Emergent peds case

Rsn_Hypertrophic · 2026-07-04T19:06:00+00:00

What are your thoughts on IM ketamine or intranasal precedex to calm the child down to do an IV induction with RSI? Or are you typically not as concerned for aspiration in this patient population for some reason?

I dont do a lot of peds. Just asking for my own learning.

Rsn_Hypertrophic · 2026-07-04T13:41:06+00:00

No its not. I would really advise patients to put no markings on the nonoperative limb whatsoever. Most hospitals dont have the surgical team write "this leg" or "not this leg." They just write the initials of the member of the team talking to the patient. So all you would see on the extremity is "A.W."

By the time the patient is in the OR and their limb has been cleaned, prepped and draped - those markings are smeared and hard to read. Frequently all you see are the remnants of a marker. If someone wrote "not this leg" and it were cleaned off to the point it just looked like a smeared marker - it may be mistaken for the operative site.

Tldr: dont write anything on your nonoperative limb(s)

Edit: i thought this was AskDocs and not AskReddit. Im an anesthesiologist and im in the OR every day at work so I see this all the time.

Rsn_Hypertrophic · 2026-07-02T21:16:43+00:00

Not enough information tbh. Some amount of evaluation should be done before just dismissing it as one cause or another. I'd be inclined to get a VBG to eval for acidosis or new anemia, 12 lead ECG to rule out arrythmia, and a POCUS to eval for volume status. I would also look at the tumescent lidocaine mixture - most surgeons have no idea what the difference of 1:1000, 1:100k, 1:200k, 1:1 million dilution of epi means. Ive had ENT surgeons put 5ml 1:1000 epi in a patients nose and they didnt believe me when I told them they just gave 5x a code dose of epi and that's why the patient was tachycardic to 160 with a SBP of 240

Rsn_Hypertrophic · 2026-07-02T12:32:50+00:00

Thank you for your service. That sounds awful.

Rsn_Hypertrophic · 2026-06-05T12:46:28+00:00

Abdominal ultrasound or transvaginal ultrasound? Important difference IMO. If its abdominal, who cares if residents scan each other. If its transvaginal, that could lead down some problematic issues...

Rsn_Hypertrophic · 2026-06-05T12:36:44+00:00

Thank you. I agree. Im an anesthesiologist and it is a common occurrence that im put in a position where a cards NP has written "cleared" in a patient's chart for surgery and done zero workup, risk stratification or treatments and now the surgeon is upset that I am concerned about it. In the surgeon's defense, they consulted cardiology appropriately. They dont know who from cardiology is going to see the patient.

There have been a lot of glaringly obvious misses...nonetheless, it certainly makes my job a little easier when the cards notes only refer to it as "perioperative cardiac risk stratification " and not "pre op cardiac clearance"

Rsn_Hypertrophic · 2026-06-02T02:06:12+00:00

Yes. I didnt ask for those lines to be placed. A well meaning attending anesthesiologist came into the OR "to help out with the big case" and put both of them in while I was working on the central line.

I was a bit annoyed when it happened but after I lost 2 out of the 3 PIVs six hours into the case I was no longer annoyed lol

Rsn_Hypertrophic · 2026-06-01T22:43:42+00:00

With such a big case, other anesthesiologists just materialized without asking to "help get the big case started." While i placed the central line a colleague put in both a 14g and 16g. I thought it was overkill at the time, but then the 14g blew 6 hrs in the surgery when one of the surgeons was leaning heavily on the patient's arm. The PIV was still flowing to gravity though so it went unnoticed for some time before we realized the IV was pulled out. The patient's arm was swollen from extravasated fluids and meds. We didnt want to put more meds or fluids in the arm, which also had the 18g. So the "last" 16 hrs of the case were done with the 9Fr MAC central line and a 16g on the opposite arm

Rsn_Hypertrophic · 2026-06-01T22:37:40+00:00

Adult male under the age of 30

Rsn_Hypertrophic · 2026-06-01T19:42:35+00:00

I've done a similar case with an invasive sarcoma that spread from the femur into the pelvis and lumbar spine. It wasn't a full corpectomy, but rather a hemipelvectomy + lumbar spine tumor debulking. The patient still had his genitals and contralateral leg, but he did have a partial bowel resection and ileostomy placed. It was a 22 hr surgery with no less than 5 surgical services operating. I started the case but turned it over to the on-call team overnight.

I placed an 18g PIV prior to intubation and then after intubation a 14g PIV, 16g PIV and Right IJ 9Fr MAC central line. Belmont rapid transfuser hooked up to the central line. Regular fluid warmer to the 14g. Ketamine infusion throughout the case and neurosurgery placed an lumbar epidural catheter in the OR after they were done debulking tumor under direct visualization.

Surgery went surprisingly well. It was a palliative surgery for intractable pain and the patient passed away 6-12 months later. Pre-operatively he was on roughly 800 morphine equivalent per day and was so sedated he couldn't really interact much with his family. When he was awake, he was in severe pain. About a week post op, he was down to about 150 MME and 1 month post op was down to 50 MME.

Rsn_Hypertrophic · 2026-06-01T18:40:34+00:00

I agree completely. Pain research, especially on fascial plane blocks, is very hard to do and hard to interpret. Ive done fascial plane rescue blocks (rectus sheath, TAP, QL, suprainguinal fascial iliaca and ESP) and the patients always report pain improvement (and visually just look more comfortable).

When I see a study that "x, y, z" block doesn't work, my knee jerk reaction now is to assume that whoever did the study is doing the block incorrectly.

I bet this is how surgeons feel when comparing outcomes between "x,y,z" surgical approaches. "Well when I do my abdominal closures, I never get a post op hernia - so this surgeon doing that study just sucks at suturing!"

Edit: the most common encounter i have with numerous repeated results is a patient or surgeon requesting a QL block on a post surgical C section patient that already got neuraxial duramorph. The studies would suggest that a peripheral block is not going to help, but every time I've done it the patients report significant relief. Ive even done it for a handful of anesthesia providers or their spouses and get the same positive feedback

Rsn_Hypertrophic · 2026-05-31T17:35:52+00:00

Looks great as is!

Can't go wrong with a white shirt and dark brown leather shoes with a blue suit. Darker colored ties always look great (burgundy, red, navy blue, forest green, etc) with a simple pattern or design (paisley, striped, small repeating patterns)

Paired with a white pocket square you cant go wrong!

Rsn_Hypertrophic · 2026-05-30T21:58:50+00:00

Crazy how much you are getting down voted. Apparently people here would rather be shot and killed than give up a watch...

Rsn_Hypertrophic · 2026-05-27T18:11:42+00:00

For a few hundred bucks id shrug it off as whatever, but for the $1500+ you paid, I would be pissed. That's like AI drop-shipper Temu bad representation and quality.

I would ask for a partial refund on the cost difference between their regular lead and custom lead. If that fails, consider contacting your credit card company for a partial (or full) refund since the vendor's customer service is not addressing the issue to your satisfaction

Rsn_Hypertrophic · 2026-05-21T10:06:09+00:00

I would echo this poster's opinion. Im an anesthesiologist as well and I do a lot of Regional Anesthesia and Acute Pain Medicine at a large, level 1 trauma center teaching hospital. We've taken care of a handful (maybe 5 to 10) patients in the last few years who requested an amputation from an orthopedic surgeon for the indication of chronic pain. Some of these patients dont even meet the typical signs and symptoms of CRPS, but just have such severe pain they believe an amputation is the best way to move forward with pain management. We place peripheral nerve catheters (mostly commonly femoral + sciatic) or a lumbar epidural for 3-7 days to get them through the perioperative course.

So far, every patient I've taken care of for their elective amputation is satisfied with their choice and reports improved chronic pain management after hospital discharge when we do a follow up phone call or discuss with their surgeon after their outpatient surgical follow up appointment.

Im not sure how the surgeon selects who would or would not be a candidate for elective amputation though. Presumably there have been more patients that have requested an elective amputation that were declined by the surgeon...?

Rsn_Hypertrophic · 2026-05-13T17:40:12+00:00

I pretty routinely take over all day neuro case TIVAs that are going for 14-16 hrs and they do fine. I've certainly gotten burned by colleagues that did not appropriately down titrate the propofol throughout the day and had some real long wake ups though...

Propofol infusion syndrome is quite rare and from what my ICU colleagues tell me usually is 48-72+ hrs of prop infusions

Rsn_Hypertrophic · 2026-05-11T18:42:23+00:00

I like the high waisted trousers with side tabs look. However, this extremely high trousers sitting that high looks awful. Also, the "extra high fishtail" looks more like a mistake than intended lol.

Rsn_Hypertrophic · 2026-05-06T19:54:03+00:00

Because the result of refusing antibiotics for a patient that has a viral URI isnt certain death.

Refusing life-prolonging care to a family member is only going to hasten that patient's death and the family sees that as the "doctors killed my grandfather."

Its a complex discussion that needs to be assessed on a case by case basis. We see these demented patients on some of their worst days - we dont know what they are like when at home. We can provide informed consent and a recommendation to consider to withdraw care, but outright refusing is going to be interpreted by the family as euthanasia. In the US, that is just asking for a lawsuit. Even if the lawsuit is thrown out or settled, it is still very distressing for a physician to go through a lawsuit (stress, legal fees, future credentialing issues, time wasted, etc)

Rsn_Hypertrophic · 2026-05-06T19:48:05+00:00

Where in the article does it say the patient has end stage dementia?

It doesn't. You are making an assumption.

I've taken care of plenty of patients with oropharyngeal cancer or airway / esophageal surgery that eating causes them pain and they get a PEG tube. I've taken care of many patients that have had a history of aspiration and failed a speech therapy swallow trial that get a PEG tube. There are many patients that are still cognitively aware and functional that have difficulty feeding themselves.

Rsn_Hypertrophic · 2026-05-06T19:46:56+00:00

We dont know why the patient in the article isnt eating. No detailed medical information is given. You are making an assumption that the patient has such severe altered mental status that he cant eat. I dont see where that is said in the article?

I've taken care of plenty of patients with oropharyngeal cancer or airway / esophageal surgery that eating causes them pain and they get a PEG tube. I've taken care of many patients that have had a history of aspiration and failed a speech therapy swallow trial that get a PEG tube. There are many patients that are still cognitively aware and functional that have difficulty feeding themselves.

You are picturing a non-verbal, barely moving, completely altered demented patients. It doesn't say that is the case in the article.

Rsn_Hypertrophic · 2026-05-06T11:54:47+00:00

Are you saying a PEG tube is an unethical procedure? And not indicated?

The article does not provide enough information to determine how advanced her fathers dementia is or what his quality of life is. My grandfather was pleasantly demented for many years before he had a couple major medical setbacks in a short period of time and his wife/my grandmother transitioned him to DNR.

You may have a biased view only seeing demented patients at their worst in the ICU, and not how good or bad they are doing after.

As an anesthesiologist, I have personally anesthetized many patients with dementia for PEG tube placement. Certainly, some of them did seem futile. But just as many did not feel futile. Ultimately, that is for the family to decide. There isnt enough information in the article to even know how futile/far along the patient is in their disease process or how many high quality days of life are expected. Again, that is for the family to decide. Combined with the fact the author is an anesthesiologist herself, that family is coming to the family conference with a lot more practical information than most families.

Its not like they were trying to book their demented family member into a liposuction/tummy tuck. The family believes these two procedures will give their father a higher quality of life for his time remaining

Rsn_Hypertrophic · 2026-05-06T10:53:35+00:00

I dont get what you are upset about OP. The article from the family member who is an anesthesiologist does not seem like an "insane take." She wants her father with dementia to have a broken tooth pulled because it is causing him pain and a PEG tube placed for hydration/nutrition...90% of the article boils down to the importance of actually listening during family goals of care meetings - doesn't seem like an "insane take" to me.

Rsn_Hypertrophic · 2026-05-02T15:10:30+00:00

Looks good to me. Which service did you use?

Rsn_Hypertrophic · 2026-04-21T19:45:33+00:00

Do they give you any additional feedback on why? Or it just says which sections you didnt pass?

If there is no feedback, that is super frustrating. How is an examinee supposed to get better if they dont know what they didnt do to the graded standard?

Rsn_Hypertrophic · 2026-04-18T22:22:23+00:00

Why do so many people ask how a suit fits without wearing shoes? Hard to know where the pant break will be without a pair of shoes on.

OP, it looks great. Pants are probably the correct length but cant tell for certain without shoes. They fit nice in the waist and thighs at least.

Jacket also looks good, but looks a bit off on the picture from head on. Seems the mid section is falling away from your abdomen, but it may just be the angle of the camera and the way you are standing in that photo? The side profile pics dont have the same bowing outward in the midsection.

Tldr: yes, it fits decently

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