Cosyntropin, An Alternative for PDPH

I was on the OB this week, and had a patient who developed classic PDPH on POD2. She was a difficult epidural placement with a success on the second attempt. She is 21 years old, BMI 43 otherwise healthy. Her headache started on POD1 and progressively got worse on POD2. She has the classic presentation…

Ask For Help! No. 1 Skill to Have!!!

I never thought I would write a topic on asking for help. But my experience recently made me realize that we need to emphasize asking for help in our training whether you are in school or in practice. Let me tell you the story first. I was giving lunch breaks to the providers. All of…

Pain Perception and the Role of ANS

This is a topic that I have been continuously exploring for the past 4 years. It all started out with a question that I had with an attending whether patient has pain under general anesthesia. It is a fundamental question but a key question that laid foundation to pain management. Based on the definition of pain,…

Application of Ultrasound in Airway Management

Hi everyone, I hope your week is going well. I have recently played with ultrasound more often at work and grow fond of it. The topic on airway is one of my favorites since we have to deal with this everyday. In addition, we had a lost airway case. This made me think what we…

Should We Do Tight Blood Pressure Control?

Recently I had a conversation with one of my colleagues regarding tight blood pressure control intraoperatively. I was told that the blood pressure should be strictly controlled within 10% of resting pressure based on this study from JAMA in 2017. As you all know me, I don’t take other people’s word for it. I like…

Pharmacology Revisit: Context Sensitive Half Time

I have been working at an University Medical Center for almost two years. Often times, I take over all day long cases as I am the late person in the OR. Most of those cases are spine cases. As we all know, ERAS protocol has been implemented in most of the big spine cases. They…

Dexmedetomidine, A Perfect Drug for Aortogram Run-off

Hi everyone, I hope you are all doing well. I can’t believe it is almost Christmas. Time flew by. I have been absent for a little while as I mentioned that I started my new job at an academic center. Starting this August, I took on research projects. I have submitted two prospective clinical research…

Synergistic Effect of Cisatricurium and Rocuronium

This topic has been on my mind for about a year. But I wasn’t able to find a satisfactory answer until recently. Here is my story with the use of cisatricurium and the rocuronium for a patient who has ESRD. About a year ago, I was doing an abdominal wound closure. Patient had wound vac…

No Narcotic Induction

As some of you remembered, I have recently changed my job to a university academic center where I have picked up a few new tricks and some new understandings of the effects of common drugs we use. I would love to share one of my favorites with you.  I am in love with no narcotics induction because…

Use of Sugammadex on Patients who have ESRD

This is a follow-up post on the Use of Sugammadex on Patient Who Has Myaesthenia Gravis. Last week, I had a patient who has ESRD and on HD and patient was scheduled for a laparoscopic hernia repair case. Patient has active acid reflux and obese with BMI=40. We all know cisatricurium takes forever to take effect. Now that we…

ERAS and Individualized Iron Therapy

Enhanced recovery programs have been implemented perioperatively to reduce stress and restore baseline function at most of the hospitals in US. As a result, complications and length of stay have significantly reduced. The new trend of ERAS is gearing toward more patient-centric approach to improve longer term outcomes rather than functional recovery. One element of the…

Use of Sugammadex on Patient Who Has Myaesthenia Gravis

Happy Monday everyone. I hope you all had a great weekend. I had a case last week with a patient who has myasthenia gravis. Patient has to be paralyzed due to the type of the surgery she had to undergo. I figure it would be a good topic to discuss. As we all know, MG…

Anesthetic Management of Patients Who is on Buprenorphine-Naloxone

Last week, I had a patient who is on suboxone.  As we know, patients who are on maintenance therapy of suboxone can pose a challenge for postop pain control as they often have severe postoperative pain due to  limited efficacy in the presence of buprenorphine. Hence, I figure it would be a good case for us to…

Can We Minimize Narcotics Use Intra-Op?

This is a topic that I have been wanting to discuss with you guys. I feel that it is a learning process for me to understand that we don’t always have to give narcotics intraoperatively. I remembered when I was a student, I was doing my cardiac rotation at a university medical center, the attending…

Shall We Use Ropivacaine in Spinal Block for ERAS Patients

ERAS has gained so much popularity in orthopedic surgery as we all know that standardized ERAS program has shown to reduce postoperative morbidity and length of hospital stay (LOS). Lately, in our facility, we have been emphasizing early ambulation and physical therapy for the patients right after surgery. Surgeons want patients to have patient’s motor function…

Pheochromocytoma and the Role of Remifentanyl during Adrenalectomy

In the past few years, I have had a few encounters with pheochromocytoma cases. It gave me an opportunity to compare different anesthetic techniques in managing the laparoscopic adrenal mass resection case. The traditional anesthetic management includes vasodilators and vasopressors to control hemodynamic changes in response to adrenaline resection. The first 2 cases of pheochromocytoma…

How to Prolong Spinal When You Don’t Want to Convert to GA?

Hi everyone, I am back after hibernating for a couple of months. Today I want to talk about something that is relevant to all of us  — something we all have been through which is how to not to convert to general anesthesia by prolonging the spinal block if the surgery runs longer than expected….

ALS and Anesthetic Management

Two weeks ago, I had a patient who came in for exploratory laparotomy s/p peg tubal insertion. She has unrelieved pain after the peg tube placement. Patient is in her mid 30’s. Needed the ped tube due to losing weight. She has been bedridden for a year and exhibited muscle atrophy in her extremities. She…

Using Muscle Relaxant with LMA

Have you ever used muscle relaxant with LMA? Is muscle relaxant contraindicated with the use of LMA? We all know what is the answer in the textbook: the use of muscle relaxant in LMA case would not be supported. But recent studies have shown that the use of muscle relaxant with LMA cases are beneficial…

Healthcare Reform

The media has been focusing on the healthcare reform for a while on whether to repeal and replace OBAMA’s healthcare with something more sustainable. Today, I am going to talk about something bigger than just anesthesia. I feel that as a healthcare provider, it is my duty to give feedbacks on our current healthcare system….

A Great Combo: Food Poisoning and My First Clinical Day!

I got food poisoning this week when I finally had me time. Sighs…… when I was laying in bed, it reminded me of my last food poisoning on my first clinical day in the OR….. I can still remember vividly the night before my first clinical day in the OR. It all happened when I…

Does Pretreatment of Non-Depolarizing Neuromuscular Blocker Prevent Myalgia?

I had a discussion the other day with one of the attendings at work on whether pretreatment of rocuronium prevents myalgia. We all know that the most common practice is to administer a small dose (10–30%) of the ED95 of a nondepolarizing neuromuscular blocker such as rocuronium a few minutes prior to administration succinylcholine, with…

Epidural Fever?! Have You Heard of it?

Have you seen this in your clinical practice that a patient you placed an epidural 10 hours ago developed a fever? You may not have thought into it too much. After all, there are many possibilities that laboring woman can develop fever. There are many etiologies that can cause  intrapartum fever such as maternal chorioamnionitis and…

Students and the Darn Grades

“What should I write in my blog this week?” I asked myself this morning on the way to work. I feel that it is time for me to write about SRNAs and their grades since it has been on my mind for a while. I have been teaching a class to SRNAs this semester. It made me…

Keep the Physical Youth!

I know this post is not directly related to anesthesia, but it is important to us because we want to take care of ourselves first. What I want to advocate here is caloric restriction diet. The reason is that calorie restriction without malnutrition increases not only longevity but also delays the onset of age-associated disorders in multiple species. Don’t we…

CSE Practice Points/Tips

A couple of weeks ago I was on OB, I was called to assess the discomfort patient experienced in her perineal area. Patient was in early stage of labor, 4cm dilated and had epidural in place. Patient had a good bilateral sensory block, suggesting that the epidural was working well. As we know, labor epidural…