Sustained, exhaled carbon dioxide by waveform capnography is an essential component of tracheal intubation. But what if there is bronchospasm? Tracheal intubation can be confirmed using flexible bronchoscopy. #AnSky doi.org/10.1002/anr3...

This week in RSI news: www.judiciary.uk/prevention-o...

The amazing team at @sciencevs.bsky.social dropped a #Tylenol podcast a few days ago, giving explanation of why the link has been made and how it's not quite as it seems A great example of bias and confounding, and how meta-analysis isn't always the pinnacle of evidence #EpiSky #MedSky

Does Tylenol Cause Autism?

Podcast Episode · Science Vs · 09/18/2025 · 28m

podcasts.apple.com

This has been a long time coming. However, there is a, bizarre lack of emphasis (as in 2016) on confirmation of venous placement, with plenty of words dedicated to tip positioning on CXR and only one reference to pressure transduction (seemingly as a preliminary check where the CXR will be (1/2)

Anaesthesia@anaesjournal.bsky.social · 11mo ago

Should you request a PICC, a tunnelled CVC or a midline for your patient? What factors should influence your choice of vascular access device? #AnSky #MedSky doi.org/10.1111/anae...

Just a little too late for last week's #MedSkyDebate! Look forward to digging into this... Thanks to @medicluke.bsky.social for sharing it.

Anaesthesia@anaesjournal.bsky.social · 11mo ago

Pre-hospital placement of a large-calibre central venous catheter can be a life-saving measure. The insertion site attempted most frequently was the right subclavian vein using a landmark-guided technique. #AnSky #MedSky doi.org/10.1111/anae...

If you wanted to minimise risk of awareness, we could give our patients enough anaesthesia to be at near burst suppression, but then what would be the NNT and what harms would we cause from this?

If however you accept Pandit's definition of anaesthesia - "a chemically induced state which renders surgery acceptable to the patient" - then you can have awareness and even recall under anaesthesia provided those conditions are concurrently and subsequently acceptable to the patient.

Our practice of anaesthesia has been empirically derived over the last two centuries. We have yet to identify the neurophysiological basis of anaesthesia because we have yet to identify the neurophysiological basis of consciousness. So what we do is fundamentally a sophisticated guess.

Hey @chrimesy.com, we tried really hard to finally write a case report that doesn't massively misrepresent the PUMA guidance: how did we do? 🫣😜 (Congrats @jrobinson22.bsky.social on your first publication!) onlinelibrary.wiley.com/share/author...

The Mallampati classification is considered by many to be a core part of airway assessment, but it has poor inter-rater reliability; this may in part stem from the myriad conflicting versions in textbooks and other resources. I'll start this #badmallampati thread with the OG descriptions:

Nicholas Chrimes@chrimesy.com · last yr.

That’s a bit different from the original 1985 description. Even after 3 got altered & 4 added w the Samsoon modification in 1987, I’ve never heard of the tonsils getting involved!

I think this is the crucial thing. Drawing up emergency drugs isn't about the physical act of drawing up drugs. It's about cognitive load in a high-stress situations.

As an ethnic minority in the UK where there is a rise in right-wing populism, I'd like to stake my credentials as a citizen on the basis that when asked what emergency drugs I draw up for anaesthesia, rather than picking vasopressors or muscle relaxants, I said "tea".

I’m petrified about today’s science news. Genetically modifying crabs to have cheetah genes? This could go sideways fast.

The challenges of using ultrasound to measure the trachea: a brief report #pocus #airway ccforum.biomedcentral.com/articles/10....

The challenges of using ultrasound to measure the trachea: a brief report - Critical Care

Background Tracheostomy is a common procedure in intensive care medicine, involving the insertion of an artificial airway through the front of the neck into the trachea. The size of tracheostomy tube ...

ccforum.biomedcentral.com

Nice study confirming my prior beliefs about ketamine and its role in reducing post-op delirium. Unmeasured confounding always a possibility but pretty impressive efforts made to minimise this! TL;DR optimum intra-op ketamine dose to reduce delirium risk (compared to no ket) is 0.25-0.34mg/kg ABW.

Anaesthesia@anaesjournal.bsky.social · last yr.

Does the use of intraoperative ketamine affect the incidence of postoperative delirium? Does the dose matter? Compared with patients not receiving ketamine, a low dose (≤ 0.35 mg.kg-1) was associated with lower risks of postoperative delirium. #AnSky #PainSky #MedSky doi.org/10.1111/anae...

OpenEvidence is generally very good, but it's occasionally horrifically wrong One place it falls down a lot is drug allergy (where it's often too conservative) There are NO absolute contraindications to acetylcysteine for acetaminophen OD Reported "allergy" = anaphylactoid rxns... (#1/3) #EMIMCC

Interesting study. Importantly, although the study only excluded obese patients with a BMI >60, they didn't actually recruit any patients with a BMI between 40 and 60. I suspect we can do better at individualising PEEP than simply BMI/3...

Anaesthesia@anaesjournal.bsky.social · last yr.

Adjustment of positive end-expiratory pressure based on body mass index during general anaesthesia: a randomised controlled trial #AnSky doi.org/10.1111/anae...

Another excellent reason not to use cricoid pressure (badly): the patient perspective.

Dr Mel T@drmel.bsky.social · last yr.

I was like ‘Shit, this guy is trying to strangle me!’ Then blackness.

My major concern is ‘ear to sternal notch’ which is misunderstood as being relative to the horizontal rather than coronal plane resulting in neck hyperextension & poor positioning. (apologies, underscoring your point, the 2nd image was made when I’d understood ramping to mean torso elevation).

A long overdue (but topical), nuanced and thorough discussion of "RSI" whose final conclusion I happen to entirely agree with. Well done @sthjournalclub.bsky.social

Anaesthesia@anaesjournal.bsky.social · last yr.

Editorial: Rapid sequence induction: a modern-day example of Theseus' Paradox? Stept and Safar described ‘rapid induction/intubation’ in 1970. PUMA recently issued a consensus statement on RSI. Let's compare. @sthjournalclub.bsky.social #AnSky #AirwaySky doi.org/10.1111/anae...

A normal CT head ≠ a low risk of raised ICP/herniation after LP in meningitis❗️ “80% of pts with ABM who herniate have no CT abnormalities” 🔑 Take-away: Clinical signs (e.g. GCS <9, seizures, pupil changes) are the best indicators of WHO SHOULD NOT have a LP journals.sagepub.com/doi/epub/10....

Great articles on lactate interpretation. I call lactate a "marker of badness" and even that most nebulous of definitions is only true-ish before you start treatment with things that might cause the lactate to go up, but still help the patient.

josh farkas 💊@pulmcrit.bsky.social · last yr.

New editorial in ICM about the dysutility of lactate as a perfusion goal in sepsis I reviewed lactate physiology & why it’s not a perfusion index 10 years ago here: https://emcrit.org/pulmcrit/understanding-lactate-in-sepsis-using-it-to-our-advantage/ Talk more in 2035. Nothing will change #EMIMCC

Assessing fluid responsiveness in spontaneously breathing MV patients is tough, so this work on SIGH35 by Messina et al. is really 👌 ▪️ Apply a 35cm H20 ‘sigh breath’ for 4 secs and measure the change in pulse pressure from baseline to nadir Simples. 1/ ccforum.biomedcentral.com/articles/10....

SIGH35 and end-expiratory occlusion test for assessing fluid responsiveness in critically ill patients undergoing pressure support ventilation - Critical Care

Background Assessing fluid responsiveness is problematic for critically ill patients with spontaneous breathing activity, such as during Pressure Support Ventilation (PSV), since spontaneous breathing...

ccforum.biomedcentral.com

Anyway, here is something I wrote about p-values (ICYMI). statsepi.substack.com/p/no-you-can...

No, you can't explain what a p-value is with one sentence (Parts I, II)

But I'm going to try and do it in as few as possible. #fml

statsepi.substack.com

Great work from @iainmoppett.bsky.social and everyone else on the #AnSkyMedSkyDebate on whether TIVA is over-rated (it isn't 😅). I'm running away for family stuff for the rest of the weekend now though.

BREAKING: Prime minister announces govt will abolish @nhsenglandldn.bsky.social "I have absolutely no intention of wasting time with a big costly reorganisation" - @rthonwesstreeting.bsky.social told me in Dec 2023. Clearly the temptation - and perhaps his frustration proved too much

Out of 241 reported incidents of arterial trauma from CVC insertion, in 75 cases initial confirmatory checks (if any) failed to identify arterial cannulation. CXR most commonly implicated in this, with blood gas/transduction failing for mostly predictable reasons. What's your department's practice?

Flowchart of diagnosis, management and patient outcomes for central venous catheter-related arterial trauma incidents #AnSky #MedSky @intensiveperson.bsky.social https://doi.org/10.1111/anae.16570

Arterial trauma is a rare, but potentially life-threatening complication of central venous catheter insertion. In this interrogation of two national databases of incident reports, outcomes included: • stroke (10%) • death (4%) #AnSky #MedSky https://doi.org/10.1111/anae.16570