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4/Point being made : MAC VL gives you superior laryngeal views than DL and superior training can get the ETT into the trachea without an introducer / Stylet.
Awake tracheal intubation: the default technique?
Where there is predicted anatomical, pathological and/or physiological difficulty with the primary airway plan and reliability of rescue oxygenation plans, the default technique should be awake, where possible.
#anaesthesia #MedTwitter #MedX
doi.org/10.1111/anae.70429
Selvan Ramsamy retweeted
In 2027, ultrasound assessment of airway anatomy will be added to the Objective Structured Clinical Examination component of the APPLIED Exam, expanding the role of POCUS, especially for early-career anesthesiologists.
Learn more:
ow.ly/6AKx50ZWqaa
Improve view or delivery of the ETT ? And where is the evidence ?
HAVL will improve success over Mac with no downsides (provided you have access to equipment & know how to use it)
Re Mac 3 vs Mac 4, see video…
youtu.be/gYxwhEmYb9w?si=PTfI…
A working regional , and you would hardly get to GA without a tube ( or GA without Eye Tapes) with sedation .
#RegionalAnesthesia 👇🏿 @ASRA_Society
asra.com/about-asra/recognit…
Regional should be awake …. NOT GA without Tube !!! Gaston Labat 🥰
Selvan Ramsamy retweeted
Endovascular thrombectomy is suitable for at least 15% to 20% of acute ischaemic stroke patients, yet mean adoption rates range from less than 1% to 7% in different areas. 📉 M. Elwishi et al. #BJAEd #Neuroanaesthesia bjaed.org/article/S2058-5349…
NAP last one ( ? 7 ) , recall that it showed cardiac arrests to be high in that scenario . Need to find the defence
It is done a lot in Australia. Endoscopy, for example is done with anaesthetists administering Propofol. I will add though, the levels of sedation and airway reflexes vary. I do aim to “lighten” once the endoscope is introduced. The pain intervention lists however involve patients who are very difficult to sedate/have high requirements.
@jeffgadsden
“… regardless of dose, duration, route of administration or withholding time.”
POGUS: if stomach full- RSI or regional
If no POGUS : RSI or regional .
Postponing and withholding may not change anything.
POGUS , from @jeffgadsden - bedside gastric ultrasound
You've got a 59 yr old woman for knee replacement. She's been taking semaglutide for six months. Had chicken nuggets at 6 pm yesterday, but nothing since. How do you approach this? Do you need to know her dosing schedule? What fasting regimen do you advise patients to use when on these meds? Is there an empiric "acceptable" fasting interval? Why are chicken nuggets so good? I have so many questions. #Blocktober26
Selvan Ramsamy retweeted
I see what you mean. That has not been my experience though. Most fasted patients are empty, those who aren’t, get cancelled, reshuffled and rescanned or neuraxial only. The idea is that it is hard to predict the GLPs, therefore scanning gives us a bit more info & options than the blanket decisions ie rsi or cancel.
Like with VL , we need to stop thinking about whether the stomach is non empty and think about what to do if the stomach is non empty in patients on GLPs
Selvan Ramsamy retweeted
1. My scannings have been passing patients more than cancelling. They also reassure patients, my team AND it increases efficiency. Unless I missed something, the technique is pretty clear. I was taught by @PerlasAnahi
2. I have seen solids in patients who have claimed to fast according to GLP protocol. Similarly, I have scanned patients who simply forgot the instructions.
3. I think we should accept that there are things we don’t know about this group of drugs, & the evidence behind this cessation times and fasting times are vague. We will also soon be inundated with many types of GLPs in the future. Saying that “7 days or 14 days (however many days that’s the latest guidelines) cessation should be fine”, is not enough information for me.
4. My ability to manage an airway has not reduced simply because I scan the stomach. It has enhanced my ability to exercise all my options for my patients, including RA.
5. The overlap in Pocus and RA is competency in ultrasound. Hence the bilateral endorsements. But we are all anaesthetists, first and foremost. And we love our specialty, tube or tubeless!
Selvan Ramsamy retweeted
Strong disagree. Jeff, if you really like to ruin a surgical list with this re scanning, you will not make many friends. And your spinal technique for full stomachs can be dangerous. What do you do if you have a high spinal or the patient wants sedation or you have hypotension that makes the patient vomit.
I clearly do not see and understand the gastric pocus idea. We know which patients take GPL-1 medications and we can adjust our airway technique or maybe use a second generation SGA. Its an interesting discussion but for me gastric ultrasound for decision making in airway management is too vague and can lead to unwanted complications or postponing surgery. Even if the stomach is full, we can manage those airways safely. We do it all the time in emergencies in the ED and OR and ICU # anes2026
Selvan Ramsamy retweeted
Thanks @AirwayMxAcademy , I do appreciate there's no evidence that gastric US changes outcomes. That said, there are lots of things we use every day that provide useful information while lacking evidence. Pulse oximetry has not been shown to reduce periop mortality, but I sure ain't gonna stop using it while I await some dude to do a meta-analysis on it.
Here's the real value: In the above example, if I scan and find stomach is empty, that means I can proceed confidently with my plan of spinal plus propofol sedation (aka unconsciousness/loss of airway reflexes). If I were just to reflexively intubate the tracheas of every joint replacement on a GLP1 (about 15-20% now), I would now be exposing those patients -- as you point out -- to a new set of risks (airway trauma, bronchospasm, blah blah blah).
If I DO find a full stomach, then we have some decisions to make. Spinal with the patient awake through the procedure is one option. Postpone is another. Re-scan an hour or two later is a third. GA with RSI is an option I suppose BUT....RSI is hardly a guarantee of safety. Most operative aspiration events occur during RSI/full stomach.
Here's a question for everyone out there (and I'm genuinely curious). If you have a known full stomach and you proceed with GA/ETT for an elective case and the patient has a serious aspiration event, is that defensible? I reaaaallllyyy hate questions that start with "Dr. Gadsden, please explain to the jury ..."
In elective surgery , regional is not the answer to a full stomach . Whether regional or GA , the decision is independent of full or empty stomach
@doctimcook
@jeffgadsden
@NicholasChrimes
@AirwayMxAcademy
@DrRobbieErskine
You've got a 59 yr old woman for knee replacement. She's been taking semaglutide for six months. Had chicken nuggets at 6 pm yesterday, but nothing since. How do you approach this? Do you need to know her dosing schedule? What fasting regimen do you advise patients to use when on these meds? Is there an empiric "acceptable" fasting interval? Why are chicken nuggets so good? I have so many questions. #Blocktober26
Selvan Ramsamy retweeted
@nehapadhi dear have a look
Selvan Ramsamy retweeted
And maybe…pubmed.ncbi.nlm.nih.gov/3654…
