George Zhong

Do not agree with routine large bore iv insertion, esp awake without local

Hope registrar learnt smth to better care for his future pts

Power imbalance and would like to hear his side of story (how he truly felt inside, in confidence, to decide if it's truly "consent" and "good friends")

It's the same as asking a 3-Michelin star Japanese chef and a 3-Michelin star French chef: what's better, sushi or beef bourguignon?

I'm sure the Japanese chef would never go to a 3 star French restaurant and force them to make sushi ... 😅😅

#TIVASky #AnSky #ASM25CNS

It’s the start of the Antipodean weekend and that means #AnSkyMedSkyDebate time. Here’s the question: TIVA: bees knees or emperor’s new clothes? What do you think? What would you choose for you? Why? @anzca.bsky.social @rcoanews.bsky.social @assocanaes.bsky.social @maffygirl.medsky.social

Both are very valid anaesthetic techniques, it's more about the operator than the tool.

For my pt, I prefer to use TIVA. 😁

For myself and my family, I prefer the anaesthetist use what they are best at using and then focus on other more important anaesthesia decisions.

TIVA w NMBA = always pEEG

TIVA w/o NMBA - case by case depending on risk/benefit:

If at risk of either awareness or excessive anaesthesia depth = use pEEG

If risk is low and outweigh cost then no pEEG

I suspect when plotting probability of inciting debate vs provocativeness of a comment, it's a (upside down) parabolic relationship

The only difference is in the coefficients 😅😅

Spot on!

The crux of the problem of performing RSI with a TCI pump is whether the maximum pump rate suffices for the given induction dose

For an old frail smaller patient, probably suffices

For an young healthy larger patient, grossly inadequate

It's about the pt not one size fit all technique.

Feature preview: RSI mode coming soon to simtiva.app! How do you do RSI with TIVA? The algorithm suggests a bolus dose based on user-defined CE target at a specified time point (e.g. 60s). It also predicts a CE overshoot & when to resume infusion. Also testing live preview feature...
#ansky

dexmedetomidine TCI

Feature preview: testing dexmedetomidine TCI on simtiva.app - coming soon

#ansky

Thank you for all your interest in our work. Due to popular demand, here's the link to our article behind paywall, free for 50 days

authors.elsevier.com/a/1kWpX1dCDy...

Thank you @bjajournals.bsky.social

#TIVASky #AnSky #TCI

Of course, depth of anaesthesia is a 3-way balance between
(1) PK (how much propofol)
(2) PD (pt sensitivity)
(3) how much stimulus

It seems from our study that when stimulus is standardised (i.e. minimised), it may be possible to reliably predict wake up time 🤔🤔

To try our wake up prediction algorithm today, just search for Propofol Dreams in the app store on your phone. Free for the world forever!

propofoldreams.org

Reference doi:
10.1016/j.bja.2025.01.007

As a pilot study, we validated our novel prediction algorithm in 2 small cohorts of patients: painful and non-painful surgeries (defined as whether additional analgesics were required in PACU). The predictive value of the algorithm was excellent, esp in the No Pain group. 7/7

Final hybrid regression wake up model implemented in Propofol Dreams app

EXPERIMENT: we tested our hypothesis by examining a simplified cohort of patients where external stimuli (pain, verbal, tactile) at the time of emergence were minimised.
We built a hybrid regression model that predicts the awakening Cp for from maintenance Cp and SE. 6/7

HYPOTHESIS: if we solve for the sigmoid Emax model parameters using maintenance phase data (propofol concentration, state entropy) for a given patient, we may then be able to use these to predict their individualised awakening propofol concentration 5/7

ASSUMPTION: the Hill coefficient and other model parameters quantifying the pharmacodynamic effect of propofol are unchanged between the maintenance phase shortly before emergence and at the time of emergence 4/7

LEMMA: the sigmoid Emax model relates propofol concentration to its pharmacodynamic effect. 3/7

We came up with a novel algorithm for predicting individualised wake up Cp during propofol TCI based on:
(1) maintenance Cp
(2) corresponding state entropy
Here's how we did it. 2/7

When do you switch off propofol #TCI at the end of a case? How do you predict when the patient will spontaneous eye open and emerge from general anaesthesia?
We tackled this Q in our latest study published in BJA. Here's a quick summary ... 1/7 #AnSky #TIVASky

You can also mimic Eleveld infusion regime almost exactly by using Marsh on your existing pump together with an adjusted input weight. 😜😜

propofoldreams.org/elemarsh-mode/

Have used all 4. BD Nexus and Agilia (Fresenius) are both good daily drivers
Don't mind the Braun

Not a fan of the Arcomed because it's clunky to exchange syringes (hardware issue) and over the top safety confirmations (litigation avoidant > clinician centred design, easy software fix)

Or "inadequate trace, check place"

But I agree with you, it's a risk-benefit balance of a catchy rhyme that efficiently raises awareness vs inducing cognitive bias

I feel the problem with "no trace, wrong place" is that there are two negatives (no and wrong) which are easy to mentally flip, which then becomes the unintended message of "yes trace, right place"

What about using verbs which cannot be easily flipped like
"abnormal trace, check place"

Check out the new BJA Special Issue on #sustainability in anaesthesia. Guest-edited by Prof Jodi Sherman.

#anaesthesia #Ansky #environment

www.bjanaesthesia.org/current#Spec...

The climate crisis is a healthcare crisis!

#ThereIsNoPlanetB #AnSky #sustainability

I think to get a rough estimate, all you need would be

(1) Local cost of air, oxygen, soda lime, electricity

(2) Local GWP of oxygen and air.

The GWP of soda lime is pretty consistent (differ by transport). The duration of canister also quite constant.

So we deliberately avoided making an utility judgement of the $$$$ vs environmental trade-off in our manuscript and just stuck with the science.

Personally, I also wouldn't touch durian but my better half loves it 😁😁 but you get the point 😂😂

Indeed, when we designed the original study, we hypothesised that there would be both an economic AND environmental benefit.

Unfortunately, reality is there's a potential trade off for Sydney, Australia (environmental analysis is v conditional)

You are right Danny. I guess it depends on the dollar cost you price carbon emission ...

How many apples do I need to trade for your durian? 😁😁

doi.org/10.1016/j.bj...

Our follow up clinical study 😁