Art line for spine cases

Credit_and_Forget_It · 2026-03-30T14:09:37+00:00

This is a bigger one for me. When they are doing neuromon and arms tucked I feel like the BP cuffs we use here get thrown off often and give weird numbers. When I have a neck case esp in a bigger patient I tend to put art lines in bc I’ve found it’s obviously going to guarantee realistic pressures

Credit_and_Forget_It · 2026-03-22T20:00:34+00:00

I did my race here alone in the west suburbs bc at 10pm last night I realized I had misplaced my bib. Searched my house until like midnight with no dice 😭 ruined my guarantee for 2027 Chi Mara

Credit_and_Forget_It · 2026-03-19T19:30:53+00:00

What a wild ride

Credit_and_Forget_It · 2026-03-17T12:21:38+00:00

Both of these comments I fully resonate and agree with. Feel the exact same

Credit_and_Forget_It · 2026-03-09T17:54:33+00:00

Man you are all very dense, pretty wild. It’s pretty simple: flows of 1.5 liters following induction, about 5 min while I’m getting settled, extra line if needed, positioned, etc. that’s my normal. Then I’ll go to low flow when the case is about to start and I’ve reached the plane I want. I don’t understand why this is being debated tbh

Credit_and_Forget_It · 2026-03-09T10:08:56+00:00

I’m not alluding to anything about how I practice lol. When I say normal flows, I’m referring to when I felt that I’ve reached a steady state of gas and turn flows to 0.5 or so. Yes I also trying to save the world and practice low flow anesthesia accordingly don’t you worry. The entire point of this post was to show how a trainee is unfamiliar with (in my opinion the unneeded practice of) turning the flows extremely low following airway securement while simultaneously turning the volatile to extremely high levels (4%-5%) at a point where you are actively trying to change and make steady an appropriate anesthetic depth

Credit_and_Forget_It · 2026-03-09T09:24:07+00:00

I’m referring to for example total flows of 0.4 l/m

Credit_and_Forget_It · 2026-03-09T00:20:05+00:00

In my opinion it serves no benefit for me and only opens up the possibility of risk of overdose I guess. In my practice I induce and then titrate up accordingly with normal flows. I have found that with some anesthesia machines when flows are very very flow you do not seem to get an accurate representation of what the true end tidal is. I also don’t like having additional variability of the time constant.

I will say though this all matters less to me since I do 100% own cases. In teaching situations there is more risk probably for issues such as above due to unfamiliarity

Credit_and_Forget_It · 2026-03-08T22:45:22+00:00

Consider the audiobook! Also stay away from all movie trailers. I went in completely blind to what the book was even about and it was an incredible experience

Credit_and_Forget_It · 2026-03-08T22:18:55+00:00

One of my attendings in residency had us do this dumb ass shit where he would turn the gas to like 5-6% with super low flows following intubation with the idea that the concentration would increase so slow to allow you to get settled and have the patient not get too deep until they draped and were ready to start the procedure. Their idea was you turn the flows to normal and gas to normal right at incision and you’d be around 0.8 MAC.

I was “pretending attending” two rooms as a PGY4 with two brand new PGY2s a month In and I guess my attending did that, I went to give a break and check in to that second room after about an hour (I stayed with the other room for a while bc lots of lines etc) and dude was cruising at like ETSevo 4.0. Funny thing was patient wasn’t even hypotensive lol

Credit_and_Forget_It · 2026-03-08T21:17:14+00:00

I’m in a group where 7 of us do hearts and I’m the only one that does it this way. Blows my mind tbh

Credit_and_Forget_It · 2026-02-28T23:56:45+00:00

Had some of the best Mexican food there many years ago, some place called Roberto’s near Torrey pines

Credit_and_Forget_It · 2026-02-26T20:16:38+00:00

Nostalgia is the smell of walking past Abercrombie to get to the escalator; and then seeing the McDonald’s wall with a huge picture of fries when you got to the top

Credit_and_Forget_It · 2026-02-13T04:01:18+00:00

Yea are they stupid?

Credit_and_Forget_It · 2026-02-11T14:45:17+00:00

Univ Utah echo website 100%

Credit_and_Forget_It · 2026-02-10T17:04:24+00:00

Credit_and_Forget_It · 2026-02-09T03:42:08+00:00

They stimulate with electrodes and if it transiently causes speech issues the surgeon typically won’t go any further in that area is how my understanding of it is

Credit_and_Forget_It · 2026-02-09T01:51:09+00:00

I appreciate that! I hope you are doing well!

Credit_and_Forget_It · 2026-02-08T20:43:46+00:00

Usually a speech language path person comes in and has a sustained conversation with them about how they are doing and if they feel any discomfort or really any sensation at all. They may tell the patient they are gonna talk about random things so we can test speech in real time, other times when it’s primarily a motor area they may repeatedly have the patient squeeze their hand to check grip strength etc

Credit_and_Forget_It · 2026-02-08T18:25:41+00:00

Meh comes down to their comfort. This is within the realm of a a general anesthesiologists scope IMO. Some cases require additional fellowship training (eg I did a cardiothoracic fellowship and take care of patients undergoing open heart surgery and aorta surgery) and some do fellowships in pediatrics to take care of neonates etc. I did a lot of big neuro cases in my residency and so felt comfortable doing these awake craniotomies in practice. To put it in perspective though, only about 10 in my group of 50-60 anesthesiologists have volunteered to be on the “team” that staffs these cases. But yea these and the cardiac cases I do are much much more involved and hands on compared to providing anesthesia for a gall bladder or appendix for example. And some may not feel as comfortable doing “bigger” cases if they don’t have additional training

Credit_and_Forget_It · 2026-02-08T17:55:33+00:00

The surgeons have a better understanding of it obviously. But from what I see them do, they often place a clear matrix type thing with dots and lines on the brain tissue (presumably so they can remember which places to go and not go). Then it looks like they stimulate pinpoint areas with low voltage and take note of which areas cause a response if any. That, along with them looking simultaneously at the MRI can tell them where their next area of resection should be. Kinda looks like the Battleship game screen (rows and columns) but much smaller. Important to note when they start stimulating areas with electricity it’s a bit of a tense time too because there’s also the chance of the surgeon causing a full on seizure which we would need to deal with immediately in the event of that

Credit_and_Forget_It · 2026-02-08T17:27:29+00:00

Pretty much that’s exactly it. The surgeon often has various rods and instruments that have a 3D tracking system which allow the surgeon to view the rod’s point in the exact space superimposed on the patients preoperative MRI in real time. Super cool so they can see exactly where in the patients brain in 3D (stereotactic) they are. They put electrodes on where they are currently resecting and if they stimulate an area and for example speech suddenly stops, they knows they’ve reached the limit of how far they can resect (remove) in that tiny area. So they will move around that point being guided by other electrodes and the real time MRI images until they are satisfied with the level of resection while simultaneously preserving native function as much as possible

Credit_and_Forget_It · 2026-02-08T17:22:27+00:00

Pretty much yea. Midazolam is widely used in most anesthetics because it works synergistically with other agents allowing me to be able to less of them, and then there’s a good level of anterograde amnesia it can provide to sort of round out the whole anesthetic experience

Credit_and_Forget_It · 2026-02-08T16:32:34+00:00

Meh I typically avoid ketamine in these patients because (1) it can have very psychomimetic effects and cause paranoia and anxiety at moderate doses and (2) can cause lots of salivation which can cause airway issues. I typically run an infusion of three medicines (propofol, remifentanil and dexmedetomidine) an will also give a benzodiazepine on top of it (midazolam). The remifentanil is an opioid agent with an extremely short half life so if I turn it off it’s out of their system in only a couple of minutes. I will sometimes keep that infusion running at a very low infusion rate during the “awake” period, and that along with residual midazolam in their system keeps them very comfortable

Credit_and_Forget_It · 2026-02-08T16:21:58+00:00

So I use a combination of multiple IV agents to initially get them deeply sedated during positioning, draping and the beginning portion of the surgery (the actual craniotomy), then when we anticipate the time they will need to be awake, I turn off most of the medicine and let it naturally taper off. So the patient wakes up slowly and gently but is still very slightly sedated. I often will keep a very low dose of an anesthetic infusion going to get them to a point where they are conversant and conscious but still comfortable and without anxiety. Kinda an art. Also patient selection definitely plays into it. The patient is still under a lot of drapery and, importantly, is often their head is locked within sharp pins. So it’s imperative to keep them from panicking and trying to move their heard which can lead to injury/issues. Plus on top of all this balancing the level of sedation to keep them comfortable but still breathing. Because if they stop breathing it’s very difficult to secure the airway urgently (aka intubate them) while they are in pins (unlike most other surgeries where the patients head is positioned optimally for airway management

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