial line monitoring. I, as her partner, think that's stupid. I put in preinduction arterial lines for those cases. Perhaps she thinks I'm slow. I put in very few LMAs, insist on full preox for all, bring the bronchoscope to most airways I think could be difficult, etc. IDGAF.

I noticed that when physicians insist on sensible things that end up not being used (like full preox or putting defib pads on), the nurses say " Dr. X made us wait to do...". And when there's something you insist on, they say "WE delayed the case because of antibodies, and it's a good thing because the patient bled...". Whatever.

If my retirement card says "...and you were always known for being too safe...", fine.

 

[deleted171991]

OP -
If my retirement card says "...and you were always known for being too safe...", fine.

I almost posted the almost same thing yesterday; I was thinking about a similar text for my epitaph.

 

[MoMoGesiologist]

Regarding severe valvular disease or CAD and inducing, why not just do a slow careful induction? I can imagine that critical AS with reduced EF, it wouldn't matter if you're doing anesthesia for a haircut, you would place a preinduction aline. But for cystos, EGDs, toe amps, lap choles, aka cases where anesthesia induction will be the biggest hemodynamic swing, can't you cycle your cuff continuously or q1min or look at your pulse ox tracing and do a gentle induction? I've generally just pretreated these people with pressors, get their SBP high, then slowly induced. An aline would warn me of hypotension visually 30 seconds faster, but sometimes I'll even place my finger on the pulse as inducing. If it's a <30min case, I feel the aline isn't changing my management much. Also, if they're gonna code with slow titrated induction, the aline isn't going to save the patient. I'm not saying alines are pointless, but can't one be vigilant and careful enough to induce without it and not have a patient code (again not speaking about patient with active MI or critical AS with no EF)? I don't have enough experience to say...

@bigdan, you say your partner's technique is stupid for not placing an aline in an LVAD patient prior to heart transplant. Do you place alines for LVADs coming to the endoscopy suite for GIBs? At my place we didn't. How is the induction different for a cardiac case vs for EGD that requires an aline? And if you go to a center where all the partners are placing alines post induction for certain cases that you find disagreeable, who's to say who is right or wrong? If your partner isn't having bad outcomes, I don't think it's fair to say her technique is stupid. It's just different.

I'm starting to think anesthesia practices may very widely between places... and we would all consider each other's techniques blasphemous!

 

[T-burglar]

OP -

It took me a bit to differentiate between two entirely separate things that you address in your post: 1) cutting corners on dogma that might be related to safety, and 2) doing things that effect what other MDs or CRNAs think of you. Those are not the same thing

I have a partner that puts pt's with LVADs to sleep prior to heart transplant without arterial line monitoring. I, as her partner, think that's stupid. I put in preinduction arterial lines for those cases. Perhaps she thinks I'm slow. I put in very few LMAs, insist on full preox for all, bring the bronchoscope to most airways I think could be difficult, etc. IDGAF.

I noticed that when physicians insist on sensible things that end up not being used (like full preox or putting defib pads on), the nurses say " Dr. X made us wait to do...". And when there's something you insist on, they say "WE delayed the case because of antibodies, and it's a good thing because the patient bled...". Whatever.

If my retirement card says "...and you were always known for being too safe...", fine.

That’s crazy. Heart transplant programs and outcomes are scrutinized with a microscope and held to a very hard standard. Messing up any of the process including killing the recipient at any point is be a serious problem.

 

[deleted162650]

You guys are lame. Style points are what really matters.

 

[MoMoGesiologist]

You guys are lame. Style points are what really matters.

What are common ways you see many anesthesiologists lose style points Dr. Butt Snorkeler?

 

[deleted697535]

If they're proper sick preox to 90, aline preinduct, rsi, sux bla bla.

If they ain't sick, leave them be.

History comes before reading the echo report, not the other way around...

Hypotension kills fast, hypertension rarely does.

When someone's sick, giving them a big push of any form of drug is probably going to **** everyone's **** up. You can always give more, you can't give less...

 

[pgg]

Hypotension kills fast, hypertension rarely does.

When someone's sick, giving them a big push of any form of drug is probably going to **** everyone's **** up. You can always give more, you can't give less...

What a monitor might look like 30 seconds after someone pushes 200 mg of propofol on a 60-something year old guy with severe mitral stenosis and an 80% left main:

 

[deleted162650]

What are common ways you see many anesthesiologists lose style points Dr. Butt Snorkeler?

Oooooo, that’s a great idea for a thread all by itself. Stay tuned.

 

[deleted697535]

What a monitor might look like 30 seconds after someone pushes 200 mg of propofol on a 60-something year old guy with severe mitral stenosis and an 80% left main:

Lol

What a monitor might look like 30 seconds after someone pushes 200 mg of propofol on a 60-something year old guy with severe mitral stenosis and an 80% left main:

Fairly sure I've been criticised by old fogie loon staff for not pushing '2 per kilo' in a similar ish type of case. The flute thought the hypotension was anaphylaxis for 20 mins... Fairly sure she even wrote me up for not thinking it was anaphylaxis!!

 

[deleted162650]

What a monitor might look like 30 seconds after someone pushes 200 mg of propofol on a 60-something year old guy with severe mitral stenosis and an 80% left main:

I don’t see what the problem is - the dude has a MAP of 60 and he’s satting 100%

 

[bigdan]

@bigdan[/USER], you say your partner's technique is stupid for not placing an aline in an LVAD patient prior to heart transplant. Do you place alines for LVADs coming to the endoscopy suite for GIBs? At my place we didn't. How is the induction different for a cardiac case vs for EGD that requires an aline? And if you go to a center where all the partners are placing alines post induction for certain cases that you find disagreeable, who's to say who is right or wrong? If your partner isn't having bad outcomes, I don't think it's fair to say her technique is stupid. It's just different.

MoMo -

You are certainly entitled to your opinions, as I am as well. I think that specific instance I mentioned is stupid. I don't think my way is the only way, it's just my way.

To answer you question about VADs getting OHTxp vs EGDs, I don't routinely target abolition of spontaneous ventilation and then subject the right heart to the effects of positive pressure ventilation as part of my EGD induction, whereas the VAD patient undergoing transplant does face that. Or were you asking a rhetorical question?

I'm intrigued by the question and the comparison you made. Tell me: do you place arterial lines preinduction for your VAD cases getting heart transplants?

 

[pgg]

Fairly sure I've been criticised by old fogie loon staff for not pushing '2 per kilo' in a similar ish type of case. The flute thought the hypotension was anaphylaxis for 20 mins... Fairly sure she even wrote me up for not thinking it was anaphylaxis!!

Tunnel vision is a powerful thing. In this particular case, I convinced them to give some norepi, but they refused to cardiovert the patient, for fear of a LAA thrombus. Unstable patient with a heart rate between 150 and 180, but you can't cardiovert someone before doing an echo to rule out thrombus, period. This person spent an hour and a half like that while a surgical assistant harvested a saphenous vein.

Potential case report on the use of non-pulsatile flow in non-VAD patients presenting for MVR & CABG?

IIRC this picture was right before they went on CPB, about 90 minutes after induction:

Anyway, to get back to the point of the thread. It wasn't just this case. The facility was awash with M&M. Two days before this case, a spinal for an elective orthopedic procedure promptly resulted in CPR and death. If there was anything they consistently did poorly, it was the basics - H&P, use of standard monitors, equipment checks. Mostly in the name of efficiency and a freely admitted fear of upsetting surgeons by slowing things down.

What are the things that matter? CA-1 stuff. Vigilance. Respect for patients' diseases, the drugs we give them, and the things we do to them. I'll tell you what good style is: it's being the most boring anesthesiologist you can be.

 

[MoMoGesiologist]

MoMo -

You are certainly entitled to your opinions, as I am as well. I think that specific instance I mentioned is stupid. I don't think my way is the only way, it's just my way.

To answer you question about VADs getting OHTxp vs EGDs, I don't routinely target abolition of spontaneous ventilation and then subject the right heart to the effects of positive pressure ventilation as part of my EGD induction, whereas the VAD patient undergoing transplant does face that. Or were you asking a rhetorical question?

I'm intrigued by the question and the comparison you made. Tell me: do you place arterial lines preinduction for your VAD cases getting heart transplants?

I don't do cardiac and for residency we would place preinduction alines for all cardiac cases then central lines, TEE, and often PA caths. My question was more along the lines of, when cardiac patients come for procedures that are <30min with minimal hemodynamic shifts, would you place an aline if you are doing GA/ET? For example an LVAD patient needing a cysto or EGD with GA/ET, or would you use the NIBP or doppler cuff? I've seen it done both ways.

 

[sethco]

Tunnel vision is a powerful thing. In this particular case, I convinced them to give some norepi, but they refused to cardiovert the patient, for fear of a LAA thrombus. Unstable patient with a heart rate between 150 and 180, but you can't cardiovert someone before doing an echo to rule out thrombus, period. This person spent an hour and a half like that while a surgical assistant harvested a saphenous vein.

Potential case report on the use of non-pulsatile flow in non-VAD patients presenting for MVR & CABG?

IIRC this picture was right before they went on CPB, about 90 minutes after induction:

Anyway, to get back to the point of the thread. It wasn't just this case. The facility was awash with M&M. Two days before this case, a spinal for an elective orthopedic procedure promptly resulted in CPR and death. If there was anything they consistently did poorly, it was the basics - H&P, use of standard monitors, equipment checks. Mostly in the name of efficiency and a freely admitted fear of upsetting surgeons by slowing things down.

What are the things that matter? CA-1 stuff. Vigilance. Respect for patients' diseases, the drugs we give them, and the things we do to them. I'll tell you what good style is: it's being the most boring anesthesiologist you can be.

Convinced them to give Norepi? Refused to Cardiovert? No TEE for a CABG/MVR and worried about a LAA Thrombus? Where is the PA and CVP on the screen? I am very confused by your case. I would have immediately Cardioverted after I dropped the TEE. I don't think you need surgeon permission for this. 90 minutes limping along before going on CPB is ridiculous

 

[DM27]

I almost always place a lines for LVADs, especially for cases that would require the a line anyways.

If they have some degree of ventricular recovery or at least low LVAD flow you can expect enough pulsatility for a pulse ox and NIBP to give consistent values.

If you are comfortable interpreting LVAD values you can definitely get a very good sense of what is going on hemodynamically from a combination of your end tidal CO2 and pump parameters. When I was training I had an Attending (Cardiac) that routinely didn’t place a-lines for non major cases on LVAD patients so while I didn’t personally agree with it, I learned how to use the data to understand the patients hemodynamics at a given time.

Now that I am an attending I honestly place a-lines in all LVAD patients because I think it’s overall safer and what I would want done if I had an LVAD and also if I didn’t place one and anything went wrong I think I would appear fairly stupid.

 

[pgg]

Convinced them to give Norepi? Refused to Cardiovert? No TEE for a CABG/MVR and worried about a LAA Thrombus? Where is the PA and CVP on the screen? I am very confused by your case. I would have immediately Cardioverted after I dropped the TEE. I don't think you need surgeon permission for this. 90 minutes limping along before going on CPB is ridiculous

It was ridiculous. Without being too specific, I'll just say this was a hospital in a developing country, and as a visitor I didn't have the authority to alter the course of care.

 

[T-burglar]

Laughing my ass off at:

- no arterial lines for emergent non-cardiac surgery in critical valve disease (must be emergent because why are you doing it instead of whacking out the symptomatic valve first)

- no arterial lines for GETA for frozen hostile chest LVAD DIGOUT

- risking entire heart transplant program cause can’t be bothered to put a fvcking arterial line in

- can’t understand difference between short spontaneously breathing case and long GETA case in lvad patient

- no TEE for CABG/MVR

- no CV for unstable arrhythmia in combined SEVERE mitral CAD

- spinal assassin

 

[DM27]

The no cardioversion because of the LAA thrombus possibility sounds reminiscent of the side-site time out before ACLS initiation post on gomerblog.

 

[Southpaw]

It was ridiculous. Without being too specific, I'll just say this was a hospital in a developing country, and as a visitor I didn't have the authority to alter the course of care.

Sounds like someone somewhere needs to go back in time and ask the good Lord for a real deal set of balls or ovaries rather than the defective set they were given.

 

[sethco]

It was ridiculous. Without being too specific, I'll just say this was a hospital in a developing country, and as a visitor I didn't have the authority to alter the course of care.

"Undisclosed Location", huh?

 

[PainDrain]

It was ridiculous. Without being too specific, I'll just say this was a hospital in a developing country, and as a visitor I didn't have the authority to alter the course of care.

Developing country? Like West Virginia?

 

[pgg]

Sounds like someone somewhere needs to go back in time and ask the good Lord for a real deal set of balls or ovaries rather than the defective set they were given.

I think they need a generation of medical students to leave, train in a developed country, and go back. The elders' culture has a lot of inertia.

The no cardioversion because of the LAA thrombus possibility sounds reminiscent of the side-site time out before ACLS initiation post on gomerblog.

Eventually a TEE got done, no thrombus, but by then the chest had been prepped, and they didn't want to contaminate the field with paddles. Or maybe they were worried about the wetness of the skin/paddle contact. I'm not kidding, watching some of these cases ranks up there with some of the more traumatic things I've experienced in my life.

To their credit, they work hard, for very little money, for very little respect or prestige, and they do a lot of good with what they've got.

Developing country? Like West Virginia?

Might as well be another planet, albeit one with a hardware store:

 

[anbuitachi]

Tunnel vision is a powerful thing. In this particular case, I convinced them to give some norepi, but they refused to cardiovert the patient, for fear of a LAA thrombus. Unstable patient with a heart rate between 150 and 180, but you can't cardiovert someone before doing an echo to rule out thrombus, period. This person spent an hour and a half like that while a surgical assistant harvested a saphenous vein.

Potential case report on the use of non-pulsatile flow in non-VAD patients presenting for MVR & CABG?

IIRC this picture was right before they went on CPB, about 90 minutes after induction:

Anyway, to get back to the point of the thread. It wasn't just this case. The facility was awash with M&M. Two days before this case, a spinal for an elective orthopedic procedure promptly resulted in CPR and death. If there was anything they consistently did poorly, it was the basics - H&P, use of standard monitors, equipment checks. Mostly in the name of efficiency and a freely admitted fear of upsetting surgeons by slowing things down.

What are the things that matter? CA-1 stuff. Vigilance. Respect for patients' diseases, the drugs we give them, and the things we do to them. I'll tell you what good style is: it's being the most boring anesthesiologist you can be.

lots of developing countries do not use TEE for cardiac surgeries since its too expensive. luckily we have the luxury of doing so in the US.

not sure why they are afraid to give Norepi..
I guess they are afraid of thrombus b/c they can't transplant a brain, but can transplant a heart

how did the patient do?

 

[pgg]

how did the patient do?

Survived the OR. Don't know the long term outcome.

 

[deleted162650]

Might as well be another planet, albeit one with a hardware store:

Man, couldn’t even afford a Makita.

 

[Twiggidy]

Now that I'm out in the real world doing anesthesia, I'm learning so much from my colleagues that would be unimaginable in residency. So many things that seemed so critical, so vital, now when supervising multiple rooms, really no longer seem to matter. Pre-induction alines for severe valvular disease? Pfft who needs it! OB airways are difficult and avoid GA at all costs? Yea right! Can't do a spinal after a failed epidural? Puh-lease!

However, sometimes it's hard to tell whether I'm concerned about something that was ingrained in me unnecessarily by an ivory tower attending vs maybe the people around me are lackadaisical and I shouldn't pick up their practice patterns. Hence I've come here to ask, what are the things you insist happen in the OR for a safe anesthetic that you feel maybe some other MDs or CRNAs are lax on? I don't want to pick up habits that could compromise patient care...

I'll start first:

If there's someone's airway I'm concerned about, I really want to see good pre-oxygenation, meaning a good seal, and to see TVs and EtCO2 and EtO2>70% on the monitor. Not just place the mask on the patients face and look at me like why I'm not inducing yet...

To put simple, in residency things matter because not only are the people performing the anesthetic for the most part are inexperienced but the people actually doing the surgery are inexperienced as well. There's too much inexperience in those rooms to take things for granted. On the other hand, in private practice where people have years of "real world experience" you can "get away with things" so to speak. An anesthesiologists can get away with not pre-oxygenating because they've likely handled 1000s of airways. You may not always need a pre-induction A-line for a CV patients because you've done 1000s and have experience with both U/S and no U/S guided lines, where as a resident on CV rotation who may have only done a handful may take 20 minutes to put an A-line in a patient with a bounding pulse. The surgeons are also experienced. Not every "sick" patient may need invasive monitoring or special techniques because surgeons will literally be "in and out". You'll learn who those surgeons are vs the surgeons who still seem to operate like residents vs All OBs (lol).

In summary, yes, private practice anesthesiology is very different from private practice anesthesiology. You'll get the hang of it, but remember, don't do ANYTHING at the expense of patient safety, even if it means a surgeon has to twiddle his thumbs and wait or they complain you're slowing them down. If the later is a big issue with your dept/hospital then that may not be the right practice to work.

 

[WholeLottaGame7]

IIRC this picture was right before they went on CPB, about 90 minutes after induction:

Those a-line parameters are driving me crazy.

 

[Dexmetaketapropofol]

Tunnel vision is a powerful thing. In this particular case, I convinced them to give some norepi, but they refused to cardiovert the patient, for fear of a LAA thrombus. Unstable patient with a heart rate between 150 and 180, but you can't cardiovert someone before doing an echo to rule out thrombus, period. This person spent an hour and a half like that while a surgical assistant harvested a saphenous vein.

Potential case report on the use of non-pulsatile flow in non-VAD patients presenting for MVR & CABG?

IIRC this picture was right before they went on CPB, about 90 minutes after induction:

Anyway, to get back to the point of the thread. It wasn't just this case. The facility was awash with M&M. Two days before this case, a spinal for an elective orthopedic procedure promptly resulted in CPR and death. If there was anything they consistently did poorly, it was the basics - H&P, use of standard monitors, equipment checks. Mostly in the name of efficiency and a freely admitted fear of upsetting surgeons by slowing things down.

What are the things that matter? CA-1 stuff. Vigilance. Respect for patients' diseases, the drugs we give them, and the things we do to them. I'll tell you what good style is: it's being the most boring anesthesiologist you can be.

This exact scenario happened to me when I was a new attending. I couldn't use TEE because of some esophageal issues. I wasn't having it. I told them to take the surface probe and look at the LAA. They looked at me like a deer in headlights. I scrubbed in, took the epi-aortic probe, ruled out LAA thrombus and pressed the damn cardioversion button myself.

One good thing after that day was that I wasn't the "new" guy anymore, haha

 

[fakin' the funk]

Gonna point out that the "things that matter" depend on your situation and clinical practice.

There's a reason in the ivory tower you do everything "by the book" - YOU AND EVERYONE ELSE ARE LEARNING and you don't know ****.

Contrast to a practice where you know your surgeon well, you have some experience under your belt, have a stable group of nurses techs etc, and do the same type of cases frequently.

Totally changes whether or not you put in an art line, how aggressively you preO2, etc.

 

[deleted171991]

It was ridiculous. Without being too specific, I'll just say this was a hospital in a developing country, and as a visitor I didn't have the authority to alter the course of care.

Thank gods you're back! Now you know why some foreign docs immigrate to the US.