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,…

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…

Serotonin Syndrome…more common than we think?

So, think about. You’ve just given this great anesthetic. During the pre-operative period, you were able to make your nervous patient laugh, smile and with the help of versed, become more comfortable with you. You have an uneventful intra-operative course and only used standard medications: fentanyl, lidocaine, propofol, rocuronium, sugammadex, decadron and zofran. Now, the…

Revisiting PONV Prophylaxis

Most of us routinely administer decadron and zofran in the OR. Recently, I started at an academic medical center and noticed providers frequently use Haldol for PONV prophylaxis. Initially, I was completely against using this anti-psychotic medication as part of my PONV regimen. However, with a little bit of knowledge and research, I’ve changed my…

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…

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…

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…

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….

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…

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…

KCentra, Have You Used it Before?

Today, I have learned a drug Kcentra which can be useful in emergency cases for patients who need a quick reversal with high INR. I figured I would share it with you in case you haven’t heard it before. We have a patient today who is coming in for an emergent abdominal I&D. She is…

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…

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…

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…

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….

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,…

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…

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…

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…