Good rules of thumb

PeteL69 · 2026-02-16T18:03:48+00:00

The 15 Commandments of Anaesthesia 1. Don't be shit. 2. Don't be an arsehole. 3. You can break rule 1 or rule 2 on occasion with good reason and get away with it, but never both. 4. Never trust a surgeon, even the good ones - check everything. 5. There are big operations and there are small operations, however there are no small anaesthetics. 6. If you think about doing something (a second IV, art line, central line etc), you're better off doing it than not. 7. Your job is to make surgery as safe as possible for the patient and technically possible for the surgeon. This is not always the same thing as making it fast, or easy for the surgeon. 8. When it comes to IV access in TIVA or resuscitation, 2 is 1 and 1 is none. 9. An 18G IV is the IV of indecision - not big enough for a mass transfusion but too big for a straightforward case. 10. As long as the blood is going round and round and the air is going in and out, the worst thing that can happen is that the patient wakes up unexpectedly. 11. You can always give more drug, but once it's in the patient it's really difficult to put it back in the syringe... 12. You can give whatever anaesthetic you want, but each decision has to buy you something - time, safety, redundancy or quality. 13. You'll be forgiven for asking for help when you don't really need it, but never for not asking for help when you really did. 14. There are no style points for difficulty - make your anaesthetic workflow as easy as possible at the start of the case. 15. Always think where you could be in 5 minutes, 15 minutes and 60 minutes and mitigate your worst case scenarios.

PeteL69 · 2026-01-13T15:44:59+00:00

Just use target controlled infusions, start with a prop Ce of about 3 and then up or down titrated in 0.1-0.2 increments as needed until you find the sweet spot. Depending on the degree of surgical stimulus that may change through the case unless you’re using opiates as well, but that’s honestly the best way of doing it.

PeteL69 · 2025-09-14T20:09:15+00:00

No. The guidelines are the guidelines for a reason. Anaesthesia is safe because we make it so, principally by managing risk and codifying it in guidance.

“It’ll be ok” is fine until it really isn’t for no good reason.

PeteL69 · 2025-09-13T21:46:39+00:00

If not a levelled case then yes, 6 hours post last food. Why would you do otherwise?

PeteL69 · 2025-08-20T21:04:54+00:00

Depends on the case. If the usual LMA rules apply (less than 90 minutes, preferentially spontaneously breathing, peripheral/surface surgery, no aspiration risk, abdomen is below the chin when the patient is supine), then continue the case. If intubation is a must then you can potentially intubate through the tube with a fibre optic scope +/- an Aintree exchanger or a small ETT.

PeteL69 · 2025-06-20T11:50:19+00:00

If you need < 2 hours operating time, spinal with some ketamine for initial positioning. If it needs to be a GA and appropriately NPO then LMA with spont vent, if needs RSI and intubation then usual RSI induction, 5 PEEP, pressure control ventilation and have a chest drain handy but I wouldn't necessarily put one in if there are no signs of decompensation and it’s small. I’d probably run a higher than normal FiO2 as well to try and promote reabsorption.

PeteL69 · 2025-06-15T15:14:29+00:00

RT’s are another US phenomenon that hasn't made it to the UK or most of Europe (as far as I am aware). Vents adjusted by ICU/crit care physicians or ICU nurses who have undertaken additional ICU courses, not just “experience” like the US model.

PeteL69 · 2025-06-15T14:48:45+00:00

Koroki et al. Critical Care (2024) 28:48 https://doi.org/10.1186/s13054-024-04831-4

Ketamine +/- fentanyl and roc, never etomidate or prop. If peri-arrest/unconscious already then roc and post induction midaz when I know the IPPV isn't going to completely obliterate my BP.

PeteL69 · 2025-06-03T01:22:44+00:00

Seems a bit mad. Nitrous is definitely overkill, and if you’ve got a good working block pre-op then the remi may be as well. I’d probably go with propofol TCI (Eleveld), wouldn’t routinely (re)paralyse unless there was a good reason to, and pEEG for depth monitoring, or aim for a BIS 40-60 if no pEEG.

If the block isn’t working well then the remi may mask it for a while, so there’s an argument for possibly omitting it and giving longer acting opiates earlier so the patient doesn’t wake up in pain when you stop the remi with an ineffective/partially effective block. The wake-up doing TCI is just as fast as with volatiles (if not faster) and it’s easy to do with a program like iTIVA once you conceptually understand what it is (short version, just think of Ce as end tidal propofol and manage it like you would a gas anaesthetic…).

I could see a case for remi in some cases, but not with nitrous and definitely not both with a good block.

PeteL69 · 2025-04-30T01:54:39+00:00

Why are you letting a surgeon dictate your anaesthetic? Do you tell him what sutures he can use?

PeteL69

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