Pete Hart

Policies are sometimes a necessary substitute for careful and intelligent decision-making.

I also encourage residents to turn down the norad to reassess fluid-responsiveness, as excess norad can render patients non-responsive through effects on diastolic function.

Anything can destroy perfusion if no-one pays attention. But I do agree that a lot of patients who hit 0.5 of norad need adrenaline rather than vaso. Or both.

Not generalisable from Aus/NZ. We have very different incidence rates from NAP6 in the UK

I should point out that most cases of bronchospasm will not give you a flat capnograph (if you screw down the APL valve a bit - and you should). But it is at least possible for this to be the cause. In this case the tube was - appropriately - initially assumed to be in the oesophagus, and removed.

Sustained, exhaled carbon dioxide by waveform capnography is an essential component of tracheal intubation.

But what if there is bronchospasm?

Tracheal intubation can be confirmed using flexible bronchoscopy.

#AnSky

doi.org/10.1002/anr3...

Not sure if cricoid, reverse Trendelenberg, or any other potential anti-regurgitation measures were applied.

TL;DR patient with SBO died of massive aspiration during GA induction, having refused an NGT but without that refusal discussion being adequately documented by the clinical teams. Anaesthesia gets off lightly for seemingly having used a "low" dose of roc and a Guedel (to bag, we presume).

This week in RSI news: www.judiciary.uk/prevention-o...

Interesting "standard care" - 24h lidocaine infusions and gabapentin for all!

The things I do to reduce risk of regurg/vomiting are 1) Rev T'berg, 2) Avoiding proemetic stimuli (large opioid bolus, cricoid pressure!) before/during LOC, 3) No bagging unless they need it, and therefore PreO2 +/- ApOx, large dose of relaxant. IMO time/speed is overemphasised. (2/2)

RSI is a failed construct. It no longer represents any consistent set of interventions and so is not a useful term to communicate meaning. So the answer to the question "Can you do an RSI with TIVA" depends entirely on what components of RSI you think are important. (1/2)

First: define RSI.

Comparison of the effects of lidocaine pre-administration and local warming of the intravenous access site on propofol injection pain: Randomized, double-blind controlled trial Lidocaine reduces pain that occurs upon the intravenous injection of propofol. But, there are few non-pharmacological nursing interventions to reduce …

I've never heard of a connection with warming the patient before today - interesting, thanks. www.sciencedirect.com/science/arti...

Maybe patients having ECT are on CNS depressants already that reduce the incidence? Speculatively. I think 5-10% of my patients used to get it before I started using lidocaine.

Characteristics that increase the risk for pain on propofol injection - BMC Anesthesiology Background Propofol for anesthesia has become increasingly popular for endoscopic procedures. However, pain on propofol injection (POPI) remains an issue with administration. The primary endpoint of this study was to identify patient characteristics and factors, such as IV site and gauge, that could predict the occurrence of POPI. Methods This was a prospective chart review study of 291 patients undergoing endoscopic procedures. The patient’s demographics, intravenous (IV) site, and gauge were extrapolated. POPI was scored 0–3: 0 for no pain, 1 for minimal discomfort or awareness of sensation, 2 for discomfort but manageable/tolerable, and 3 for severe discomfort with writhing. Results 291 patient charts were reviewed. One patient was excluded for a lower extremity IV site. 225 (77.6%) had no pain, 48 (16.6%) grade 1 pain, 16 (5.5%) grade 2 pain, and 1 (0.3%) grade 3 pain. 137, 13, and 140 patients respectively had antecubital (AC), forearm, and hand IVs. Zero patients with an AC IV experienced a score greater than 1. Compared to AC, forearm IVs with pain of 2–3 had a univariate odds ratio (OR) of 11.3 (0.66,1.92; p-value < 0.001), and hand IVs had a univariate OR of 18.8 (2.46,143.3; p-value < 0.001) with a multivariable OR 15.2 (1.93,118.9; p-value 0.004). Patients with anxiety/depression and pain had a univariate OR 2.31 (1.09, 7.27; p-value 0.031) with a multivariable OR 2.85 (1.06, 7.74; p-value 0.039). SSRI/SNRI use had a univariate OR 1.56 (0.57,4.28; p-value 0.38). Alcohol use had a univariate OR 1.24 (0.39,3.91; p-value 0.71). Narcotic use had a Univariate OR 6.18 (1.49,25.6; p-value 0.012). Diabetic patients had a univariate OR of 1.42 (0.45,4.48; p-value 0.55). Chronic pain had a univariate OR of 3.11 (1.04,9.28; p-value 0.042). Females had a univariate OR 0.98 (0.37,2.63; p-value 0.95). Conclusion This study identified potential characteristics for having POPI. The incidence of POPI was statistically significant in patients with hand and forearm IVs compared to AC IV sites, larger IV gauges, history of depression/anxiety, history of chronic narcotic use, fibromyalgia, and chronic pain syndromes. This shows the potential of premedicating with analgesics or using AC sites on these select patients to help reduce the risk of POPI.

It's really variable in incidence. Do you use ACF/proximal cannulae? Or maybe you give the propofol really slowly via a 3-way tap? Problem is you don't know they'll have it until they have it, hence my routine use of lidocaine. bmcanesthesiol.biomedcentral.com/articles/10....

I use it almost routinely to prevent propofol injection pain, and very occasionally intra-op (still reduces post-op opioid requirement a little), but safety concerns around post-op infusions are very much warranted - renal function can be dynamic and accumulation/LAST can develop quickly.

My favourite bang-for-buck intervention is pre-warming the operating table/trolley (especially if there's a gel pad) with a Bair hugger (just tubing under a drawsheet, so no additional consumables). Got sick of seeing people instantly drop a degree from lying, bare-backed, on a cold surface.

Does Tylenol Cause Autism? Podcast Episode · Science Vs · 09/18/2025 · 28m

The amazing team at @sciencevs.bsky.social dropped a #Tylenol podcast a few days ago, giving explanation of why the link has been made and how it's not quite as it seems
A great example of bias and confounding, and how meta-analysis isn't always the pinnacle of evidence
#EpiSky #MedSky

I would like to propose that this incident is not representative of UK anaesthetic practice. Lancashire anaesthetic practice, maybe...

(There is some good stuff in here as well, reinforcing appropriate device selection - we have a long way to go in typical UK hospital practice - and advising against routine correction of coagulopathy for low-risk insertions.) (3/2)

...delayed. This is worrying when there are countless incidents of arterial CVCs not being recognised on CXR, and when we now know that delayed recognition is associated with increased risk of harm. It also means the guidelines are yet again lagging behind most people's practice. (2/2)

This has been a long time coming. However, there is a, bizarre lack of emphasis (as in 2016) on confirmation of venous placement, with plenty of words dedicated to tip positioning on CXR and only one reference to pressure transduction (seemingly as a preliminary check where the CXR will be (1/2)

.. multiple large CVC studies show no apparent strokes or deaths due to arterial injury, because they weren't defined complications. (2/2)

It's great to have some data on emergent prehospital trauma line insertion, and clearly it's reasonable/inevitable to accept a higher complication rate in this setting. You do need to take care comparing complication rates between studies, as definitions vary widely. For example (1/2)

Just a little too late for last week's #MedSkyDebate! Look forward to digging into this... Thanks to @medicluke.bsky.social for sharing it.

You only need the tourniquet inflated while there's muscle relaxant circulating, you'd only need to reinflate if you redose.

Absence of memory for intra-operative information during surgery with total intravenous anaesthesia While using the isolated forearm technique, we wished to determine whether patients who did not respond to commands during general anaesthesia with a …

Yes @icmtim.bsky.social, they've often done "squeeze my hand if you are comfortable" and the like, and it seems uncommon for them to experience discomfort: www.sciencedirect.com/science/arti...

Indeed - which is why people need to decide if they're okay with this "obeying" (and not really knowing whether they're conscious without recall) or if they think this is verboten (and then presumably doing something to make sure it's not happening?)

If you wanted to minimise risk of awareness, we could give our patients enough anaesthesia to be at near burst suppression, but then what would be the NNT and what harms would we cause from this?