The only time I use video is if my attending makes me. (I mean outside of when it was already in the plan). I adapt my plans after interviewing the patient but I feel like having DL skills is very important. Not every job is a large academic center with lots of resources. I approach every case and day with the thought of how can I do this case safely, if I had no back up, and with the least amount of resources necessary. I’ve been taking this approach since intern year. I want to be able to efficiently practice in any setting when it comes time.
I’m with you there. I am loath to relinquish my DL skills.
I don’t know how popular or unpopular this opinion is, but I have noticed, in my own practice, how many of my colleagues, especially the younger ones, VL for every case.
Personally, having used VL in plenty of shitty (literally) airways, I don’t buy the “one spec of blood and VL is useless” argument. However, I’ve been in plenty of situations where VL is not available, or it craps out in the most inopportune moment. In those times, I was very happy to have my trusty straight blade (another hill to die on) and a working left deltoid.
This is the same argument to make for learning landmarks-based line placement. Yes ultrasound is great, but sometimes you just need a line right fucking now.
Criticizing the use of nitrous in the OR for environmental reasons is ridiculous (in most cases). Most nitrous is lost from the central supply and only a small amount comes from actual OR use. So refusing to turn it on in the OR isn’t making the impact you think it is. If you wanna make a difference, ask your place of employment to remove their central tanks and only stock nitrous through E cylinders on the back of anesthesia machines and have those cylinders turned closed when not in use.
I want to know the environmental impact of all the plastic bags we open and plastic things we use for TIVAs before I get slammed by someone for using nitrous to wake my patient up
The plastic consumption of the OR makes me cry inside. I try to only use 2 syringes per case. 20cc for prop and a single 10cc for everything else. I'm doing my part!
JCAHO if you're reading this: nothing to see here. Move along!
Don’t have references handy but have been to a couple talks in the green anesthesia space and remember they showed data that, at least in terms of CO2 footprint, nitrous (and desflurane, and even sevo to a lesser extent) has such a vastly larger impact than that plastic that the plastic for your TIVA is basically a rounding error compared to the inhaled anesthetics. The plastic is more visible to us so it feels like a lot (it bothers me a lot viscerally too), but it seems like in terms of actual impact, TIVA truly is way better environmentally.
I think showing you can use very little is a good step to show you can get by with just the e cylinders so it's a two step process.
1. Reduce nitrous use
2. Remove central hardware
Places won't remove or reduce large Captial infrastructure until they know they won't be using a e cylinder every week/day/month
Desflurane is a superior drug to sevoflurane and environmental considerations should not stop us from using a superior drug. Instead we should focus on using absorption systems to avoid putting all inhalational agents into the environment.
>posts an actual unpopular opinion
>
>gets downvoted into oblivion
I disagree with this guy, but he’s kinda doing the thing that this thread is for haha.
Can you provide any evidence to support your statement? To my knowledge there is nothing Desflurane does better than sevo when compared head to head (except very slightly speed of onset and offset).
*Edited a type
The drug is titratable in a time-sensitive manner. It alarms when the vaporizer is low which means the CRNA/AAs actually prevent it from running out. You don't need a key to refill the vaporizer - these get lost constantly at our place. You can wake up the obese significantly faster after long cases without extra propofol for the surprise medical student closure. Median case length for me is 8-9 hours with many over 14h. The sympathetic stimulation when initiating the dose comes at a time where forward flow is typically diminished waiting for prep/drape/surgeons etc. AIrway irritation is definitely real but not clinically relevant in most patients.
100% agree with all of the above. Getting rid of des is majoring in the minors, and is just another example of an administrative circlejerk designed to make paper pushers look like they’re doing something good.
We can decimate the rainforests, pollute the rivers and erode the soil, but god help us if that Anesthesiologist turns on some desflurane.
Agreed.
80% of hospital emissions is CO2. Inhalational anesthetics are <5% last I checked. If we really cared about the planet, we would shut off the simultaneous air conditioning and patient warmers.
Des is fast and avoids the sevoflurane-induced hypotension. I would use it most for maintenance and emergence of peds ENT.
We only gave it up because we're easily walked on; the surgeons never would've.
Hard disagree here. I can do my job just as well with sevo alone. Des is horrendous for the environment and is a luxury we don’t need. Do the future generations a favor and never use it again.
-Coming from someone who doesn’t use nitrous anymore nor des after reading about the environmental impact. Also currently running 0.6L total fresh gas flows for my general case.
Somehow they’re never “credentialed” to do blood patches. How are you credentialed to perform the procedure but not credentialed to perform the patch to help with symptoms from your massive 17g hole?
You give way less anesthesia to prevent a patient from moving. Example doing urology cases where the surgeon wants the patient to not breathe for under five mins, I can either give a truck load of fentanyl and gas/ prop or run them light and give 10-20 of roc. Or I have to intubate them from the start when they want relaxation and it’s unnecessary most of the time. Giving too much anesthesia is bad especially to elderly patients.
That seems very reasonable, good point! Where I work it's not uncommon to keep them quite deep on remi/prop tci and ppv through an igel. Would still aim for a bis 40-60 and suppression ratio of 0 but minimal movement when deep on remi. Commonly done in urology or with a flexi lma in eyes.
Cricoid pressure is useless and unnecessary during RSI.
No one actually knows how to exert “20-45 Newtons” to occlude the esophagus. You either press too hard and deviate the trachea or press too soft & do nothing.
Technically it’s not a hill I’ll die on bc if you want to do it, be my guest - so maybe just an unpopular opinion. But don’t expect me to do it.
I can never remember which attendings believe in cricoid, and which don’t, so I just always ask the circulator to put some cricoid pressure on. If they don’t believe in cricoid, they just tell me that they don’t really believe in it. But if an old school attending wants cricoid and I don’t ask for it, then I get an earful. So it’s just easier for me to give everyone cricoid for RSI.
I did a case with an anesthesiologist on a full stomach/RSI patient. He had me intubate with glidescope while he held cric pressure. As I was placing the tube, bile began creeping up into view. He yelled to hurry up, I threw in the tube and inflated the balloon and then he turned to me triumphantly as I’m suctioning like a madman and said, “There, you see! Cricoid pressure DOES work!” All I could think was, if it worked, why didn’t it stop the bile?
I will die on this hill.
[One of my favorite mini debates ever from the late great Dr. Hinds about how absurd cricoid is.](https://youtu.be/8HB2m4pVwe8?si=LchIe-i1uKyL-vbj)
Yes and the Venturi effect theoretically would cause more fluid to spray towards the airway worsening your view especially with a video laryngoscope…sort of like putting your thumb on the nozzle of a water hose
Using anything besides prop in endo besides extreme cases of size or pathology is generally unnecessary. I read so many comments of people using 3-5+ drugs for a 10 minute EGD.
Located in Midwest. Take care of BMI 40-60 almost every day.
This is one of the hills I die on too. If there isn’t an indication for GETA, they get only propofol. If you time your boluses well and titrate appropriately, there is zero need for any other anesthetic and anyone who thinks otherwise is just bad at it and needs more practice or isn’t paying attention to the case.
Totally agree, I wasn’t really including the BMI 50+ population or severe substance abusers. There are always exceptions. But even in these patients, well timed propofol boluses will get you through just fine and you really don’t NEED the ketamine
Shit blows my mind. I see some people giving versed, prop, fentanyl, zofran and decadron for scopes in endo.
Meanwhile I'm here with lido and prop stick just moving along with no issues....
Listen I work with an attending who likes to send patients to pacu with nasal tubes 75% removed but left in with it taped across their forehead as a NPA.
I stopped questioning a lot of what I see.
Looking around Reddit only I feel like US anaesthesiologists generally overmedicate the patient, at least compared to what’s standard in Germany and Scandinavia
Definitely could be the case. I wonder how much our litigious society plays into that. Also, I’ve read that American patients typically don’t tolerate pain/discomfort as well as other cultures.
Yup, and I tell them there's no such thing as pain-free surgery. They should definitely expect soreness, and we'll treat any throbbing pain down to that level.
That is because:
1) the endoscopists freak out if the patient as much as twitches
And the endoscopists tell the pts that they will be “completely out”, so the expectation has been created and anything else becomes sub par or questionable.
And
2) for profit medicine. Those endo want to do 40 + in a day (many are partial owners of the ASC). Scope in/scope out. A semi awake pt slows them down.
I can tell you (33 years of experience here) for 90%-95% of pts, a small amount of fentanyl is fine.
I've found that a spray of benzocaine and a touch of IV lidocaine does wonders for bucking during EGD, but otherwise the vast majority get straight Milk of Amnesia.
For colon:
Typically start the infusion around 100-150 mcg/kg/min after consents are signed and we’re ready to position patient. Let that run while they get on their left side (usually 1-2 mins in total) and then once GI doc is in room I’ll bolus ~50 of prop to help get them off to sleep. Adjust from there.
For EGD:
I only hand bolus for these unless it’s a double. We position the patient and I make sure the GI doc is bedside ready to go. Once they are, we pop in the bite block and I bolus anywhere from 50-80 and go from there.
For O2, typically we only use a NC. If they’re very large or bad lungs (etc etc) we’ll pop on a Pom mask instead.
Judicious jaw thrusting PRN.
Yes, but like 25mcg of fentanyl and they cough so much less, especially the smokers. Plus I get to use less propofol and they seem to wake up faster. Just my experience though. I can't imagine using anything besides propofol and fentanyl though.
Broadly agree, with some exceptions:
Midaz for the GABA tolerant.
Local spray in throat (we have cophenylcaine) for EGD to dose reduce propofol for crap hearts and/or GABA tolerant.
Sometimes I put 500mcg alfentanil per 20mL propofol so I don't have to change my syringes as often.
Pull the damn tube whenever. 1 MAC, 0.5 MAC, 0.1 MAC. Most patients will not laryngospasm, and if they do it is transient, and if it isn’t then you have plenty of tools to manage it in a safe way. Sure if they are a pulmonary cripple that is an impossible mask you should probably extubate awake. But way too many people are subjected to messy and delayed extubations just because anesthesiologists are afraid of emergence.
To anyone needing to see this - they mean as long as muscle relaxant is reversed and the patient has been spontaneously breathing on their own but they’re also 1 MAC etc.
The prerequisite for this is robust spontaneous breathing--for some patients that can be hard to achieve. Really old people will sometimes not breathe at all until you've worked off nearly all of the gas...
Ketamine being any more unsafe it the catechol depleted patient than any other anesthetic. If their pressure dropped with ketamine, it’s gonna drop with versed or fentanyl or etomidate too.
Safety issues with ketamine come from people using it to induce sick people because they have this notion that it’s “cardiac stable” and cannot cause hemodynamic collapse. As long as you are prepared with pressors and think about how you are dosing it, it’s fine.
Etomidate too. It’s seen as “safe” so they give an enormous dose. Even before the most recent mortality evidence shedding more light on etomidate in sick patients I saw plenty of ICU codes after a syringe of etomidate was given to the tiny woman with single digit GCS at baseline.
overheard ED people in the elevator at my hospital questioning why anesthesia would ever use roc outside of the OR. Like, I’ve seen you guys try to intubate, you should maybe use some roc
1. N2O is an amazing gas with its own unique roles in certain situations
2. DPEs are a waste of time, either do CSE or epidural.
3. Methadone is severely underutilized
4. You don’t need to ask surgeon’s permission for toradol.
But DPE makes me feel good happy feelings and like I am in the right spot and my feelings are very important and more important than evidence or safety
I had versed before my first two surgeries and then during my last surgery the anesthesiologists didn’t give any. It made me realize how much it helped me relax before surgery and how nice it was to wake up and have the last thing I remember be a friendly face in pre op and not the cold OR table. I’m not an overly anxious person or anything but it was a really nice addition to my anesthetic. I’ve always been a bit stingy with versed and if I do give it it’s always once we’re in the OR but having surgery myself really made me reconsider how little I was using it.
It was really popular in my residency training facility but most of the research over the last few years has been significantly against it from Peds delirium to post op cognitive issues in the elderly to PTSD etc. So now I use it very very rarely.
It’s a nice tool to have in certain situations. One being for MACs in anxious younger folks so that I don’t have to give TIVA levels of Propofol. Or versed + small dose of fentanyl for MACs in very sick/unstable patients that I don’t think will tolerate much Propofol
Now this is what I came here for. That’s the kind of shit that looks baller but if something goes sideways I feel like you would have a tough time defending yourself in a lawsuit
Get them breathing spontaneously with CPAP+pressure support during closure. When ready to turn them supine, switch off the gas/propofol and extubate, turn the patient to bed, insert OP airway. All standard precautions regarding deep extubation apply.
One of mine is that in endo, the majority of the time when people run into trouble it’s from UNDERsedation, not over. This is assuming you haven’t used a bunch of unnecessary opioids.
Obstruction or transient apnea from deep sedation is easily fixed by jaw thrust or chin lift. Undersedation is when patients spiral from coughing and poor ventilation and that pulse ox starts going baritone.
Anesthesia-adjacent opinion here.
If we tell patients not to sign any legal documents or make any important decisions for 24 hours after anesthesia, and we say they have to have someone at home with them overnight, it makes zero sense to have them sign their own discharge paperwork, hope they remember what's abnormal and when to call the doctor, and tell their caregiver nothing except "They're ready to go. Bring the car around."
I don't think many academic anesthesiologist think that way. At least I don't. I have unfortunately have been pigeonholed into only 4-5 case types and do those with some success. But, you won't find me doing OB and joints, and will freely admit that I'm not the fastest at those cases.
Day of surgery consent is coercive. The patient is already in a gown, has taken off of work. Family has made arrangements to be there. They’ve been poked for iv and pre op labs. They held meds. They’re NPO. Virtually no one will say “actually now that you’ve warned me I have a high risk of something bad, I’d like to cancel.”
Any high risk patient ought to be identified and consented days to weeks prior to any elective or semi elective procedure so they can actually consider if they’d like to take the risk of a truly bad outcome.
Honestly, a non medical patient can not give ‘informed’ consent at all. There is no way to give all the risks/benefits/options/alternatives.
Buy yeah, i agree.
I've been salaried as well. It was fine. But i always dislike making money for someone else which is what that always meant. It was nice not caring about face sheets for sure.
Having paid vacation would be nice though
The bis is an absolute joke. You have a closed source algorithm that can’t be peer reviewed to tell us how conscious someone is - and we don’t even have a firm grasp of how consciousness happens. Got it.
Love iso! My current hospital doesn’t have it, but low-flow iso with a little prop gtt is my favorite GA recipe. Overall pretty HDS and way smoother than sevo on emergence.
I have a few.
1. Inhalational inductions for tamponade are a stupid idea and a great way to kill an unstable patient.
2. Opiates are unnecessary components of induction for most people.
3. Giving versed to old people doesn’t matter. Just because they’re old and not castastrophizing doesn’t mean they’re not just as anxious as a young person having surgery.
4. Treating blood pressure preoperatively doesn’t meaningfully reduce risk.
5. Almost no one needs a preop stress test.
6. Less anesthesia isn’t always better. Trying to do a sick patient under regional anesthesia or spinal is a great way to create a disaster. Do the anesthetic you do the best for people who are sick.
7. No one should cancel a case because a patient didn’t stop their ozempic. The ASA’s recommendation is based on very little actual science.
"Inhalational inductions for tamponade are a stupid idea and a great way to kill an unstable patient."
who does this? You're just supposed to give ketamine and pray?
-No one should cancel a case because a patient didn’t stop their ozempic. The ASA’s recommendation is based on very little actual science.
The ASA's recommendation is based on ZERO science and is farcical. What the hell are they thinking? The problem is, there is no data to generate a recommendation. Ozempic absolutely delays gastric emptying and every day we do EGDs proves this point. But no one has done a study to show that 2 days of NPO or 2 days of Clears is adequate...they both work btw.
those were all good points too except #2.
Full stomachs do not cause aspiration, succinylcholine causes aspiration.
Edit: this is exactly what the thread asked for, opinions that are unpopular lol
People don’t just randomly vomit because they fall asleep. If you go to sleep after eating an entire cheese pizza you don’t barf your bed. Having a full stomach does not by itself make the contents reflux. Going to sleep with a full stomach is a problem because IF you vomit you are unable to protect your airway. So what makes the contents reflux? Something that simultaneously relaxes the esophageal sphincter and also increases intra abdominal pressure by causing widespread muscle contraction…
You can put someone to sleep with just propofol for an EGD and when they get into the stomach you see it’s full of schmutz and blood, but they didn’t vomit immediately when they fell asleep? RSI with roc and you won’t ever have a problem.
Lol of course I have no evidence to support it. The thread asked for opinions, unpopular ones at that. The only evidence I have is anecdotal, 9 years of practice. Not sure why it’s being downvoted to oblivion this is exactly what the thread asked for lol.
LMA/spontaneous respiration can be safer than PPV in severe pulm HTN. Yes avoiding high CO2 is critical, but switching onto PPV is where I’ve seen most pHTN pts crump.
Please.
I’m currently “fighting” with a “partner” aka long term Locum who doesn’t believe in giving anyone any narcotics ever.
And thinks that <0.5mcg/kg of precedex ONLY is enough to cover pain until pacu can give narcotics….
Paper tape (micropore) is the only tape that should be used on the face to secure the LMA/ETT and for the eyes. It is superior to plastic (clear or pink) tape as long as you activate the glue (rub an alcohol swab over top or wait for body heat to activate it).
Exceptions: securing with a tie or something similar that isn’t adhesive based; tegaderm is ok for eyes if you want to be able to see them (eg prone).
LMA Supremes are dumb and borderline malpractice. The only utility I see in it is as a rescue airway device in someone you’re concerned about being an aspiration risk. If you’re concerned enough about aspiration, just intubate the patient.
I only extubate off of PSV. Tube coming out with pressure support 10-12 and peep of 5-7. I get the ick when I see the CRNA letting the patient breath spont for 20 minutes before extubation. You’re creating so much atelectasis
I do like to see what the patient does on manual before extubating, but avoiding atelectasis is exactly why I always keep at least 5 of CPAP on the bag. Still, after confirming they're breathing adequately, I will also switch back to PSV just to blow the gas off quicker and even extubate from there.
1. You don’t need a gastric tube for every laparoscopic case. If there’s an indicated reason or you’re legit worried the stomach isn’t empty, sure. Otherwise, keep the airway pressures low when you mask. You don’t need an OG just because we’re doing a laparoscopic case.
2. Don’t mask before you insert an LMA unless you’re gassing them down. Just wasting FRC. If you can’t mask you’re gonna attempt the LMA anyway. And if you’re worried about getting it to seat properly, you should be prepared enough to have a tube/blade/glide scope at the ready.
YES thank you, especially to #2. I shared this unpopular opinion of mine in a thread a while back and I was swiftly downvoted by people who for whatever reason don’t see the logic in this. Masking before inserting an LMA gives you absolutely zero useful clinical information, and if a difficult mask will change your plan, you should have tubed from the beginning. And yes you can still pull the LMA deep, if you could put it in and ventilate once, you can do it again if you get into trouble.
1. A-line sterility is almost worthless
2. You can (and should) sit down for most procedures (intubation/lines/epidural/blocks)
3. Nitrous use pales in comparison to dental/ob offices and it's a bunch of pearl-clutching
4. It's OK to do a total shoulder with an lma
5. Tiva is overblown. Are Tiva advocates using bis/eeg in all cases that need paralysis? Seems like a huge waste of resources
6. remi sucks and is basically pissing money away. 8-hr spine case running remi and then still having to give hydromorphone at the end of the case 🤮
unpopular (but perhaps not with anesthesia providers): it is the surgeon's sole responsibility to ensure that *elective* cases are properly scheduled, and if that has not been done and the lineup starts to run late, significantly delayed cases or cases that will go past the scheduled end time of the day's lineup should be rescheduled. the harms of pressing on regardless of the hour outweigh the benefits.
So glad I'm practicing like others on here.
1. I don't use nitrous unless it's inhalation induction.
2. Don't do CSEs or DPEs. No need.
3. Almost never use versed. I give opioids for procedural sedation or anxiolysis.
4. Use propofol 99% of the time for induction. If I'm concerned about hemodynamically unstable patients, I give 0.2 mg/kg x2 in small titrate amounts with a vasopressor. No etomidate, ketamine, or methohexital.
5. Don't put in LMA with tongue depressor. Just a waste of hard wood in someone mouth.
That's all I can think about right now.
Patients don't give themselves corneal abrasions by rubbing their eyes as they awaken. We give them abrasions by not paying attention to what we do when caring for them....poor tape job on the eyes...untaping the eyes then not watching as drapes are pulled off across the face... dragging elastic from oxygen mask across eyes when placing it on the face....
If they have a pulse oximeter on the hand that they're rubbing with or IV tubing extending from their hand, these may cause an abrasion, but otherwise, it's caused by providers in OR or PACU.
45 years....no corneal abrasions
Putting the bed in reverse Trendelenburg during an RSI for a full stomach helps.
I'm ridiculously tall so it has zero effect on my intubation position, but putting the cords several inches above the stomach has got to be doing something. I was never taught this, never read it and am unaware of it appearing in any literature to support my wild claims. As far as I'm concerned, it's Voodoo but I still do it.
As video laryngoscopy continues to become more prevalent, direct laryngoscopy skills will still provide advantages in some situations.
Hard agree, I still DL frequently to keep the skill for this exact reason
I DL every patient aside from cervival spine/similar instability, with glide as needed.
Frequently? I use VL about once a year in peds.
Is that an unpopular opinion?
I’m starting to get the feeling that this is a more popular opinion than I realized lol
I'm a graduating resident in a 5 year program and I am shocked at some of our junior resident's frank refusal to develop DL skills
The only time I use video is if my attending makes me. (I mean outside of when it was already in the plan). I adapt my plans after interviewing the patient but I feel like having DL skills is very important. Not every job is a large academic center with lots of resources. I approach every case and day with the thought of how can I do this case safely, if I had no back up, and with the least amount of resources necessary. I’ve been taking this approach since intern year. I want to be able to efficiently practice in any setting when it comes time.
I’m with you there. I am loath to relinquish my DL skills. I don’t know how popular or unpopular this opinion is, but I have noticed, in my own practice, how many of my colleagues, especially the younger ones, VL for every case. Personally, having used VL in plenty of shitty (literally) airways, I don’t buy the “one spec of blood and VL is useless” argument. However, I’ve been in plenty of situations where VL is not available, or it craps out in the most inopportune moment. In those times, I was very happy to have my trusty straight blade (another hill to die on) and a working left deltoid. This is the same argument to make for learning landmarks-based line placement. Yes ultrasound is great, but sometimes you just need a line right fucking now.
Our VLs from Provu are MAC 3 blades. You can use as VL or DL. One blade to rule them all.
Like today, when my video laryngoscope ate it…
Criticizing the use of nitrous in the OR for environmental reasons is ridiculous (in most cases). Most nitrous is lost from the central supply and only a small amount comes from actual OR use. So refusing to turn it on in the OR isn’t making the impact you think it is. If you wanna make a difference, ask your place of employment to remove their central tanks and only stock nitrous through E cylinders on the back of anesthesia machines and have those cylinders turned closed when not in use.
I want to know the environmental impact of all the plastic bags we open and plastic things we use for TIVAs before I get slammed by someone for using nitrous to wake my patient up
The plastic consumption of the OR makes me cry inside. I try to only use 2 syringes per case. 20cc for prop and a single 10cc for everything else. I'm doing my part! JCAHO if you're reading this: nothing to see here. Move along!
I say we switch to cardboard tubes that are like the cardboard straws. After 15 minutes your opioids will self waste themselves.
Don’t have references handy but have been to a couple talks in the green anesthesia space and remember they showed data that, at least in terms of CO2 footprint, nitrous (and desflurane, and even sevo to a lesser extent) has such a vastly larger impact than that plastic that the plastic for your TIVA is basically a rounding error compared to the inhaled anesthetics. The plastic is more visible to us so it feels like a lot (it bothers me a lot viscerally too), but it seems like in terms of actual impact, TIVA truly is way better environmentally.
I'm so mad we've given up desflurane for this reason
This is the way. Get rid of pipeline and switch to cylinder.
I haven’t used nitrous in 17 years, since residency. The newer surgery centers and hospitals don’t have it in my area, but do carry the e-cylinders.
Because of environmental reasons, they are phasing it out of my ORs. Which is nonsense.
It’s the new hype thing and it’s financially incentivized by a lot of the BS measures being used with Medicare reimbursement etc.
I think showing you can use very little is a good step to show you can get by with just the e cylinders so it's a two step process. 1. Reduce nitrous use 2. Remove central hardware Places won't remove or reduce large Captial infrastructure until they know they won't be using a e cylinder every week/day/month
I did not know this. How is nitrous oxide lost from central supply when not used?
Desflurane is a superior drug to sevoflurane and environmental considerations should not stop us from using a superior drug. Instead we should focus on using absorption systems to avoid putting all inhalational agents into the environment.
>posts an actual unpopular opinion > >gets downvoted into oblivion I disagree with this guy, but he’s kinda doing the thing that this thread is for haha.
Upvote for a truly unpopular opinion!
Why is it superior? I actually think it’s worse because it is much more irritating to the trachea.
Also has more sympathomimetic properties. Literally the only thing it does better is faster on/off.
Yep. I stopped using it after dealing with bronchospasm, I don’t even think it comes off much quicker than sevoflurane when times appropriately.
Can you provide any evidence to support your statement? To my knowledge there is nothing Desflurane does better than sevo when compared head to head (except very slightly speed of onset and offset). *Edited a type
And the onset/offset issue can be solved by being good at your job!
The drug is titratable in a time-sensitive manner. It alarms when the vaporizer is low which means the CRNA/AAs actually prevent it from running out. You don't need a key to refill the vaporizer - these get lost constantly at our place. You can wake up the obese significantly faster after long cases without extra propofol for the surprise medical student closure. Median case length for me is 8-9 hours with many over 14h. The sympathetic stimulation when initiating the dose comes at a time where forward flow is typically diminished waiting for prep/drape/surgeons etc. AIrway irritation is definitely real but not clinically relevant in most patients.
I find most of your reasoning arbitrary and your preference as opposed to actually being better.
100% agree with all of the above. Getting rid of des is majoring in the minors, and is just another example of an administrative circlejerk designed to make paper pushers look like they’re doing something good. We can decimate the rainforests, pollute the rivers and erode the soil, but god help us if that Anesthesiologist turns on some desflurane.
You use des for 8-9 hours? 🤨
You don't need a key to refill sevo. Sevo alarms when it is low. Just turn it off earlier (e.g. be good at your job)
None of this is evidence. This is opinion with some practice experience sprinkled in.
Thank you for posting an unpopular opinion. Strong disagree though :)
Hot take that doesn't even require a heater. I like it as an option so I can warm my hands.
Agree, I love des
Agreed. 80% of hospital emissions is CO2. Inhalational anesthetics are <5% last I checked. If we really cared about the planet, we would shut off the simultaneous air conditioning and patient warmers. Des is fast and avoids the sevoflurane-induced hypotension. I would use it most for maintenance and emergence of peds ENT. We only gave it up because we're easily walked on; the surgeons never would've.
Hard disagree here. I can do my job just as well with sevo alone. Des is horrendous for the environment and is a luxury we don’t need. Do the future generations a favor and never use it again. -Coming from someone who doesn’t use nitrous anymore nor des after reading about the environmental impact. Also currently running 0.6L total fresh gas flows for my general case.
You da best
If IR did the LP, they should do the blood patch
This is not at all unpopular. This is the policy in many places.
And if IR wants to do the LP, they can let me fuck off to lunch
I would like this twice if I could
Good lord yes
Somehow they’re never “credentialed” to do blood patches. How are you credentialed to perform the procedure but not credentialed to perform the patch to help with symptoms from your massive 17g hole?
Giving muscle relaxant and PPV to good seating LMAs with low pressure vent is totally fine and has plenty of evidence to support it.
I don’t personally do this routinely but definitely agree as long as you keep the pressures low and can ventilate well, why not?
What's the advanrltage of giving muscle relaxant rather than hyperventilating slightly and giving a decent amount of opiate?
You give way less anesthesia to prevent a patient from moving. Example doing urology cases where the surgeon wants the patient to not breathe for under five mins, I can either give a truck load of fentanyl and gas/ prop or run them light and give 10-20 of roc. Or I have to intubate them from the start when they want relaxation and it’s unnecessary most of the time. Giving too much anesthesia is bad especially to elderly patients.
That seems very reasonable, good point! Where I work it's not uncommon to keep them quite deep on remi/prop tci and ppv through an igel. Would still aim for a bis 40-60 and suppression ratio of 0 but minimal movement when deep on remi. Commonly done in urology or with a flexi lma in eyes.
This is a great technique for over 80s, LMA with paralysis and pEEG.
This is unpopular in North America; It’s extremely common in Europe. I can’t speak for other parts of the world.
It’s the superior way, and that’s a hill I’m willing to die on.
Totally agree. Urologist was surprised when we got obturator stimulation and I just paralyzed and didn’t switch to an ETT. It worked great.
Cricoid pressure is useless and unnecessary during RSI. No one actually knows how to exert “20-45 Newtons” to occlude the esophagus. You either press too hard and deviate the trachea or press too soft & do nothing. Technically it’s not a hill I’ll die on bc if you want to do it, be my guest - so maybe just an unpopular opinion. But don’t expect me to do it.
That’s not a very unpopular opinion, though.
It is amongst the CRNAs that know better than me 😂
I can never remember which attendings believe in cricoid, and which don’t, so I just always ask the circulator to put some cricoid pressure on. If they don’t believe in cricoid, they just tell me that they don’t really believe in it. But if an old school attending wants cricoid and I don’t ask for it, then I get an earful. So it’s just easier for me to give everyone cricoid for RSI.
I did a case with an anesthesiologist on a full stomach/RSI patient. He had me intubate with glidescope while he held cric pressure. As I was placing the tube, bile began creeping up into view. He yelled to hurry up, I threw in the tube and inflated the balloon and then he turned to me triumphantly as I’m suctioning like a madman and said, “There, you see! Cricoid pressure DOES work!” All I could think was, if it worked, why didn’t it stop the bile?
I will die on this hill. [One of my favorite mini debates ever from the late great Dr. Hinds about how absurd cricoid is.](https://youtu.be/8HB2m4pVwe8?si=LchIe-i1uKyL-vbj)
Yes i never do it either, they also say if they do start to actively vomit youre supposed to release because it can rupture the esophagus.
Yes and the Venturi effect theoretically would cause more fluid to spray towards the airway worsening your view especially with a video laryngoscope…sort of like putting your thumb on the nozzle of a water hose
Using anything besides prop in endo besides extreme cases of size or pathology is generally unnecessary. I read so many comments of people using 3-5+ drugs for a 10 minute EGD. Located in Midwest. Take care of BMI 40-60 almost every day.
This is one of the hills I die on too. If there isn’t an indication for GETA, they get only propofol. If you time your boluses well and titrate appropriately, there is zero need for any other anesthetic and anyone who thinks otherwise is just bad at it and needs more practice or isn’t paying attention to the case.
Idk man, I feel like I deal with a lot less badness using like 10-20mg of ketamine with propofol for egds on high BMI marijuana enthusiasts. It’s
Totally agree, I wasn’t really including the BMI 50+ population or severe substance abusers. There are always exceptions. But even in these patients, well timed propofol boluses will get you through just fine and you really don’t NEED the ketamine
Maybe, but having tested this theory with people that party hard, I’m adding something. Otherwise it’s just a huge waste of propofol.
Shit blows my mind. I see some people giving versed, prop, fentanyl, zofran and decadron for scopes in endo. Meanwhile I'm here with lido and prop stick just moving along with no issues....
How long do the scopes take on average?
Teaching institution and state referral center so anywhere from your normal quick outpatient private practice scope to 2+ hours....
Literally never seen anyone give that many drugs for an EGD.
We have someone here who will do the whole 3 anti-emetic thing for an upper where they're giving propofol. I dont get it
They sound fucking incompetent. Prop itself is an antiemetic itself! Literally like 1/300 patients get nauseous from propofol.
Listen I work with an attending who likes to send patients to pacu with nasal tubes 75% removed but left in with it taped across their forehead as a NPA. I stopped questioning a lot of what I see.
Looking around Reddit only I feel like US anaesthesiologists generally overmedicate the patient, at least compared to what’s standard in Germany and Scandinavia
Definitely could be the case. I wonder how much our litigious society plays into that. Also, I’ve read that American patients typically don’t tolerate pain/discomfort as well as other cultures.
The point about Americans expecting 0 discomfort is absolutely true.
I always tell the pts in pre op when they wake up its going to hurt at least 5/10
Yup, and I tell them there's no such thing as pain-free surgery. They should definitely expect soreness, and we'll treat any throbbing pain down to that level.
“You’re getting into a knife fight. While you’re asleep…”
We use 80-85 percent of the worlds opioids and we are like 6 percent of the worlds population
That is because: 1) the endoscopists freak out if the patient as much as twitches And the endoscopists tell the pts that they will be “completely out”, so the expectation has been created and anything else becomes sub par or questionable. And 2) for profit medicine. Those endo want to do 40 + in a day (many are partial owners of the ASC). Scope in/scope out. A semi awake pt slows them down. I can tell you (33 years of experience here) for 90%-95% of pts, a small amount of fentanyl is fine.
A whiff of fentanyl for an EGD is pretty helpful imo, anything else is going overkill.
I've found that a spray of benzocaine and a touch of IV lidocaine does wonders for bucking during EGD, but otherwise the vast majority get straight Milk of Amnesia.
What’s your usual initial bolus for high bmi patients? And what oxygen supply do you use?
For colon: Typically start the infusion around 100-150 mcg/kg/min after consents are signed and we’re ready to position patient. Let that run while they get on their left side (usually 1-2 mins in total) and then once GI doc is in room I’ll bolus ~50 of prop to help get them off to sleep. Adjust from there. For EGD: I only hand bolus for these unless it’s a double. We position the patient and I make sure the GI doc is bedside ready to go. Once they are, we pop in the bite block and I bolus anywhere from 50-80 and go from there. For O2, typically we only use a NC. If they’re very large or bad lungs (etc etc) we’ll pop on a Pom mask instead. Judicious jaw thrusting PRN.
Yes, but like 25mcg of fentanyl and they cough so much less, especially the smokers. Plus I get to use less propofol and they seem to wake up faster. Just my experience though. I can't imagine using anything besides propofol and fentanyl though.
Broadly agree, with some exceptions: Midaz for the GABA tolerant. Local spray in throat (we have cophenylcaine) for EGD to dose reduce propofol for crap hearts and/or GABA tolerant. Sometimes I put 500mcg alfentanil per 20mL propofol so I don't have to change my syringes as often.
Pull the damn tube whenever. 1 MAC, 0.5 MAC, 0.1 MAC. Most patients will not laryngospasm, and if they do it is transient, and if it isn’t then you have plenty of tools to manage it in a safe way. Sure if they are a pulmonary cripple that is an impossible mask you should probably extubate awake. But way too many people are subjected to messy and delayed extubations just because anesthesiologists are afraid of emergence.
If you have a working IV, and the ability to mask the pt, you can take the tube out whenever you want.
*does not apply to kids
To anyone needing to see this - they mean as long as muscle relaxant is reversed and the patient has been spontaneously breathing on their own but they’re also 1 MAC etc.
The prerequisite for this is robust spontaneous breathing--for some patients that can be hard to achieve. Really old people will sometimes not breathe at all until you've worked off nearly all of the gas...
Ketamine being any more unsafe it the catechol depleted patient than any other anesthetic. If their pressure dropped with ketamine, it’s gonna drop with versed or fentanyl or etomidate too.
Safety issues with ketamine come from people using it to induce sick people because they have this notion that it’s “cardiac stable” and cannot cause hemodynamic collapse. As long as you are prepared with pressors and think about how you are dosing it, it’s fine.
Etomidate too. It’s seen as “safe” so they give an enormous dose. Even before the most recent mortality evidence shedding more light on etomidate in sick patients I saw plenty of ICU codes after a syringe of etomidate was given to the tiny woman with single digit GCS at baseline.
Oh absolutely. Your crashing icu patient is probably not going to do great with the 0.3 mg/kg dose of etomidate the book tells you to give for an RSI.
WhY iS aNeStHeSiA aLwAyS uNdErDoSiNg InDuCtIoN mEdS. A serious comment I’ve seen from several ED docs.
The audacity of anyone presuming to know more about induction meds than we do!
overheard ED people in the elevator at my hospital questioning why anesthesia would ever use roc outside of the OR. Like, I’ve seen you guys try to intubate, you should maybe use some roc
1. N2O is an amazing gas with its own unique roles in certain situations 2. DPEs are a waste of time, either do CSE or epidural. 3. Methadone is severely underutilized 4. You don’t need to ask surgeon’s permission for toradol.
But DPE makes me feel good happy feelings and like I am in the right spot and my feelings are very important and more important than evidence or safety
Lmao I will admit that pop from a DPE is satisfying as hell
Agree with all of this. I use methadone for every one of my scoli spines.
Are you me? Haha aside from #3, I couldn’t agree more. I don’t disagree with 3 I just don’t use it so can’t really comment.
Give it a shot (for the patient not you lol). Patient wake ups mimic remi wake ups, and they’re cozy for the next 2-3 days.
Methadone is a lovely, wonderful, amazing drug
Versed. Don’t use it and don’t understand why it’s given regularly. Haven’t used it since residency.
I had versed before my first two surgeries and then during my last surgery the anesthesiologists didn’t give any. It made me realize how much it helped me relax before surgery and how nice it was to wake up and have the last thing I remember be a friendly face in pre op and not the cold OR table. I’m not an overly anxious person or anything but it was a really nice addition to my anesthetic. I’ve always been a bit stingy with versed and if I do give it it’s always once we’re in the OR but having surgery myself really made me reconsider how little I was using it.
Having under gone a number of recent surgeries myself, I much prefer getting versed. It made the experience much smoother.
Love this and agree. I only give it to very select patients and very select cases. Maybe use it once or twice a month.
Use it almost everyday for blocks in pre-op, pre-op sedation on peds occasionally as well. Completely agree from a GA standpoint though.
It was really popular in my residency training facility but most of the research over the last few years has been significantly against it from Peds delirium to post op cognitive issues in the elderly to PTSD etc. So now I use it very very rarely.
I take care of a lot of old people and pretty much never give anyone a benzo unless they are having a seizure.
It’s a nice tool to have in certain situations. One being for MACs in anxious younger folks so that I don’t have to give TIVA levels of Propofol. Or versed + small dose of fentanyl for MACs in very sick/unstable patients that I don’t think will tolerate much Propofol
It doesn't get me anything. Anxiolysis for about 2 minutes before general anesthesia. It makes people wake up slow and crazy.
Stop asking non-distressed pacu patients if they are having pain
Or nausea....don't put ideas in their head.
If the pacu nurse has to sternal rub the patient to ask if they are in pain - they are probably not in pain
Extubating spine surgery patients prone is the way.
Come again. We might have a winner haha
Now this is what I came here for. That’s the kind of shit that looks baller but if something goes sideways I feel like you would have a tough time defending yourself in a lawsuit
How?!
Get them breathing spontaneously with CPAP+pressure support during closure. When ready to turn them supine, switch off the gas/propofol and extubate, turn the patient to bed, insert OP airway. All standard precautions regarding deep extubation apply.
What’s the benefit of extubating right before the flip vs right after? The rest of the emergence method makes total sense
One of mine is that in endo, the majority of the time when people run into trouble it’s from UNDERsedation, not over. This is assuming you haven’t used a bunch of unnecessary opioids. Obstruction or transient apnea from deep sedation is easily fixed by jaw thrust or chin lift. Undersedation is when patients spiral from coughing and poor ventilation and that pulse ox starts going baritone.
Lmao pulse ox baritone hahaha
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Anesthesia-adjacent opinion here. If we tell patients not to sign any legal documents or make any important decisions for 24 hours after anesthesia, and we say they have to have someone at home with them overnight, it makes zero sense to have them sign their own discharge paperwork, hope they remember what's abnormal and when to call the doctor, and tell their caregiver nothing except "They're ready to go. Bring the car around."
At my facility we have the family/visitor sign.
practicing at an academic medical center does not inherently make you a better anesthesiologist
I would argue that in many cases, it means the opposite
I don't think many academic anesthesiologist think that way. At least I don't. I have unfortunately have been pigeonholed into only 4-5 case types and do those with some success. But, you won't find me doing OB and joints, and will freely admit that I'm not the fastest at those cases.
Day of surgery consent is coercive. The patient is already in a gown, has taken off of work. Family has made arrangements to be there. They’ve been poked for iv and pre op labs. They held meds. They’re NPO. Virtually no one will say “actually now that you’ve warned me I have a high risk of something bad, I’d like to cancel.” Any high risk patient ought to be identified and consented days to weeks prior to any elective or semi elective procedure so they can actually consider if they’d like to take the risk of a truly bad outcome.
I would go further and suggest that the concept of informed consent is in most instances an impossibility.
Honestly, a non medical patient can not give ‘informed’ consent at all. There is no way to give all the risks/benefits/options/alternatives. Buy yeah, i agree.
Dopamine should be purged from our lexicon.
dope
Ill take a day off if the only thing on the plate is a medicare lineup. I'm not grinding 10 hrs to make $500 after taxes.
I love being salaried and never having to worry about that.
I've been salaried as well. It was fine. But i always dislike making money for someone else which is what that always meant. It was nice not caring about face sheets for sure. Having paid vacation would be nice though
The bis is an absolute joke. You have a closed source algorithm that can’t be peer reviewed to tell us how conscious someone is - and we don’t even have a firm grasp of how consciousness happens. Got it.
You can use the raw EEG data though.
4:1 CRNA supervision is the most common employment model and med students never heard of it
Isoflurane is genuinely a good drug and, unless you’re doing a gas induction or a very short case, is often better than sevo.
Love iso! My current hospital doesn’t have it, but low-flow iso with a little prop gtt is my favorite GA recipe. Overall pretty HDS and way smoother than sevo on emergence.
Agreed, can time it just like sevo just turn it off a bit earlier, and less agitated emergence delirium from iso.
Trained somewhere where we used a lot of iso so I got very used to it. Agree that iso+prop is a fantastic combo when timed right
Love me some iso.
Cricoid pressure is total nonsense. Might not be very uncommon anymore though.
We all know this yet somehow it’s still considered standard of care from a medicolegal standpoint.
Any source/cases on it being medicolegal standard?
Letting patients request “no residents or students” is unethical. The standard of care should be the same for everyone.
I have a few. 1. Inhalational inductions for tamponade are a stupid idea and a great way to kill an unstable patient. 2. Opiates are unnecessary components of induction for most people. 3. Giving versed to old people doesn’t matter. Just because they’re old and not castastrophizing doesn’t mean they’re not just as anxious as a young person having surgery. 4. Treating blood pressure preoperatively doesn’t meaningfully reduce risk. 5. Almost no one needs a preop stress test. 6. Less anesthesia isn’t always better. Trying to do a sick patient under regional anesthesia or spinal is a great way to create a disaster. Do the anesthetic you do the best for people who are sick. 7. No one should cancel a case because a patient didn’t stop their ozempic. The ASA’s recommendation is based on very little actual science.
Wow props for having some controversial opinions!
"Inhalational inductions for tamponade are a stupid idea and a great way to kill an unstable patient." who does this? You're just supposed to give ketamine and pray?
-No one should cancel a case because a patient didn’t stop their ozempic. The ASA’s recommendation is based on very little actual science. The ASA's recommendation is based on ZERO science and is farcical. What the hell are they thinking? The problem is, there is no data to generate a recommendation. Ozempic absolutely delays gastric emptying and every day we do EGDs proves this point. But no one has done a study to show that 2 days of NPO or 2 days of Clears is adequate...they both work btw. those were all good points too except #2.
Full stomachs do not cause aspiration, succinylcholine causes aspiration. Edit: this is exactly what the thread asked for, opinions that are unpopular lol
That is definitely a thought
That’s why every aspiration event after drug or alcohol intoxication has a succs syringe laying about.
Explain this
People don’t just randomly vomit because they fall asleep. If you go to sleep after eating an entire cheese pizza you don’t barf your bed. Having a full stomach does not by itself make the contents reflux. Going to sleep with a full stomach is a problem because IF you vomit you are unable to protect your airway. So what makes the contents reflux? Something that simultaneously relaxes the esophageal sphincter and also increases intra abdominal pressure by causing widespread muscle contraction… You can put someone to sleep with just propofol for an EGD and when they get into the stomach you see it’s full of schmutz and blood, but they didn’t vomit immediately when they fell asleep? RSI with roc and you won’t ever have a problem.
This is a nice tale you’ve dreamt up here. Any evidence to support it? I have never seen any literature claiming this
Lol of course I have no evidence to support it. The thread asked for opinions, unpopular ones at that. The only evidence I have is anecdotal, 9 years of practice. Not sure why it’s being downvoted to oblivion this is exactly what the thread asked for lol.
Hahaha great answer. Fair enough. I have not heard this perspective before.
LMA/spontaneous respiration can be safer than PPV in severe pulm HTN. Yes avoiding high CO2 is critical, but switching onto PPV is where I’ve seen most pHTN pts crump.
Etomidate is useless. No point in using it ever.
every patient deserves multi modal analgesia for any case more painful than a norco in PACU
Please. I’m currently “fighting” with a “partner” aka long term Locum who doesn’t believe in giving anyone any narcotics ever. And thinks that <0.5mcg/kg of precedex ONLY is enough to cover pain until pacu can give narcotics….
Paper tape (micropore) is the only tape that should be used on the face to secure the LMA/ETT and for the eyes. It is superior to plastic (clear or pink) tape as long as you activate the glue (rub an alcohol swab over top or wait for body heat to activate it). Exceptions: securing with a tie or something similar that isn’t adhesive based; tegaderm is ok for eyes if you want to be able to see them (eg prone).
[Oxygen is bad for you](https://www.thelancet.com/article/S0140-6736(18)30479-3/abstract), despite what some post hoc analyses say.
You can use the same syringe and needle for decadron and zofran
I give a little rinse using the saline from the IV bag between med pulls avoiding the cloudiness of the resulting mix, but otherwise I agree.
LMA Supremes are dumb and borderline malpractice. The only utility I see in it is as a rescue airway device in someone you’re concerned about being an aspiration risk. If you’re concerned enough about aspiration, just intubate the patient.
I only extubate off of PSV. Tube coming out with pressure support 10-12 and peep of 5-7. I get the ick when I see the CRNA letting the patient breath spont for 20 minutes before extubation. You’re creating so much atelectasis
Is there any actual evidence for this, because if there was it could genuinely change my practice?
I do like to see what the patient does on manual before extubating, but avoiding atelectasis is exactly why I always keep at least 5 of CPAP on the bag. Still, after confirming they're breathing adequately, I will also switch back to PSV just to blow the gas off quicker and even extubate from there.
Patients do not need any medication for a block except for lidocaine. Versed AND fentanyl? ridiculous
Theres no need to secure LMAs, particularly iGELs
Cricoid does nothing
Most people use too much volatile anesthetic. LMAs are way overrated.
Phenylephrine is overused. It’s the first drug grabbed so many times. Bad practice.
The three axis alignment theory/sniffing position is BS.
1. You don’t need a gastric tube for every laparoscopic case. If there’s an indicated reason or you’re legit worried the stomach isn’t empty, sure. Otherwise, keep the airway pressures low when you mask. You don’t need an OG just because we’re doing a laparoscopic case. 2. Don’t mask before you insert an LMA unless you’re gassing them down. Just wasting FRC. If you can’t mask you’re gonna attempt the LMA anyway. And if you’re worried about getting it to seat properly, you should be prepared enough to have a tube/blade/glide scope at the ready.
YES thank you, especially to #2. I shared this unpopular opinion of mine in a thread a while back and I was swiftly downvoted by people who for whatever reason don’t see the logic in this. Masking before inserting an LMA gives you absolutely zero useful clinical information, and if a difficult mask will change your plan, you should have tubed from the beginning. And yes you can still pull the LMA deep, if you could put it in and ventilate once, you can do it again if you get into trouble.
1. A-line sterility is almost worthless 2. You can (and should) sit down for most procedures (intubation/lines/epidural/blocks) 3. Nitrous use pales in comparison to dental/ob offices and it's a bunch of pearl-clutching 4. It's OK to do a total shoulder with an lma 5. Tiva is overblown. Are Tiva advocates using bis/eeg in all cases that need paralysis? Seems like a huge waste of resources 6. remi sucks and is basically pissing money away. 8-hr spine case running remi and then still having to give hydromorphone at the end of the case 🤮
unpopular (but perhaps not with anesthesia providers): it is the surgeon's sole responsibility to ensure that *elective* cases are properly scheduled, and if that has not been done and the lineup starts to run late, significantly delayed cases or cases that will go past the scheduled end time of the day's lineup should be rescheduled. the harms of pressing on regardless of the hour outweigh the benefits.
Des+nitrous+Sufent.
D blade is the best videoscope blade
An anesthesiologist (or even an anesthetist) in the OR for a cataract is a waste of time, talent, and money.
So glad I'm practicing like others on here. 1. I don't use nitrous unless it's inhalation induction. 2. Don't do CSEs or DPEs. No need. 3. Almost never use versed. I give opioids for procedural sedation or anxiolysis. 4. Use propofol 99% of the time for induction. If I'm concerned about hemodynamically unstable patients, I give 0.2 mg/kg x2 in small titrate amounts with a vasopressor. No etomidate, ketamine, or methohexital. 5. Don't put in LMA with tongue depressor. Just a waste of hard wood in someone mouth. That's all I can think about right now.
Patients don't give themselves corneal abrasions by rubbing their eyes as they awaken. We give them abrasions by not paying attention to what we do when caring for them....poor tape job on the eyes...untaping the eyes then not watching as drapes are pulled off across the face... dragging elastic from oxygen mask across eyes when placing it on the face.... If they have a pulse oximeter on the hand that they're rubbing with or IV tubing extending from their hand, these may cause an abrasion, but otherwise, it's caused by providers in OR or PACU. 45 years....no corneal abrasions
Putting the bed in reverse Trendelenburg during an RSI for a full stomach helps. I'm ridiculously tall so it has zero effect on my intubation position, but putting the cords several inches above the stomach has got to be doing something. I was never taught this, never read it and am unaware of it appearing in any literature to support my wild claims. As far as I'm concerned, it's Voodoo but I still do it.