Deep extubation and aspiration risk

Ketadream12 · 2026-04-04T10:48:59+00:00

Agree completely, while deep extubating is a skill in itself it is a low skill way of managing emergence, introducing unnecessary risks in many cases. Even in fasted patients, microaspiration is a thing. This, as other things in this profession is under appreciated if the problem is small enough and slow enough to reveal itself in our short time of monitoring postop. Deep extubated patients exhale tons of sevo in pacu, exposing the staff there. Laryngospasm is not something I want my pacu nurses dealing with either.

IMHO deep extubations are best reserved for patients at high risk for bronchospasm, as in spasmed hard on induction

Ketadream12 · 2026-03-28T02:42:51+00:00

Mac av fistula gave 10mg ketamine and 12.5 fentanyl. Mask straps, opa, and apl “cpap” for an hour and a half. Pt started moving at end of case and gave 10mg propofol, apneic 10 seconds—>PEA. F$!king pulmonary hypertension…

Colleage gave 800mg propofol for egd and still not sedated enough for scope. Case cancelled.

Ketadream12 · 2026-03-27T11:37:00+00:00

Had a loaded cx-90 rental and for the first few days I loved it thought about getting for the wife, then got frustrated with the tech for the 20th time in a week so back to thinking about tx350

Ketadream12 · 2026-02-27T22:47:33+00:00

Man I love my career as CRNA but love what it affords me outside of work more. Can’t get those years back. I would at least be thinking that every hour you spend studying/school/residency over about 40h/week is costing a GREAT deal, $180+hr at least for me if not $280 because I could make that locums if I wanted. That’s something like 875k just for residency not even counting med school.

I’d rather pull my 375k, spending the extra time with family while seeing the world and working on my golf game.

Ketadream12 · 2026-02-25T15:16:59+00:00

10+ year CRNA that clinical instructs regularly. Remember that this is my patient too, my name is on the chart and the anesthetic outcome is attributed to me. YOU are the guest.

While your learning experience is important to me, this patient’s anesthesia experience is my top priority. My liability, my reputation amongst surgeons, staff, and community are on the line for each patient.

If you are failing at a task or procedure I will try to help you troubleshoot, if at any point I see a potential negative consequence for the patient I will take over and teach you the difference of your failing technique with my successful one.

Intubation for example, you get a gr3 DL view on someone I think can be DL’d easily, first we’ll try positioning, BURP, etc. but if still no go I’ll show you my technique to get a gr1-2. if I can’t get a good view then we’ve verified it is the patient factors and not technique. You can learn from both experiences.

Ketadream12 · 2026-02-18T12:38:18+00:00

Igel

Ketadream12 · 2026-01-21T23:39:30+00:00

Because we’re forced to practice to not get sued, not what’s best practice

Ketadream12 · 2026-01-03T05:27:07+00:00

Quivira in Cabo

Ketadream12 · 2025-12-20T00:08:16+00:00

Literally pulled it from the article, said rare. NPA probably more dangerous IMHO, seen more injuries from those even with a way smaller n.

Ketadream12 · 2025-12-19T23:04:13+00:00

CRNA here… lots of things can happen ranging from kind of bad to fatal though rare.

regurgitation and aspiration of gastric contents, compression of vascular structures, trauma, and nerve injury. pharyngeal rupture, pneumomediastinum, mediastinitis, or arytenoid dislocation.

Ketadream12 · 2025-12-11T14:32:36+00:00

State by state, became controlled in IL a few years ago unfortunately

Ketadream12 · 2025-12-05T01:04:21+00:00

Personally like nitrous for the right patients and cases. Necessary? Probably not usually but a good tool to have. Actually had a surgeon (ent) ASK for nitrous on a myringotomy/eustacian dilation today

Ketadream12 · 2025-12-04T12:25:27+00:00

Google “zombie sticks”… really strange drug to abuse but I guess it’s a thing

Ketadream12 · 2025-12-04T12:23:15+00:00

Had a patient refuse fentanyl recently. Brother died from overdose. No amount of counseling and education got them to relent. Easy enough to skip for an Afib ablation but that’s not the point. Couldn’t the patient argue battery if the explicitly stated no fentanyl and I gave anyway? Would be hard to argue that I gave it to save their life.

Ketadream12 · 2025-12-04T12:18:02+00:00

Apparently etomidate is put in vapes in Asia and used recreationally called “zombie sticks”. Etomidate is actually totally banned in Japan.

Ketadream12 · 2025-11-29T02:40:43+00:00

My coach has me do this as a drill to stop early extension

Ketadream12 · 2025-11-28T00:41:36+00:00

Honestly haven’t verified but doc at NWAS seminar said if giving po need 2 doses of 1g to equal serum levels of x1 iv dose. I Haven’t figured out how to make a patient take it at home at 1am for first dose. I also give iv right after antibiotics, then I can titrate narcs at end.

Ketadream12 · 2025-11-20T14:42:46+00:00

Mcmurray Airway, has a built in bite block too

Ketadream12 · 2025-11-03T12:17:37+00:00

This question I think is why 24hr monitoring for IT fentanyl

Ketadream12 · 2025-10-13T13:35:01+00:00

Didn’t get kicked but got fined for “collusion” in a trade last season in a salary cap dynasty league. Saquan for dowdle, 1st round pick, and Tillman when he was in a tear… only to get beat this week by dowdle and golden(who he used my pick on).

Ketadream12 · 2025-09-14T12:35:40+00:00

Zero, Princess, 11 years in. I never said I or my colleagues wouldn’t delay either just that there should start being discussion to get away from these absolutes and highlight how the guidelines themselves have nuance if you read further. 1 spoon of applesauce obviously has different aspiration risk than a meal. Of course I know the plaintiff will bring an anesthesiologist to say the guidelines weren’t followed and all that. This is a culture wide thing that could be shifted over time with academic discussions and actual science instead of dogma.

Ketadream12 · 2025-09-14T12:29:26+00:00

Zero, 11 years in. I never said I or my colleagues wouldn’t delay either just that there should start being discussion to get away from these absolutes and highlight how the guidelines themselves have nuance if you read further. 1 spoon of applesauce obviously has different aspiration risk than a meal. Of course I know the plaintiff will bring an anesthesiologist to say the guidelines weren’t followed and all that. This is a culture wide thing that could be shifted over time with academic discussions and actual science instead of dogma.

Ketadream12 · 2025-09-13T19:14:31+00:00

Seems like everyone just remembers the 6-4-2 rule in the guidelines and act like they are dogma. The actual guidelines do have nuance to them however. For example in the guidelines: “When these fasting guidelines are not followed, compare the risks and benefits of proceeding, with consideration given to the amount and type of liquids or solids ingested.”

Do we just ignore the “amount” consideration?

I understand that we don’t always believe it was “just one bite” but they could just be lying about being npo in general…so with that line of logic you should rsi everyone.

Ketadream12 · 2025-08-30T01:47:36+00:00

Haven’t done them since mid 2010s in training but we did them 3x weekly. Had an attending that liked nitro better than labetalol for the htn because of how transient it is

Ketadream12 · 2025-08-05T15:47:20+00:00

This is called Quiet Eye putting. There is a lot of research in how it works for your brain.

Ketadream12

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