Pete Hart
@intensiveperson.bsky.social
Policies are sometimes a necessary substitute for careful and intelligent decision-making.
November 14, 2025 at 9:01 PM
Policies are sometimes a necessary substitute for careful and intelligent decision-making.
I also encourage residents to turn down the norad to reassess fluid-responsiveness, as excess norad can render patients non-responsive through effects on diastolic function.
November 14, 2025 at 8:23 PM
I also encourage residents to turn down the norad to reassess fluid-responsiveness, as excess norad can render patients non-responsive through effects on diastolic function.
Anything can destroy perfusion if no-one pays attention. But I do agree that a lot of patients who hit 0.5 of norad need adrenaline rather than vaso. Or both.
November 14, 2025 at 8:15 PM
Anything can destroy perfusion if no-one pays attention. But I do agree that a lot of patients who hit 0.5 of norad need adrenaline rather than vaso. Or both.
Not generalisable from Aus/NZ. We have very different incidence rates from NAP6 in the UK
November 13, 2025 at 8:34 AM
Not generalisable from Aus/NZ. We have very different incidence rates from NAP6 in the UK
I should point out that most cases of bronchospasm will not give you a flat capnograph (if you screw down the APL valve a bit - and you should). But it is at least possible for this to be the cause. In this case the tube was - appropriately - initially assumed to be in the oesophagus, and removed.
October 24, 2025 at 9:27 PM
I should point out that most cases of bronchospasm will not give you a flat capnograph (if you screw down the APL valve a bit - and you should). But it is at least possible for this to be the cause. In this case the tube was - appropriately - initially assumed to be in the oesophagus, and removed.
Not sure if cricoid, reverse Trendelenberg, or any other potential anti-regurgitation measures were applied.
October 21, 2025 at 9:22 PM
Not sure if cricoid, reverse Trendelenberg, or any other potential anti-regurgitation measures were applied.
TL;DR patient with SBO died of massive aspiration during GA induction, having refused an NGT but without that refusal discussion being adequately documented by the clinical teams. Anaesthesia gets off lightly for seemingly having used a "low" dose of roc and a Guedel (to bag, we presume).
October 21, 2025 at 9:22 PM
TL;DR patient with SBO died of massive aspiration during GA induction, having refused an NGT but without that refusal discussion being adequately documented by the clinical teams. Anaesthesia gets off lightly for seemingly having used a "low" dose of roc and a Guedel (to bag, we presume).
Interesting "standard care" - 24h lidocaine infusions and gabapentin for all!
October 19, 2025 at 6:07 PM
Interesting "standard care" - 24h lidocaine infusions and gabapentin for all!
The things I do to reduce risk of regurg/vomiting are 1) Rev T'berg, 2) Avoiding proemetic stimuli (large opioid bolus, cricoid pressure!) before/during LOC, 3) No bagging unless they need it, and therefore PreO2 +/- ApOx, large dose of relaxant. IMO time/speed is overemphasised. (2/2)
October 5, 2025 at 7:33 AM
The things I do to reduce risk of regurg/vomiting are 1) Rev T'berg, 2) Avoiding proemetic stimuli (large opioid bolus, cricoid pressure!) before/during LOC, 3) No bagging unless they need it, and therefore PreO2 +/- ApOx, large dose of relaxant. IMO time/speed is overemphasised. (2/2)
RSI is a failed construct. It no longer represents any consistent set of interventions and so is not a useful term to communicate meaning. So the answer to the question "Can you do an RSI with TIVA" depends entirely on what components of RSI you think are important. (1/2)
October 5, 2025 at 7:33 AM
RSI is a failed construct. It no longer represents any consistent set of interventions and so is not a useful term to communicate meaning. So the answer to the question "Can you do an RSI with TIVA" depends entirely on what components of RSI you think are important. (1/2)
First: define RSI.
October 4, 2025 at 9:35 PM
First: define RSI.
I've never heard of a connection with warming the patient before today - interesting, thanks. www.sciencedirect.com/science/arti...
Comparison of the effects of lidocaine pre-administration and local warming of the intravenous access site on propofol injection pain: Randomized, double-blind controlled trial
Lidocaine reduces pain that occurs upon the intravenous injection of propofol. But, there are few non-pharmacological nursing interventions to reduce …
www.sciencedirect.com
September 27, 2025 at 4:01 PM
I've never heard of a connection with warming the patient before today - interesting, thanks. www.sciencedirect.com/science/arti...
Maybe patients having ECT are on CNS depressants already that reduce the incidence? Speculatively. I think 5-10% of my patients used to get it before I started using lidocaine.
September 27, 2025 at 3:55 PM
Maybe patients having ECT are on CNS depressants already that reduce the incidence? Speculatively. I think 5-10% of my patients used to get it before I started using lidocaine.
It's really variable in incidence. Do you use ACF/proximal cannulae? Or maybe you give the propofol really slowly via a 3-way tap? Problem is you don't know they'll have it until they have it, hence my routine use of lidocaine. bmcanesthesiol.biomedcentral.com/articles/10....
Characteristics that increase the risk for pain on propofol injection - BMC Anesthesiology
Background Propofol for anesthesia has become increasingly popular for endoscopic procedures. However, pain on propofol injection (POPI) remains an issue with administration. The primary endpoint of this study was to identify patient characteristics and factors, such as IV site and gauge, that could predict the occurrence of POPI. Methods This was a prospective chart review study of 291 patients undergoing endoscopic procedures. The patient’s demographics, intravenous (IV) site, and gauge were extrapolated. POPI was scored 0–3: 0 for no pain, 1 for minimal discomfort or awareness of sensation, 2 for discomfort but manageable/tolerable, and 3 for severe discomfort with writhing. Results 291 patient charts were reviewed. One patient was excluded for a lower extremity IV site. 225 (77.6%) had no pain, 48 (16.6%) grade 1 pain, 16 (5.5%) grade 2 pain, and 1 (0.3%) grade 3 pain. 137, 13, and 140 patients respectively had antecubital (AC), forearm, and hand IVs. Zero patients with an AC IV experienced a score greater than 1. Compared to AC, forearm IVs with pain of 2–3 had a univariate odds ratio (OR) of 11.3 (0.66,1.92; p-value < 0.001), and hand IVs had a univariate OR of 18.8 (2.46,143.3; p-value < 0.001) with a multivariable OR 15.2 (1.93,118.9; p-value 0.004). Patients with anxiety/depression and pain had a univariate OR 2.31 (1.09, 7.27; p-value 0.031) with a multivariable OR 2.85 (1.06, 7.74; p-value 0.039). SSRI/SNRI use had a univariate OR 1.56 (0.57,4.28; p-value 0.38). Alcohol use had a univariate OR 1.24 (0.39,3.91; p-value 0.71). Narcotic use had a Univariate OR 6.18 (1.49,25.6; p-value 0.012). Diabetic patients had a univariate OR of 1.42 (0.45,4.48; p-value 0.55). Chronic pain had a univariate OR of 3.11 (1.04,9.28; p-value 0.042). Females had a univariate OR 0.98 (0.37,2.63; p-value 0.95). Conclusion This study identified potential characteristics for having POPI. The incidence of POPI was statistically significant in patients with hand and forearm IVs compared to AC IV sites, larger IV gauges, history of depression/anxiety, history of chronic narcotic use, fibromyalgia, and chronic pain syndromes. This shows the potential of premedicating with analgesics or using AC sites on these select patients to help reduce the risk of POPI.
bmcanesthesiol.biomedcentral.com
September 27, 2025 at 3:28 PM
It's really variable in incidence. Do you use ACF/proximal cannulae? Or maybe you give the propofol really slowly via a 3-way tap? Problem is you don't know they'll have it until they have it, hence my routine use of lidocaine. bmcanesthesiol.biomedcentral.com/articles/10....
I use it almost routinely to prevent propofol injection pain, and very occasionally intra-op (still reduces post-op opioid requirement a little), but safety concerns around post-op infusions are very much warranted - renal function can be dynamic and accumulation/LAST can develop quickly.
September 27, 2025 at 2:08 PM
I use it almost routinely to prevent propofol injection pain, and very occasionally intra-op (still reduces post-op opioid requirement a little), but safety concerns around post-op infusions are very much warranted - renal function can be dynamic and accumulation/LAST can develop quickly.
My favourite bang-for-buck intervention is pre-warming the operating table/trolley (especially if there's a gel pad) with a Bair hugger (just tubing under a drawsheet, so no additional consumables). Got sick of seeing people instantly drop a degree from lying, bare-backed, on a cold surface.
September 27, 2025 at 2:03 PM
My favourite bang-for-buck intervention is pre-warming the operating table/trolley (especially if there's a gel pad) with a Bair hugger (just tubing under a drawsheet, so no additional consumables). Got sick of seeing people instantly drop a degree from lying, bare-backed, on a cold surface.
I would like to propose that this incident is not representative of UK anaesthetic practice. Lancashire anaesthetic practice, maybe...
September 20, 2025 at 10:11 PM
I would like to propose that this incident is not representative of UK anaesthetic practice. Lancashire anaesthetic practice, maybe...
(There is some good stuff in here as well, reinforcing appropriate device selection - we have a long way to go in typical UK hospital practice - and advising against routine correction of coagulopathy for low-risk insertions.) (3/2)
September 20, 2025 at 8:25 PM
(There is some good stuff in here as well, reinforcing appropriate device selection - we have a long way to go in typical UK hospital practice - and advising against routine correction of coagulopathy for low-risk insertions.) (3/2)
...delayed. This is worrying when there are countless incidents of arterial CVCs not being recognised on CXR, and when we now know that delayed recognition is associated with increased risk of harm. It also means the guidelines are yet again lagging behind most people's practice. (2/2)
September 20, 2025 at 8:11 PM
...delayed. This is worrying when there are countless incidents of arterial CVCs not being recognised on CXR, and when we now know that delayed recognition is associated with increased risk of harm. It also means the guidelines are yet again lagging behind most people's practice. (2/2)
.. multiple large CVC studies show no apparent strokes or deaths due to arterial injury, because they weren't defined complications. (2/2)
September 17, 2025 at 5:35 PM
.. multiple large CVC studies show no apparent strokes or deaths due to arterial injury, because they weren't defined complications. (2/2)
It's great to have some data on emergent prehospital trauma line insertion, and clearly it's reasonable/inevitable to accept a higher complication rate in this setting. You do need to take care comparing complication rates between studies, as definitions vary widely. For example (1/2)
September 17, 2025 at 5:35 PM
It's great to have some data on emergent prehospital trauma line insertion, and clearly it's reasonable/inevitable to accept a higher complication rate in this setting. You do need to take care comparing complication rates between studies, as definitions vary widely. For example (1/2)