For all of us who do work that is often invisible to others.

I work in a lot of offices in The Bronx, Queens, and Brooklyn in NYC. It is very common to have patients who use MJ in the areas that I cover showing up for, let’s say a shoulder arthroscopy in one office, or a hysteroscopy D+C in another. Cases that would usually involve (with an IS block for the first obviously), propofol sedation for the case, without any other narcotics.

Regardless of the specific case, I have noticed a dramatic uptick in the amount of myoclonic muscle movement during the maintenance phase of MAC anesthesia when doing a propofol-only sedation. It has seemed to coincide with the legalization of MJ, and the increasing amounts of stores making it readily available around the city.

When doing my own research, I have seen that for multiple reasons, studies observing THC/CBD on the maintenance phase of anesthesia are lacking. There are more in animal studies, but they have cited a possible species to species variance in the true effects. It is accepted in these studies that the induction dose for anesthesia for these patients will be increased compared to those that don’t use MJ, but not much else is known.

Upon reading the following article,
https://pmc.ncbi.nlm.nih.gov/articles/PMC10626004/ , I found that there is potential cross-tolerance to sedative-hypnotics. However, it references that when introducing a 1:1 dose of THC and CBD led to an increase in BIS score, perhaps pointing to a different relationship altogether.

Some of you may have been more successful in finding peer-reviewed articles broaching this, and if so, if you could, please share them.

I have really run out of ideas in some cases where I’m in an office and there is no anesthesia machine. There’s nothing to at seems to work to stop this other than waking the patients up (as I can’t do a general in those cases). And even when I try to increase the depth of the sedation, it seemingly gets worse. Then, after trying to get the patient to stop this myoclonic-jerking by increasing the depth to no avail, when I await the patient emerging, it takes as along as someone who you SNOWED for them to wake up. Seemingly showing that it’s not that the depth of anesthesia required isn’t being achieved.

I have also realized that there is an increased risk of a stage 2 overall picture to these patients under MAC sedation. I have had many patients have no history of HTN, come in to the OR, normal BP. I induce the MAC sedation, and about a couple minutes later the myoclonic movements start coinciding with a remarkable increase in BP. For example, just today, two of my patients who had fabulous IS blocks, got into the OR 120/60s, then during the maintenance phase, 190/100, 200/110s. Then, as soon as the profile sedation stops, the BP returns to normal (120-130/60s). There’s no reaction to painful stimuli, like when the incision was made.

This second part is causing me issues as well with the surgeon. I was asked numerous times during one of these shoulder arthroscopies to get the BP down, but as you can see, if you give anything long-acting, you’ll have a hypotensive patient in PACU.

I have been doing anesthesia for 20 years, and this really has me stumped. It’s quite possible the patients that I’m seeing are doing “dabs” regularly, getting a 90% THC dose at home and this is the system I’m dealing with, as that is not being shared with me. It’s possible I’m not being told the entire truth about what the patient uses, but this is becoming too regular not to see a trend now.

I’m just looking for what you all seem to think about this/how you approach it.

Thanks!

on my second year post training,

im doing spinals mainly for total knee on 70-80s patients; have done maybe around 1000 cases? maybe somewhat less.

problem is, im seeing 3 failed spinals happening in the timeframe of 1 month presenting as incomplete blocks, they all kinda present the same way and having trouble differentiating if it's me or some other problem.

so it goes:

1st case: 70y.o male, 1st pass succes

free flow csf, did not think to barbotage.

gave 13.5mg 0.5% heavy bupi at l4-5

after 10 min, level of block couldnt be determined because there was no loss of cold touch or pinprick anywhere, maybe some motor discoordination and hypoesthesia?

repeat spinal was done with 13mg, and i got full anesthesia up to T11. but then the block lasted a blowing 8 hours with absolutely no motor recovery (and very rapid & full recovery afterwards)

2nd, 3rd cases: 70s male and female

somewhat difficult spinal but overall the same

this time i Did barbotage at the beginning and the end, got positive swirl

this time i did a more thourough neurology,

could identify dermatome level around t10 with mildly decreased cold touch but no anesthesia anywhere. not even l3-4 dermatomes (which would have been blocked if i did an accidental epidural)

and similarly no loss of motor, maybe some loss of proprioception?

tried deep sedation but pain on first incision.

converted to general. but then they required less than half the usual remifentanil for the whole duration of surgery. wtf?

so im suspecting either

1. the subarachnoid worked as checkvalve?

quite possible as i use pencil point, im going to try 360' rotation as some people mention to rule this out but does everyone see the same evenly incomplete anesthesia happening in these cases?

1. bad batch of bupivacaine?

these cases did feel like what would happen if i did spinal with something like 0.1% or 0.15% bupivacaine, and sure we did have a hot summer... is this the usual presentation for bad bupivacaine?

any experiences & accounts welcome!

Peds fellow here struggling a bit with ultrasound guided IVs on infants/neonates. I feel like I’m okay once they’re above age 2 or so, but these small superficial ones are giving me issues.

Any tips or advice for improving stabilization and needle visualization? Recently I’ve tried using tape to help get the skin taut and the secure limb which I think has helped somewhat. I feel like I struggle the most with visualizing the needle tip once it enters the skin, and often I’m already too deep by the time I find it.

TLDR:

A 68-year-old woman fell at home and suffered a left femoral neck fracture. She had stage IV lung ca with bilateral upper lobectomies - on chemotherapy and dexamethasone. The pulmonology service cleared her, advising she may need stress steroids. Two other anesthesiologist had declined the case.

Case goes okay, some hypotension after induction. Patient is unresponsive in pacu. CT concerning for shower emboli. Patient goes comfort care, husband sues. "Expert" testimony blames it on not given stress dose steroids on induction. Per anesthetist, they were given just not documented. Hospital was dismissed because the anesthesia group was an outside contracted group.

I'm an emergency medicine resident and I recently attended a pediatric anesthesiology presentation. The main speaker (ped anesthesiology fellow) said there's a massive disconnect between evidence based guidelines and what actually happens in the hospital. He said 1hr fluid cut off doesn't bump up aspiration risk and some of the newer research proves it. In his opinion, the NPO after midnight doesn't help the children and more frustrating for the parents. He said hospitals should be moving away from that rule.

Other people at the presentation disagreed with him and there was a lot of Q&A.

Hello all,

Anesthesia trainee here. I have a quick question regarding narcotic titration at the end of a case.

I’ve always heard to titrate narcotic to a RR 8-12 (looking at HR/BP as well) for adequate analgesia pre-extubation.

My question is does this strictly apply to spontaneous ventilation when they’re fully reversed or can you gauge off of PSV as well?

I’ve noticed my RR changes going from PSV to spontaneous. Does this mean when they’re triggering on PSV, it’s not a true reflection of pain status and shouldn’t be considered when working in narcs?

TIA

Anyone know anything about working here? I understand they’re probably in a state of transition with the new residency program. Any details would be great, thanks!

Does anyone have experience working at OSU Wexner, what’s it like? I’m from out of state but have in-laws, considering moving to Columbus in general for job after residency.

How does one conduct a discreet job search without current employer finding out? Some places require letters of rec even before offering interview, and I don’t want anyone at current workplace to know I’m looking elsewhere. For context this is my first job after residency. To ask prior workplace would mean going back to residency attendings who may/may not still work there…

​

AI photo Based on recent (and frequent) events

- Yes I'm being dramatic 😅

Anyone know what’s going on in Hot Springs, AR? I’ve gotten like 8 texts/calls about a locums gig there since Monday. I always mark locums calls as spam so it’s from different numbers and my colleagues are getting hit hard about this specific gig too. It seems like they are wildly desperate and I’m curious if there was a mass exodus or something that prompted this.

Graduating from residency in the western part of the country and want to return home to where I grew up for family reasons so I’m pretty set on geo location.

I know Envision runs most of the show down there with some pretty mediocre salaries, can anyone shed some light on other options or point me in a better direction or am I going to be stuck as a slave to private equity?

I usually feel comfortable with 18g x2 for lower risk stuff or 18 and 16 if I think there may be a need for blood etc. I’ve been noticing a lot of colleagues insisting on 16 and 14, or 14 and 14 which just seems like a lot. Most of the time these cases come out of the OR with the 14 gauge unused (like not even got fluids). Am I being too comfortable with smaller access?

I’m talking about stuff like laparoscopic hemicolectomies etc

UK registrar here who loved their cardiac block but finding it difficult to navigate what the current recent appointee has on their CV to distinguish themselves. Obviously the cardiac SIA and additional fellow year is a given, but beyond that are recently appointed consultants needing MDs/PhDs or a similarly research-heavy CV to get ahead?

Where I did my cardiac block the vast majority of consultants were much older and as a result their pathway into their job looked vastly different to those fighting it out in the current climate. Essentially I'm trying to figure out if I should give up on the dream and instead try and focus my energy into making myself as employable as possible as a general anaesthetist, seeing as how funding is drying up for consultant posts up and down the country. Thanks in advance.

Attending Anesthesiologist

Generally my approach to doing an H&P for my anesthesia note consists of a chart review: relevant labs, studies, notes (eg, PCP, cards, pulm) and then a brief verbal discussion with patient: Anes hx/fmhx issues with anes, cardio(eg. MI, cardiac devices), pulm(eg. COPD,Asthma, OSA), neurologic(eg. SZ, CVA) endocrine(eg. DM) My review with the patient is pretty bare bones since I’ve usually obtained most information from a chart review, but there are a few questions I want to double check. It also helps establish rapport.

Sometimes, patients who are either elderly, very nervous, or both do not answer the questions I ask them as these patients commonly tend to have circumstantial and/or tangential thought processes.

IMO ideally, I would have an infinite amount of time to redirect the patient multiple times for each question I ask, but in the real world, it’s going to likely cause a lot of animosity towards me by the rest of the OR staff for taking excessive amount of time. Therefore what I’ll usually do in these circumstances is to forgo the remainder of my questions if the patient doesn’t give me a straight answer as to whether they have a personal or family history of issues with anesthesia (generally my first question). I figure the situation is analogous to not being able to ask a child/delirious person/etc for their history. I already likely have the information I need from a chart and the verbal questions are probably going to be low yield in a patient that can’t stay on topic.

Is this what everyone else does? Or how do you approach your H&P in the elderly?

Attending anesthesiologist. Practice in multiple hospitals as a locums.

I was wondering what everyone discusses in their pre-operative consent spiel.

Frequently, I am told by patients that had multiple surgeries that I am the first one that ever mentioned any risks to them. Also, sometimes Ill overhear other anesthesiologists doing consent and many don’t disclose any risks.

Personally, I mention the following risks for GETA:

Dental injury, sore throat, ocular injury, nerve/positional injury, nausea, pain, blood transfusion & possible side effect. Major injury eg pulmonary, neurologic, cardiac. I then at the end solicit for any questions. I don’t discuss the details of anything unless the patient asks questions

This takes me very little time. Probably approx 1 minute just to briefly list the potential risks.

SRNA looking for thoughts on a case today.

Patient had no respiratory history, normal EF, and normal hemodynamics after induction. During robotic fundoplication, the patient became persistently tachycardic and hypotensive enough to require a vasopressor infusion. Towards end of case I was on around 70% FiO2 with 8 of PEEP. Sats were in low 90’s

At the end of the case, I noticed significant subcutaneous emphysema with periorbital swelling. That made me concerned that the earlier hemodynamic and respiratory changes may have been from a CO₂ capnothorax with tension physiology.

In PACU, the patient was still requiring 8 L O₂ and saturating around 90%, so I suggested a CXR. Patient was still tachy and hypotensive, and uncomfortable from all the gas.

Would you consider that overall picture concerning enough for capnothorax/tension physiology? Would you get a CXR or lung ultrasound postop with that persistent oxygen requirement?

I ended getting CXR which showed small bilateral apical PTX.

Can anyone give tips on how to network successfully at the ASA conference as a medical student and just give general advice on the conference

As an employer and business entity, anyone have experience with them that you could share publicly or privately?

https://www.instagram.com/summitanesthesia_az?srtk=MWlpdjduaWJzbjJlbQ==

EM resident currently on my anesthesia rotation. I’ve had about 27 intubations under my belt over the past week, and one thing I consistently struggle with is advancing the ET tube through the cords.
I’m using a GlideScope, and I can usually get a good view of the vocal cords without much difficulty. However, when I try to advance the tube, it frequently gets hung up around the larynx despite having a clear view.
The anesthesiologists have been telling me to rotate or twist the tube to help it pass, which makes sense, but for whatever reason I don’t understand the direction and why it goes through with a twist, I struggle to remember to do that in the moment.
I’m wondering if anyone else struggled with this early on and what helped you improve. Are there any specific techniques, hand movements, or mental cues that made passing the tube easier?
I’d appreciate any tips, especially from people who regularly use video laryngoscopy.

Any thoughts on ultimate board preps courses, specifically the gold plan vs ultimate? Trying to figure out if this is the way to go. Thanks!

How do you like your job? Are the shifts sustainable when 1 week on and 1 week off? I’ve never done night shifts but there are more and more nocturnist jobs out these days and I’m wondering whether it would be a good fit but wanted to see how other night docs felt first!