On balance, the marginal utility of cricoid pressure (in this position) is outweighed by its potential disadvantages. Seldinger’s cadaveric studies (in steep head down) have utility in demonstrating pressure is transmitted to the oesophagus, but..

Cross sensitivity between neuromuscular blocking agents If a patient has had a POHR to: • rocuronium, suxamethonium or vecuronium, then atracurium is the lowest risk alternative • atracurium, then rocuronium and suxamethonium are low risk alternatives #AnSky doi.org/10.1111/anae...

Here is the first consensus-based core outcome set for airway management research, with agreed definitions and measurement instruments. This will harmonise evidence synthesis and improve the translatability of findings to improve clinical care. #AnSky #AirwaySky doi.org/10.1111/anae...

2025 DAS guidelines for the management of unanticipated difficult airway published today in the British Journal of Anaesthesia. #airway #difficultairway #intubation #anaesthesia #anesthesia https://www.bjanaesthesia.org/article/S0007-0912(25)00693-2/fulltext

Every time I write "explained anaesthetic" in the notes as part of a pre-assessment, I'm reminded of the fact that even the most expert professor of anaesthesia wouldn't *really* be capable of making that true.

Postoperative sore throat has an incidence of up to 62%. The current literature lacks high-quality randomised controlled trials on treatments that prevent a complication that is of importance to patients and their recovery. #AnSky #MedSky doi.org/10.1111/anae...

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Airway Triage App reviews #airwaytriageapp

Save the date #AAF26

Sustained, exhaled carbon dioxide by waveform capnography is an essential component of tracheal intubation. But what if there is bronchospasm? Tracheal intubation can be confirmed using flexible bronchoscopy. #AnSky doi.org/10.1002/anr3...

Having said that in that first case of hyperacute onset, neurological symptoms started almost immediately post op and peaked after two days. That would be quite the coincidence.

A more plausible mechanism would be the inflammatory effects of surgery, rather than toxicity/triggering from a spinal. I feel like the spinal is an innocent bystander. In this SR of case reports, the majority of surgeries are spine and cardiac. pmc.ncbi.nlm.nih.gov/articles/PMC...

I think it is a coincidence. GBS can occur within 4 weeks of campylobacter infection. Preop diarrhoea can be common in some populations (eg bariatrics ~ nearly 10%), and it isn’t usually asked about.

Have any authors proposed a mechanism whereby a central drug exposure creates a peripheral neuropathy?

One could probably calculate the odds of it arising by chance using the prevalence of GBS in the general population and the odds of needing a spinal/epidural

Yes I wondered that too. Association is not causation

Onset apparently almost immediate, peaking day two post spinal jmedicalcasereports.biomedcentral.com/articles/10....

This article reported acute onset GBS in 4 patients within 1-2 weeks of epidural anaesthesia www.neurology.org/doi/10.1212/...

This case report of a pt developing GBS 4-5 days post spinal for renal calculi. It's rare, but it happens. www.jcpsp.pk/archive/2013...

Although quite rare, I think there are enough independent case reports of spinals triggering acute GBS (temporally linked) to support the claim that there is some association that we don't yet understand. That's not the same as saying it's unsafe to do a spinal on a post-GBS pt. I don't think it is.

Carbon footprint of total intravenous anaesthesia vs. inhalational sevoflurane anaesthesia in adults: a modelling study #AnSky #climate #MedSky doi.org/10.1111/anae...

Save the date 📆 The SALG Patient Safety Conference is coming up! This year’s themes are👇 ➡️Local Anaesthetic Systemic Toxicity (LAST) ➡️Rapid Sequence Induction (RSI) ➡️Plus poster competition for anaesthetists in training Book👉 ow.ly/YAvo50WXl9v #Ansky #Medsky

I feel I deserve the Nobel Peace Prize for the judicious use of a small syringe of saline with a red sticker, rather than a full on rant when the surgeon asks for muscle relaxation just before the end of the case.

4/9 The child's head was quite heavy and asymmetrical due to the tumour, and awkward to hold in a good position to maintain the airway. Eventually we got the child deep enough to attempt bronchoscopy.

3/9 We decided to breathe the child down with halothane and try an asleep oral fibreoptic intubation. The child was cooperative and we soon got him under, but keeping his airway patent was a challenge, which meant getting him deep was also a struggle.

2/9 Anil and I were both on one day, and we were presented with a 3yo with a massive craniopharyngioma. I don't recall what the procedure was but the child needed to be intubated, and we thought it would be good to do it together. (I hope he remembers this the way I do.)

I do a normal RSI then once intubated start my pump low at around Cet 2 and titrate up over the case to BIS. The effect of the initial bolus on the model being inaccurate becomes decreasingly relevant as the case goes on

Airway Triage application is a non-profit global patient safety project of the Airway Management Academy. Triage airways to risk stratify the procedure and prevent complications #airwaytriageapp

"... a ‘RSI–TCI’ mode with a pre-programmed manual bolus offers a pragmatic solution for those who wish to preserve an intact pharmacokinetic model for accurate propofol delivery, while allowing the rapid induction clinicians expect from a manual bolus." #AnSky #MedSky doi.org/10.1111/anae...

Really thoughtful exchange, do you think more research is needed on the long term effects of these techniques?

Oooh, this is interesting! "Surgical start timing was an independent risk factor for increased short- and long-term postoperative mortality, morbidity and healthcare resource utilisation." #AnSky doi.org/10.1111/anae...

An editorial by Matava et al. analyzes the impact of the recent Japan Pediatric Difficult Airway in Anesthesia study and discusses opportunities for future inquiry. Read the article: ow.ly/zwAE50WUaYl

Totally depends on individual patient need. “Anticoagulated therefore don’t even think about spinal” is to automatically exclude a sometimes better option. If GA plus block has benefits over spinal plus block then choose GA OtherwiseSpinal plus block even if anticiagulated(benefit/risk assessment)

Airway POCUS POCUS was associated with higher odds of first-pass success rates during percutaneous tracheostomy when compared with landmark techniques. #AnSky #AirwaySky #MedSky doi.org/10.1111/anae...

The differences between the 'what' and the 'how' are the subtle, subliminal changes in assessment, preparation and execution an expert accumulates through reflection upon years of successes and failures. And not running away from failures btw, but working through them. A kind of personal kaizen.

Stepping back for a moment, one can see that there is always a 'metatechnical' dimension to these discussions. Someone brings up a particular technique or device or drug, and we argue over the technical merits/demerits, but the real meat of the discussion is never in what we do but *how we do it*

I know Alf is inferior. The point of my story was that relaxant free intubation is a different technique that comes with different baggage. It's not interchangeable with a relaxant based technique.

7/7 So my question for this forum would be - those of you who use high-dose remi for relaxant-free intubation, what other parameters/caveats do you need to keep in mind to guide those of use who do not do this routinely? 🙏

6/7 I was always taught that the window for good intubating conditions with Alf was quite narrow - 90 sec at best - if you didn't get in first go you either had to redose with alf or give a relaxant.

5/7 Long story short sats dropped to 50 but they got the tube down and pts fine. The point is when you use a different technique other things that you take for granted also change without you knowing.

1/7 Interestingly I've was having a debrief recently with a colleague who was supervising an advance trainee. they were introducing them to relaxant-free intubation with alfentanil for a dental case. 🧵👇

2/7 The senior colleague had be doing this for years without problems. But they gave the trainee no briefing or special guidance, just said "try this, I do it all the time, just make sure they're nice and deep".

3/7 So the trainee induced with a propofol infusion, waited, got the pt deep, gave 1mg Alf, waited some more had a look, great view on VL but had some trouble hockey sticking the tube, so pulled and decided to use a bougie.

4/7 Second pass, great view again, passed bougie no problem, got the tip past the cords but couldn't advance the cuff, sats start to drop, colleague tells the trainee to pull out. Patient goes straight into laryngospasm.

I can't remember when it was necessary. With VL we just give on the Remi.

Hans people do not use techniques routinely that do not work. Clearly only skilled anaesthetists would be using a non relaxant intubation, very skilled in my opinion.

Yes, but of no consequence. Low HR is associated with positive outcome in all our data. I think our fear is related to outdated methods of anaesthesia

One thing to reflect upon is that you have ceiling level sympatholysis in most with 5 mcg/kg remi and dose can be increased further with little effect - as high as 20 mcg/kg has been used in studies on haemodynamics. So if I am in doubt I go higher dose....

When VL was used as the first-choice device: ⬇️ patients experiencing at least 1 complication (5.5% vs. 9.7%) ⬇️ 3+ intubation attempts (1.2% v 2%) ⬇️ need to change operator (1.8% vs. 4.9%) ⬇️ oesophageal intubation (0.5% vs. 1.4%) #AnSky #MedSky doi.org/10.1111/anae...

You can just test it. Induce do not relax. Test if pt reacts to blade and tube (the solution is not roc as a 1st thought). Deepen. If nothing happens but cords are meh, relax. But you don’t need much to relax the cords (the laryngeal muscles are last to come back for a reason). 1/2