Podcasts about rocuronium

Drs. Girish Joshi, Nikolas Georgakis and Daniel Arango discuss the article “Risk of Acute Complications with Rocuronium versus Cisatracurium in Patients with Chronic Kidney Disease: A Propensity-Matched Study” published in the May 2025 issue of Anesthesia & Analgesia.

Show notes at pharmacyjoe.com/episode1008. In this episode, I’ll discuss the time to delivery of sedation and analgesia after RSI using rocuronium vs succinylcholine. The post 1008: This Problem With Rocuronium Keeps Coming Up appeared first on Pharmacy Joe.

Let's hear it for the pharmacists who make every emergency medicine shift easier and safer. EMRA*Cast host Dustin Slagle, MD, picks up some pearls from Mike Perza, PharmD, BCPS.

Contributor: Aaron Lessen MD Educational Pearls: Why is airway management more difficult in obesity? Larger body habitus causes the chest to be above the head when the patient is lying supine, creating difficult angles for intubation. Reduced Functional Residual Capacity (FRC) causes these patients to deoxygenate much more quickly, reducing the amount of time during which the intubation can take place. What special considerations need to be made? Positioning. The auditory canal and sternal notch should be aligned in a horizontal plane. Do this by stacking blankets to lift the neck and head. Also, try to make the head itself parallel to the ceiling. Pre-oxygenation. Use Bi-level Positive Airway Pressure (BiPAP) with Positive End Expiratory Pressure (PEEP) or a Bag-Valve-Mask (BVM) with a PEEP valve. PEEP helps prevent alveoli from collapsing after every breath and improves oxygenation. Dosing of paralytics. Succinylcholine is dosed on total body weight so the dose will be much larger for the obese patient. Rocuronium is dosed on ideal body weight, but adjusted body weight may also be used in obese cases.  References De Jong A, Wrigge H, Hedenstierna G, Gattinoni L, Chiumello D, Frat JP, Ball L, Schetz M, Pickkers P, Jaber S. How to ventilate obese patients in the ICU. Intensive Care Med. 2020 Dec;46(12):2423-2435. doi: 10.1007/s00134-020-06286-x. Epub 2020 Oct 23. PMID: 33095284; PMCID: PMC7582031. Langeron O, Birenbaum A, Le Saché F, Raux M. Airway management in obese patient. Minerva Anestesiol. 2014 Mar;80(3):382-92. Epub 2013 Oct 14. PMID: 24122033. Sharma S, Arora L. Anesthesia for the Morbidly Obese Patient. Anesthesiol Clin. 2020 Mar;38(1):197-212. doi: 10.1016/j.anclin.2019.10.008. Epub 2020 Jan 2. PMID: 32008653. Singer BD, Corbridge TC. Basic invasive mechanical ventilation. South Med J. 2009 Dec;102(12):1238-45. doi: 10.1097/SMJ.0b013e3181bfac4f. PMID: 20016432. Summarized by Jeffrey Olson, MS2 | Edited by Jorge Chalit, OMSII  

Moderator: James Rathmell, M.D. Participants: Andrew Bowdle, M.D., Ph.D. and Michael M. Todd, M.D. Articles Discussed: A Dose-Finding Study of Sugammadex for Reversal of Rocuronium in Cardiac Surgery Patients and Postoperative Monitoring for Recurrent Paralysis Sugammadex is Not a Silver Bullet: Caveats Regarding Unmonitored Reversal Transcript

This week on Pharm5: Narcan possibly OTC soon Dexcom G7 now available PBM Transparency Act hearing Rocuronium shortage Phase I Rankings now open Connect with us! Listen to our podcast: Pharm5 Follow us on Twitter: @LizHearnPharmD References: Hoffman J. Narcan is safe to sell over the counter, advisers to the F.D.A. conclude. The New York Times. http://bit.ly/3S2btPf. Published February 15, 2023. Accessed February 16, 2023. Person, Bhanvi Satija PJ. U.S. FDA panel backs OTC opioid overdose drug, proposes label changes. Reuters. http://bit.ly/3xrx0r5. Published February 16, 2023. Accessed February 16, 2023. New Dexcom G7 CGM Nick Jonas Super bowl 2023. Dexcom. http://bit.ly/3Is32cU. Accessed February 16, 2023. Dexcom G7 receives FDA clearance: The most accurate continuous glucose monitoring system cleared in the U.S. Business Wire. https://bit.ly/3UMwMnv. Published December 8, 2022. Accessed February 16, 2022. Bringing transparency and accountability to Pharmacy Benefit Managers. U.S. Senate Committee on Commerce, Science, & Transportation. http://bit.ly/3YAhjKg. Published February 16, 2023. Accessed February 16, 2023. FDA drug shortages. FDA Drug Shortages. http://bit.ly/3Ir1kZb. Accessed February 16, 2023. Drug shortage detail: Rocuronium injection. ASHP. http://bit.ly/3Kat9q3. Accessed February 16, 2023. Schedule of dates. ASHP Match | Schedule. http://bit.ly/3I8MJA7. Published January 19, 2023. Accessed February 16, 2023.

In Part Two of this "Mini Grand Rounds" series, let's look at the 1 mg/kg dosing of roc. Could it be optimized? Click HERE to leave a review of the podcast!Follow HERE!References:All references for Episode 85 are found on my Read by QxMD collectionDisclaimer: The information contained within the  ER-Rx podcast episodes, errxpodcast.com, and the @errxpodcast Instagram page is for informational/ educational purposes only, is not meant to replace professional medical judgement, and does not constitute a provider-patient relationship between you and the authors. Information contained herein may be accidentally inaccurate, incomplete, or outdated, and users are to use caution,  seek medical advice from a licensed physician, and consult available resources prior to any medical decision making. The contributors of the ER-Rx podcast are not affiliated with, nor do they speak on behalf of,  any medical institutions, educational facilities, or other healthcare programs.Support the show

In Part One of this "Mini Grand Rounds" series, we discuss the factors that determine how to dose meds, in this case rocuronium, in obesityClick HERE to leave a review of the podcast!Subscribe HERE!References:All references for Episode 84  are found on my Read by QxMD collectionDisclaimer: The information contained within the  ER-Rx podcast episodes, errxpodcast.com, and the @errxpodcast Instagram page is for informational/ educational purposes only, is not meant to replace professional medical judgement, and does not constitute a provider-patient relationship between you and the authors. Information contained herein may be accidentally inaccurate, incomplete, or outdated, and users are to use caution,  seek medical advice from a licensed physician, and consult available resources prior to any medical decision making. The contributors of the ER-Rx podcast are not affiliated with, nor do they speak on behalf of,  any medical institutions, educational facilities, or other healthcare programs.Support the show

Guidance on Essentially a Copy for 503B Outsourcing FacilitiesLearning Objectives1.   Describe the decision tree to evaluate if a compounded preparation is essentially a copy.2.   Identify, when given a preparation, if the drug shortage exclusion applies.3.   Recognize, when given a preparation, if the Clinical Need exclusion applies.CE accredited for Pharmacists and Technicians. To get credits for this talk go https://compoundingce.com/courses/pharmasalon-guidance-on-essentially-a-copy-for-503b-outsourcing-facilities-evaluation/To watch the accompanying slides go to: https://youtu.be/XYK4OtB3MAsSelf-Assessment Questions  1. Your facility compounds a succinylcholine 20 mg/ml syringe both from API powder and sterile sourced vials. Succinylcholine is not on the FDA drug shortage list.a. The syringes made from either source are essentially a copy of the commercial product.b. The syringes made from both sources are essentially a copy of the commercial product.c. The syringes made from API powder are essentially a copy of the commercial product.d. The syringes made from sterile sourced vials are essentially a copy of the commercial product.2. An outsourcing facility compounds morphine 1 mg/ml syringes from API powder. These are available commercially in the same presentation.  However, morphine is currently on the drug shortage list and the syringes are on backorder.a. The syringes are not essentially a copy of the commercial product at this time.b. The syringes are always essentially a copy of the commercial product regardless of the drug shortage list.c. The syringes are not essentially a copy as long as there is a clinical need for Morphine.d. Morphine is a controlled substance and therefore must not be sourced from API.3. An outsourcing facility compounds preservative free rocuronium from API powder.  Rocuronium is available in preservative free form commercially and is not on drug shortage.  The facility asks you to check a box on its website stating that there is a clinical need for this product.a. The product can be sourced commercially and hence there is no clinical need for the outsourced product.b. The product is only available in vials, hence there is a clinical need for the product in syringes.c. It is the responsibility of the outsourcing facility to determine clinical need, so if they state there is a clinical need, it is okay to check the box.d. The box can only be checked by an OR physician.#compoundingpharmacy #compoundingpharmacists #compoundingpharmacies #pharmacists #pharmacytechnicians #pharmacytechniciansCE #pharmasalon#ACPE #pharmacyCEcredits #PharmacyCE #503b #essentialcopiesSupport the show (https://www.buymeacoffee.com/pharmasalon)

Show notes at pharmacyjoe.com/episode682. In this episode, I’ll discuss what happens if you add fentanyl to ketamine+rocuronium for rapid sequence intubation? The post 682: What happens if you add fentanyl to ketamine+rocuronium for RSI? appeared first on Pharmacy Joe.

Show notes at pharmacyjoe.com/episode682. In this episode, I’ll discuss what happens if you add fentanyl to ketamine+rocuronium for rapid sequence intubation? The post 682: What happens if you add fentanyl to ketamine+rocuronium for RSI? appeared first on Pharmacy Joe.

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Show notes at pharmacyjoe.com/episode666. In this episode, I’ll discuss what happens if you accidentally get rocuronium in your eye. The post 666: What happens if you accidentally get rocuronium in your eye? appeared first on Pharmacy Joe.

Show notes at pharmacyjoe.com/episode666. In this episode, I’ll discuss what happens if you accidentally get rocuronium in your eye. The post 666: What happens if you accidentally get rocuronium in your eye? appeared first on Pharmacy Joe.

Neuromuscular Blockade: - Facilitates intubation - Facilitates better surgical conditions - Facilitates mechanical ventilation (i.e. ARDS, hyperventilating in increased ICP) Two Categories: - Depolarizing: ex. Succinylcholine (1-1.5mg/kg IV) depolarizes the muscle and prevents repolarization. - Non-depolarizing: ex. Rocuronium (0.6-1.2mg/kg IV) Outcompetes ACh for the receptor on the endplate. Big thanks to Suzanne George MD 2022 Candidate from the University of Calgary for editing the episode script! References: 1. Butterworth J, Mackey D, Wasnick J. Morgan & Mikhail's Clinical Anesthesiology. 5th ed. McGraw-Hill Education; 2013. 2. https://www.openanesthesia.org/aba_phase_ii_depolarizing_blockade/ 3. Zhang Z, Guo Q, Wang E. Hyperventilation in neurological patients: from physiology to outcome evidence. Curr Opin Anaesthesiol. 2019;32(5):568-573. doi:10.1097/ACO.0000000000000764

Effects of magnesium sulphate on the onset time of rocuronium is this BJANcast's main theme with Flavia Serebrenic PhD. The article we based our interview is "Effects of magnesium sulphate on the onset time of rocuronium at different doses - a randomized clinical trial". You can download this and other articles directly from BJAN's website. BJAN helps to improve the research and brazilian science. #citeBJAN #joinBJAN Social Networks: bjan-sba.org Instagram Facebook LinkedIn Twitter

Contributor: Aaron Lessen, MD Educational Pearls: Known risk factors for being awake and paralyzed in the OR include only receiving IV medications, long-acting paralytics, and no formal monitoring system for being awake The ED-AWARENESS study, a prospective single-center study found 2.6% of patients with induced paralysis during mechanical ventilation were aware Rocuronium was a risk factor for developing awareness while paralyzed in this study Ensure adequate sedation during paralysis for mechanical ventilation in the ED setting, especially when using rocuronium References Pappal RD, Roberts BW, Mohr NM, et al. The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department. Ann Emerg Med. 2021;77(5):532-544. doi:10.1016/j.annemergmed.2020.10.012 Pappal RD, Roberts BW, Winkler W, Yaegar LH, Stephens RJ, Fuller BM. Awareness With Paralysis in Mechanically Ventilated Patients in the Emergency Department and ICU: A Systematic Review and Meta-Analysis. Crit Care Med. 2021;49(3):e304-e314. doi:10.1097/CCM.0000000000004824   The Emergency Medical Minute offers AMA PRA Category 1 credits™ via online course modules. For more information and to access this content,, visit our website at www.emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today!

Dr. Calvin Brown discusses recent research on risk factors associated with peri-intubation mortality, an easy-to-use bedside screening technique for assessing anatomic difficulty using thyromental height, and rocuronium dosing for emergency RSI.

Theme: Retrieval Medicine. Participants: Dr Ruby Hsu, Dr Ruth Parsell, Dr Pramod Chandru, Shannon Townsend, Yelise Foon, Shreyas Iyer and Samoda Wilegoda Mudalige.Discussion 1:Benoit, J., Stolz, U., McMullan, J., & Wang, H. (2021). Duration of exposure to a prehospital advanced airway and neurological outcome for out-of-hospital cardiac arrest: A retrospective cohort study. Resuscitation, 160, 59-65. https://doi.org/10.1016/j.resuscitation.2021.01.009.Presenter - Yelise Foon - ED senior resident medical officer. Summary: This study was a retrospective cohort study that looked at adult, non-traumatic OOHCA patients with an advanced airway (supraglottic or endotracheal). The timing of airway placement (intra-arrest versus post-ROSC) and patient outcomes (with respect to the cerebral performance category, or CPC) were analyzed.  They observed a higher CPC in the group that had the advanced airway placed post-ROSC (i.e. 21.7% in post-arrest group versus 7.5% in intra-arrest group). They concluded that the timing of the airway placement was not associated with poor neurological outcomes.  Discussion 2:Aziz, S., Foster, E., Lockey, D., & Christian, M. (2021). Emergency scalpel cricothyroidotomy use in a prehospital trauma service: a 20-year review. Emergency Medicine Journal, 38(5), 349-354. https://doi.org/10.1136/emermed-2020-210305.Presenter - Shannon Townsend, ED advanced trainee at Orange Health Service.Summary & Take-Home Points: This was a retrospective observational study conducted from 2000 to 2019 using clinical records and aimed to (1) ascertain the rate of scalpel cricothyroidotomy and (2) understand indications for and factors associated with this procedure. They observed that the main indication for scalpel cricothyroidotomy was as a rescue airway (for failed laryngoscopy due to a large volume of blood in the airway). They noted high levels of procedural success, but the overall mortality in patients receiving this procedure was high (due to a number of factors).  The rate of scalpel cricothyroidotomy has decreased over the years due to factors such as the introduction of supraglottic airways and longer-acting muscle relaxants (rocuronium versus suxamethonium).  It is important to remember that, if we optimize our intubation conditions (e.g. improving patient position, carefully choosing drugs and equipment according to patient's clinical situation), we are likely to increase our first pass success with laryngoscopy.  It is important to (1) recognize the indications for scalpel cricothyroidotomy, (2) be familiar with the procedure itself, (3) overcome the mental barriers against performing it, and (4) perform it confidently and competently. Discussion 3:Sperry, J., Guyette, F., Brown, J., Yazer, M., Triulzi, D., & Early-Young, B. et al. (2018). Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. New England Journal Of Medicine, 379(4), 315-326. https://doi.org/10.1056/nejmoa1802345.Presenter - Dr Ruth Parsell. Summary: In this pragmatic, multi-center, cluster-randomized, phase 3 superiority trial, the efficacy of administering thawed plasma to patients at risk of haemorrhagic shock was studied.  The comparative arm was standard-care resuscitation (with crystalloid fluids). The primary outcome was mortality at the 30-day mark.  They concluded that administration of thawed plasma to patients at risk of haemorrhagic shock resulted in (1) lower 30-day mortality and (2) lower median prothrombin-time ratio.  Interlude Segment 1:Presenter - Dr Ruth Parsell. Interlude Segment 2:Presenter - Dr Ruby Hsu.Credits:The discussions were mediated by retrieval specialists and ED consultants, Dr Ruby Hsu and Dr Ruth Parsell and ED consultant Dr Pramod Chandru. This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney, Deepa Dasgupta, Cynthia De Macedo Franco, and Paul Scott.Music/Sound Effects Beach Volley by Scandinavianz | https://soundcloud.com/scandinavianz, Music promoted by https://www.free-stock-music.comCreative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.  Hands High by LiQWYD | https://www.liqwydmusic.com, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.  Lose My Mind by ASHUTOSH | https://soundcloud.com/grandakt, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.  Medical Examination by MaxKoMusic | https://maxkomusic.com/, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US.  Nightswim by Scandinavianz | https://soundcloud.com/scandinavianz, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US. 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The Leap by Sapajou | https://soundcloud.com/sapajoubeats, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.  Thinking Of You by Ron Gelinas Chillout Lounge | https://soundcloud.com/atmospheric-music-portal, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.  ~Thank you for listening!Please send us an email to let us know what you thought.You can contact us at westmeadedjournalclub@gmail.com.You can also follow us on Facebook, Instagram, and Twitter!See you next time,Caroline, Kit, Pramod, Samoda, and Shreyas.

Show notes at pharmacyjoe.com/episode577. In this episode, I ll compare succinylcholine vs rocuronium with magnesium pretreatment. The post 577: Succinylcholine vs rocuronium with magnesium pretreatment appeared first on Pharmacy Joe.

Join the Med4 podcast and Shock Trauma Physician Dr. Galvagno while he reviews current medical literature. Listen as he comments on the Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation A Randomized Clinical Trial.

This podcast presents, Dr. Nate Beerling, a Ridgeview Medical Center anesthesiologist, who discusses two rare but life threatening events - malignant hyperthermia (MH) and local anesthetic systemic toxicity (LAST). Dr. Beerling will discuss how they occur and how to treat these conditions.  Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: Recognize risk factors related to local anesthetic system toxicity (LAST) and for malignant hyperthermia (MH) Differentiate signs and symptoms of local anesthetic system toxicity (LAST) and for malignant hyperthermia (MH). Determine initial treatment for local anesthetic system toxicity (LAST) and for malignant hyperthermia (MH). Distinguish the differences in resuscitation between Advanced Cardiac Life Support (ACLS) protocols for local anesthetic system toxicity (LAST) and for malignant hyperthermia (MH CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "Shake and Bake: LAST and MH" (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. SHOW NOTES: CHAPTER 1: Malignant hyperthermia first appeared in letters written between anesthesiologists who noticed patients having "ether convulsions" in surgery.  It was formally discovered in the 1960s by Dr. Michael Denborough, in Australia. One of his patients' required surgery for a tibia fracture, and the patient was terrified about having surgery because 10 of his family members had died during surgery. This patient did actually have a malignant hyperthermia event, but survived. Pathophysiology is of course complex, but remember 2 things: calcium release and ryanodine receptors. First, let's trace the normal pathway for muscle reaction. Signal generates from the brain, travels down the nerve pathway till it synapses with a motor neuron. here acetylcholine is released and triggers a voltage. That voltage is sodium channels opening and causing depolarization and generating action potential, aka, the electrical signal. This signal travels down the muscle cell to the T-tubules where a dihydropyridine receptor is mechanically linked to an organelle called the sarcoplasmic reticulum where calcium lives. When that voltage travels down and sets off the dihydropyridine receptor, that then opens the ryanodine receptor, calcium is released into the cell which sets off the muscle contraction cycle. Calcium binds to troponin, attracts it to the myosin. The myosin then contracts and shortens, causing an overall muscle contraction. ATP, the energy unit of the cell, has already been broken apart to cause the contraction. In order for the muscle cell to relax, a new ATP must attach to the myosin. That process will repeat as long as calcium is around. In malignant hyperthermia, there is a double hit phenomenon. The patient has mutated ryanodine receptors and exposure to an induction agent (which we'll talk about later). The agent binds to the mutated ryanodine receptor and doesn't allow it to close. Calcium continues to leak which sets off this cycle of muscle contraction, release, contraction. As new ATP is required to relax the muscle, ATP is quickly depleted. When ATP is gone, there is muscle contraction without ATP to release it. That's what causes the rigidity in malignant hyperthermia. The cell will now try to make energy in any way possible and reverts to anaerobic metabolism, with lactic acid production. The clinical effects are hypoxia, increase in CO2 or hypercapnia, and lactic acidosis. Let's use an example. Let's say there is a patient who is going to undergo a laparoscopic appendectomy. The induction agents that would be used include propofol, a neuromuscular blocking agent, fentanyl, versed, and lidocaine. In addition, the patient will receive an inhalation agent like cevoflorine, desflurane or isolflurane via a ventilator. It's these agents as well as the neuromuscular blocking agent, succinylcholine, that can cause a malignant hyperthermia event. In a situation where malignant hyperthermia would develop, the obvious sign would be a rise in end tidal CO2. Though in this case example, which is laparoscopic, CO2 is used to insufflate the abdomen, and thus is part of your differential diagnosis. Look for rise in end tidal CO2 that does not respond to ventilation, arrhythmias, and hyperthermia. Rigidity in a patient is a pathognomonic sign of malignant hyperthermia. What are the clinical manifestations? A rise in end tidal CO2 and tachycardia. Hypoxia if they're using up all their oxygen. Hypertension in the presence of a huge catecholamine dump as a compensatory mechanism, and arrhythmias due to hyperkalemia. To drag it back to pathophysiology, all the energy or ATP has been used up in the cells, and they can't support normal metabolic processes. The cell dies, and potassium which mainly lives in the cell, gets released in the bloodstream causing hyperkalemia. We mentioned the differential diagnosis earlier when talking about surgical insufflation of CO2, but other rule outs would be a rise in CO2 due to hypoventilation or hypermetabolic processes, like neuroleptic malignant syndrome or serotonin syndrome. Arrhythmias could be the result of a primary cardiac event. When intubating the emergent patient with unknown past medical history, can succinylcholine be used? In general, succinylcholine is a "nice, safe drug". However, there is another neuromuscular blocking agent, Rocuronium, which has a reversal agent, sugammadex, that would work faster than succinylcholine would wear off, and also is not a malignant hyperthermia triggering agent. Always consider whether or not any neuromuscular blocking agent is actually appropriate for that particular patient and situation. CHAPTER 2: The first step when treating malignant hyperthermia, is to recognize it, then treat the life-threats. Treat the hyperkalemia, ventilate with 100% oxygen to replace what's being used up and most importantly - dantrolene. In this case, dantrolene is the life-saving drug, the gold standard that has significantly decreased the mortality of malignant hyperthermia events. Discovered in the 1970s, it works by attaching to the ryanodine receptor and disengages the triggering agent from the ryanodine receptor and allows it to function normally again. Bolus dose for dantrolene is 2.5 mg/kg bolus that can be repeated. This is a change, as it used to be recommended that a bolus dose plus a drip be administered, but a new formulation has made reconstituting the drug easier. Thus, the recommendation is a bolus, with repeated boluses, if required. The malignant hyperthermia kit should include: dantrolene (obviously), but also ACLS drugs. For treatment of hyperkalemia - insulin/dextrose and albuterol. Bicarbonate, which treats low pH, hyperkalemia, and helps alkalize the kidneys in light of muscle breakdown. Calcium is extremely important for myocardial stabilization. Cooling in the OR could involve lavage of an open cavity, but also cold IV saline, and or ice packs to the axillary and groin areas. Once the body temperature has dropped below 38o C, cooling should be terminated to avoid hypothermia. Ongoing care would include transfer to a tertiary care facility, where the patient can undergo continued monitoring. Dantrolene can be given intermittently every 4-6 hours for 24-hours, because malignant hyperthermia recrudescence can occur. Watch for kidney failure due to rhabdomyolysis, DIC, and if recrudescence occurs, hyperkalemia. Malignant hyperthermia is an inherited autosomal dominant trait. When assessing for risk, a thorough history and physical is required to look for individual problems, as well as looking for a lethal family history from anesthesia. If there is a family history, it's best to avoid triggering agents. If a patient has a malignant hyperthermia event, they don't need any further testing, they are confirmed. However, they may want genetic testing. There are 30 mutations of both the ryanodine and dihydropyridine receptors that have been linked to malignant hyperthermia. Those results can be used to help identify family members with the same mutations. Unlike the caffeine/halothane test, genetic testing doesn't require a muscle biopsy. The caffeine/halothane test is another way to confirm patients with malignant hyperthermia. It's done by applying caffeine and halothane to a fresh muscle biopsy. If a certain amount of contraction is achieved, it is diagnosed for malignant hyperthermia. However, to complete the test, the patient must be physically present at the institution performing it, and there are only 5 such institutions in North America. It would be best to refer these patients to a specialized institution before a scheduled surgery. MHAUS.org is a great resource for information on malignant hyperthermia. There is also a hotline that can bel called during an event. It's staffed 24/7 by anesthesiologists that are highly trained in malignant hyperthermia. It's important to remember that these events are rare, and it's important to have all the resources and help possible during an event. CHAPTER 3: LAST is local anesthetic systemic toxicity. Much like MH, it is a life threatening reaction that is almost completely preventable when care is take while injecting local anesthetics. It is also managed differently than a normal cardiac arrest. There are 2 types of symptoms of LAST, cardiac and neurological. Most of the time it is felt that the neurologic symptoms precede the cardiac ones. These anesthetic agents work by blocking the sodium channels, and thereby block the depolarization of the nerves, both cerebral and cardiac. These agents are not always specific to sodium channels and can block other channels. What predisposes cardiac effects depends on the agent, bupivacaine is most likely to cause cardiac issues; followed by ropivacaine, then lidocaine.  This is related to the properties of the individual agents. The more lipophilic the agent, the more potent it is. Each anesthetic has a ratio of where it's most likely to be toxic at. Lidocaine is more likely to be toxic in the brain, than the heart. Bupivacaine is more likely to affect the heart at the same time it affects the brain. So, for example, if lidocaine were injected, there would be neurologic symptoms, but bupivacaine, if injected, because it's ration is lower, would have both cardiac and neurologic effects. Safety of local anesthetics administered IV is due to dosage. For example, before almost every surgical case, a 1 to 1.5mg/kg bolus is given IV because it helps some of the sympathetic response i.e. the cardiac response to laryngoscopy and intubation, bronchospasms etc. Lidocaine is an antiarrhythmic, as well and probably one of the safest legal anesthetics to give IV. It's used as IV infusion for enhanced recovery after surgery for colorectal surgeries, and it's also used for renal colic in the emergency room setting. Giving IV lidocaine within that range of 1 to 1.15 mg/kg has been shown to be safe with almost zero chance of LAST. LAST can also occur when high doses are given and absorbed into the bloodstream.   It can get confusing looking at different percentages of drugs, and mixes. Lidocaine with epinephrine tends to depot the drug. The max dose of local anesthetic are based on the mass of the dose, the mg/kg, not the volume of the dose. For example, a fascia iliaca block is a volume block. You want to get a large volume of the medication to get a good coverage. A large volume of a dilute anesthetic is safe if it remains within the normal dose ranges. Max doses for local anesthetics are:  - Lidocaine:  4mg/kg  - Lidocaine with Epi:  7mg.kg  - Bupivacaine: 3mg/kg  - Ropivacaine: 3mg/kg For quick dosing, if using 25% bupivacaine, the max dose is the patient's weight in mls. For example, a patient that is 70kg, their max dose would be 70mls of 25% bupivacaine. If using 50% bupivacaine, the max dose is half their weight. For the same 70kg patient, the dose would be 35 mls. This same quick dosing can be used for ropivacaine. Predisposition of patients for LAST include extremes of age, low muscle mass, the very end stages of liver or renal disease along with low-protein binding states. Areas where LAST has a higher prevalence, is due to the vascularity of the tissue being injected, and how quickly it can be absorbed. This list of highest absorption to lowest is as follows: IV, tracheal, intercostal, paravertebral, epidural, abdominal wall, tap blocks and brachial plexus blocks, sciate, femoral, and then subcutaneous. CHAPTER 4: LAST presentation can be variable, but the classic presentation of LAST is first neurologic symptoms: excitatory, circumoral numbness, ringing in the ears, agitation, and just "not feeling right". This then can lead to delirium, sedation, coma and/or seizures. Then cardiac toxicity can develop. This can also be quite variable resulting in tachycardia to bradycardia, widening of the QRS, elongation of the QT, and/or flat out Vtach/Vfib. In the event of LAST, treatment depends on the variable presentation. Mild symptoms require 1:1 monitoring of Spo2, cardiac rhythms and blood pressures to make sure it doesn't advance. If severe signs develop, in particular seizures, treatment must be aggressive and intralipid infusion should be started. Intralipid or lipid emulsion therapy is the first line drug in LAST; and works by affecting the agent through lipophilicity. It helps shift the diffusion gradient, and pull the anesthetic agents like bupivacaine off the sodium channels in the cardiac myocytes, and shuttle them away from the heart to the skeletal muscle and to the liver. A secondary mechanism  is that it helps limit ischemia reperfusion syndrome and acts as a fluid bolus. It generally works fast - within minutes. In a LAST event, ACLS doses are different. EPI doses should remain under a 100mcgs or a 1mcg/kg. EPI is arrhythmogenic and standard ACLS doses contribute to local anesthetic induces arrhythmias. Sodium channel blockers like lidocaine or procainamide should not be used. Other aspects of the ACLS protocol: CPR, defibrillation, and airway management remain unchanged. It is recommended that in this event that transfer to a facility that has ECMO should be considered. Lipid emulsion dosing for adults over 70kg, is 200mls for the first bolus, with repeat doses of 100mls every few minutes. If under 70kg, the dosing returns to the old formulation of 1.5ml/kg bolus, and then an infusion of 0.25ml/kg/min. If rebolusing, increase the rate or the drip. Max dose is 12ml/kg. If reaching the max dose, consider that this event may not be LAST. Is ultrasound or nerve stimulator better at reducing the risk of LAST when injecting anesthetic?  It depends on who you ask. Ultrasound is like "turning the lights on". It allows you to see the spread of the anesthetic being injected. Thanks for listening.

8 spannende Studien haben wir dieses Mal für Euch, hört rein ! Duff, Jonathan P., et al. „2019 American Heart Association Focused Update on Pediatric Advanced Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.“ Circulation 140.24 (2019): e904-e914. Guihard, Bertrand, et al. „Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success […] Der Beitrag "titriert" Journal Club Januar 2020 erschien zuerst auf pin-up-docs - don't panic.

We discuss everything you need to know about Succinylcholine and Rocuronium, both our two must trusted NMBAs for RSI in the ED. We discuss why we use paralytics the majority of the time, side effects, differences in practice, and classic board-relevant side toxicity. Website: www.emboardbombs.com

Moderator: James P. Rathmell, M.D. Participants: Albert Dahan, M.D., Ph.D. and Jaideep J. Pandit, M.A., B.M.B.Ch, D.Phil, F.R.C.A., D.M. Articles Discussed: Reversal of a Partial Neuromuscular Block and the Ventilatory Response to Hypoxia: A Randomized Controlled Trial in Healthy Volunteers Reversing Neuromuscular Blockade: Not Just the Diaphragm, but Carotid Body Function Too Transcript 

This month we have a discussion on the Manchester Bombing | Scribes in the ED | TERN TIRED | PTX and haemothorax in the CT era | Horse Trauma | Roc Rocks - ED RSI with Rocuronium or Suxamethonium

Educational Pearls: RSI includes induction agent (sedative) and a paralytic Succinylcholine is a depolarizing paralytic of rapid onset and short duration with contraindications in hyperkalemic states and muscular dystrophy Rocuronium and vecuronium are longer acting, non-depolarizing paralytic, more commonly Common induction agents are etomidate and ketamine Ketamine can be particularly beneficial for bronchodilator effects in those with reactive airway disease References:   Stollings JL, Diedrich DA, Oyen LJ, Brown DR. Rapid-sequence intubation: a review of the process and considerations when choosing medications. Ann Pharmacother. 2014 Jan;48(1):62-76. doi: 10.1177/1060028013510488. Epub 2013 Nov 4. Review. PubMed PMID: 24259635. Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

Using a case-based approach, Dr. Calvin Brown III and guest presenter, Dr. Brian Driver, introduce the latest published airway research and discuss its impact on clinical practice.

Georg Bruckmann Der Operateur Immer wieder verschwimmen die Kacheln des kalten Operationsraumes, wenn er sich auf seine Aufgabe konzentriert. Der Operateur weiß, dass er sich zusammenreißen muss. Das regelmäßige Piepen des Herzmonitors hilft ihm dabei. Seine Aufgabe ist nicht einfach. Er wischt sich mit dem Ärmel über die Stirn, um den Schweiß daran zu hindern, ihm in die Augen zu laufen. Er braucht seine Augen. Jetzt mehr denn je. Die Operation ist lebenswichtig. Die Umstände sind widrig. Das arme Schwein, dass da vor ihm auf dem Tisch liegt, ist vom Schicksal arg gebeutelt worden. Der Fuß und der Unterschenkel fehlen bereits. Das andere Bein musste schon komplett abgenommen werden. Rauch, denkt der Operateur. Jetzt ist der verbleibende Oberschenkel an der Reihe. Sie hatten versucht, so viel wie möglich zu retten. Der Patient sollte die Chance bekommen, ein halbwegs normales Leben zu leben, wenn er diese unglückliche Sache hinter sich gebracht hätte. Es sieht nicht so aus, als ob das klappen würde. Bedauern, fast schon eine tiefe Traurigkeit erfüllt den Operateur. Der Mann ist im selben Alter wie er selbst. Auch er hat eine Frau und zwei Kinder. Eine Tochter und einen Sohn. Beide in ihren frühen Zwanzigern. Er darf sich davon nicht ablenken lassen. Wie es weitergehen würde, würde man sehen, wenn die Operation geglückt wäre. Die vorangegangenen Amputationen hatten den Patienten schon ziemlich geschwächt. Der Operateur verfluchte die Umstände, unter denen er arbeiten musste. Die Anästhesieschwester und der Assistenzarzt sind unzuverlässig. Nein. Das ist ungerecht, denkt der Operateur. Vermutlich verlassen sie den Operationssaal immer wieder, weil sie in dieser Karikatur eines Krankenhauses noch mehr Leben zu retten haben. Wo ist er hier nur gelandet? War gelandet überhaupt das richtige Wort? War er nicht selbst daran schuld? Egal. Er muss sich jetzt konzentrieren. Im Geiste geht er die notwendigen Schritte durch. In der Leiste abbinden, so fest es nur möglich ist. Es gibt hier keine Blutkonserven und jeder Tropfen ist kostbar. Die Hände des Operateurs gleiten fast schon nachdenklich über den Gurt, den er dazu verwenden wird. Er wird halten, weiß er. Er hatte ihn auch schon für die anderen Operationen benutzt. Dann vergewissert sich der Operateur, dass auch die Stange da ist, die er verwenden wird, um den Gurt so lange in sich zu verdrehen, bis der Druck groß genug ist und die Amputation vorgenommen werden kann. Er weiß, dass das Abbinden dem Patienten große Schmerzen verursachen wird. Er weiß auch, dass diese Schmerzen erst der Anfang sein werden. Die Anästhesieschwester wird zwar helfen, aber ihre Mittel sind eingeschränkt. Kein Propofol, Thiopental oder Etomidat und auch kein Succinylcholin oder Rocuronium. Nur Alkohol und die Muskelkraft des Assistenzarztes und der Schwester, die den Patienten ruhig halten sollen. Der Operateur hat alle Instrumente geschärft und gereinigt, so gut es geht. Klinge, Schere und Säge. Sie stehen bereit, sind in hochprozentigen Alkohol eingelegt und glitzern den Operateur böse an, in ihrer präzisen, mitleidslosen Schönheit. Sie wollen schneiden und trennen und entfernen. Dem Operateur wird kalt, obwohl er schwitzt. Er fühlt sich müde. Schon viel zu lange wach. Schon viel zu lange nichts gegessen. Denkbar ungeeignet. Eigentlich sollte jemand anders diese Operation durchführen, aber er weiß, dass er es ist, der es tun muss. Es ist kein Arzt verfügbar. Er weiß auch, dass er nicht mehr allzu lange warten sollte. Mit jeder Minute, die verstreicht, wird der Patient schwächer. Er bringt den Gurt an, führt die Stange durch die Schlaufe und beginnt zu drehen. Wenn er fertig ist, wird er die Schwester und den Assistenzarzt rufen. Der Herzmonitor sendet seine akustischen Signale jetzt in einer etwas höheren Frequenz aus. Ab jetzt darf er kein Mitleid mehr kennen. Weder mit seinem Patienten, noch mit sich selbst. Jedes Zaudern, jedes winzige Quäntchen von Schwäche kann am Ende dazu führen, dass der Patient stirbt. Er verdreht den Gurt, und mit jeder Drehung der Stange bäumt der Patient sich auf und schreit. Verhalten zuerst, dann immer lauter und hemmungsloser. Mit jeder Drehung der Stange wird der Schmerz stärker. Der Operateur stöhnt jetzt ebenfalls vor Anstrengung. Beinahe klingen die beiden Männer, als ob wilde Tiere miteinander kämpfen würden. Oder Ficken, denkt der Operateur. Dann überlegt er für den Bruchteil einer Sekunde, wie groß die Chancen auf Sex für einen Beinlosen wohl sein mochten. Dann: Was ist eine Frau ohne Arme und Beine? Ein Bumsklumpen. Galgenhumor. Unangebracht und hässlich, aber er hilft ihm dabei, die nötige Distanz zu wahren. Mehr, mehr, mehr. Mehr drehen und nicht auf die Schreie des Patienten achten. Noch mehr drehen. Der Gurt schneidet jetzt tief ins Fleisch hinein. Ausreichend tief, um all die großen Adern fest genug zusammen zu pressen? Tief genug, um erneut zu verhindern, dass der Patient verbluten wird? Der Oberschenkel ist dicker als die Stelle unterhalb des Knies, an der die letzte Amputation durchgeführt worden war. Der Operateur schafft noch drei Umdrehungen. Mehr bekommt er nicht hin. Das muss reichen. Er fixiert die Stange und das Jammern des Patienten ebbt langsam ab. Auch der Operateur atmet jetzt ruhiger. Man kann sich an so vieles gewöhnen. Der Mensch ist ein Wunder der Natur. Widerstandsfähiger, als man glaubt, macht der Operateur sich Mut. Die nötigen Schritte müssen jetzt schnell und präzise auf einander folgen. Er strengt sich an und ruft laut nach der Anästhesieschwester und dem Assistenzarzt. Er muss eine Weile auf sie warten und in dieser Zeit redet er beruhigend auf den Patienten ein. Automatisch abgespulte Floskeln, wie man sie eben gegenüber Patienten benutzt. Während sein Mund die Worte formt, denkt er sich an angenehmere Orte, will vergessen, dass er müde und hungrig ist und Angst hat, dass er versagen könnte. «Nur ruhig. Sie werden sehen, es ist gleich vorbei.» Zuhause, im kleinen Garten hinter dem Haus. Es ist Sommer. Die Kinder toben halb nackt mit Spritzpistolen und Wasserbomben. Unschuldig, wie im Garten Eden. Ein sachter Wind weht und spielt mit ihrem goldenen Haar. «Wir kriegen das schon hin.» Neben ihm sitzt seine Frau mit ihm am Tisch auf der Terrasse. Sie blättert in einer Zeitschrift, und wenn sie von ihr aufschaut, um einen Blick auf die Kleinen zu werfen, lächelt sie. «Nur noch etwas Geduld. Bald haben sie es überstanden.» Ein späterer Zeitpunkt. Ein anderer Ort. Eine Schulaufführung. Die Klasse seiner Tochter hat Theater gespielt. Weder das Stück, noch die Darbietung war besonders gut, aber der Applaus der Eltern ist wohlwollend und zaubert den Kindern Freude in die Gesichter. «Es wird wehtun, das schon. Da kann und will ich ihnen nichts vormachen. Aber sie werden sich hinterher nicht mehr an die Schmerzen erinnern.» Noch später im Leben. Abendessen. Der Operateur sitzt mit seiner Frau und seiner Tochter am Tisch. Der Sohn kommt herein. Er ist stolz, weil er die Führerscheinprüfung im ersten Anlauf bestanden hat. Der Operateur hat Bedenken, weil sein Sohn ein Heißsporn ist. «Keine Sorge. Sie werden es überstehen, das verspreche ich Ihnen.» Der Operateur mit seiner Frau im Theater. Die Nibelungen. Er weiß, dass seine Frau diesen schweren, deutschen Kram nicht mag und nur ihm zuliebe mitgekommen ist. Sie lässt es ihn nicht spüren. «Bleiben Sie ruhig liegen. Sie können mir vertrauen. Ich bin ein Profi.» Er selbst. In einer Kneipe nahe seines Arbeitsplatzes. Überall sind seine Freunde um ihn herum. Sie feiern seine erste erfolgreiche Operation. Blinddarmentfernung. Hat reibungslos geklappt. «Denken Sie jetzt nicht an die Zukunft. Konzentrieren Sie sich aufs Hier und Jetzt. Alles andere wird sich fügen.» Ein Ferienhaus in Schweden. Sie schwimmen im See. Manchmal angelt er. Sie überlegen, ob sie es kaufen sollen, für den Ruhestand. «Wenn es vorbei ist, bekommen Sie als Erstes etwas Leckeres zu essen.» Er und seine Frau kochen zusammen. Sie lachen viel und trinken Wein und das Essen brennt an. Sie küssen sich und lachen noch mehr. «Sie haben schon so viel hinter sich, da ist das hier doch ein Klacks!» Eine Skipiste. Schmerz, als er stürzt und sich den Arm bricht. Er selbst auf dem OP-Tisch. Sie setzen Schienen und Schrauben ein. Die Zeit der Genesung danach. Seine Familie ist am Krankenbett, als er aufwacht. Die Nerven in seiner rechten Hand haben durch den Bruch etwas gelitten, aber er übt und übt und übt, so lange, bis er wieder operieren kann. Freude, als es soweit ist. «Mein Team ist gleich da. Sie müssen nicht mehr lange warten.» Endlich kommen sie. Wieder flimmern die Wandkacheln vor den Augen des Operateurs und er blinzelt. Er hat einfach schon zu oft operiert in der letzten Zeit. Die blonde Anästhesieschwester lächelt dem Operateur freundlich und professionell zu. Dann macht sie sich ans Werk und flößt dem Patienten den Alkohol ein. Der Operateur kann beinahe selbst fühlen, wie die Flüssigkeit in der Kehle brennt und sich danach warm im Magen ausbreitet. Der Patient schluckt ein halbes Wasserglas, mehr wäre nicht ratsam. Die Anästhesieschwester findet lobende Worte für den Patienten, die sie ruhig und gelassen, beinahe schon hypnotisch ausspricht. Sie hat Routine. So redet sie mit jedem ihrer Patienten. Auch hier haben ihre Worte eine Wirkung, wenn auch eine kleine. Das Piepen des Herzmonitors wird etwas langsamer. Der Operateur weiß jedoch, dass das nicht lange so bleiben wird. Er wirft einen Blick auf den Beinstumpf. Der Oberschenkel ist blass, fast schon blau. Ein gutes Zeichen. Der Gurt sitzt fest genug und das Fleisch wird kaum noch durchblutet. Die Anästhesieschwester tritt jetzt um den OP-Tisch herum und legt dem Patienten ihre Hände auf die Stirn, beginnt dann sachte seine Schläfe zu massieren, während sie weiter in ihrem hypnotischen Tonfall spricht. Der Operateur weiß aus irgendeinem Grund, dass die Berührung ihrer Hände kühl sein muss. Der Assistenzarzt ist jetzt auch da. Er streicht sich eine Strähne seines etwas zu langen, hellen Haares aus der Stirn und macht sich daran, den Docht einer selbst gebaut aussehenden Lampe anzuzünden. Die Flamme lodert hoch und der Operateur kann etwas von ihrer Wärme spüren. Gerne würde er seine Hände in die Nähe des Feuers bringen, bevor er sich ans Werk macht. Er weiß aber, dass die Flamme einen anderen Zweck hat. Der blonde Assistenzarzt ist vielleicht ein paar Jährchen älter als die Anästhesieschwester und jetzt hält er ein dünnes Stück Blech mit Hilfe einer Zange in die Flamme. Er bewegt es hin und her, damit es gleichmäßig erhitzt wird. Für die Dauer der Operation wird er nichts anderes tun, als das. Er wird das Blech zum Glühen bringen, es ist dünn genug. Erst wenn der Oberschenkel abgetrennt ist, wird er in Aktion treten und den Stumpf ausbrennen. Der Patient sieht das auch und beginnt unruhig zu werden, weil er schon ahnt, welchen Zweck dieses Blech hat. Er will sich trotz seiner Fixierung aufsetzen, hebt den Kopf, doch die Anästhesieschwester drückt mit sanfter Gewalt seine Stirn zurück auf den OP-Tisch. Sie gibt ihm noch einen Schluck. Dann sagt sie, dass es nun aber reichen muss, und wirft dem Operateur einen Blick zu, der besagt, dass er nun endlich anfangen soll. Der Operateur schluckt. Sein Blick verschwimmt, und wieder wischt er sich den Schweiß aus dem Gesicht, damit er ihm nicht in den Augen brennt. Auch der Assistenzarzt hat sich jetzt halb zu ihm umgedreht und der Operateur kann in den Gesichtern seiner beiden Helfer das grenzenlose Vertrauen sehen, dass sie ihm entgegenbringen. Beide, die Anästhesieschwester und der Assistenzarzt nicken ihm zu. Keinesfalls will er sie enttäuschen. Der Gedanke schenkt ihm Zuversicht und endlich bringt es über sich, nach dem Instrument zu greifen. Er holt es aus dem Gefäß mit dem Alkohol, schüttelt es ab, macht es bereit und setzt die Klinge an. Kaum berührt das Metall das Fleisch, beginnt der Patient erneut zu brüllen und der Monitor wird geradezu hysterisch. Aber es hilft nichts. Der Oberschenkel muss weg und jetzt ist nicht die Zeit, zu verzagen. Es würde das Leiden nur unnötig in die Länge ziehen. Die Klinge schneidet tief ein, durchtrennt Haut, Fettgewebe und Muskelfasern. Sie zerteilt Venen, Arterien und Nerven. Der Operateur wendet alle Kraft auf, die er in sich hat, sowohl mental als auch physisch, denn die Klinge ist kurz und mit der anderen Hand muss er Fleisch und Gewebe wegdrücken, damit er sehen kann. Der Assistenzarzt klemmt das Blech jetzt so ein, dass es von selbst über der Flamme bleibt und kommt der Anästhesieschwester zur Hilfe, die Mühe hat, den Patienten ruhig zu halten. Die Hände des Operateurs zittern jetzt merklich. Er muss durchatmen und zieht die Klinge aus der Wunde. Sofort beginnen seine Helfer auf ihn einzureden. Machen Sie weiter! Sie dürfen jetzt nicht aufhören. Nur ruhig, sie schaffen das! Los! Weitermachen! Wir verlieren Ihnen sonst! Nicht aufgeben! Wir wissen, dass es schwer ist, aber es muss sein! Los. Bis runter auf den Knochen an der Oberseite. Dann das Bein hoch und in die Rückseite schneiden, bis gesägt werden kann! Die Anästhesieschwester spricht auch mit ihm in ihrem ruhigen, hypnotischen Tonfall, während der Assistenzarzt deutlich mehr Dringlichkeit in seine Worte legt. Sehen die beiden denn nicht, wie weh es tut? Und all das Blut, das trotz des straff gespannten Gürtels aus den Adern strömt und mir die Sicht erschwert? Wie können Sie das von mir verlangen? Verzweiflung macht sich breit im Operateur und gleichzeitig weiß er, dass sie Recht haben. Er sammelt sich und schneidet weiter. Aber er kann es jetzt nicht mehr so schnell tun. Er weiß nicht, ob die Klinge bereits wieder stumpf geworden ist oder ob es an seinen schwindenden Kräften liegt. Er braucht wirklich etwas zu essen. Aber das geht jetzt nicht. Es ist nichts da. Er kann nicht einfach aufhören. Es führt kein Weg zurück, nachdem der erste Schnitt gemacht ist. So lautet das grausame Gesetz seiner Zunft. Er reißt sich zusammen und strengt sich mehr an. Noch immer hat der Patient Kraft genug, um laute, tierische Schreie auszustoßen. Der Herzmonitor stimmt mit ein, verleiht Ihnen noch mehr irremachende Dringlichkeit. Die Rückseite des Oberschenkels, nur wenige Zentimeter unterhalb des Gesäßes ist schwieriger zu erreichen. Der Operateur muss jetzt fast blind arbeiten und nur seine Erfahrung macht es möglich, dass er nicht einfach nur willkürliche Schnitte ausführt, sondern seinem Ziel Millimeter für Millimeter näher kommt. Der Operateur ist beinahe am Ende seiner Kräfte, als er den ersten Etappensieg erringt. Der Knochen. Er liegt endlich frei und noch ist die Menge von Blut, die austritt, überschaubar. Die Schwester und der Assistenzarzt loben ihn, ermutigen ihn aber sogleich, um Himmelswillen jetzt nicht aufzuhören. Der Operateur macht die Säge bereit, taucht sie erneut ein in den Alkohol, dann setzt er sie am Knochen an. Die desinfizierende Flüssigkeit brennt höllisch im Fleisch des Patienten, setzt die durchtrennten Nerven in Brand. Der Patient zuckt und windet sich. Die Schreie sind jetzt etwas leiser, aber der Herzmonitor scheint wie wahnsinnig zu brüllen. Die geschundene Kreatur zuckt erneut und der Operateur lässt sein Instrument fallen. Es kullert ein Stück über den von Blutspritzern bedeckten Boden. Die Assistenten halten den Patienten weiterhin fest, helfen dem Operateur nicht, es wieder aufzuheben. Dafür schreien sie ihn jetzt an. Sie schreien, dass er sich beeilen muss, dass er machen soll, dass er einfach machen soll, dass alles gut wird. Die Anstrengung, als er sich vorbeugt und nach der Säge greift, lässt ihn beinahe bewusstlos werden. Er kommt nicht ganz an sie heran, es fehlen wenige Millimeter. Er strengt sich noch mehr an, beugt sich zur Seite hin und flucht - und dann gelingt es ihm. Er bekommt die Säge zu greifen! Er muss das Fleisch erneut auseinanderziehen und jetzt schreit nicht nur der Patient, auch er, der Operateur, schreit und flucht und dann beginnt er zu sägen. Der Knochen ist dick an der Stelle kurz vor dem Kugelgelenk und wie die Klinge es war, ist auch das Sägeblatt nur kurz. Diese Geräusche! Oh, diese Geräusche! Hölzern, auf falsche Weise laut und doch fleischig und nass. Schlimmer als das Schreien, schlimmer als das inzwischen rasende Piepen des Herzmonitors. Die Hand des Operateurs wird schwächer und schwächer, im selben Maße wie er selbst den Mut zu verlieren droht. Wieder beginnen sie, auf ihn einzureden. Sie feuern ihn an und er bewegt methodisch und manisch zugleich die Hand mit dem Sägeblatt hin- und her, ignoriert die Schreie des Patienten. Sägt und sägt und sägt und sägt und dann - Dann ist es endlich geschafft. Der Operateur ist schweißgebadet und blutbespritzt, als der Oberschenkel nach unten hin wegklappt, nur noch von etwas Haut gehalten. Dem Operateur ist schlecht, gleichzeitig glaubt er zu Schweben. Hier ist nichts mehr mit Schweben, dabei will ich Schwimmen in Schweden. Er lacht hysterisch. Mit Mühe und zitternden Fingern hantiert er an seinem Instrument herum, macht die Schere bereit. Er ist nervös, fiebrig, er glaubt, er wird krank werden. Am Ende gelingt es ihm und er benutzt die Schere, um die Amputation zu vollenden, indem er die letzten nötigen Schnitte macht. Mit einem nassen Laut fällt der Oberschenkel herunter. Der Assistenzarzt und die Anästhesieschwester applaudieren laut und ausgelassen. Etwas von ihrer Freude strahlt auf das Gemüt des Operateurs ab und für eine Sekunde fühlt er sich euphorisch. Ja, er hat es geschafft. Er hat es hinbekommen. Er atmet die eisige Luft tief ein, kostet dieses simple Vergnügen aus bis zur Neige. Dann noch mal und noch mal. Er fühlt sich leicht, so als wäre eine schwere Last von ihm genommen worden. Die Anspannung fällt von ihm ab. Er will den Assistenzarzt und die Anästhesieschwester fragen, ob sie zur Feier des Tages etwas mit ihm essen gehen möchten, aber sie sind schon weg. Sie sind wirklich unermüdlich, diese Kinder, denkt er und greift nach dem Fleisch auf dem Boden. Als seine Finger den Oberschenkel berühren durchzuckt ihn ein jäher Gedanke. Hat der Assistenzarzt nicht etwas vergessen? Doch natürlich! Die Wunde muss ausgebrannt werden. Tut mir leid, mein Freund. Wir sind noch nicht ganz fertig. Der junge Assistenzarzt ist eben doch unzuverlässig. Langsam beugt der Operateur sich vor und versucht, die Zange zu fassen, um mit ihrer Hilfe das inzwischen glühend heiße Blech benutzen zu können. Er muss sich weit vorbeugen, über die Operationswunde des Patienten hinweg, und dann passiert es. Der so fest verdrillte Gurt löst sich plötzlich, die Stange, die er selbst vor ein paar Minuten noch zum Festziehen benutzt hatte, wird in Drehung versetzt und, noch bevor der Operateur sie zu fassen bekommt, wird sie nicht mehr vom Zug des Gurtes an Ort und Stelle gehalten. Mit einem metallischen Klappern fällt sie zu Boden, aber der Operateur hört es nicht mehr. Mit bloßen Händen versucht er panisch, das ausströmende, heiße und in der kalten Luft dampfende Blut im Körper des Patienten zu halten. Aber es rinnt unaufhaltsam und dunkelrot zwischen seinen Fingern hindurch und immer, wenn er die Position seiner Hände verändert, um den Druck besser aufrechterhalten zu können, schießen wieder und wieder große, rote Fontänen hervor. Ein Schwall von Flüssigkeit, wie wenn man mit einer Spritzpistole schießen würde. Er schreit nach dem Assistenzarzt und der Anästhesieschwester, brüllt ihre Vornamen, aber sie hören ihn wohl nicht. Sie sind anderswo. Sonst würden sie doch kommen, oder? Sonst würden sie doch kommen. Es wäre schön, wenn sie jetzt hier wären. Schön ... Der Herzmonitor wird immer leiser, und schließlich kann der Operateur ihn gar nicht mehr hören. ENDE Mehr von mir gibt es hier: https://www.youtube.com/channel/UC2-7wMH65EJPCJ6qyqAjSDQ https://www.amazon.de/Georg-Bruckmann/e/B00WXIR5D2/

There has been some interesting debate in the past couple weeks in the #FOAMed community about the proper sequence to deliver RSI medications. Specifically, the debate centers around whether to administer Ketamine or Rocuronium first when performing RSI. Rocuronium is a non-depopmarizing paralytic that has an onset time of approximately 60-90 seconds. Ketamine, meanwhile is a wonderful sedative that has ... Read More The post MSM Shorty- Ketamine or Rocuronium first for RSI? appeared first on Medschoolmedic.

More on rocketamine...

In this episode I welcome Dr. Amit Prabhakar, one of our critical care fellows, to the show to discuss Sugammadex, a relatively recently approved (in the USA) reversal agent for Rocuronium and Vecuronium. Outline by Brian Park: Sugammadex outline

Kevin and Shelly do a bit of "role playing" in a listener request for a conventional teaching episode about muscle relaxant/paralytic drugs. Shelly has a "canned" lecture on paralytics routinely given to the residents about how relaxants work and how to approach their use. Kevin plays the "resident" somewhat berated about lack of knowledge about these routine medications. Enjoy the banter!!!

This podcast is a recorded lecture from our conference on why Rocuronium should be the go to drug for RSI in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_31_0_Final_Cut.m4a Download 2 Comments Tags: Airway, Rocuronium, RSI, Succinycholine Show Notes Sydney HEMS Sux Contraindications Read More: Strayer RJ. Rocuronium versus succinylcholine: Cochrane synopsis reconsidered. Ann Emerg Med 2011; 58(2): 217-8 Strayer RJ. Rocuronium vs. succinylcholine revisited. Ann Emerge Med 2010; 39(3): 345-6. Mallon WK et al. Response to Rocuronium vs. succinylcholine revisited. Ann Emerge Med 2010; 39(3): 346-7. Strayer RJ. (2010, January 14). Screencast: Rocuronium vs. Succinylcholine in 8 minutes. Retrieved from http://emupdates.com/2010/01/14/rocuronium-vs-succinylcholine/

This podcast is a recorded lecture from our conference on why Rocuronium should be the go to drug for RSI in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_31_0_Final_Cut.m4a Download 2 Comments Tags: Airway, Rocuronium, RSI, Succinycholine Show Notes Sydney HEMS Sux Contraindications Read More: Strayer RJ. Rocuronium versus succinylcholine: Cochrane synopsis reconsidered. Ann Emerg Med 2011; 58(2): 217-8 Strayer RJ. Rocuronium vs. succinylcholine revisited. Ann Emerge Med 2010; 39(3): 345-6. Mallon WK et al. Response to Rocuronium vs. succinylcholine revisited. Ann Emerge Med 2010; 39(3): 346-7. Strayer RJ. (2010, January 14). Screencast: Rocuronium vs. Succinylcholine in 8 minutes. Retrieved from http://emupdates.com/2010/01/14/rocuronium-vs-succinylcholine/...

This podcast is a recorded lecture from our conference on why Rocuronium should be the go to drug for RSI in the ED. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_31_0_Final_Cut.m4a Download 2 Comments Tags: Airway, Rocuronium, RSI, Succinycholine Show Notes Sydney HEMS Sux Contraindications Read More: Strayer RJ. Rocuronium versus succinylcholine: Cochrane synopsis reconsidered. Ann Emerg Med 2011; 58(2): 217-8 Strayer RJ. Rocuronium vs. succinylcholine revisited. Ann Emerge Med 2010; 39(3): 345-6. Mallon WK et al. Response to Rocuronium vs. succinylcholine revisited. Ann Emerge Med 2010; 39(3): 346-7. Strayer RJ. (2010, January 14). Screencast: Rocuronium vs. Succinylcholine in 8 minutes. Retrieved from http://emupdates.com/2010/01/14/rocuronium-vs-succinylcholine/ References Sluga M,

Pediatric airway management is a skill that integrates the three types of knowledge as described by the ancient Greeks: episteme, or theoretical knowledge, techne, or technical knowledge, and phronesis, or practical wisdom, also called prudence. Here we’ll invoke each type of knowledge and understanding as we go beyond the anatomical issues in pediatric airway management – to the advanced decision-making aspect of RSI and the what-to-do-when the rubber-hits-the road. Case 1: Sepsis Laura is a 2-month-old baby girl born at 32 weeks gestational age who today has been “breathing fast” per mother.  On arrival she is in severe respiratory distress with nasal flaring and intercostal retractions.   Her heart rate is 160, RR 50, oxygen saturation is 88% on RA.  She has fine tissue-paper like rales throughout her lung fields.  Despite a trial of a bronchodilator, supplemental oxygen, even nasal CPAP and fluids, she becomes less responsive and her heart rate begins to drop relatively in the 80s to 90s – this is not a sign of improvement, but of impending cardiovascular collapse. She is in respiratory failure from bronchiolitis and likely viral sepsis.  She needs her airway taken over. Is this child stable enough for intubation? We have a few minutes to optimize, to resuscitate before we intubate. Here’s an easy tip: use the sterile flushes in your IV cart and push in 20, 40, or 60 mL/kg NS.  Just keep track of the number of syringes you use – it is the fastest way to get a meaningful bolus in a small child. Alternatively, if you put a 3-way stop-cock in the IV line and attach a 30 mL syringe, you can turn the stop cock, draw up stream from the IV bag into the syringe, turn te stop cock, and push the fluid in the IV. Induction Agent in Sepsis The consensus recommendation for the induction agent of choice for sepsis in children is ketamine. Etomidate is perfectly acceptable, but ketamine is actually a superior drug to etomidate in the rapid sequence intubation of children in septic shock.  It rapidly provides sedation and analgesia, and supports hemodynamic stability by blocking the reuptake of catecholamines. Paralytic Agent in Sepsis The succinylcholine versus rocuronium debate… Succinylcholine and its PROS 82% of RSI in the ED used succinylcholine (According to the National Emergency Airway Registry, in 2005).  We know it, we are comfortable with it. Succinylcholine produces superior intubating conditions when comparing 1 mg/kg succinylcholine versus 0.6 mg/kg rocuronium, succinylcholine is that at 45 seconds. Succinylcholine and its CONs Raises serum potassium in everyone, typically 0.5 to 1 mEq/L.  That is not usually a problem, but for those with preexisting or inducible hyperkalemia, it can precipitate an arrest, as in renal failure, underlying neurologic or myopathic conditions like multiple sclerosis, muscular dystrophy, ALS, or those who had a stroke or a burn more than 72 hours prior. We often have limited information in critical situations. Succinylcholine gives us a false sense of security.  In children, there really is no “safe apnea” period. Succinylcholine’s effect on the nicotinic receptors results in mydriasis, tachycardia, weakness, twitching and hypertension, and fasciculations (Think nicotine overdose: M/T/W/Th/F). Succinylcholine’s effect on muscarinic receptors manifest (as in organophosphate overdose): SLUDGE – salivation, lacrimation, urination, defecation, GI upset or more apropos here: DUMBBELLS – diarrhea, urination, miosis, bradycardia, emesis, lacrimation, lethargy, salivation. Second dose of succinylcholine – beware of the muscarinic effects and bradycardia. Co-administer atropine, 0.01 mg/kg, up to 0.5 mg IV. Coda: succinylcholine is not that bad – we would not have had such great success with it during the early years of our specialty if it were such a terrible drug.  The side effects are rare, but they can be deadly.  So, what’s the alternative? Rocuronium and its PROs It has none of the side-effects of succinylcholine Rocuronium and its CONs Argument 1: the duration is too long if there is a difficult airway, since rocuronium can last over an hour. Still need to intubate, and now your patient is potentially worse. Argument 2: succinylcholine produces better intubating conditions at 45 seconds compared to rocuronium. At 0.6 mg/kg, rocuronium is inferior to succinylcholine at all time intervals. At 1.0 mg/kg, rocuronium is still inferior at 45 seconds.  At 1.2 mg/kg rocuronium – the dose now commonly recommended – there was no difference in intubating conditions, per a study by Heier et al. in Anethesia and Analgesia in 2000. Case 2: Multitrauma Joseph is a 3-year-old boy who is excited that there are so many guests at his house for a family party and when it’s starting to wind down and the guests begin to leave, he is unaccounted for. An unsuspecting driver of a mini-van backs over him. He is brought in by paramedics, who are now bagging him. Induction Agent in Trauma Need something that is hemodynamically stable – agents such as midazolam or propofol would cause too many problems. Etomidate is a short-acting imidazole derivative that acts on GABA-A receptors to induce loss of consciousness in 5-15 seconds. It can cause apnea, pain on injection, and myoclonus. Etomidate reduces cerebral blood flow, reduces intracranial pressure, and reduces cerebral oxygen consumption, all while maintaining arterial blood pressure and cerebral perfusion pressure. Ketamine is reasonable as well: there is no contraindication to ketamine except for known hydrocephalus. It is safe in head trauma. It is a good choice for the hypotensive trauma patient.  TBI is not a contraindication. In the case of the critically injured child who is normotensive, ketamine will raise his blood pressure and perhaps foster further bleeding.  The goal is a good general perfusion and a balanced resuscitation, ensuring enough cerebral perfusion without disrupting nascent clots.  On the other side of the spectrum, permissive hypotension is not described in children, as hypotension is a late and dangerous sign of shock. Paralytic Agent in Trauma Are your surgeons in an uproar about a long-acting agent and the pupillary response?  Relax, it’s a myth. Caro et al in Annals in 2011 reported that the majority of patients undergoing RSI preserved their pupillary response.  Succinylcholine actually performed worse than rocuronium. In the rocuronium group, all patients preserved their pupillary response. In the critically ill, we rethink your dosing of both the sedative and the paralytic. In a critically ill child or adult, perfusion suffers and it affects how we administer medications.  The patient’s arm-brain time or vein-to-brain time is less efficient; additionally, as the patient’s hemodynamic status softens, he becomes very sensitive to the effects of sedatives. We need to adjust our dosing for a critically ill patient: Decrease the sedative to avoid falling over the hemodynamic compensation cliff. Increase the paralytic to account for prolonged arm-brain time. Case 3: Cardiac/myocarditis/congenital heart disease Jacob is a 6-year-old-boy with tricuspid atresia s/p Fontan procedure who’s had one week of runny nose, cough, and now 2 days of high fever, vomiting, and difficulty breathing. The Fontan procedure is the last in a series of three palliative procedures in a child with complex cyanotic congenital heart disease with a single-ventricle physiology. The procedure reroutes venous blood to flow passively into the pulmonary arteries, because the right ventricle has been surgically repurposed to be the systemic pump.  The other most common defect with an indication for a Fontan is hypoplastic left heart syndrome. Typical “normal” saturations are 75 and 85% on RA.  Ask the parents or caregiver. Complications of the Fontan procedure include heart failure, superior vena cava syndrome, and hypercoagulable state, and others. A patient with a Fontan can present in cardiogenic shock from heart failure, distributive shock from an increased risk of infection, hypovolemic shock from over-diuresis or insensible fluid loss – or just a functional hypovolemia from the fact that his venous return is all passive – and finally obstructive shock due to a pulmonary thromboembolism. Types of shock mnemonic: this is how people COHDe – Cardiogenic, Obstructive, Hypovolemic, Distributive. Do we give fluids? Children after palliative surgery for cyanotic heart disease are volume-dependent.  Even if there is a component of cardiogenic shock, they need volume to drive their circuit.  Give a test dose of 10 mL/kg NS. Pressors in Pediatric Shock Children compensate their shock state early by increasing their SVR. Epinephrine (adrenaline) is great at increasing the cardiac output (with minimal increase in systemic vascular resistance; tachycardia)  In children the cardiac deleterious effects are not pronounced as in adults.  Later when the child is stabilized, other medication such as milrinone (ionotrope and venodilator) can be used. Epinephrine is also fantastic for cold shock when the patient is clamped down with cold extremities – the most common presentation in pediatric septic shock. Norepinephrine (noradrenaline) is best used when you need to augment systemic vascular resistance, such as in warm shock, where the patient has loss of peripheral vascular tone. Induction Agent in Cardiogenic Shock A blue baby – with a R –> L shunt – needs some pinking up with ketamine A pink baby – with a L –> R shunt – is already doing ok – don’t rock the boat – give a neutral agent like etomidate. Myocarditis or other acquired causes of cardiogenic shock – etomidate. Case 4: Status Epilepticus Jessica is a 10-year-old girl with Lennox-Gastaut syndrome who arrives to your ED in status epilepticus. She had been reasonably controlled on valproic acid, clonazepam, and a ketogenic diet, but yesterday she went to a birthday party, got into some cake, and has had stomach aches – she’s been refusing to take her medications today. On arrival, she is hypoventilating, with HR 130s, BP 140/70, SPO2 92% on face mask. She now becomes apneic. Induction Agent in Status Epilepticus Many choices, but we can use the properties of a given agent to our advantage. She is normo-to-hypertensive and tachycardic. She has been vomiting. A nice choice here would be propofol. Propofol as both a sedative and anti-epileptic agent works primarily on GABA-A and endocannabinoid receptors to provide a brief, but deep hypnotic sedation.  Side effects can include hypotension, which is often transient and resolves without treatment.  Apnea is the most common side-effect. Ketamine would be another good choice here, for its anti-epileptic activity. Paralytic Agent in Status Epilepticus Rocuronium (in general), as there are concerns of a neurologic comorbidity. Housekeeping in RSI What size catheter doe I use?  If you know your ETT size, then it is just a matter of multiplication by 2, 3, 4, or 5. Remember this: 2, 3, 4 – Tube, Tape, Tap The NG/OG/Foley is 2 x the ETT – tube The ETT should be taped at a depth of 3 x the ETT size – tape A chest tube size 4 x the ETT – tap In summary, in these cases of sepsis, multitrauma, cardiogenic shock, and status epilepticus: Resuscitate before you intubate Use the agent’s specific properties and talents to your benefit Adjust the dose in critically ill patients: decrease the sedative, increase the paralytic Have post-intubation care ready: sedation, verification, NG/OG/foley

Background: The patient's individual anemia tolerance is pivotal when blood transfusions become necessary, but are not feasible for some reason. To date, the effects of neuromuscular blockade (NMB) on anemia tolerance have not been investigated. Methods: 14 anesthetized and mechanically ventilated pigs were randomly assigned to the Roc group (3.78 mg/kg rocuronium bromide followed by continuous infusion of 1 mg/kg/min, n = 7) or to the Sal group (administration of the corresponding volume of normal saline, n = 7). Subsequently, acute normovolemic anemia was induced by simultaneous exchange of whole blood for a 6% hydroxyethyl starch solution (130/0.4) until a sudden decrease of total body O-2 consumption (VO2) indicated a critical limitation of O-2 transport capacity. The Hb concentration quantified at this time point (Hb(crit)) was the primary end-point of the protocol. Secondary endpoints were parameters of hemodynamics, O-2 transport and tissue oxygenation. Results: Hb(crit) was significantly lower in the Roc group (2.4 +/- 0.5 vs. 3.2 +/- 0.7 g/dl) reflecting increased anemia tolerance. NMB with rocuronium bromide reduced skeletal muscular VO2 and total body O-2 extraction rate. As the cardiac index increased simultaneously, total body VO2 only decreased marginally in the Roc group (change of VO2 relative to baseline -1.7 +/- 0.8 vs. 3.2 +/- 1.9% in the Sal group, p < 0.05). Conclusion: Deep NMB with rocuronium bromide increases the tolerance of acute normovolemic anemia. The underlying mechanism most likely involves a reduction of skeletal muscular VO2. During acellular treatment of an acute blood loss, NMB might play an adjuvant role in situations where profound stages of normovolemic anemia have to be tolerated (e.g. bridging an unexpected blood loss until blood products become available for transfusion). Copyright (C) 2011 S. Karger AG, Basel

In the December 2019 BJA Education Podcast, Anthony Wynn-Hebden talks with Professor William Fawcett from Royal Surrey County Hospital about his paper for Essential Notes, 'Suxamethonium or rocuronium for rapid sequence induction of anaesthesia'. Professor Fawcett talks us through the changes in practice that he has seen throughout his career when anaesthetists perform rapid sequence induction of anaesthesia, including the latest thoughts on best management strategies.