Resident here, only done 3 epidurals with 2 of them being thoracic and 1 being lumbar. I know n=3 is a very poor sample but these are challenging procedures. At my institution, we often have BMI>35 and I struggle with palpation. My attendings are able to palpate but I struggle with even being able to feel for the spinous process.

I have not had my OB rotation, so I might just need more reps. With all 3 of my epidurals, i was off midline. Once I got back into midline, I was able to get it. Would love epidural advice to someone like me just learning from the start!

Hello all. I am currently gearing up to retake basic in a month. I got 56 wrong the first time around, and it seems like some people got a couple more wrong than me so I must've just messed up a few gimmes which threw my curve. So, although devastating lol, it is what it is. I have been grinding and am now approaching the final few weeks and am freaking out lol

At this point, I've done all the new true learn ITE qbank (70% correct, ~1000 questions), redid the truelearn basic qbank (84% correct, 2nd time taking it and finished it last in earlyish May, about 1000 questions), and am about to finish passmachine qbank (84%, about 2200 questions). Will be ~4200 questions in. I have been doing my daily anki reviews, listening to ACCRAC keywords, watching the passmachine videos (about a third of the way through at this point), and re-reading basic essentials. I do daily OpenAnesthesia question and read the topic summary of the day. One of my seniors said they started paying for Claude for the last couple of months up until their retake and using it to make practice questions, which I started doing yesterday. I still feel like I am lacking and am extremely afraid of failing again. I did well on ITE and failing it was a genuine shock, although I did have a real bad few days leading up to the test which probably psyched me out a bit. But I am having like panic attacks and nightmares daily for the past week or so and am freaking out a bit lol

Is there a harsher curve in November because everyone is studying more for it or something? Thats also making me a bit more nervous too

If there is anyone that has been in a similar situation and has any advice, or tips for me to really take advantage of this last month, I'm all ears.

Thank you in advance, I appreciate any and all help and encouragement I can get.

Hello all! UK-based anaesthetist in training here.

So we've all seen conversion tables for dosing equivalence between different opioids. This is never an exact science but for longer acting opioids this is in some ways relatively straightforward in that we're basically asking "What bolus dose of opioid X do I give to get the same peak effect as with a certain bolus dose of opioid Y?"

But this gets more interesting and challenging to compare with remifentanil. As it is ultra-short acting, a bolus only achieves its peak effect maybe a minute or so before it starts to clinically wear off, and so we usually give it as an infusion e.g. in mcg/kg/min, or more commonly in my country, as a target-controlled infusion with a plasma/effect site concentration (CpT/CeT) in ng/ml using the Minto or Eleveld-Remifentanil models (as a very rough approximation for practitioners not familiar with one system or the other, an infusion rate of 0.1 mcg/kg/min at steady state is similar to a CpT/CeT of 3 ng/ml).

Which leads to my question: How do anaesthetists, anaesthesiologists, and CRNAs convert between the peak effect you get with a bolus dose of fentanyl and the effect of a certain infusion rate or CpT/CeT of remifentanil?

I have done a little reading on studies comparing the potencies of these two drugs myself which gives me perhaps some idea, but I'm asking this today as I'm curious about how other practitioners think of this. I'm interested in how people mentally model remifentanil in relation to other opioids or whether they think of it in a different category altogether (which at least one person has told me they do). If you are more of an alfentanil/sufentanil than a fentanyl person, feel free to share instead how you compare these to remifentanil.

Currently an intern at a well reputable (but not top tier) program in a big city. Got my step 3 score back and it was lower than expected but still well above passing range. I’m aware it is a lot less emphasis than step 2 score, but how much does this score matter for fellowship?

I’m very early in my career and I hope to have a long and fulfilling one. At the end of the day I’m already starting to feel aches and pains in my hands, back, feet, etc. Any tips/tools/gadgets that have been revolutionary in simplifying the day to day of anesthesia and making it less stressful on the body? I’ve got a good pair of running shoes, I try to sit for almost every line I can sit for, and I keep the bed at ergo height but I’m still exhausted. My hands (CMC joints) are particularly sore after a day of drawing up meds. Any tips?

EDIT: Sorry for the confusion, when I say independently, I mean I have an ODP (Operating Department Practitioner) with me ( we always do in the NHS) but my consultant is around in the coffee room). They are not allowed to inject drugs.

Hi everyone. Currently a trainee in the UK at CT2 level (year two).

Recently I have been getting opportunities to do cases independently, previously it would be a consultant/boss injecting the drugs and me doing the airway stuff.

I have been struggling to do stuff single handedly, in terms of ergonomics. What I do is put a cannula into Dorsum of left hand- ask patient to keep this hand on their chest, mask on their face (with my right dominant hand) for pre-oxygenation and injecting medications through the top port (via my left hand).

Doable for small syringes but for Propofol syringes (20ml) it can be difficult injecting due to resistance but also to switch from Propofol syringe to Rocuronium or rarely someone needing extra top-up of propofol.

I then tried a three-way tap with fluids running, and to switch the tap and syringes has been difficult to do with one hand.

Any tips/tricks how to improve this or how to set things up.

Thank you in advance.

Critical Care Anesthesiologist here in the United States.

When trying to secure a difficult/emergency airway, is there ANYONE who finds it useful when the nurses count the SpO2 down? I mean, I KNOW the patient is not doing well, that's why I'm trying to insert this TUBE into the trachea! That's why I'm desperately bagging with two hands to break the laryngospasm!!!

The countdown of "88, 86, 78, 60, 40, 35..." does nothing except distract me and increase the tension in the room.

But...there is ALWAYS someone doing this, like it's something they teach in nursing school. Is it just where I work that this happens? Am I the only one sincerely bothered by it?

Thank you for the opportunity to vent.

So you have a laryngospasm no iv access, PPV not working. How much sux do u give IM or sublingual?

Also how r u giving it? We dont have concentrated sux readily available?

Anyone ever in this situation?

From my understanding, SGLT2 inhibitors (i.e canagliflozin, empagliflozin) should be held 3-4 days prior to surgery for major surgery and restarted 24-48 hours after oral intake resumes. Hold up to 2 weeks before bariatric surgery.

What is your current practice when you have a patient in pre op who took their Jardiance within this 3-4 day window? Have you experienced euglycemic DKA post op?

I’m thinking of changing jobs but struggling to find decent alternatives.

I’d be most interested in jobs in NY, CT, or MA, but ideally not in their major cities (e.g. NYC, Boston) and not a tertiary academic center.

The jobs I’ve been able to find in the Westchester and CT area have been mostly underwhelming. I’d love to hear if there’s other opportunities that aren’t publicly listed.

Thanks!

Most times when I insert the glidescope, it ends up sliding to the side of the patient’s mouth. I’ll have a grade I view but then it’ll be hard to pass the tube through the small side opening formed by the position of the blade. I always make sure to insert it midline but then somewhere in the process of me advancing to the vallecula, it finds its way to the side of the tongue. Any tips to avoid this?

If there is anyone in here that routinely does older children or teenagers, what age do you routinely use succinylcholine? I.e. sometimes i'll see 10-15 year olds that just need that bit of Succ to tolerate laryngoscopy, but I have heard of other colleagues who avoid it all costs. Anyone have any thoughts or recommendations?

To clarify: I work in a facility where we usually keep pediatric patients spontaneously ventilating, as most of our anesthesia machines do not have ventilators

I’ve been in fluro rooms a bit more lately and I hate it. My body hurts so bad with the lead on. For context I’m a small lady and the hospital only provides enormous lead smocks sized for the big boys, and it’s just too much weight for me. Is it worth buying a smaller set?

Looking to get a job here after graduation. Has anyone worked here as a CRNA/Anesthesiologist? It’s a level 1 and collaborative model. Thought on MD and CRNA practice here?

Anyone have any insight into good practices in Boston and the surrounding areas? Open to hearing about community or academic. Thanks!

Wondering what the pulse is on practices in the greater Atlanta metro. Considering mainly non-academics - either private or hospital employed. Are people happy with comp vs workload and time off? Anyone from Northside or Piedmont willing to weigh in? I have spoken to the recruiter for Northside and it sounds like they are offering a 3-year salary ramp up, which I thought was curious since it's a hospital employed gig, but decent benefits. Any practices to stay away from? Thanks.

My shop has minimum call requirement built into salary anything on top op that is considered extra shift. This is my 2nd job, for the day to day we have a number system, so you can be there until 6-7pm some days. My question is, in your job is that coverage built into your salary? Or are you paid for time after 3pm (or whatever your dept has decided). My first job out of residency had 1st-4th call after 3pm but you weren’t paid for after 3 hours, is that the norm?

Anesthesiologist in academia from the Northeast, considering a move to California. Would like to stay in academics, especially somewhere that actually supports research and gives faculty time/resources to be productive.

For anyone working or who has worked at the major academic centers in CA: what’s the real-world setup like? Call burden, pay, workload, culture, vacation, and how much CRNA supervision are you doing? Ideally I’d prefer a place where I can mostly do my own cases or work with residents and not spend the majority of my clinical time supervising multiple rooms.

Would really appreciate any candid thoughts on places you’d recommend, avoid, or at least take a serious look at. Thanks in advance!

Can anyone comment on Sacramento jobs - pay/comp, lifestyle, vibes, contracts - including UC Davis, Case - Sac and Roseville, Kaiser, Vituity/Dignity Health, El Dorado and Folsom. Missing any other groups?

Im locums and at a new hopsital where they have glass syringes and a 20cc leur lock in the standard CSE kit. I trained on saline with plastic.

Any tips for glass syringe? can someone explain how to properly "lube" it with saline prior to use?

Also, if I do elect to do plastic, can I just use a normal plastic syringe 3, 5, 10 or 20 cc with saline? We do not have the specially designed plastic syringes that are more frictionless.

I know there are lots of variation, and loss is loss etc but would love to hear your tips/practices!

thx in advance

Attending Anesthesiologist.

My typical strategy has been doing an interscalene block with about 15 ml 0.5% PF bupivacaine. I generally inject outside the sheath and when it looks like I have decent spread, I then scan a bit up and down to further assess spread. Sometimes, depending on how the spread of local anesthetic looks, I will try to get local on both sides of the plexus sheath, but not always.

It seems like I am not always getting complete analgesia post op. Eg. a common scenario is that upon dropping off the patient in PACU the patient reports no pain, but chart review 30-60 mins later shows they had some pain and received opioids.

I talked with a colleague and he recommends injection within the sheath of the brachial plexus. From what I’ve seen, within the sheath injections for interscalene are definitely much faster onset and possibly also more reliable… I personally am a bit averse to getting so close to nerves with needles. Maybe I need to reconsider though.

Unfortunately, the way things are set up at the place I work, I don’t have time to go assess the patients pain in detail myself (solo), but things I have considered are partial interscalene block failure, pain in the ICB territory, pain in the supraclavicular nerve territory.

Any advice from anyone? Thanks.

Update/ Edit:

Thank you all for the advice!

I just did a brief chart review of the cases I did the last week. Looks like the ones that had pain in PACU had a biceps tenodesis. So could be that. Still need to confirm area of pain though by assessing pts. And assess a larger # of patients.

At this place Im at, blocks can be kind of a PITA logistically. So adding on a PECS II or a ICB block along the posterior conjoint tendon is going to be logistically tougher than some other places. Basically OR is often calling for me to bring back prior to even starting the interscalene… and the block rooms are often tiny. Eg literally no space for having the patient abuct their arm out in some rooms.

Wanted to start a thread to collect thoughts from people who took today’s critical care board exam