Brian Gacioch
@briangacioch.bsky.social
Emergency medicine and palliative care doctor, medical educator in Boston. Husband, dog and cat dad, veteran, outdoors lover.
I suppose I take your point if you feel that anything deeper than an amnestic dose of anything wouldn’t be safe.
May 1, 2025 at 5:58 PM
I suppose I take your point if you feel that anything deeper than an amnestic dose of anything wouldn’t be safe.
And if they weren’t intubated, why not consider etomidate, given much shorter duration than midaz?
May 1, 2025 at 5:52 PM
And if they weren’t intubated, why not consider etomidate, given much shorter duration than midaz?
Certainly frankly shocky patients are a different risk profile, although if they’re that sick and needing other procedures I would think most would also be intubated anyway.
May 1, 2025 at 5:50 PM
Certainly frankly shocky patients are a different risk profile, although if they’re that sick and needing other procedures I would think most would also be intubated anyway.
Is there reason to think it wouldn’t be safe to treat the vasodilation with a vasoconstrictor, as we would in intubated and ventilated patients?
May 1, 2025 at 5:49 PM
Is there reason to think it wouldn’t be safe to treat the vasodilation with a vasoconstrictor, as we would in intubated and ventilated patients?
I suppose, although I would also guess that for many ICU patients the risks of romazicon might outweigh the benefits (if at all habituated to BZDs). Still find it a little strange that we’ve desigmatized propofol for intubated patients, but see procedural sedation differently.
May 1, 2025 at 5:48 PM
I suppose, although I would also guess that for many ICU patients the risks of romazicon might outweigh the benefits (if at all habituated to BZDs). Still find it a little strange that we’ve desigmatized propofol for intubated patients, but see procedural sedation differently.
I figured that was the concern. Would it be reasonable to mitigate the vasodilation with a a-gonist? I mean, our ICU colleagues have been pretty adamant that the vasodilation shouldn’t stop us from using prop in ventilated patients. Not sure why we should worry more in non-ventilated patients
May 1, 2025 at 9:23 AM
I figured that was the concern. Would it be reasonable to mitigate the vasodilation with a a-gonist? I mean, our ICU colleagues have been pretty adamant that the vasodilation shouldn’t stop us from using prop in ventilated patients. Not sure why we should worry more in non-ventilated patients
This has been gnawing at me all day, and I don't mean to belabor too much (happy to discuss via DM/chat), but which patients would be too unstable for propofol, but but more safe to receive midaz? What type of instability are we worried about?
April 30, 2025 at 11:04 PM
This has been gnawing at me all day, and I don't mean to belabor too much (happy to discuss via DM/chat), but which patients would be too unstable for propofol, but but more safe to receive midaz? What type of instability are we worried about?
Fair, but few or none of your citations were in a sick ICU population either
April 30, 2025 at 1:15 AM
Fair, but few or none of your citations were in a sick ICU population either
Would invite you to include this much larger series that would question that conclusion (34474123):
April 30, 2025 at 1:09 AM
Would invite you to include this much larger series that would question that conclusion (34474123):
I think this approach is well thought-out overall for an ICU setting/population, but re: deep midaz for cardioversion: why would you use a non-low-risk sedative with a 30-60 minute duration for a <1 second procedure?
April 29, 2025 at 11:13 PM
I think this approach is well thought-out overall for an ICU setting/population, but re: deep midaz for cardioversion: why would you use a non-low-risk sedative with a 30-60 minute duration for a <1 second procedure?
Any chance the clinical circumstances had changed, or they didn't fully understand the previous conversation, or after discussion with family they felt differently? It's okay for GOC and life-sustaining treatment preferences to be fluid and context-specific.
April 20, 2025 at 11:46 AM
Any chance the clinical circumstances had changed, or they didn't fully understand the previous conversation, or after discussion with family they felt differently? It's okay for GOC and life-sustaining treatment preferences to be fluid and context-specific.
Mouth (blade)—>screen—>mouth (tube)—>screen
April 10, 2025 at 7:59 PM
Mouth (blade)—>screen—>mouth (tube)—>screen
This has honestly never crossed my mind. My proof of competency would probably be “forgiveness is better than permission”
April 1, 2025 at 1:32 AM
This has honestly never crossed my mind. My proof of competency would probably be “forgiveness is better than permission”
Do we know how unlikely, though? Antidysrhythics certainly aren’t without their own toxicities, and synchronized cardioversion is about the lowest risk procedure I can think of in critical care. In an already intubated and sedated patient it does seem like a trial of DCCV makes a bit of sense.
February 12, 2025 at 8:23 PM
Do we know how unlikely, though? Antidysrhythics certainly aren’t without their own toxicities, and synchronized cardioversion is about the lowest risk procedure I can think of in critical care. In an already intubated and sedated patient it does seem like a trial of DCCV makes a bit of sense.
(Admittedly your FONA example shouldn’t be one of those times)
January 30, 2025 at 3:08 AM
(Admittedly your FONA example shouldn’t be one of those times)
Fair, but at the same time humans in general, and doctors in particular, tend to have a cognitive bias toward action over inaction, and likely overestimate benefit and underestimate risk in many cases. Sometimes the answer is “don’t just do something, stand there”
January 30, 2025 at 3:06 AM
Fair, but at the same time humans in general, and doctors in particular, tend to have a cognitive bias toward action over inaction, and likely overestimate benefit and underestimate risk in many cases. Sometimes the answer is “don’t just do something, stand there”
Will certainly let MedSky know once our analysis is done and can share the results
January 27, 2025 at 6:19 PM
Will certainly let MedSky know once our analysis is done and can share the results
That's what I would have thought. We have a n>1600 database at one of my sites, with extremely rare serious adverse events. Hoping to get that published in next few months. That site soon allowing for full loading doses on general wards, given how safe we've found PHB to to be.
January 27, 2025 at 6:18 PM
That's what I would have thought. We have a n>1600 database at one of my sites, with extremely rare serious adverse events. Hoping to get that published in next few months. That site soon allowing for full loading doses on general wards, given how safe we've found PHB to to be.
What's their concern?
January 26, 2025 at 4:14 PM
What's their concern?
Is anyone good at guessing LOS?
January 19, 2025 at 9:12 PM
Is anyone good at guessing LOS?
4/4 For me, minimizing risk of awareness and recall outweigh this very small 1st pass success benefit, that I can also mitigate by waiting for my NMB to take full effect. I give my sedative first.
December 29, 2024 at 4:59 PM
4/4 For me, minimizing risk of awareness and recall outweigh this very small 1st pass success benefit, that I can also mitigate by waiting for my NMB to take full effect. I give my sedative first.
3/4…is safe in large majority of cases (PreVent, PREOXI) and peri-intubation HD optimization is now common. Peri-ETI resuscitation mitigates most of these time pressures.1st pass success is a surrogate outcome—albeit an important one—while awareness and recall are patient-oriented.
December 29, 2024 at 4:59 PM
3/4…is safe in large majority of cases (PreVent, PREOXI) and peri-intubation HD optimization is now common. Peri-ETI resuscitation mitigates most of these time pressures.1st pass success is a surrogate outcome—albeit an important one—while awareness and recall are patient-oriented.
2/4…and other (smaller, lower quality) studies have reported recall of RSI and laryngoscopy to be even higher. Don’t know about others, but for me the "I truly have seconds to intubate" scenario is very rare, esp as we now know that peri-intubation NIPPV/mask ventilation…
December 29, 2024 at 4:59 PM
2/4…and other (smaller, lower quality) studies have reported recall of RSI and laryngoscopy to be even higher. Don’t know about others, but for me the "I truly have seconds to intubate" scenario is very rare, esp as we now know that peri-intubation NIPPV/mask ventilation…
1/4 Sigh…K I'll bite. Said some of this on original IG post. Effect size in this study was small: 4.3% 1st pass failure w/ roc 1st vs 5.9% w/ sedative 1st. Mod quality data (eg PMID 33485698) says awareness during paralysis w/ emergency RSI is very high…
December 29, 2024 at 4:58 PM
1/4 Sigh…K I'll bite. Said some of this on original IG post. Effect size in this study was small: 4.3% 1st pass failure w/ roc 1st vs 5.9% w/ sedative 1st. Mod quality data (eg PMID 33485698) says awareness during paralysis w/ emergency RSI is very high…
Am I the only one who doesn’t see haloperidol or droperidol anywhere in those tangled webs?
December 16, 2024 at 11:21 PM
Am I the only one who doesn’t see haloperidol or droperidol anywhere in those tangled webs?