Marc Chikhani

@Anaes_Journal Interesting ideal line - would have thought it would be shallow-steep-shallow sigmoid.

Schematised patterns of skill acquisition in regional anaesthesia. • dashed black - idealised rate of skill acquisition • green - ppl w superior hand–eye co-ordination • blue - average performers • red - ppl who experience greater difficulty with procedural skills #anaesthesia #MedSky doi.org/10.1111/anae.7…

@Jopo_dr All ICU airways are difficult; anatomy, airway pathology, pathophysiology of critical illness.

I don’t think we are missing potential airway difficulties I think critical care is just more tolerant of risk - an element of pragmatism vs an element of recklessness

@DrJPGannon @BJAJournals Not always practical though. For example, how many elective lists are you willing to shut to extubate the known difficult airway in theatre? Or could you accommodate them urgently into the anaesthetic room with a spare anaesthetist? Do you have an anaesthetic room left?

One observation I would make is that airway problems that evolve in the ICU setting are often ‘managed’ within the ICU environment when , in many cases, it would have been safer to have transferred a patient to an appropriately equipped and staffed OR environment. This is certainly the case for tracheostomy problems and anecdotaly I am aware of a number of cases where this failure has led to problems.

Are we missing signs of #airwaydifficulty in #criticalcare? This new study reveals gaps in recognition and planning—see the data and learn how we can improve patient safety. Read more: bjanaesthesia.org/article/S0007-…

@NicholasChrimes @selvan_ramsamy @doctimcook @AirwayMxAcademy It's not really a myth else there wouldn't be an industry centered around bougies, stylets and introducers that get round the corner.

@selvan_ramsamy @doctimcook @AirwayMxAcademy If you can get a view w VL (whether using HA or standard geometry blade) intubation shouldn’t be difficult unless there’s periglottic pathology or operator inexperience. Beyond those situations “can see, can’t get the tube in” is a myth.

The VCI score adds nothing to airway documentation. Why does everything have to be reduced to an incomprehensible code? Why do we need a different system for documenting direct & indirect view? Why would anyone use POGO to document view when all it does is distinguish (w high inter-rater reliability!) bw degrees of easy view but loses all discriminatory value about anything the next person would actually want to know (CL 2b, 3a, 3b & 4 are all POGO zero).

@NicholasChrimes Oh right? Like.... "There's no evidence that CPR increases risk of COVID-19 transmission"

The phrase “there isn’t evidence” shouldn’t be used. We should either be talking in terms that there IS evidence that something does/doesn’t work/harm, or saying we don’t know. “There isn’t evidence” misrepresents ignorance as knowledge. Absence of evidence of effect ≠ Evidence of absence of effect.

@AlloHermes @TJCoats @ALMannixMD Exactly, not serial bleeps and calls, and serial reviews, all specialties involved, at the bedside.

@quartered_onion @TJCoats @ALMannixMD Definitely, if possible. It's amazing how much better the cooperation is when everyone actually talks to each other (especially senior decision makers).

Consultants: we don’t expect you to know how to intubate, run a code, reduce a fracture, deliver a baby, or actively manage 30 patients simultaneously. Please don’t expect us to know every nuance of your specialty, either. That’s why we call.

@AlloHermes @TJCoats @ALMannixMD Or better still, by the bedside.

@TJCoats @ALMannixMD And hand over a patient they haven't met? You know what fixes this? Hospital facilitated conference calling - why is this not a thing? Get the two/three specialists who each think it's each others problem on the phone at the same time.

@ShaunLintern @cochranecollab This is not good journalism.

Nurses can deliver hospital care just as well as doctors, according to a new @cochranecollab review eurekalert.org/news-releases/…

@doctimcook @Anaesthesia @Fionafionakel Is "can see can't intubate" a problem with HA blades - basically no... I'm sorry, what? It's a bit like the compelling evidence for VL with a success rate of over 80%

Here's a humdinger.... "Assessing the incidence of ‘can see, cannot intubate easily’ during routine use of C-MAC videolaryngoscopy." Is it a real problem - with a MacVL - with a HAVL Well basically no! Another cracking science letter from the team @anaesthesia @Fionafionakel @mhillier93.bsky.social …-publications.onlinelibrary.wiley.com/doi/epdf/10.11…

@doctimcook @Laurenc02468553 @Anaes_Journal Why so scared of an RSI? Sorry, apart from the increased CVS instability with TIVA (NAP 7) or increased awareness with TIVA (NAP 5). The most recent DAS guidelines for RSI, even has a lot of ventilation in it, and argument for NDMR after check vent is obsolete.

Why not use RSI for all patients on a GLP1 agonist? First - because (as per my previous tweet) the risk of aspiration is >600-fold lower than the risk of having a full stomach Second because RSI is not a benign technique - increases risk of failed intubation 8-fold - increases risk of anaesthetic overdose (CVS instability etc) -increases risk of anaesthetic under dose (awareness) Etc etc etc If using muscle relaxants and TT when otherwise would be using an SGA -increases risk of airway complications at insertion and removal from use of TT -increases risk of anaphylaxis from NMBA -and awareness (from NMBA) So I think quite a few reasons to pause before deciding swathes of folk need RSI

Semaglutide, fasting and gastric ultrasound Nearly 50% of patients receiving semaglutide treatment had a full stomach on pre-operative gastric ultrasound, regardless of dose, duration, route of administration or withholding time. #anaesthesia #MedTwitter doi.org/10.1111/anae.7…

@AirwayMxAcademy @NicholasChrimes @drakazaru @Asiritrauma1 @Anaes_Journal And of course get rid of respiratory rate from chest wall impedance wave form completely.

@AirwayMxAcademy @NicholasChrimes @drakazaru @Asiritrauma1 @Anaes_Journal We should just agree a standard - etCO2 goes at the bottom and is in white and it's filled in, pressure goes at the top and is just a line. Easy.

Another death involving unrecognised oesophageal intubation. Misinterpretation of chest impedence trace as ETCO2 trace. PUMA guidelines address the need for monitoring displays to be standardised and ETCO2 trace to be distinctive. Free full text in @Anaes_Journal sbs.com.au/nitv/article/n… …-publications.onlinelibrary.wiley.com/doi/10.1111/an…

@drp297 @AirwayMxAcademy @NaveenEipe @lowebrad @ketaminh Or just intubate them faster

@AirwayMxAcademy @quartered_onion @NaveenEipe @lowebrad @ketaminh Just pop an igel in until the relaxant works....

Big beard may not be a problem for mask ventilation. Plasticize the face with tegaderm @NaveenEipe @kovacsgj @airwaycam @lowebrad @ketaminh

@AirwayMxAcademy @NaveenEipe @lowebrad @ketaminh Tegaderm does hurt when it sticks onto hair

@quartered_onion @NaveenEipe @lowebrad @ketaminh Why?

@AirwayMxAcademy @NaveenEipe @lowebrad @ketaminh Do you even beard, bro?

@quartered_onion @NaveenEipe @lowebrad @ketaminh It does not hurt with Tegaderm

@AirwayMxAcademy @NaveenEipe @lowebrad @ketaminh I actually agree with you, I've done this a couple of times a few years ago.

@quartered_onion @NaveenEipe @lowebrad @ketaminh Not needed. And patients really do not like it

@doctimcook What- you mean it's more complicated than "no trace, wrong place"?

A really important study on CAPNOGRAPHY TRACES DURING OESOPHAGEAL INTUBATION Important for three reasons 1 It provides important support for needing to satisfy the criteria for sustained exhaled CO2* to exclude oesophageal intubation 2 The morphological differences in CO2 trace from oesophageal and tracheal intubation offer technological opportunity for monitoring solutions to rapidly detect unrecognised oesophageal intubation 3 Sadly, they report a >10% unrecognised oesophageal intubation rate and all out of hospital services should be monitoring theirs and making changes (capnography, capnography interpretation, VL and if this doesn’t work stopping intubating and using SGAs or changing personnel) to make sure the rate is well below this *Sustained exhaled CO2 - rises and falls with ventilation - sustained (>7 breaths) - amplitude > 1kPa - clinically appropriate resuscitationjournal.com/article/S0300-…

@Anaes_Journal No because of both infection and inhalational anaesthesia still being a thing.

Do you reuse propofol syringes during TIVA? If not, why not? 🤔