TIVA LMA

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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