"... a ‘RSI–TCI’ mode with a pre-programmed manual bolus offers a pragmatic solution for those who wish to preserve an intact pharmacokinetic model for accurate propofol delivery, while allowing the rapid induction clinicians expect from a manual bolus."

#AnSky #MedSky

doi.org/10.1111/anae...

What would you like?
I'll see what we can cobble together!

0.2mg/kg bolus has no EEG effect
(See image)
0.3mg/kg may have an effect but I feel clinically un likely
0.5mg/kg often will induce EEG changes that are associated with an rise in BIS index

If bolusing and concerned about rise in BIS value, give during a period of surgical stability

Likewise have a similar recipe. I am enjoying comparing my bolus infusion technique to intermittent boluses

After modelling do you have any thoughts on how useful TCI ketamine is Vs bolus infusion? Ie any circumstances you might choose TCI first?

Brilliant, thank you.
Caveats noted!

7x more failures!?
Do you have a study I can look at?

Eleveld et al.'s #pharmacokinetic - #pharmacodynamic model of #remimazolam begins to pave the way for its widespread use in #sedation and anaesthesia. #BJA #model #simulation

www.bjanaesthesia.org/article/S000...

If performed by a second
person, the cost isn't their salary. It's the time that could be spent elsewhere. Helping with turnover, prepping for the next case etc

If performed by airway assistant - disagree with this practice - The cost is attention divided between multiple important tasks.

If performed by a second
person, the cost isn't their salary. It's the time that could be spent elsewhere. Helping with turnover, prepping for the next case etc

If performed by airway assistant - disagree with this practice - The cost is attention divided between multiple important tasks.

Completely agree with this point about us not necessarily being great at predicting who has a full stomach, especially in the era of comorbid disease and GLP1s

Aspiration has an incidence of between 1:900 - 1:10,000 (NAP4)
Perioperative cardiac arrest has an incidence of 1:3000 (NAP7) - Arguably equally catastrophic so should every patient have defib pads put on at the start of a case?

a man in a robe is standing in a dark room with the words `` only sith deal in absolutes '' written on the screen . ALT: a man in a robe is standing in a dark room with the words `` only sith deal in absolutes '' written on the screen .

But I think your question is less about having cricoid as an absolute but maybe where are we drawing a line as to who to use it on?

Every intervention in healthcare has an opportunity cost.

Cricoid force should be performed by a team member with no other role.

Cricoid time x No of anaesthetics/ per hosp/ per year = large number

Aspiration low incidence in general anaesthetic pop. Cricoid becomes non cost effective.

That is a great study! One to be kept in the bank of interesting papers.

No thats fair. And perhaps RSI is not the answer to making us take more care. But we're not always careful for a variety of human factor-ey reasons...

Fine you've convinced me! But can I replace it with another fun acronym instead?

Interesting!
So can I gas induce them?
Arguably 8% sevo can be reasonably quick...
I joke of course but I think if you're being really careful in frail patients you can reach an accidental plane of 'excitability'

If I'm honest I don't disagree with your points

Then again, here I am arguing about the term rather than the substance of what an RSI is. Perhaps we do need to be rid of the term...

There were several cases of cardiac arrest in NAP7 related to TIVA use where anaesthetists didn't change their practice in sick patients.

The term RSI serves as a warning 'This patient is sick, Take care'
- Use roc not vec, have the suction under the pillow, think about asking for that NG prior

By your other point do you mean
that our usual practice has changed ie we should preox and sit up every patient?

I'd argue that a lot of the PUMA recommendations we don't do for all Pts - or at the very least we aren't scrupulously careful.
In a patient who 'needs' an RSI We take time to prepare.

Good points!

I would agree, deeply paralysed and anaesthetised pt before instrumentation is key
But I think the 1st part - rapid - is important.

Risk of aspiration is not proportional to length of time without a protected airway, but does this mean I can take as long as I want with my induction?

The only way to be safe 🤣

Interestingly there were several aspiration events peri-EXTubation. Does this mean we need an RSE as well as RSI?

NAP4 had an overrepresentation of junior anaesthetists involved in aspiration events.

I'd argue that teaching a 'standardish' RSI technique to your less experienced team members gives them a baseline of safety; alone, in a theatre, in the middle of the night.

Ok it’s time for the very first Midweek #AnSkyMedSkyDebate, which I will call the #VortexDebate after the wonderful @chrimesy.com.
Come on let’s get our opinions out and have a good robust discussion.
See next comment for the topic.
#AnSky #MedSky

I (personal opinion) like the term RSI. As an indicator of someone who needs 'a tube stuck in quickly'

The term is less about the recipe, more as a reminder to the team to be careful.

Certainly in anaesthetic practice where 'RSI' is not done for every pt.

Clinical Electroencephalography for Anesthesiologists: Part I: Background and Basic Signatures Abstract. The widely used electroencephalogram-based indices for depth-of-anesthesia monitoring assume that the same index value defines the same level of unconsciousness for all anesthetics. In contr...

References for all of this.
[1] doi.org/10.1097/ALN....
[2] doi.org/10.1213/ane....
[3] doi.org/10.1093/bja/...
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