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

I’m not advocating it as a standard but It works perfectly well if a little judgement is used.

Well it is very easy, when you see the cords and gently advance the tube, you see if there is any resistance at all, which there hardly never is above 5 mcg/kg of remi on top of propofol. The new meta-analysis from Anaesthesia supports this as well. I´ve done bariatrics with VL no NMB for 10+ years

I have always been guided by the Bouvet study. I use propofol 2 mg/kg and remi 5 mcg/kg together on induction as my base. between 45-60 s after induction you see the HR drop, reflecting sympatholysis and you go. associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/...

Yeah, much simpler without in most cases

Yes I am very interested in this as well @airwaymxacademy.bsky.social I want best pass the cords first pass.

If however you accept Pandit's definition of anaesthesia - "a chemically induced state which renders surgery acceptable to the patient" - then you can have awareness and even recall under anaesthesia provided those conditions are concurrently and subsequently acceptable to the patient.

If "unconsciousness" is part of your definition of what constitutes "anaesthesia", then technically as soon as you discover that someone under your care is aware, you're no longer giving "anaesthesia", it's "sedation". Under that construct, "awareness" under "anaesthesia" is a contradiction.

So how do we prevent awareness under anaesthesia? We guess, and hope our guesses get better over time. Generally expert anaesthetists are very good at it but even they occasionally get it wrong. Sometimes people make obvious mistakes and get it very wrong.

We had an MH susceptible pt for ECT a little while ago. Ended up doing a bit of research and the inevitable n=1 dose finding over the treatment course. Roc dose of 0.5mg/kg with reversal with 6mg/kg of sugammadex worked well. The issue is waiting a bit longer and therefore needing more propofol

How much rocuronium do you give? Purely curiosity - don't even know if we do ECT on site here.

Do you need decision support for awake intubation? If “awake intubations alerts” pop-up on your airway triage app summary screen, discuss with the team if awake intubation is needed. @bobfunn.bsky.social @ncglasses.bsky.social @maffygirl.medsky.social @Hypoxicchicken.med-mastodon.com.ap.brid.gy

VERY RARELY intubated - despite the drug addled fasting history (from the psych nurses - the patients rarely got it wrong), smoking, obesity, reflux etc. I am so old,I remember methohexitol - propofol is way better. I have seen non-sux ECT remifentanil, mivacurium and rocuronium. Sugammadex anyone ?

Do you need decision support for awake intubation? If “awake intubations alerts” pop-up on your airway triage app summary screen, discuss with the team if awake intubation is needed. @bobfunn.bsky.social @ncglasses.bsky.social @maffygirl.medsky.social @Hypoxicchicken.med-mastodon.com.ap.brid.gy

Well that was quite a day on call. No one has ever appreciated a MAC 3 like me today. VL saved the day as I intubated on my knees. We do not always get the best operating conditions. We do not always intubate in theatre.

I generally go from 3 straight to D if I don't get it first go. During the initial COVID waves I started routinely using a bougie to improve my FPS rate, and it's just a short step from that to routinely using HAVL + stylet/steerable bougie from there. I teach VADL but use (HA)VL routinely.

Having immersed in Vortex workshops in the last 12 months, I can see its value in a system where everyone understands it/and its terminology. However, when DAS algorithms are taught and executed right, it brings about the same outcome.

Its is a cognitive aid & that’s what’s needed in an airway crises to avoid fixation errors . Don’t ever recollect anyone reading out a DAS algorithm in my 23 yrs in anesthesia during a dynamic , rapidly evolving situation such as an airway crises .

🎥 vimeo.com/showcase/118... Short airway triage app tutorials Download the app from the app stores Google play.google.com/store/search... Apple 🍎 apps.apple.com/nl/app/airwa...

Still using Cormack-Lehane grading for VL? Why?! Out today a new @bjaeducation.bsky.social article by @naomi-gostelow.bsky.social Bhavesh Patel and me looking at grading systems for VL. #AnSky #MedSky kwnsfk27.r.eu-west-1.awstrack.me/L0/https:%2F...

🚨We have retired "no trace, wrong place" to align with PUMA guidelines. Instead, with @assocanaes.bsky.social and @dasairway.bsky.social, our message is that if sustained exhaled CO2 is not detected, then oesophageal intubation must be ruled out. See our dedicated webpage👉 ow.ly/vOZs50WA03r

The @universalairway.org guidelines for preventing unrecognised oesophageal intubation are supported by @safeairwaysociety.org, @anzca.bsky.social & @dasairway.bsky.social VL should be used routinely whenever feasible. Clinical signs should not be used to exclude oesophageal intubation.

Ooh that's interesting. I used LMAs a lot when I first started. Don't know if they were they strictly 1st gen/classical (they were disposable for one) but required actually guiding into place. I do think the jump from a classical LMA to flexi is much smaller though.

Forgive me, flexi LMAs are quite a bit trickier to site than classical 1st gen LMAs. They require an acquired knack that is different to the classic but you're right they're certainly different to iGels or the relatively more rigid 2nd gen Supremes and Ambu Auragains.

My most recent bit of learning about teaching from this week is that trainees may be less familiar with siting flexi LMAs (because you basically site them like classical LMAs). The iGel has removed that skill. And I've only been a cons for a month!

Different eras notwithstanding, I hope we can all agree, especially when it comes to complex airway management, that it is generally better to anticipate proactively than to be forced to react, however heroically.

When I trained we were not particularly taught to assess the airway but we were taught to manage an unexpected tricky airway..lots of mask holding, lots of ETTs , no SGAs..different eras need different understanding😊

Nice summary but even with preop airway assessment or not ..this would have gone better if the human factors had not been the main issue. Listen to those around you, give them a voice, stop trying to intubate when you are still able to ventilate etc 😔

9/11 So- If this is something cataclysmic like this that could happen to me on any given day without my being able to predict it, I'm going to want those few but precious extra minutes during an airway crisis that preO2 provides so that I can gather myself, get oriented and aware, and do the drill.

8/11 And it need only happen once in a career for it to be catastrophic for everyone concerned: the patient most of all, but also the family, the anaesthetist, theatre team, everyone.