Hyperoxymia, good or bad?

Some students have asked me about the reason of using FiO2 80% in my clinical practice. I figure I will list my rationals for using high FiO2 80% during most of the GA cases I do. First of all, people may worry about absorption atelectasis with high inspired FiO2.  Akca et al found that the…

Ditch the Needle? Not in Pediatrics

Thank you everyone for the best birthday wishes today! I am very grateful to have friends around. It wouldn’t be the best birthday without a new post. Here we go! Someone commented on my post entitled Ditch the Needle, Teach the Knife Part II regarding the applicability with cricothyrotomy in pediatrics. The previous post was intended for adult…

Factor VII and Postpartum Hemorrhage

Today, we had a presentation on OB hemorrhage management. It touched on the use of TXA, but it didn’t mention anything about recombinant factor VII in PPH. Although it has mixed results on the outcome with the use of factor VII, it seems that it still has its place in severe PPH based on the recent…

Exparel, what do we need to know?

Sorry guys I haven’t posted for a little while. I was doing some reflection on myself. Anyway, I am back. A friend of mine suggested a topic on Exparel and it is getting more widely used within the last couple of years. So I figure it is a good topic to discuss as it is relevant to…

Cricoid Pressure – Friend or Foe?

This is another dogma I feel overdue for discussion. This is one practice that was instilled in our training when we were students: trauma/NPO non-compliant would get RSI with CP.    Cricoid pressure was originally described by Sellick with the patient in a head down, tilted to the left position back in 1960’s. It was claimed that…

Can We Use Peep with LMA?

Lately, I have seen some threads discussing whether it is safe to use LMA with Peep. I remember when I was in school, some of the preceptors would take out the PEEP after I inserted the LMA. The reasons they gave me were insufflations of stomach. But in the back of my mind, I wondered whether…

Fun Facts for Today

Just some fun facts to refresh our memory for NCE certification/recertification in case you need to take it soon. Morphine: 10mg IV = 1mg Epidural = 0.1mg Intrathecal (1/10 ratio; very hydrophilic) Hydromorphone: 1mg IV = 0.2mg Epidural = 0.04 Intrathecal (1/5 ratio; intermediate) Fentanyl: 100mcg IV = 33mcg Epidural = 6-10mcg Intrathecal (between 1/3…

Are We Afraid of General Anesthesia for Cesarean Section?

Are we afraid of general anesthesia for cesarean section? I remember when I was in school, I learned from the lecture that there are 3 reasons for avoiding GA besides decreased patient’s satisfaction and sleepy baby with GA. They are (1) difficult airway management (2) increased risk for aspiration (3) increased risk for uterine atony. I…

CRNA School and Kids

This is the topic that I haven’t tackled which I should have a while ago. I am sure you have wondered whether it is possible to get through the school when you have a family and small kids. Dealing with the demands of anesthesia school and parenthood simultaneously is by no means easy. But it is doable….

Should We Ausculatate After Intubation?

Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5943 (Published 09 November 2010)Cite this as: BMJ 2010;341:c5943 Since I graduated from anesthesia school, I have given up the time-honored habit of routine chest auscultation after passing the tracheal tube through the…

When Can We Use Tranexamic Acid?

Lately, I have noticed some changes on the usage of tranexamic acid. In the past, it would be contraindicated to use on patients who had a history of stroke, DVT, A-fib, valvular disease, or SAH. Recent studies have shown that the use of TXA doesn’t significantly increase the embolic event in surgical patients. In our institution,…

Gifts For Anesthesia Folks on Valentine’s!

Happy Early Valentine’s! I figure I will post some ideas for the anesthesia folks today. First on my list is this coffee mug shown below. This phase is the one we often hear in our daily encounters with other departments or personnel. The second one on my list is this t-shirt which I find quit…

My First Spinal Placement

Hello SRNAs out there. I just realized haven’t posted much for SRNAs lately. So, this is a long overdue post for you who just started doing spinals in either OR or OB. It has been almost 3 years since I got in my first spinal as a student. I feel that it is time for…

Sugammadex is Coming !

Our hospital is finally getting Sugammadex. I am so thrilled that we have something else to use to quickly reverse patients other than neostigmine. I figure it it time to write a post about the medication to give you a quick summary of what the drug is, how it works, and the side effects etc….

Ditch the Needle, Teach the Knife Part II

Dr. Larson, a well-known anesthesiologist at Stanford once stated that an emergency cricothyrotomy is much quicker, easier, safer and more effective than any needle-based technique. I can state with confidence that there is no place in emergency airway management for needle-based attempts to establish ventilation. As you all can tell, I love airway topics as…

Perpetuation of Three-Axis Alignment Theory and the Sniffing Position

We have read and been taught that sniffing position is the foundation for the difficult airway as placing the patient in the “sniffing position” facilitates aligning the three axes to visualize the larynx. Do you know that the THREE AXIS ALIGNMENT THEORY was proposed by Bannister and MacBeth in 1944. What they did was to take…

Judgement Day!

According to a new study published in the Journal of Neuroscience, our brains determine how trustworthy a face is before it’s fully perceived. This supports the notion that we judge people very quickly. We anesthesia folks, often judge people subconsciously by the numbers showing on the monitor when we walk in other rooms to give anesthesia providers’…

Should We Mask Ventilate Before Giving Muscle Relaxant?

Have you ever wondered whether we should mask ventilate before giving muscle relaxant? I know we were taught that we should attempt to mask ventilate first. But is this evidence based?  The answer is that this practice is really not evidence-based. There is a growing body of evidence suggesting that the NBD should be given…

Anesthesia Apps

We can’t live without our smartphones these days. There are several good apps I really like. The apps are particularly helpful for cases I don’t do on a regular basis. So this post is dedicated to the smart phone apps. First and for foremost, my favorite app is Vargo app, which provides case tips (it is…

Do We Administer Too Much Oxytocin?

Pitocin is the drug we love and hate.  If a laboring patient on pitocin for a long time end up in cesarean section, you often find that pitocin infusion after the baby is born is less effective in giving you the firm uterine tone. Your surgeon may ask you to give more pitocin in the…

Post Dural Puncture Headache, True or False?

Haven’t we all experienced the common blame game in OB? Patient may not even have an epidural but the nurse would still call you to evaluate thinking automatically the post-dural puncture headache. If patients have epidural placed, the assumption of PDPH is even higher. However, we the OB anesthesia providers know the headache of an OB…

The Use of Ondansetron in Reducing Hypotension After Spinal.

Often times, we have to deal with HOTN after spinal placed in obstetric patients. Patient may feel nauseated and throw up due to HOTN. Besides co-loading of crystalloid, ondansetron can be given 5-15mins prior to spinal placement to reduce the extend of HOTN. It is a cheap and readily available drug in our anesthesia cart….

How To Deal With Difficult Preceptors?

Recently, someone asked me for tips on how to deal with difficult preceptors. I have previously posted one titled Bad Chemistry: It Is not You; It Is Them.“, but I may not have specifically discussed the strategies of dealing with the difficult preceptors. We will face this type of situation everywhere we go whether at workplace…

Clinical Update on Amniotic Fluid Embolism

AFE is a rare but serious obstetric emergency. We all wish we don’t have to experience this during our career. For those of you who provide obstetric care to patients, it is crucial that we need to know what to do and how to optimize the patient when it happens. The new mortality rate is…

First Intubation

I got a comment from Ashley regarding preparing for the first clinical rotation, this post is for those of you who just started school and are going to their first clinical rotation soon. The first clinical rotation is always sweet and bitter in a sense that you are excited to start the real anesthesia training but scared…

Part II: What’s Your Differential?

I called my attending to be in the room as SpO2 dropped to 90%. We did our differential and treated according to what we thought it was the case. But SpO2 was still hovering low 90’s. BP was borderline low. Patient was young and healthy and no medical history. Good thing is that it was a…

The Attitude — the Key to Becoming A Superstar

I hope this blog finds you well. This is a lessen I learned albeit a little too late in my clinical training. I am sharing this with you hoping that you can become the superstar that I once wanted to become as a SRNA. Most of CRNAs to be are type A people, a very few…

What Is Your Differential?

This is the topic I thought I knew so well, yet I failed my test. Let’s see if you can get it right. I had a lumpectomy and lymph node dissection case scheduled under MAC yesterday. We were not able to get an IV in a timely manner. My attending decided that it might be the best to do…