A partner placed a continuous epidural for post-op pain management (colon surg.). I was comfortable, up, and walking the next day. 4 days post-op, I woke up paraplegic. Pharmacy error preparing the infusion pump bag is my guess. Even if the cath had migrated, a proper dilution (bupivacaine and fentantil, I believe) would not have caused my cauda equina syndrome. I was tx to a rehab hosp where I progressed from bed to wheelchair to walker to "no assistance needed". Now, almost 15 years later, I have persistent LLE and abdominal numbness and significant LLE weakness, but I can walk, drive a stick shift, and manage my adl without assistance.

It's been more than a decade, the weakness is progressing slowly, and I'ml living life as fully as I can. I'm 81, walk in my hilly neighborhood daily, and drive a stick-shift (albeit with a light clutch.)

I didn't file a lawsuit, choosing not to have to repeatedly characterize myself as a victim.

I'd really appreciate some thoughts from the anesthesiology community about WTF happened.

In neighboring boxes of the same drawer.

Anyone have any updates on them? I know they voted to unionize about a year ago. Was curious to see how things were going.

Someone told me once that some study found that 30cc of prop at the end of the case was equivalent to a drip during the whole case (with a bit of sevo in the background) for PONV prevention. I can’t find a study like this though - does anyone know of a paper that shows this?

A patient with sepsis who was stable with 0.3-05 mg/h norepinephrine infusion collapsed 3-5 min after gelatine solution started in PACU. She was also peeing while she collapsed. She didn‘t need chest compressions but lots of epinephrine. Either relieve of bladder pain made her collapse or gelatine allergy. Have you guys ever seen allergic reaction to gelatine infusion? She didn‘t react to norepinephrine anymore and she got transient flushing.

Yay or nay? In pediatric major abdominal surgery(mostly intraabdomjnal tumors) after some cases of mesenterial thrombosis we always start iv heparin let's say 5-10 IU/kg/h during surgery. Then we typically continue for some days targeting APTT 40-60. Myofascial blocks(like QL block) and opioids are really suboptimal. We had ketamine but now we are in shortage. Epidural is always gold standard for major abdominal surgery. I placed epidurals before surgery when using UFG iv 1 hour after placement, but i'm still very concerned cause there's no evidence it's safe especially in kids. And doses we use sometimes not really prophylactic. One epidural haematoma is enough to make one child disabled and for me to lose a license in my country. So what is your practice?

I feel like they, whoever they may be, could maybe pick a different color for the dust cover for these two meds and be consistent with it.

In my practice, these meds are in identical slots in the Pyxis but different drawers.

Obviously we all should be looking at the vials before drawing up a med, but I feel like this system is just begging for a medication error.

Rant over. 😇

New attending, about 5 months in. Lots of ups and downs for sure, but definitely felt like I’ve made strides in terms of my confidence. Fortunately I have a very supportive group with plenty of backup. However, a few days ago I had a situation that I’ve been thinking about over and over and wanted to share. I had a patient that was getting an appendectomy, older guy with a very large beard. After pushing the fentanyl and lido I noticed the machine was giving me an error that I had not seen before. I don’t remember the exact error message, but it said something along the lines of there being a flow mismatch (it was one of those old Drager Apollos, which I did not use in residency and am not as familiar with). I had my flows up to 13, turned it down to 10 and the message went away, I was getting end tidal etc, so I figured it was safe to proceed. Induced with prop and roc, put in an oral airway, tried to bag. Bag deflates instantly, so I figure there’s a leak, turn up the flows and turn up the APL, two hand mask and ask the PA who’s assisting me to bag. Bag deflates.

At this point, I should be going down the difficult airway algo, considering intubating instead of mask ventilating. However, I was worried that maybe there was something wrong with the machine since it was giving me that error message, so I didn’t want to intubate and connect him to the machine vent. At this point I admittedly started to panic. I’ve handled plenty of stressful situations fine the past, but the error message threw off my thinking.

I looked back and didn’t see the ambu bag where it’s supposed to be (should have checked for it during my setup) but saw Jackson Reese circuits. Called a stat. Grabbed one of those, tried to plug it in to the aux O2 but it wouldn’t connect! I learned later that the connector is meant to plug into the vent circuit instead, but in that moment that issue totally threw me for a loop. This whole time people are trying to help me out but are giving me things I don’t need or asking me questions that aren’t helpful. Fortunately by then a colleague came in and found the Ambu bag (it had fallen behind the cart), I double handed and we were able to bag the patient easily. I intubated and things were fine. Patient never desatted even though the situation felt like an eternity. The machine worked perfectly fine and the error message didn’t pop up again.

In retrospect I should have intubated after not being able to ventilate, but my brain kept biasing me away from using the anesthesia machine. I should have investigated the error message before giving the prop/roc, but I figured that since it went away it should be fine, but this error totally scrambled my ability to think straight under pressure. I also should have located the ambu bag ahead of time.

What I feel bad about is 1) not making sure I knew where my ambu was, 2) not stopping to figure out what the error was before proceeding and 3) losing my cool and panicking in the situation. I’m glad I called for help early but I still feel like ass about the whole situation.

Hungarian attending here. Volatile maintenance requires low or minimal flow, but TIVA is more economic with higher flows so that soda lime degradation is slower. I was wondering if both are used what would be the optimum?

Thanks

I have seen several anesthesiologist influencers on TikTok and Instagram.

Who’s your favorite anesthesia influencer.

Usually I use Midazolam syrup for kids, but we ran out of it today at our facility. I had a nurse tell me that at her previous facility they used to just dilute the IV form of Midazolam into a small amount of juice for the patient to drink. Can anyone else confirm if this is an appropriate practice?

I’m an anesthesiologist in NY/NJ/PA. I was part of a private practice group that covered high end plastic surgery, dermatology, and fertility cases in the tristate area. I recently branched out on my own (with one partner) and I’ve made connections with multiple surgeons who are eager to contract with us….the only problem is hiring the right number of per diem anesthesiologists to ensure adequate coverage for all of our contracts. Recruiting for such a niche anesthesia practice is difficult and our advertisements haven’t gotten many responses even though we offer HIGH pay and flexibile hours… has anyone else gone through this process? Any advice?

Hello everyone! If you've ever read Morgan & Mikhail's Clinical Anesthesiology textbook, what chapters do you think would benefit an incoming CA-1? Thank you in advance!

Speaking with an attending today, who stated that if you don't stop advancing the dilator/start withdrawing in a push pull fashion after the second 'pop' when placing an introducer 9Fr central line in the Right IJ there is risk of atrial perforation or damage to the innominate artery. Is this true? Have any of you seen complications like these

I've heard of people doing IL succinylcholine vs IM. In the few cases I have seen this it seems like it may be more cumbersome to try and scissor the mouth open, not to mention increased bleeding in the oropharynx. I was wondering if anyone has any experience with intralingual administration or experience, stories, etc specifically in pediatrics.

Our group is replacing our anesthesia machines, and are in the process of trialing different machines. I'm finding that 1-2 days in the OR doing elective cases hasn't been quite enough to figure out all the issues or potential of the machines.

For those who have or are currently using the Mindray A9 machines - what are your thoughts? Happy to hear about their other machines, the A9 is just the one we trialed and are considering.

Example, today the surgeon was talking about the airline tragedy in Washington and couldn’t remember who the Russians on board were, if they were ice skaters or gymnasts. I said, “oh they were ice skating champions in the early 90s.” They ignored me lol. This happens pretty often.

I’m one of those types of girls who just does her work and goes home, not really chatty so it doesn’t bother me.

Five years on the job and I still can’t figure this out. Has anyone else noticed this? Maybe it’s a me problem.

I’m an OR nurse and recently worked with a new doctor(new for us but he’s been in practice for a while). The CRNA was doing the spinal and doc gave propofol and the patient ended up basically falling on me. Thankfully another nurse was close by and propped us up before hitting the floor. The patient was 6’8, 275# so I had no hope by myself. I only saw the propofol in the IV tubing after the fact, so there was no warning. Even though I was braced for the patient, I wasn’t expecting sudden unconsciousness.

I have never seen this before. Is this a standard practice? I’ve seen versed and/or fentanyl given during spinals. But never propofol. To be clear this was while it was being placed, not after. I don’t want to assume it was “wrong” just because I had never seen it before. Thanks!

Current CA3 in a substaffing role. Have some CA1s that insist on getting vaso from pharmacy/omnicell every morning when doing GA, "just in case". They tell me they've been burned a few times in ortho cases (think elderly, sick heart, maybe septic, getting a hip fixed) or vascular cases that require GA instead of sedation.

I've told them it's not necessary and you often do not need it, when phenylephrine or norepi is often adequate. And unless it comes in premade syringes, it's just wasteful to get it out routinely.

Sure enough, we've had 2-3 patients this month who needed it. Under GA, hypotension refractory to fluid/anesthestic depth adjustment/adrenergic pressors/positioning, etc. These patients have healthy enough hearts and have been on Lisinopril (which is the classic teaching).

Of course, they're all too quick to say "I told you so". Am I wrong that grabbing vaso routinely is overkill? How often do you find you need to use it, and under what circumstances? Are the concerns about coronary/renal vasconstriction clinically substantial?

Has anyone taken a local chief position with an equity group. I'm considering applying for I've but would like a little unbiased advice. My group is mid sized mostly direction with cardiac and pedi docs.

I'm pretty sure you guys do during procedure, but my institution is very opposed to it post op unless maybe for hocm pts with septal myomectomy. Could you explain why it might be less favorable post surgery even if pts are very vasoplegic (they rice methylbue before even starting neo). My institution is also run by lot of interventional/cardiologists who are often consulted too so idk..

So let me just lay out the scenario here

My PP groups staffs a few sites within a local health system. This health system is opening a new center and our group bid for the contract. We didnt get it, nbd. This site will probably suck for at least 3 years, and there's a certain degree of resentment we have with this health system. The group that did get the contract is some national group with no current presence in our city, and maybe not even our state. Okay, good for them. But now, myself and others are getting those annoying locums recruiter emails about openings at the new site. We assume this national group is on a push to find staff quickly, given that none of them currently live or work in our city.

I'm looking at this recruiter email thinking "hmm well all my partners and I have the state license, we all live in town, we are all already credentialed within this hospital system, and we have enough staff currently to spare a few docs. Hell, we even know personally the OR nurses and surgeons who will be working here. Why don't they just recruit our group for 1-3 docs a day instead of try to find individual 1099"

I'll be very upfront that i'm naive to contract negotiations with hospitals, the incentives of locums recruitment agencies, and the whole 9 yards. I'm just curious if this arrangement of an agency going through a group rather than an individual has ever been done before. What does the agency care as long as they are getting their cut of the payment?

Like, can I just respond to the recruiter with "Hey, for xxx$/hr, my group will send a doc there every day for however long you want. We all are credentialed within the system and have licenses. Just make the checks out to our group please. We can work for a few weeks or a few months, whatever you want"

It just seems like a crazy russian nesting doll of middle men (hospital system-->the national group-->locums agency-->my group), but this hospital system makes terrible financial decisions as if its in their core values statement.

Anesthesia resident here. Based upon your interactions with other healthcare workers and patients, what do you think is the most ubiquitous misconception about anesthesia?

I've found many patients don't realize we manage all vital signs and they assign this role to the surgeon. I also completed my OB rotation about 6 months ago and still cannot get over how many people so staunchly will try to avoid an epidural.

Saw an awake fiberoptic for a patient today with a BMI of 60. Administered 4% topical lidocaine, 2 mg Versed, and ran a Precedex drip. Had one doctor try to run the fiberoptic scope 3 times until another attending took over and tried to intubate 2 more times, however, the patient would not tolerate the intubation until we gave 50 mg of Ketamine. 20 mg initially which almost let the attending intubate the patient but the patient bucked out the tube so we gave another 30 mg of ketamine a couple minutes later since the patient started kind of going crazy. Surprisingly the sats were pretty stable throughout the multiple attempts made. We did get the ETT in successfully btw!

Didn’t do any transtracheal blocks or run anything else otherwise. I was told Remifentanil drips are great for these since patients remain quite still and listen and I’ve had good experience extubating them under TIVA while running it at a low dose during emergence.

Anyone has extensive experience with difficult airway and awake fiberoptics? If so, what are your go to preoxygenation techniques and drugs/drips/blocks to keep the patient still and intubate/confirm appropriately without having the patient desat quick?

Edit/Update 1: The patient received a lidocaine nebulizer treatment prior in pre-op. Glyco/Versed was given too but the IV was not working so another IV was placed and only the Versed was redosed again. I do agree the patient was not localized appropriately and a better job could have been done to calm/support the patient pre-op. The Precedex infusion was not run at a good enough dose either to calm the patient.

The reason for the patient having an awake fiberoptic done was in the previous anesthesia note, the patient had a surgery at another facility where two different attending attempted to use the Glidescope 3-4 times but could not get a view so they decided to do a blind approach. Therefore, the attending planned to do AFOI at our facility.

Current CA-2 looking to move to Seattle. Most of the openings I see are USAP, Somnia, and Virginia Mason, but down at St Joe's in Tacoma. All seem like mediocre options - can anyone add anything about the market there?

Did it take 6 weeks like the summer exam?

Hellooo.
what iis your preferred BP during non cardiac surgery (eg laparoscopy) on non hypertensive pacients And why? trying to understand a little bit about this
Our anaesthesia specialist tend to allow a higher BP around 140 SBP during all surgery but i find it a little to higher especially for pacients under 50 years old with no hypertension past.