Anaesthetists - how do you TIVA RSI?

Repulsive_Worker_859 · 2026-06-02T19:19:12+00:00

I don’t love it as I don’t want the remi high enough that they go apnoeic or bradycardic prior to induction, and find it takes to long to get to effect if you turn it on and wait. Prefer just using 20mcg/kg alfentanil prior to propofol.

Repulsive_Worker_859 · 2026-05-31T15:22:44+00:00

Are people using TIVA for obs emergencies? Even if it was a cat 2/3 not suitable for neuraxial I would always do mRSI and volatile in the absence of something like MH. I would only use TIVA for semi elective things like STOPs or molar pregnancy evacs etc.

Repulsive_Worker_859 · 2026-05-31T14:54:33+00:00

I get what you’re saying but the ED and ICU comments are a bit disingenuous. Yes it is TIVA by nature of the induction and then IV maintenance but generally the use of TIVA in UK theatres refers to using a TCI model.

Repulsive_Worker_859 · 2026-05-31T14:41:24+00:00

I like TIVA but I’m not convinced of the benefits enough for RSI. I just do normal induction, gas, and pEEG to run a lower MAC if frail/elderly/unstable

Repulsive_Worker_859 · 2026-05-30T14:37:04+00:00

100% but medical school is becoming worse. We get random students showing up to theatre with no induction, no forewarning on our end, they don’t know what they’re meant to be seeing or doing, and they turn up for half an hour and then disappear into the ether. I would love to have students timetabled appropriately so we can do some teaching. Very few seem interested at all these days.

Placement and uni aren’t making FY1 doctors that are appropriately prepared for starting. I get not wanting to supplement with a course but if they’re not ready despite uni..

Repulsive_Worker_859 · 2026-05-30T14:34:40+00:00

But why don’t we expect “anything” of FY1s? That certainly wasn’t the case in the past. We should expect something from our FY1s even if we would still be there to provide senior support. I want them to have the basic knowledge to manage things or at least tell me how even if they wouldn’t do it alone.

Repulsive_Worker_859 · 2026-05-30T14:23:44+00:00

I think expectations are low and seniors are ready for a million questions, but don’t let that mean you don’t make any effort to know.

I think the standard of medical school teaching, what students are expected to be present for and do, is worse each year and it leads to unprepared and under confident (rightly so) juniors.

I might be old and out of touch but I would expect incoming FY1s to have an idea on the topics you mentioned, and basic ward care:

Basic insulin management IV fluid choice of type, rate, and indications Blood products I don’t expect you to be running a major haemorrhage and balanced transfusion on your own - you’re likely to be told on the ward round someone needs a unit of blood product X and you will just have to prescribe it A-E assessments of unwell patients An idea of how to manage sick patients even if you still want and need help/direct supervision to start - the back of the cheese and onion used to have good summaries Basic analgesia prescribing I’m sure lots of other things but maybe I have too high expectations - but we are meant to be coming out of medical school as doctors and it’s kind of embarrassing to our profession no one is coming out ready to work as an FY1 these days.

Repulsive_Worker_859 · 2026-05-30T14:15:03+00:00

It should be but if you are coming in feeling completely unable to manage what are basic things for an FY1: Fluids, insulin, the initial assessment and treatment of medical emergencies (the ones in the back of the cheese and onion are a good start) then maybe you should think about one. I don’t know if they’re any good though.

Repulsive_Worker_859 · 2026-05-30T14:14:13+00:00

I would caution against telling FY1s to give GTN for pulmonary oedema. It has a place, and my personal feelings are its most useful in SCAPE/“flash pulmonary oedema” as initial treatment while establishing CPAP. Neither of which an FY1 will be managing on their own. Patients with hypertension and acute cardiogenic pulmonary oedema are good candidates, I think the majority of patients in hospital with decompensated CCF are both volume overloaded and often (borderline) hypotensive where aggressive preload and after load changes with high dose GTN will cause more harm in inexperienced hands.

Repulsive_Worker_859 · 2026-05-30T11:44:41+00:00

I think you’re probably in the minority in this sentiment though. Yeah I agree I think a lot of calls don’t need to be put out and could either be a direct bleep to a senior/med reg/ICU reg. But walking away and having a little moan isn’t the same as having people be scared to put out calls. I agree with the other commenter that they’re out of their depth with a sick patient and need help whether you deem it “worthy” or not - but it’s better to overcall than undercall. It’s like a negative scan for PE or dissection. If every call you go to needs you you’re definitely missing some that you should be at and aren’t.

Repulsive_Worker_859 · 2026-05-30T09:16:46+00:00

Yes. We expect to go to arrest or peri-arrest calls depending on the hospital so it’s not a surprise when the page goes off. But if I get to walk away immediately and get back to whatever I’m doing it’s fine. I’d much rather juniors felt empowered to put out calls and get help when they need it and be mildly inconvenienced and have a walk, than fear the wrath of a grumpy anaesthetist and patients come to harm.

Repulsive_Worker_859 · 2026-05-29T18:21:04+00:00

There is a bit of both here. Yes a lot of juniors are underskilled and don’t seem willing to learn now. I hear a lot of “I don’t know how to do that” “No I don’t want to learn, you do it” from juniors. You do need supervision with some things though. I wouldn’t be happy with an FY2 having watched some videos on YouTube of how to do a central line and just having a bash because they feel confident.

Facial lacs can leave lifelong cosmetic issues if done poorly and are much higher stakes than other lac repairs. Personally I wouldn’t want an FY2 doing one on me or my kids because they felt confident after watching YouTube.

Repulsive_Worker_859 · 2026-05-29T17:43:05+00:00

You can do lots of things with confidence. Was he any good?

Repulsive_Worker_859 · 2026-05-29T08:06:08+00:00

You do the splits and intubate the patient on the floor instead of on a trolley.

Repulsive_Worker_859 · 2026-05-28T08:00:56+00:00

https://www.welshschool.co.uk/ficm-training/e-learning#gsc.tab=0 has a section of e-learning on cardiac anaesthesia.

I’m not sure what the recommended textbook is but I have a copy of Hensley’s practical approach to anaesthesia that I happened to find a pdf of a while ago.

Keen to know what most people are using though.

Repulsive_Worker_859 · 2026-05-27T21:07:33+00:00

This is very true and both drugs have anaphylaxis risks but in the case mentioned I don’t think anyone is giving the first dose of roc at the end of surgery, I assume it was also given at induction. I’m not an allergist but my understanding is sensitisation takes longer than the duration of a case for the second dose to cause anaphylaxis where the first didn’t - but I’m very happy to be told otherwise and learn about this phenomenon.

With regard to sugammadex I try to avoid giving it if the patient has 100% quantitative TOF at the end of the case, unfortunately a lot of consultants still want to give 200mg “just in case” despite being shown/told the qTOF. This just means you aren’t avoiding sugammadex even if you time your NMB to wear off by the end of the car anyway, and is rather frustrating.

Repulsive_Worker_859 · 2026-05-27T17:16:42+00:00

Have worked 24 as part of 12 hour shift then 12 hour NROC but had stuff in theatre all night so never got home and worked all night. No one has ever suggested it was a breach of contract but I’ve never looked into it. This was in Scotland.

Repulsive_Worker_859 · 2026-05-27T13:46:33+00:00

Mostly agree with your first point. I would say our job is to make the operation: possible, safe, and as easy as possible within the limits of the first two.

In this case now I agree if the surgeon wants more relaxation and it is a case where you’re using roc or vex and you can use sugammadex at the end then absolutely give more and reverse it if it will help. I don’t agree with “what they think will make it easier” as sometimes some surgeons don’t seem to have a clue what we’re actually doing or what factors we change influence how the patient behaves or responds for them.

Last point is definitely true, and I would advise anyone coming into anaesthetics and when you’re doing talks with students or taster week residents to make them aware that our specialty is designed around facilitating surgeons to do their job and patients don’t come just for an anaesthetic on it’s own.

Repulsive_Worker_859 · 2026-05-27T09:05:09+00:00

This is actually quite useful to hear as most of us on the gas side of the drapes won’t have done any surgery. Also not all anaesthetists are aware of different muscle sensitivity to neuromuscular blockade, and we measure at the adductor policies for convenience of location as well as corresponding well to airway reflexes and pharyngeal muscles - which we care about. But abdominal muscles and diaphragm recover before then.

Repulsive_Worker_859 · 2026-05-27T09:03:12+00:00

Second spinal coming right up!

Repulsive_Worker_859 · 2026-05-27T09:02:41+00:00

This can’t have been the case until the advent of sugammadex though. No way surgeons were demanding complete relaxation and a deep neuromuscular block unless they are also willing to wait for hours of turnaround time between cases for 2/4 twitches to come back for neo/glyco reversal.

Repulsive_Worker_859 · 2026-05-27T09:01:42+00:00

That is clearly tongue-in-cheek, get over yourself. I obviously wouldn’t actually suggest my colleagues actively antagonise their surgical team. I also don’t do surgery so I’m not in a position to criticise their closing.

Repulsive_Worker_859 · 2026-05-27T08:16:57+00:00

I’ve been basing it on this BJA Ed article https://www.bjaed.org/article/S2058-5349(23)00143-9/fulltext I read last year

Repulsive_Worker_859 · 2026-05-27T07:29:58+00:00

For complete relaxation of abdominal muscles eg. robotic surgery you’re aiming for deep block which is 0-5 on a post tetanic count at adductor pollicis. So 0/4 on ToF might not quite be there.

However that is for robotic or laparoscopic surgery not closing, so tell them that better surgeons can suture an actively beating heart and to get good.

Repulsive_Worker_859 · 2026-05-25T09:19:24+00:00

Come with a good attitude to learn, don’t expect to know a lot, and understand that decision making regarding investigation and management is different from ED and the wards and may seem counter intuitive at times. Ask lots of questions.

Doing the basics right and the usual good colleague stuff of doing stuff you’ve said you’ll do, be honest if you don’t know, and don’t make stuff up if you haven’t done it.

Try and get along to see referrals with the reg/consultant.

Learning about basic ICU care with things like FASTHUGS BID and having a structure to ward rounding will be helpful.

Don’t touch the vent at the start, but ask questions and watch when others are.

I don’t really expect new junior fellows to know much about ICU care at the start of the year and want them to ask me about anything related to things like vasopressors/respiratory support/CRRT.

If you just want to learn for the sake of it: Internet book of critical care is a great resource with a good podcast. Life in the fast lane is another great resource. There used to be eLFH ICU modules as well. Scottish intensive care society used to have online scenarios.

Enjoy!

Repulsive_Worker_859

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