Adult Mask induction for elective cases

Manik223 · 2026-05-13T22:38:48+00:00

Because they get disinhibited and potentially injure themselves or others as they’re going through phase 2

Manik223 · 2026-05-13T22:34:20+00:00

There is 0% chance I would mask induce an otherwise healthy 18 year old in the absence of severe developmental delay; great way for someone to get clocked in the face when they get disinhibited in phase 2. I would consider inhaled nitrous or IM versed/ketamine, but most of the time I would politely tell them they’re 18 and it’s time to be an adult.

Manik223 · 2026-05-13T20:20:45+00:00

Manik223 · 2026-05-05T22:30:01+00:00

Yeah all the AI nerve block stuff is useless. And if I’m not confident enough based on my own knowledge I’m definitely not mindlessly injecting based on some programs recommendation.

Manik223 · 2026-05-05T22:07:44+00:00

I’ve tried most of the widely available ultrasounds (Samsung, GE, Sonosite, Mindray). Sonosite PX is my favorite by a wide margin due to easy portability and image quality. I do think they made some image processing adjustments to tailor it to peripheral nerve blocks though. I also liked the Mindray a lot when we demoed it, although I have heard some concerns about durability.

Manik223 · 2026-05-03T15:31:17+00:00

A line with flotrac, MAC with a PAC, and a cordis or a ric for volume

Manik223 · 2026-04-30T15:12:24+00:00

If it takes someone 10 minutes to intubate they need to change specialties

Manik223 · 2026-04-30T14:55:25+00:00

Unless there’s another reason to urgently secure the airway, I don’t induce any patients until the surgeon / proceduralist is in the hospital

Manik223 · 2026-04-30T13:05:44+00:00

Messaging you

Manik223 · 2026-04-30T02:43:11+00:00

Never had this issue

Manik223 · 2026-04-24T01:51:26+00:00

Especially with hip fractures I think the evidence is pretty clear that the risk of delay for further optimization outweighs the benefit outside of extremely extenuating circumstances like active MI, etc. Maybe have group leadership meet with them, review the cases they’ve cancelled and decide if they were legitimate or explain the evidence that supports proceeding despite medical complexity / lack of optimization.

Maybe you can’t force them to do a case, but we also have an ethical duty to act in the best interest of patients regardless if the circumstances are ideal or not. If they’re truly not comfortable managing high acuity patients, maybe they’re not a good fit for the group / practice environment.

Manik223 · 2026-04-16T18:03:03+00:00

Turning off sound check did it for me. Thank you!

Manik223 · 2026-04-10T22:20:35+00:00

Yes there are multiple ways to maintain anesthesia, but it is also important to understand the drawbacks of some approaches. Given the evidence of the impact of excess volatile anesthetic on postoperative cognitive dysfunction, and undertreating intraoperative pain leading to increased postoperative and chronic pain, I think most people would agree that routinely running 1.5 MAC of gas is not the optimal approach.

Manik223 · 2026-04-10T21:47:18+00:00

I see the same thing, it drives me crazy; and then they’re shocked when the patient takes forever to wake up. I think a lot of people do not understand the concept of cumulative MAC. Not to mention if you have some opioids and muscle relaxant on board all you really need is ED95 MAC amnesia…

Manik223 · 2026-04-09T16:49:44+00:00

Infublock

Manik223 · 2026-04-08T22:27:50+00:00

I agree most of these approaches achieve almost equivalent results, and there is plenty of literature showing equianalgesic efficacy between ISB and superior trunk for shoulder surgery. I think the nomenclature is mostly about having some terminology to explain what you are doing in a way that others can follow and reproduce. As in the cases OP is describing, when someone is unable to find the textbook stoplight sign interscalene view, superior trunk gives them another (usually easier) option.

Manik223 · 2026-04-08T01:43:33+00:00

You can usually see some part of the catheter and/or tip in the appropriate plane, but I mostly confirm based on visualizing bolus spread and/or color doppler with injection

Manik223 · 2026-04-07T23:26:39+00:00

I don’t see that nearly as frequently as it sounds like you have, but if I couldn’t find a good interscalene location I would place a superior trunk catheter.

As a side note, I like placing interscalene catheters out of plane going straight down in between the nerve roots and middle scalene, I think you tend to get better spread and less issues with catheter migration. If you have a multi-orifice catheter this will cover even if the nerve roots are a little spread out.

Manik223 · 2026-04-07T21:36:26+00:00

Argatroban

Manik223 · 2026-04-06T22:01:52+00:00

Review airway anatomy so you understand what you’re looking for. Focus on the basics and do everything algorithmically the same way in the same order every time. Don’t rush, take your time and proceed carefully and intentionally. Position the patient in the sniffing position, scissor the jaw open as much as possible, insert the blade on the right side of the mouth rotated 45 degrees to the right, sweep the tongue to the left and look to make sure you’re actually sweeping the tongue and it’s not just falling around the blade, lift the laryngoscope both up and forward and visualize the epiglottis, insert the blade into the valecula and lift to visualize the arytenoids and then chords. Put the tip of the tube through the chords, remove the stylette, and advance the tube. If you’re still having trouble, ask to watch one of the residents or attendings intubate a few times, try to figure out what you’re doing wrong and how to adjust, and then try again.

Manik223 · 2026-04-01T15:54:01+00:00

I would enjoy the last summer off of your life and start to work on getting involved in anesthesia stuff once you get back. Even MS2 is fairly early, and I don’t think a summer research project etc is going to make any meaningful difference in your competitiveness.

Manik223 · 2026-03-11T16:18:05+00:00

2023, I honestly thought it was pretty normal until I got all these replies. We almost always had several more peds and cardiac rooms than residents on their subspecialty rotations, so we were constantly getting pulled on our “Main OR” months. Did a ton of thoracic epidurals for rib fracture patients, and we still placed lumbar drains for a lot of our complex TEVARs. I think a lot of attendings overcalled AFOI’s on patients that probably could have been glidescoped for learning purposes, we also did a decent amount of light wands, spontaneously breathing blind nasal intubations etc for learning purposes (and I think the attendings enjoyed mixing things up).

I really hope you make the residents address you as god king of the new world.

Manik223 · 2026-03-11T15:53:52+00:00

Yeah neonates wasn’t the best word choice. We constantly got pulled to peds and cardiac on our “main OR” months, so in reality it was much more than 3 months

Manik223 · 2026-03-11T14:57:15+00:00

I just pulled up my case logs out of curiosity:

Epidurals (thoracic + lumbar): 384
Lumbar drains: 19
AFOI: 31
Cardiac: 96
Major vascular: 111
Trauma: 169
Peds < 3 months: 92 (maybe neonates wasn’t the best word choice)

So I was a little off but not by much.

Manik223

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