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…

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…

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…

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…

What Does the Airway Assessment Really Tell You?

Every time you see a patient in preop, you do your routine airway assessments to predict whether patient has an easy or difficult airway. Have you ever asked yourself  what the assessments really tell you and why some patients would have difficult airways based on your Mallampati score, neck circumference mouth opening or the protruding teeth? It…

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…

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…

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…

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…

Should We Ausculatate After Intubation?

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 glottis. This is another practice that we have been taught in school as one of the best ways to confirm tube placement. I still remembered the first time I was asked…

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…

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…

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….