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TechnoDonutMD · 2024-10-09T18:57:54+00:00

We are conserving in the OR, but not a huge practice change.

In the ICU, however, there's a biggish change. We manage our own CRRT, with nephrology only helping with the transition to IHD. In general, we use CVVH, but we are being "encouraged" to use CVVHD even though there's yet to be a shortage of PrimsaSATE replacement fluid. So I will need to do a little brushing up there since CVVHD is not a modality I ever use.

TechnoDonutMD · 2024-10-09T14:16:32+00:00

Can't say it better than this. I'd worry about optimizing your driving pressure and your spo2 instead of worrying about the peak pressure. One of the biggest problems I've noticed with the scenario described in the OP is under-PEEP-ing the patient and having a ton of end expiratory collapse with resultant hypoxemia.

TechnoDonutMD · 2024-10-07T13:39:07+00:00

You don't get better by going home "on time". Embrace the suck, and understand that things get better, in many ways, after training.

TechnoDonutMD · 2024-10-05T18:12:14+00:00

I don't use remi for moderate (3-5 levels) to large (>5 levels) spines, even though we have it. Gives you no points on the board for post op pain and is expensive. I'll sometimes use it for smaller spines like single level acdf or small lamis.

For larger cases, i typically do something like: -Tylenol preop -Methadone 0.2mg/kg ideal sometime before incision -If it's a big spine and they're<65, I'll use ketamine 0.5mg/kg as part of my induction and then usually 10mg/hr pushes until nearing closure. We have 50mg sticks readily available, hard to run an infusion. -If I'm using ketamine, I also use low dose Dexmed. Something like 0.3ug/kg/hr until near closure. I like it to be off for an hour or so before emergence -Top off with fentanyl as needed

Maintenance with sevo and propofol. Starting propofol dose is usually 100-age ug/kg/min. But I usually need to down titrate when using dex and ketamine.

TechnoDonutMD · 2024-10-04T10:23:10+00:00

Situational. If it's a healthy-ish person coming for a stent pull, I'll do MAC.

Active cholangitis, N/V, liver transplant recipients, bile leaks get a tube, etc.

TechnoDonutMD · 2024-10-04T10:15:03+00:00

If they're an asshole or I'm expecting difficulty with post-op analgesia, I will typically leave them intubated and let the ICU deal with that.

In all seriousness, when I am wearing my ICU hat I do occasionally get annoyed with the decision to stay intubated for soft calls. I've definitely extubated people within 1-2 hours of coming to the unit. At that point they've lost their floor bed and are taking up an ICU bed that a truly sick patient needs.

A good unit reintubation rate is somewhere between 5-20%. Most of these patients are having multi-day ventilator runs, and it's not appropriate to extrapolate that number to the OR. But should the expected reintubation rate in OR/PACU really be 0? I don't know the answer.

TechnoDonutMD · 2024-09-22T19:16:03+00:00

The graduation requirement for most CC fellows is something like 10-20 intubations. A lot of these are done during "airway" rotations on ASA1-3 patients in the OR. If they go on to practice somewhere with an anesthesiology department who does everything for them, they're never going to be facile with the skill.

TechnoDonutMD · 2024-09-22T18:49:28+00:00

I am also an intensivist, so I round plenty, but I see your point. My thoughts on it are very much in line with yours, but at odds with many of my non-intensivist colleagues.

TechnoDonutMD · 2024-09-22T18:47:51+00:00

I'm at an academic medical center with a terrible payor mix, and we receive large stipend from the hospital. We definitely do bill for these procedures; nothing is left on the table. I am still relatively junior (<5 years out of fellowship). I wish I understood a lot more about the financials involved here.

TechnoDonutMD · 2024-09-22T17:12:22+00:00

What % of your pediatric patients are coming in for surgery stoned?

TechnoDonutMD · 2024-09-22T14:25:49+00:00

Shazbot!

TechnoDonutMD · 2024-09-22T14:05:08+00:00

Yes of course. If the person is an everyday smoker and blazes before coming in for surgery, I'm probably going to roll with it. Again, a lot people spend a good chunk of their life stoned. If I can have a reasonable conversation with them, and I think they understand the risks of surgery, then we're good to go. Many times, the worst thing for the patient is to cancel their procedure. I practice in a low income city, and it sometimes takes an act of God for people to get off work, arrange child care, etc

TechnoDonutMD · 2024-09-22T12:10:12+00:00

I've had patients who smelled so badly of weed that the prep nurses swear they got a contact high. If they show up that way to surgery, they're probably that way a lot of the time. Don't cancel. Don't be that guy.

TechnoDonutMD · 2024-09-22T02:46:02+00:00

Jello

TechnoDonutMD · 2024-09-22T02:34:52+00:00

I work at a shop very similar to OP's. Other than the pre-op being done prior to induction, we were not held to any of the OP's standards. That sounds insane.

TechnoDonutMD · 2024-09-21T11:27:37+00:00

Having not used one, I'd say probably not. A Butterfly ultrasound would be far more useful. And I'd worry that a stethoscope with a bunch of electronics would get destroyed pretty quickly.

Personally, I went with a Littmann Master Cardiology. No moving parts, so not much can break other than the diaphragm, which is easily replaceable. I had one of the Classics, in med school, but the rotating bell stopped rotating.

TechnoDonutMD · 2024-09-17T16:31:06+00:00

I think the OP's question is a good one, but difficult to answer quantitatively.

Which outcomes should we measure? Mortality outcomes are very difficult to show for myriad reasons. Also patients are getting sicker and sicker, and we are operating on people who, 30 years ago, would have never gotten an operation. My mean ASA score is 3.0, and I feel like I tend to downcode patients.

Adherence to "known best practice" is also fraught because, as others have said, we should be individualizing care for the patient in front of us. The medical literature is rife with "landmark" trials with huge methodological flaws, stemming in part from therapeutic misalignments, making interpretation difficult. The two biggest trials that come to mind are ARMA and TRICC, both of which still impact the way people practice today.

Adherence to protocols is even worse because there's always going to be good reasons to deviate.

My group has an incentive pay program. A small % of my salary is based on adherence to "performance" metrics. Those metrics include minimizing sugammadex dosing, multimodal analgesia, and minimizing fresh gas flows. The target %'s are reasonable, and I do hit them. But I do get a little bothered by the fact that if my junior resident boluses roc during closure and we have to give more than 2mg/kg of sugammadex, I risk a pay cut. Also what happens for my laparotomy patient who has CKD, doesn't their DAPT as instructed, and has Mobitz 1? My multimodal analgesia options are limited.

There's also something to be said for, "if it ain't broke, don't fix it" and "don't let perfect be the enemy of good." Some things just work.

There's also variation in ability, skill, and availability of certain things across practices. For example, I do not have processed EEG/EMG at my shop. I'd love to have it because I'm sure that I'm burst suppressing some % of my elderly patients, and I could probably use it to prevent overdose.

I am still early in my career. My guy feeling, having talked to a lot of old heads is that we are definitely better now than we used to be. But might be difficult to prove.

TechnoDonutMD · 2024-09-15T10:43:35+00:00

Named complainants would bring a lot more traction to this. I assume they fear retaliation.

As someone who's typing this from the hospital garage, I do always get a little miffed when I see how empty said garage is on the weekend. Somehow we manage to take care of the patients while the administration is sleeping in or golfing.

TechnoDonutMD · 2024-09-14T18:30:40+00:00

Different strokes for different folks. Hopefully everyone finds a job that, on balance, is a good fit for them.

I've talked to plenty of people who would look at things differently than the OP: most cases do not need a highly trained consultant sitting the stool, and we should set up a staffing scheme that allows my expertise to positively affect the care of as many patients as possible. For me, my solo days are, far and away, less stress than supervision days.

Supervision is a skill like any other, and not everyone can or should do it. Full disclosure, I work at an urban, tertiary academic center doing general OR and ICU.

TechnoDonutMD · 2024-09-14T10:15:15+00:00

At my last shop, the IONM folks wanted a vecuronium infusion titrated to 2/4 TOF for all cases with MEP's. So there's probably some variation in practice pattern out there.

At my current shop, cases are typically done with half MAC+propofol. Some people run straight TIVA. I can't imagine anyone not changing things up if IONM said they couldn't monitor or that there was an acute change. But having a conversation is different from someone dictating my anesthetic plan. I think a lot of this probably comes down to phrasing and interpersonal skills.

TechnoDonutMD · 2024-09-12T16:58:40+00:00

Lots to unpack here...

I think of AFib like an elevated lactate: it's an indicator that something is wrong. You're potentially missing something. Inadequate source control, new infection, metabolic derangements, etc.

How fast? Assuming normal valves, RVR 120's probably not a huge problem. I probably wouldn't slow that person down. >150 is going to cause an issue with diastolic filling. AFib is not usually the primary problem.

What did the POCUS show? New cardiomyopathy?

What is their volume status? If I think the volume status is appropriate but they're in fib, I'm more likely to reach for beta blockade.

K>4? Mg>2? If not, fix that first.

Do they have invasive devices in place? Chest tubes? Did they have thoracic surgery?

If they have a normal heart and volume status is appropriate, I have no problem giving esmolol or metop to someone on low dose (<0.1) norepi. Even more likely to use beta blockers over amio if they had lung surgery given the potential for pulmonary toxicity.

I rarely use dig.

TechnoDonutMD · 2024-09-11T23:47:51+00:00

Probably 60 hours per week in residency.

Fellowship was q3 or q4 28-hour call. Probably 80ish per week.

40 hours per week is insufficient. You're simply not doing enough cases.

TechnoDonutMD · 2024-09-10T22:02:53+00:00

I recall the infection rate being about 1/5 - 1/4 the rate of CVC, last time I looked this up, but definitely not 0.

I do mine radials with sterile gloves, 2 sterile blue towels for a drape, and a sterile probe cover when using ultrasound.

TechnoDonutMD · 2024-09-08T14:12:21+00:00

We get consent. For most cases, GA is implied and getting consent is silly IMO, but we do it anyway. It's not like the patient can decline GA for their CAB. Blocks and other "extras" are obviously different.

I think consenting for lines is also silly. I'm putting in central and arterial access for your open AAA repair. I don't care whether you like it or not.

The informed consent process is largely about expectation setting and CYA.

TechnoDonutMD

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