Nic B Foss

This vibe 😌

Never give atropine to opioid induced bradycardia - it is completely harmless

Washington Post sub cancelled today

Yes again - but whether we are actuallt masking or preventing is not really solved by this - delirum seems to be triggered by inflammation or cerebral ischaemia...Both will give a NE response

Denmark close to wiping out leading cancer-causing HPV strains after vaccine roll-out A nationwide study suggests infections with human papillomavirus (HPV) types 16 and 18 have been virtually eliminated since vaccination began in 2008 – protecting even unvaccinated women.

I am here to say vaccines are awesome because guess what Denmark is close to completely eliminating the two most dangerous HPV strains (serotype 16 and 18) and with the cervical cancer.I think that is bloody AMAZING!!!!
bit.ly/4pbHxjT

Does anyything that sedates a patient actually prevent delirium, or are we simply masking symptoms of hyperactive delirium?

a woman is waving her hand in front of a purple background and saying `` oh pick me '' . ALT: a woman is waving her hand in front of a purple background and saying `` oh pick me '' .

Australians putting up our hands re anaphylaxis with rocuronium.
We see in multiple times a year just at my institution.
We are all absolute experts at diagnosis and management.
I have assisted in at least 6 in the past 10 years.
The rapid administration of adrenaline saves lives.

a cartoon of a group of people with the words keep on truckin ' written above them ALT: a cartoon of a group of people with the words keep on truckin ' written above them

😆

Alf is far inferior to Remi for this. I mainly caution that if you do not want to give sufficient dose of remi and propofol, then you should relax. Besides this we dont really see problems with it, and we train a lot of new doctors every year

It is about whether you think you can anaesthetize the patient, or whether you need the patients stress to control haemodynamics.....😊

Well, it has been shown that haemodynamic max out at 5, you can give 20 without extra effect, since it works via sympatholysis. Bradycardia and hypotension is not a problem if you have a vasopressor. The key is being proficient at haemodynamics.

Exactly, as I wrote: This discussion started with stating NMB is never a free lunch, neither when discussing awareness or postop. pulmonary complications - NMB is one of the main risks for both. And I have not even started on anaphylaxis to both NMB and Suggammadex
www.thelancet.com/journals/lan...

Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study We showed that the use of neuromuscular blocking drugs in general anaesthesia is associated with an increased risk of postoperative pulmonary complications. Anaesthetists must balance the potential be...

Because - as this discussion started with stating - NMB is never a free lunch, neither when discussing awareness or postop. pulmonary complications - NMB is one of the main risks for both. And I have not even started on anaphylaxis to both NMB and Suggammadex
www.thelancet.com/journals/lan...

Remifentanil for tracheal intubation without neuromuscular blocking drugs in adult patients: a systematic review and meta‐analysis There is increasing interest in the use of short-acting opioids such as remifentanil to facilitate tracheal intubation. The aim of this systematic review was to determine the efficacy and safety of r...

associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/...

Bolus. It is the slow infusion that gives rigidity.

No. You get rigidity with low dose. Given at this dose together with propofol I have yet to see it.

I am not advocating this in extreme or complex cases. You are making a strawman argumentation here

I am not advocating it in all patients, but in the majority it is quite safe. If you read the meta analysis I linked it does you all the data on safety, including a lot of emergency patients. But feel free not to try.

I can't remember when it was necessary. With VL we just give on the Remi.

Yes, but of no consequence. Low HR is associated with positive outcome in all our data. I think our fear is related to outdated methods of anaesthesia

Oh well, we have not had anymore failed intubationse, and it has been standard practice at the department and most of denmark for many years. The comment on vomting is ridiculous, and the bradycardia issue is outdated - and should not be considered an issue for anyone versed in haemodynamics.

One thing to reflect upon is that you have ceiling level sympatholysis in most with 5 mcg/kg remi and dose can be increased further with little effect - as high as 20 mcg/kg has been used in studies on haemodynamics. So if I am in doubt I go higher dose....

It means many inductions are closer to RSI, because there is no waiting time and thus no need for ventilation. If you are used to maintaining cardiovascular tone with high sympathetic activity, BP/HR will drop a bit more with this technique and we ofte use vasopressors.

Optimal remifentanil dosage for providing excellent intubating conditions when co‐administered with a single standard dose of propofol This dose–response study aimed to determine the dose of remifentanil combined with propofol 2.5 mg.kg−1 which provided excellent intubation conditions in 95% of patients. Ninety premedicated female A...

I have always been guided by the Bouvet study. I use propofol 2 mg/kg and remi 5 mcg/kg together on induction as my base. between 45-60 s after induction you see the HR drop, reflecting sympatholysis and you go.
associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/...

Well it is very easy, when you see the cords and gently advance the tube, you see if there is any resistance at all, which there hardly never is above 5 mcg/kg of remi on top of propofol. The new meta-analysis from Anaesthesia supports this as well. I´ve done bariatrics with VL no NMB for 10+ years

I can definitely sympathise with that, but it seems that a lot of doctors are making a lot of money through the system as well, which is common in privatised health care.

Yeah, much simpler without in most cases

I have almost completely removed NMB from intubation in favour of prop/remi, I do believe it practically eliminates awareness under induction.