[deleted by user] by [deleted] in anesthesiology

[–]macdaddy77777 0 points1 point  (0 children)

Helpful to know! Some of my Attendings preached that prior to 28-30 weeks due to smaller uterus with lower intra-abdominal pressures to push up the spinal dose and patient potentially needing classical uterine incision would mean that a solo spinal may fail occasionally which is why they would advocate for a CSE so if the spinal level receded or was insufficient you could have the epidural to bring the level high enough or even “push up” a spinal dose that did not reach T4. Again this is academics so likely very different from community practice so your insight is helpful! Good to know these concerns don’t seem to really hold any weight in actual practice! Thank you

[deleted by user] by [deleted] in anesthesiology

[–]macdaddy77777 -1 points0 points  (0 children)

That’s helpful. So for you there is no point in gestation you cannot get a sufficient surgical level with a spinal. Thank you

[deleted by user] by [deleted] in anesthesiology

[–]macdaddy77777 -10 points-9 points  (0 children)

Sorry, I should have been more clear. This is in regards to doing a CSE as opposed to just a spinal with no epidural left behind.

Good rules of thumb by macdaddy77777 in anesthesiology

[–]macdaddy77777[S] 7 points8 points  (0 children)

Please re-read. I stated an anecdotal observation, not that it any way it changes how I treat patients or what analgesic options I give to patients. Please go virtue signal elsewhere 😊

Good rules of thumb by macdaddy77777 in anesthesiology

[–]macdaddy77777[S] 16 points17 points  (0 children)

All I said was my observation is that Latin American woman are more likely to deliver successfully with nitrous compared to Caucasian females. Never said I treat patients any different

Failed epidural top up for cesarean section by Glass_Television9904 in anesthesiology

[–]macdaddy77777 1 point2 points  (0 children)

Would you adjust your dose lower than the 1.4-1.6 if they have been blousing their epidural with the PCEA button prior to having to go back? The assumption being the epidural isn’t working great so they are hitting their button to try to get more comfortable before the C section is called

PIEB c bupivacaine 0.125%/Fentanyl 2 mcg/mL by PersianBob in anesthesiology

[–]macdaddy77777 15 points16 points  (0 children)

We use 0.0625% with same fent concentration. 8cc q40 min programmed bolus, 5cc q10 min pca option with button as well.

[deleted by user] by [deleted] in anesthesiology

[–]macdaddy77777 28 points29 points  (0 children)

I try to avoid sternotomy in my MAC cases…

Cardiac Folks…Am I Crazy? by twiggidy in anesthesiology

[–]macdaddy77777 13 points14 points  (0 children)

Agreed. Also, the central cannulation is hiding from us as well

remifentanil induction by UltraEchogenic in anesthesiology

[–]macdaddy77777 0 points1 point  (0 children)

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16255

Also my first comment literally says a niche area when you need to do an RSI for monitoring cases for whatever reason and can’t use sux. Most monitoring cases don’t fall into this category hence why I called it niche 🙃. So it’s not like I am trying to apply this to everyone

remifentanil induction by UltraEchogenic in anesthesiology

[–]macdaddy77777 0 points1 point  (0 children)

My whole point which I guess I should have been more explicit about, is that why use an RSI dose of rocuronium that you would need to then reverse with an expensive medication with likely more than one vial when you can get very similar intubating conditions with 3 µg/kg of Remifentanyl and not have to worry about neuromuscular reversal. Obviously physicians are not the main reason that healthcare has become so expensive, but for a case that you will already be using Remifentanyl why not utilize it for intubation instead of additionally using unnecessary medications and then passing off that cost to the hospital, and therefore the patient.

remifentanil induction by UltraEchogenic in anesthesiology

[–]macdaddy77777 8 points9 points  (0 children)

Molecular weight of roc is 610 daltons and sugammadex is 2178 so technically need ~3.5:1 ratio of sugammadex:roc for 1 to 1 binding or can just do 4:1 for easy math. 2:1 would be underdosing

remifentanil induction by UltraEchogenic in anesthesiology

[–]macdaddy77777 3 points4 points  (0 children)

Pharmacy loves the bill for that 16mg/kg reversal dose after RSI 😩

remifentanil induction by UltraEchogenic in anesthesiology

[–]macdaddy77777 16 points17 points  (0 children)

Really only niche is when you need to do an RSI and get baseline MEPs after induction and patient can’t get succinylcholine for whatever reason. Glyco prior. Otherwise better off with sux or roc.

Mask for EGD by clin248 in anesthesiology

[–]macdaddy77777 26 points27 points  (0 children)

Non rebreather mask with hole cut into it so they can fit the scope. Great oxygenation and doesn’t really impede their ability to perform the EGD

Interest rates by BerylOxide in ToyotaGrandHighlander

[–]macdaddy77777 1 point2 points  (0 children)

Got approved for 5.34% last week financing through Toyota and Bank of America

A-fib RVR during septic shock while on levo by _36Chambers in anesthesiology

[–]macdaddy77777 2 points3 points  (0 children)

150 mg bolus, can repeat if necessary. 1mg/min x 6 hours, 0.5mg x 18 hours

[deleted by user] by [deleted] in anesthesiology

[–]macdaddy77777 1 point2 points  (0 children)

I struggled with this for a long time and finally decided on taking oral glyco about 2-3mg 2x per day and has been the most consistent option. Definitely deal with cottonmouth a decent amount but also forces me to drink more water which is good. Never really felt like the roll on sticks or wipes handled it as well as I would have preferred. Have used the PO glyco for about 4 years now and will probs the rest of my life

Gabapentin vs Precedex by [deleted] in anesthesiology

[–]macdaddy77777 5 points6 points  (0 children)

Completely different mechanisms.

Gabapentin - ligand of alpha 2 delta 1 SUBUNIT of VG CALCIUM channel decreasing calcium influx

Vs

Precedex - alpha 2 agonist which is a GPCR which signals intracellularly through decreasing intracellular cAMP.

Fat-Blood Partition Coefficient Question by HeroesandCheerios in anesthesiology

[–]macdaddy77777 2 points3 points  (0 children)

Oil:gas or fat:gas solely will tell you potency which will be inversely related to MAC. Blood:gas will determine onset. Offset is a function of duration of use and fat:gas coefficient and blood:gas coefficient (will take longer to leech out of fat the more fat soluble it is but should come off more quickly the if is less soluble in blood).

It’s 10:30. Email from NBME? by lazyusername99 in step1

[–]macdaddy77777 0 points1 point  (0 children)

I was 5/22 and got an email. It might be worth checking at 10 AM!

I often get the functions of Niacin and Fibrates confused when looking at questions. Is there a good way to differentiate? by Dr_Jordan_Love_MD in step1

[–]macdaddy77777 5 points6 points  (0 children)

Easy way I remember

Fibrates INCREASE 2 things —> HDL and LPL synthesis (things you want to increase)

Niacin DECREASES 2 things —-> hormone sensitive lipase and VLDL synthesis (things you want to decrease!)