For the students, my advice is to always scan things one last time before you push induction drugs

for
three things-dripping IV, flowing oxygen, and suction on. I actually do a quick scan on every case for
these three things before pushing drugs. It's my "preflight checklist." AND CHECK FOR BOUGIE / AMBU
on room set up. “bag and bougie!”

When determining readiness for extubation (deep or awake) he taught me to suction the airway first.
While suctioning the airway, he had me look at the respiratory rate, pattern, and tidal volume. If the
spontaneously ventilating kid had a change in respiratory rate, pattern (regular to irregular), or change
in tidal volume, the patient was in stage 2 and you risk laryngospasm. If with suctioning, the patient
remains stable, it is likely safe to extubate.

Emergence agitation/ Wake up fighting

Eliminate benzos (versed) from preop meds

Physostigmine (antilirium) 0.5mg IV push (or kids 10 mcg / kg), the rest in the IV bag. Learned this 35
years ago from a VERY pharm. savvy CRNA instructor. Extremely smooth wake ups.

0.5-1 mg IV can repeat every 10 mins to effect. Try it it's amazing!!!!

1mg. IV Push, put the rest in the IV bag and let it drip in. No, it doesn't really matter how much is left in
the bag.

clonidine 0.1mg PO holding if case isn’t too long. Central alpha-agonist effect will chill out some of that
fight-or-flight upon wake up. Use with with anyone who I am afraid can take me down upon waking
them up- Veterans, athletes, etc...

Clonidine 1 mcg/kg

Also consider a dose of prazosin. Effective in attenuating nightmares associated with PTSD.

EGD tricks

When I started doing a lot of them I would set a stop watch for a 1 minute 30 seconds from propofol
admin. Magic amount of time. No coughing!

I give them 50 of fent awake and then lido then a bolus of 50-60 of propofol. They rarely move. If they
do move or fight whent he scope goes in i give the other 50 of fent and that generally solves the issue
+/- some more prop. I never use versed because of how long it lasts but that does not mean its wrong.

I never use narcs or versed. I use lidocaine before propofol. I bolus 60+ of propofol and place patient on
propofol pump. I jaw thrust and when the patient has very minimal response I will let the GI doc begin.

I will sometimes use ketamine for the sicker patients with pressure and respiratory issues.
Preoxygenate w a facemask if you have to.

No need for fent or versed. None.

Have them hold hand up and tell them not to let it fall. (Doc must be getting ready to place scope). Push
ten ml of prop/lido. Tell them to keep breathing as deep as they can...."hold the hand up... Up ...up"

When it falls, tell doc she's ready and push a couple more ml of prop. Be ready for airway support with
jaw thrust (I do it on one side. Just a little pressure and stim right there can make them breath). Then
titrate prop as needed, a few ml at a time.

A very wise CRNA taught me the BEST method is a tincture of time. Meaning give the meds proper time
to work. I personally put pressure at jaw angle to see if they react. If they dont....proceed

100mg lido, then propofol. I watch etCO2 monitor. Usually get a 5 second period of apnea. That's when
you have the doc slide the scope down. If you do it during that apnea period they rarely cough.

One non-pharmacological tip is to make sure they are really turned on their side and don't roll back over
some after bolus. You want all the saliva to run out of their mouth and not back down into the airway
because they will cough, buck, fight and spasm the whole time if not on their side far enough.

I'm at an endo center full time and I've tried a bunch of combinations. Here's what I use for the average
pt:
50 mg Lidocaine and 120 Prop to get to sleep...wait about 2 minutes until a brief period of apnea has
passed, (make sure they're breathing) then another 50 Lido and 80 Prop. Repeat 50 Prop every 2-3 min.
If the patient is a large muscular type, I give 150 Prop and follow with 100 Prop.
If it's an 80lb little old lady, I decrease to 80ish and 50ish.
The key is you have to wait until the 1st dose has fully kicked in and respirations have returned, then
immediately give the 2nd dose and start the procedure.
I also use O2 at 6lpm which I consider essential with this technique

PRECEDEX: PEDS, 1mcg/kg IV, 2mcg/kg Nasal, 3mcg/kg oral. Adults, dilute to 10mcg/ml titrate in 10-
20mcg boluses to HR and BP. Preop Adult, mix 30mcg undiluted with 2mg midazolam for rock solid
induction with minimal narcotic.

Fixing restless leg syndrome during MAC case: don't give versed or fentanyl if you can help it. No reglan.
Do give 2 G mag, ketamine, 0.1 mg robinul, and put lead over legs
For c section patients that don't want to relax and lean forward for the SAB, I sit them on the OR table
and airplane the bed back towards me a bit. Makes them automatically lean forward!

use the separate 02 flowmeter on the anesthesia machine to inflate your mask more if needed - no
syringe required. The adapter on the mask fits on the nipple of the flowmeter. Quicker than opening a
syringe and saves $.

2 handed pressure control ventilation when inducing. On people hard to mask, I put the vent on P CV
less than 20 of course, around 17 or so with rate of 15-18. Turn flows all the way up, turn on the vent
and lift with 2 hands.

Tuck the tip of the ett into the 15mm connector (makes it into a circle shape), pop it open when ready to
intubate, usually gives plenty of curve for really anterior airways

I run the lubed LMA across the lips once before placing. Smooth all the way down and fixes chapped lips

When using the Miller I open the mouth, place the blade, and drop the tube in the mouth and let it sit
there while I do DL and when I see the prize the tube is already past the teeth... I never have to move
my eyes... I just place it.... No one ever has to get it thru the lips/jaw

Deflate cuff and put suction tubing to end of ett when extubating. U would never believe the gunk u get
almost every time!!

for those peds nasal intubations when the tube just...won't...go...in... I worked with an ologist who
would thread a soft suction cath through the tube, use magills to thread the tip through the cords, then
advance your tube over the suction cath. I rarely have to use this technique but it has seriously helped
me twice.

For the larger patients (especially with big breasts): reverse trend bed, roll 2 blankets together & place
them at the level of the scapula, now double the wimpy hospital pillow to support their head. It's a
straight shot for intubating every time!!

Take albuterol cannister out of inhaler. Take out plunger of 60mL syringe, drop albuterol in syringe and
reinsert plunger. Screw leur lock into back of elbow. Push on plunger and you just gave an albuterol tx
without disconnecting from the vent
Dilaudid and a 70/30 nitrous/O2 emergence will have every PACU nurse amazed. Plus the patients are
pain free and lucid.
"You're going to like the way you feel... I guarantee it."

I take my pulse ox, ekg leads, and bp cuff to preop and put them on the patient when time permits

DONT soften and warm your ETT for nasals. That is taught to everyone and it is less than ideal. The
firmer the ETT, the easier it passes and the less trauma it makes going thru the nose. The softer the tube
is, all it does is take every little reason to catch and get caught on all the soft tissue in the nose, making a
bloody nose and pharynx. HARDER IS BETTER.

Haven't seen it in action, but heard from MDA to use tetanus on TO4 over the VC for pt
w/laryngospasm. Can't hurt, may help. Anyone else heard of this?

I "catch" co2 from the end of insuflation to get patient back breathing right away instead of waiting for
their metabolic co2 production to shift their curve to the right. As soon as the trochars are pulled vent
off peep up to prevent alveolar collapse. 100% 02 a couple minutes prior to this and they usually always
come right back breathing before first stab wound is closed.

I find that an IM injection of 10 mg morphine at the end of a case, followed up by 12.5 ug of fentanyl
bumps (to a respiration rate of 10-12 bpm). This not only smooths out emergence, but no pain in PACU.

If your IV bag or secondary runs dry and it's only down to the 1st port...after replacing the fluids and
getting some fluid in the chamber....take the IV tubing above the port and wrap tightly around your
finger and it milks the air up to the bag and replaces with fluid- no adjusting bags or syringes needed.

keeping ETCO2 elevated keeps BP from plummeting while you are waiting for a slow surgeon to start.

1) Anterior airway and no Bougie or VL around. Use a Yankeur and pass it into the airway. Then pass an
airway exchange catheter through the Yankeur. Pull out the Yankeur and pass the ETT over the airway
exchange catheter.

2) Can't ventilate without 2 hands and the circulator is clueless? Put the machine on PCV with pressure
25 and rate of 20 then two handed jaw thrust the patient to ventilate
When inserting NTT or NGT, use the "pig nose" technique. Pull the tip of the nose up towards their
forehead, making them look like a pig. Drop NTT or NGT straight in...pig nose takes away that first
traumatic curve you have to get past. Works like a charm!

If you get in a bind and no lma and can't mask drop an ETT to the back of the throat and close off the
nose and mouth while bagging

Hard to start IVs? Two tourniquets- one high and one low also helps get those dehydrated veins to stand
up

Atropine .4-1 mg in 1 cc down the tube will break a bronchospasm every time.

When doing an epidural , use 1ml of 1.5% lido with epi. Prevents any bleeding after epidural in insertion
in case you hit that proverbial aorta of the skin. Then you can save your 1% lido for a top off dose later.
No extra charge to the patient for extra lido.

Anchoring your patients: https://en.m.wikipedia.org/wiki/Anchoring?

fbclid=IwAR11A3jZkfUESbKCgAxR_8_RHhHMk09TVR8jsnnRlin4skOxcSQUQbDJB18

http://anaestricks-blog-blog.tumblr.com/?fbclid=IwAR2r5SXVDJFwnNgh0XwtUlAM7VbGniIHg3kj7y6-
WmZpodSYljcY1J7xpLw

Edentulous elderly patients can be difficult to get a good mask seal. I put a 4x4 in each cheek. Gives just
enough structure to their face to get a great seal. Just remember to take them out before DL

Standing on the patients left side when inserting an LMA (I'm right handed). So much easier than
standing at the head of the bed! Stand at the patient's left shoulder. It's more ergonomic. Your right
hand doesn't have to rotate into an awkward angle.

Neat trick I've seen, but haven't been able to incorporate yet as a junior SRNA: patient is back breathing,
but wondering if they're reversed enough to extubate? Take the bag off the circuit. Put your hand under
the hole; when you feel your patient exhale, slap your hand over the hole and watch your airway
pressure. Cheap and dirty NIF: greater than -10, they're strong enough to breathe on their own.
For the OR staff that can't handle the sound of suctioning secretions....squirt a bunch of KY into a glove,
add a syringe of saline flush and dramatically suction out the glove behind the drapes. Its pretty
entertaining!

Save 20mg propofol and give upon wake up for generals...they'll wake up laughing or very happy 😊
Helps with nausea also.

Nasal intubation.... line up the tube and glottis and lower the scope and advance tube blindly. Puts the
tube and glottis in line and in over 30 years have never used Magills on an adult pt.

video laryngoscopy, hold both the handle and the tube in your left hand with the tip of the tube at the
tip of the blade and insert both into the mouth at the same time.

for those folks who might be predictably wild on the wake-up, I use PRECEDEX 0.5mcg/kg on a syringe
pump over 10 minutes about 30 minutes prior to the end of the case. Nice "quiet" wake-ups.

On the patients with beards (I did a ton of these...locals in Afghanistan), I always use a surgical mask to
secure the ETT. Grab one with ties (no elastic or ear-loop masks), roll it up so that there are two strings
on each end, pass one end behind the patient's neck and then tie the tube from both sides.

On abdominal cases lasting longer than 60 minutes or so, I use lidocaine infusions. I run 1.5mg/kg/hr,
and I start it as soon as I bring the patient into the room. Lidocaine bolus during induction as well. When
the case is over, I take the syringe pump to the PACU with me, and instruct the nurse to continue the
infusion for 30 minutes, then just turn it off...no titration necessary. I read a research report, and the
PACU nurses will attest to this, that claimed about a 60% less narcotic requirement in the short term,
described as 4-6 hours. So patients leave the PACU with less somnolence, and as an extension, less
nausea!

speaking of nausea, I suggest you google "OODA LOOP" and "Penelope Villars". Back in 2006 she
published in the ASPAN journal, her research that laid out a GREAT recipe (my opinion) for patients with
PONV history. I use her recipe (most of the time minus the scopolamine patch) for almost everyone who
utters the nausea word. Recipe is DEXAMETHASONE 10mg at or near induction, PROMETHAZINE 6mg
about 20 minutes prior to the end of the case, and ONDANSETRON 4mg at the last stitch. Her bottom
line PONV rate was 3.18%. For those of you concerned about somnolence with PROMETHAZINE, you'll
be surprised at how little a concern this is with just 6mg.
Central lines...sterile extension tubing connected to the catheter before the wire goes in...stick a syringe
on the tubing and aspirate a couple ml of blood...remove syringe...gently raise tubing and watch blood
level. If it falls...venous. if it raises...arterial. I have been in situations where even with ultrasound we
couldn't guarantee a venous stick.

I place a succinylcholine sticker on the ETT at lip line when doing pedi cases. No quibbling with surgeon
about is it in or out, everyone is aware and paying attention when mouth gags are placed or switching
tubes from side to side or if the surgeon turns the head..... I pass that one on to the students. Those are
airways you don't want to spend time quibbling about...

On those patients where you know they will drop their BP after a spinal, mix 25 mg of ephedrine in your
local for the skin. Will prevent the big drop and hang around while you continue to hydrate. Great for
little old ladies and on those with CHF that you don't want to overload.

Regarding nasal intubations: when the tube is in front of the cords and it just won't line up, hold steady
pressure on the tube with one hand and place the other hand under the pts head. Lift the head and flex
(nose toward chest) and the tube will slide in every time. No Magills, no inflating the cuff, no bougie, etc.
Kids or adults. Slick as....you know what! Just not for neck trauma.

Sampling EtCo2 line, tear one end off so the male connector is gone. Slip remaining tubing through
mask. Don’t need to waste a jelco needle!

Are you tired of having to level the hemodynamic transducer holder up and down the IV pole whenever
the table is adjusted? Here's my trick: Obtain a foot long metal rod. Place a Clark Socket (holds candy
cane stirrup on the OR table) on the table rail on the side or head of the table. Fasten the metal rod to
the Clark Socket and fasten the transducer holder to the metal rod. Level once and fogetaboudit!! The

transducer will always be level when you adjust the table.

Can’t place an NG tube? Despite fish hook, using a blade, or turn the head to the left:

1. Slice ETT down one side.

2. Insert ETT to 'goose.
3. Lightly lubricate og/ng
4. Insert to gastric region via cut ETT...
5. Verify placement
6. Remove ETT-introducer
7. As necessary, slide og/ng out the slit you cut prior

UNABLE TO THREAD EPIDURAL CATH

If you are in correct space but just having difficulty threading the catheter- I have mama take a deep
breath and hold for a sec and I usually am able to pass through. If not may need to identify space again.

Barely barely turn needle about 1/10 degree l/r

After getting into the epidural space, I inject 10 mL of saline through the epidural needle (our kits have
the saline I'm them) and as I thread the catheter I have the mom take a slow, deep breath. This seems to
work well for me.

Was not allowed to do CSE on my OB rotation but since graduation really helps me feel confident I am in
the right spot. Had a obese Hispanic mom figuring space would be 7-8 cm. Begin driving needle got a
LOR at 4cm. Figured I was in a false space but placed CSE needle to just make sure. + CSF , placed cath
without difficulty. Without the CSE I might have driven the toughy right though the dura.

If you take a real good look at the needle and feel confident you are midline( if you might be off to the
side a bit you will get a LOR-often "mushy" and the catheter will NEVER thread so start over and strive
for midline placement)..you can try placing normal saline in the space and try again but USUALLY it
means that you got the tip of the needle in the space and not the whole needle lumen in the space so
you get a LOR but the cath will not thread, sooooo....put on the big girl/boy pants and put the stylet in
the needle and ADVANCE just the tiniest bit, just enough to see you moved it and hope for no wet tap
and thread...move it less than the distance of the needle lumen

DOSING EPIDURAL for CSECTION

MATT LEDDEN: check a level and dose with 0.5% Marcaine with epi (10cc's). The. We can check another
level in the section room and supplement with more as needed

I turn off the epidural as soon as I get there to give the new dose more room. Then I get the OR ready. I
do 2% lido, bicarb, epi. The key is to dose 10mL in the labor room right before they come back to the OR.
Then I keep dosing up to a total of 20mLs in the OR. Followed by duramorph near the end. Works great.
I know lot of people use chloroprocaine, but I’ve always found 2% lidocaine with epi works in enough
time, takes the 5 min it takes to get pt to OR for emergent section, usually slam in 15 cc to start and 5 cc
after get to OR, have not had to go to general as long as epidural was working.

Level dependent but typically 15ish cc of 50/50 2% lido and 0.5% marcaine. The lido takes care of the up
front and marcaine helps to make the block more dense.

How long are your sections? 2% lidocaine 10cc +5cc+5cc. After baby out Duramorph 2-3 mg, toradol 30
mg at close. Still have. Good block in recovery, avg time 45 min +/-.

2% lidocaine with epi, plus 1 cc NaHCO3. Never have pain at the end, and it kicks in pretty quickly.

0.5% ropivicaine. Start dosing 10 minutes before they bring her down. 5cc every 4-5 minutes. Total of
20cc. 5 more cc at delivery. Works great. Sometimes add duromorph

2% lido with epi. Fentanyl and duramorph after baby is out. If they’re consistently having pain at the
end, either give more in the beginning or re-dose in the middle. I dose 15 ccs in their LDRP immediately
when I hear we’re going to section. They’re numb by the time they hit the OR table. I agree with
bicarbonate to hasten the onset, but it won’t prolong the block if that’s what your asking.

I use 2% for emergencies, typically redose mid way with 10ml 0.5 % Ropi as we have resident cases and
typical OR time is 2 -2 1/2 hours. If standard CS Ropi 10 ml plus Fentanyl 100 mcg, still redose during
case if needed

20 ml 3% Chloroprocaine w 1ml bicarbonate is magic for STAT sections.

I give 3% chloro and then start working in 2% lido once in the OR

Onset:
2% Lido w/o bicarb = 9-10 minutes
2% Lido w/ bicarb = 5 minutes
3% chloroprocaine w/o bicarb = 5 minutes
3% chloroprocaine w/ bicarb = 3 minutes

BTW, with chloroprocaine, you only need 10 mLs. My “true” stat go-to was always 10 mLs of
chloroprocaine and 1 mL of bicarb.

Epidurals, 14+ hours, prob OP, nothing but CS concentration of LA seems to give pain relief. What tricks
do you have?

These are so frustrating. From my own personal experience, I had a fantastic epidural and an OP baby
but was complete. No bolus given. Frequent position changes and good nursing care go a long way. Was
able to get my baby to flip and back to a great working epidural. Knee chest position works wonders.
Point being, sometimes we need to educate patients and the OB nurses on the importance of frequent
position changes in this situation. That being said, I still bolus them but with the caveat that it might not
help that much with back labor.

If baby at 0 station or more I put them in high fowlers and then bolus and leave them there for 15-30
mins. Let gravity hit those low lumbar and sacral nerves.

Sometimes a 100mcg bolus of Fentanyl or a few cc's of 2%lido. I get a 50/50 response. But if it works you
may be called back every hour or two because the pain is back.

I've diluted fentanyl with saline to do 50-100mcg in 10mLs. Sometimes works, sometimes
doesn't...that's always a sucky scenario

Reposition the patient. Sometimes being on all 4's helps. Doggy style... I agree. Doggy Style with palm of
hand applying sacral pressure/massage. Also have the patient rock in that position. That's what L&D RNs
did before labor epidurals were even available to patients.

SALINE WHEALS SUBQ near the posterior iliac crests

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2900101/ I have done these with the OB/GYN doing one
side and I did the other at the same time, because they hurt like hell for the patient at first but they did
work.

Or sufenta 25 mcgs: I usually give 20 or 25mcg of sufenta (10mcg/cc) diluted into 13cc NS for total 15cc
to epidural, maybe have to repeat it once but not commonly. Just be sure it’s not migrated
subarachnoid = fetal bradycardia!

Smooth wakeups

Inflate ETT cuff with 30 mg 2% lidocaine + 6 ml bicarb instead of air works great. Case has to have lasted
1.5+ hours
http://www.ncbi.nlm.nih.gov/m/pubmed/22569622/

Deflate the endo-tube cuff very slowly.

I titrate in some narcotic at the end when they are spont breathing. Keep it smooth and regular. Don't
lighten them up too fast while closing. Don't touch the tube. Nothing stimulating. When the Sevo is
down around 0.25%, the pupils will flash from around 2mm to 8+ (fx of optic chiasm) - that's when the
brain is "turning" back on. Pull the tube. Works every time. They will literally just open their eyes and
look at you. Makes you look VERY smooth. I think people get too aggressive when waking people by
suctioning, etc and it worsens stage II and makes them do the jitterbug on the table. Always there are
factors to consider (asthma, smoker, COPD, narcotics, muscle relaxants, TOF, room noise and stimuli,
etc).

2% lidocaine jelly on ett cuff prior to intubation. This helps with coughing during stage 1 & 2 in most pts.
When starting closing, turn off vaporizer and put total fgf at 0.5-1L/min. As youre getting the gas off,
keep 50% nitrous on until the very end. The goal is to use 50% nitrous as part of your fgf's to get your
gas concentration down to 0 as the last suture is being placed, so adjust total fgf's according to the
speed of closing so your gas doesnt come off too fast. Nitrous is great for providing a small amt of
analgesia while youre getting the gas off, as well as being amnestic at 50% concentration. When ready to
pull tube, turn o2 to 8-10 liters, and when your end tidal nitrous gets down to 10-15, patient should be
coughing or swallowing slightly, pull the tube now or wait for 5-10 more good breaths to blow off n2o if
wanting fully awake. Granted this wont always be a fully awake extubation ( with small concentration of
nitrous still in system), but for most patients less than 65 years of age, they are coughing, have
purposeful movement, and can follow commands enough to make you content with pulling the tube
and establishing it as a near awake extubation. if needed, Ill give 25mcg of fentanyl at most, 2-3 mins
prior to extubation to smooth out coughing if patient is breathing fast for their body habitus.

Tube securement ideas:

Saw it while doing iON clinical trials for ENT cases. Surgeon used a soft catheter into the nare, then
pulled up the other end from oropharynx. Tied a square knot, then tied the ETT with-square not to the
knot. Holds tube in place beautifully during head manipulation, and without tape!!

Sore Throats?

Lidocaine jelly on ETT cuff has been specifically implicated in sore throats, but it is helpful in smoother
wakeups, esp. smokers.
check cuff pressure, I was way over filling until I had a manomometer in my room. The right pressure
feels like an almost empty cuff. And recheck intraOp especially if using N2O.

Don’t give Succs if you can help it.

only inflate cuff up to achieving a seal, do not leave an oral airway in the mouth during long procedures (
don't long or short) just on emergence and if necessary for ventilation at induction), do not use lube or
lido, give decadron IV, it helps with nausea plus as an anti-inflammatory helps reduce throat pain by
decreasing inflammation. Usually have little to no soar throat post op.

Tips for ventilating morbidly obese in steep trend.

Decrease I:E to 1:1, decrease Tv, increase rate as flow volume loop allows to maintain adequate
ventilation, 5-10 of PEEP if not more to hold airways open, and just tolerate peak pressures 35-40 if you
have to.

Larger sized ETT

Make sure tube hasn’t mainstemmed

Yup like others have said 1:1 I:E ratio, or if your vent allows it you can try inverse ratio ventilation (1.5:1,
2:1). Make sure tube is still at the right depth since their anatomy will have shifted cephalad and the ETT
may be too deep (use succs sticker tape marker when tube is placed for easy ID)

If doing a laparoscopic case, ask the surgeon if they can decrease their insufflation pressure.

Tilt test prior to drape. Can I ventilate with adequate Vt and reasonable PIP. Plus it checks pt positioning
being secure. Sometimes I've pulled ETT back after tilt test (like someone mentioned) very rare occasion
we cldnt proceed cause ventilation wasn't adequate for any length of time

hypercapnea never killed anyone unless they have a CHI, significant pulmonary hypertension, or a
mixing cardiac lesion.

Toradol contrain: DM, Reactive Airway / Asthma, Nasal Polyps, ASA allergy, Renal disease, high risk of
bleeding (eg, nasal, tonsil, thyroid, breast), Ortho/Spine (non union), ACL repair, age 60+ half dose to 15
mg
warning to avoid in breastfeeding mothers so you should avoid it then. Minus c section cases because
typically their milk is not in yet and they have only colostrum-small volume so a minuscule amount
would cross over into breast milk
Video laryngoscope troubleshooting

Good video view of cords but can’t get tube to pass through? Grab and hold the end of the tube/stylet.
You will have better control to manipulate the tip.

drop my hand to the right and kinda come at the cords side ways rather than straight on

Put tube in first, then insert GS

Back the blade out until you get a grade 2-3 view and then try to pass the tube. Don’t go for the great
view like you do with direct visualization.

If you pull back the stylet with your thumb it will elevate the tip of the ETT a little

pulling back will give you a better view and going in with tube at 3 o’clock. Then turn tube to 12 andhold
at the top of the tube.

Inflating and deflating the ETT balloon to lift the tip between the cords.

If you have a difficult mask ventilation don't be shy about putting 2 oral airways in at the same
time...that saved me once.

"Poor man's LMA" Just take your ETT and insert into mouth until the size of the ETT is at patients lip (7.0,
8.0, etc) Then cup the patients chin in your left hand, reach up and pinch patients nose while forming a
seal around ETT with patients lips. Works like a charm. Takes a little practice but oh so worth the skill.

I always have a lubed up nasal trumpet for every morbidly obese patient and a #6 ETT opened. Always.

MAC DRIP:

50cc saline bag

Add 100 mg ketamine

200mg Propofol
100 mg lidocaine

Microgtt tubing and titrate to RR and depth via capnography. It’s been wonderful and I’ve received tons
of compliments on my MAC cases. I usually have 2/2 versed fentanyl on hand and will load them on the
front end.

I place all my LMAs with a syringe attached without plunger, thus making it open to air and it deflates
when making turn and then re-inflates once in oralpharynx. I get a great seal without adding more than
5ml of air in majority of cases and it drastically reduces sore throats and have gotten LMAs to seal in pts
when others have not by using this method (I also yield to the smaller sizes for pts.) The attendings that
have seen this have stolen this technique from me since they often see me get 600-700 TV without any
air added to cuff and sometimes leaks right at 20cmH20 then I put 5ml air in and no leak. I have found
that Lido lube on ETT cuff makes for smoother extubations, significantly reducing smokers coughing and
narcotics on board as well. Also bid fan of elevating HOB for everyone to aid in the pre-oxygenation. It
takes weight off diaphragm and increases TV and betters my axis and intubating conditions, plus much
more comfortable for pts. I run Lido drip at 2mg/min with Precedex. Reduces required amt and have
also started running Lido gtts in big abd surgeries and other longer cases reduces narcotic requirments
and blunts sympathetic surges with stimuli and keep it going post op which makes for smooth
emergence and less pain post-op. I've come to realize that Lido may be the most under-used drug we
have and cheap. Most places carry premixed bags of 2g in 500ml. One study showed that running it in
bowel cases and 4hrs post-op got pts out of hospital 1 day quicker d/t reduced narcotics and bowel fx
resuming quicker as it stated Lido worked as an NMDA inhibitor.
A trick taught to me from an older and great MDA is that if u r going to induce with Succs and aren't
going to pre-treat with non-depolarizer and don't want that young muscular male to fasciculate and hurt
like crazy, u can pre-treat with Succs! Sounds crazy and isn't in text books but during my inductions in
those situations I give propofol and then just barely move the plunger of my Succs syringe the slightest
bit and give it a minute and then give the Succs dose. I've seen this take all of the fascinating away to
just seeing the forehead twitch a bit in a strong healthy male. In theory u r giving such a small amt that it
doesn't obtain every alpha subunit in the NMJ and will just attach to one acting like the non-depolarizer
does so it leaks and then when the depolarizing dose is given u don't get such a rapid influx. It's a lil bit
of an art to get the small dose up front given by just moving the plunger in ur syringe and giving it a
moment to get in to work and resist from going ahead and giving ur intubation dose but once u see the
magic, you will be a believer and love it. Of course I believe as mentioned above that u don't always
need paralytics to intubate if u just get them deep enough. I rarely induce with Succs but when I do, I
use this method if I can keep others hands off the syringes from pushing it as soon as u get Loss of Lid.
I've also started giving my Zofran up front with Versed and Pepcid to go ahead and block the pathway
that may stimulate the chemoreceptor trigger zone by the anes gas or whatever may be the cause of
potential PONV instead of it being triggered and then give it in hopes of stopping PONV. Pts with hx of
PONV I give a second dose at end of case as I did for years with the other multi-modal drugs to prevent
PONV and 20ml/kg of crystalloid. Some say wow 8 mg and I say people getting Chemo get bags of 30mg
or more of zofran so 8mg is nothing. I rarely have a OT with PONV and have had pts with PONV 14/14
surgeries then see them in PACU ready to go home and they say well I'm 14/15 now. Don't think it's the
zofran upfront that's the magic but with that and every multi-modal drug u can give them plus maybe a
TIVA will work wonders.

BUYING LEAD:

I have the burmed wrap around euro set in black. I like it. I got the thickest variety in lead. It is heavy.
The lightweight stuff is certainly more comfortable but does not do as good of a job with radiation
penetration. There are studies demonstrating the difference. The lead performs better. Oh the other
hand, distancing yourself from the radiation source does far better in decreasing exposure than thicker
lead.

Just something to think about. Lead needs to be checked once per year by x-raying the lead for holes.
Also be sure if you order a two piece make sure your hips/back will tolerate the load on your waist.