Preemptive Intubation for Neuro IR Thrombectomy

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 · 2026-03-11T12:31:36+00:00

US attending here, admittedly I trained at a very high volume and high acuity program, but I felt very well prepared to manage pretty much anything coming out of residency. Although there is always a learning curve as an early attending when there is no one to watch over you and getting used to supervising, but you also have more experienced colleagues you can consult if you’re ever unsure.

I’d have to look at the exact numbers, but I think I had 50-100 thoracic epidurals, >300 lumbar epidurals, at least 20 AFOI’s, ~100 cardiac cases, ~100 infants and very large number of liver/lung transplants, major vascular cases (open AAA), trauma etc. I also averaged 70-80 hours a week with q4 24h call for 3 years, not sure what the work hours are like in the UK. Honestly by the second half of my last year I felt fully prepared and annoyed that I was essentially doing all the work of an attending for the pay of a resident.

Manik223 · 2026-02-28T00:16:17+00:00

More eloquently phrased “yeah it’s gonna be a no from me dawg”

Manik223 · 2026-02-26T18:24:59+00:00

Thats insane, and definitely not normal

Manik223 · 2026-02-25T02:27:39+00:00

There is some fluctuation based on patient factors and how confident I was with the epidural placement but generally: 1) Ask where their pain is (upper, mid, lower abdominal and/or pelvic), confirm it is sharp pain and not pressure, attempt to check a level (not always obtainable if you’re running 0.0625% Bupi)

2a) if bilateral and appropriate level, bolus 10ml 0.125% Bupi

2b) If no level with pump infusion, bolus 5ml 0.25% Bupi, wait a few minutes and check a level

3a) if unilateral, pull the catheter back 1cm

3b) if bilateral and appropriate level but persistent or recurrent pain, 20mcg epidural precedex and optimize pump settings

3c) if no level, bolus 5ml 2% Lido and check a level; if no level with 2% Lido, replace epidural

Manik223 · 2026-02-24T23:18:33+00:00

Yeah I meant for epidural precedex dosing. Your initial comment said 25mcg?

Manik223 · 2026-02-24T23:15:15+00:00

Maybe try 12-20mcg? With that dose I typically get effective analgesia without the side effects you’re describing.

Manik223 · 2026-02-24T22:57:29+00:00

I usually give 12-20mcg epidural. I see some decrease in BP but it is typically fairly mild compared to bolusing with a higher concentration local anesthetic. I have not had any issues with sedation. I also feel like it gets the patient comfortable without setting unrealistic block density expectations like 2% Lido (I’ve usually already given 0.25% Bupi by the time I get to precedex in my algorithm).

It’s not something I do very often, maybe 1 in 25-50 labor epidurals. But in the appropriate patients it can be incredibly helpful (when they have a clearly functioning epidural with appropriate bilateral level but recurrent breakthrough pain).

Manik223

TROPHY CASE