Correction I usually give morphine 0.05-0.1 mg/kg

Some good techniques, mine is most similar to gasman's:

- rarely premedicate (midaz only if pt bouncing off the walls and then only 0.25   Mg/kg)

- inhalation induction followed by PIV and IV propofol (high dose ~ 5 mg/kg), no NMBD, oral RAETT

- maintenance with o2+n2o+sevo (titrated to hemodynamic parameters)+morphine (~0.5 mg/kg) on vent

- extubation after suctioning stomach, when pt SV (RR in teens), and ET sevo at 0.3

Usually gives good results: postop pain well managed with IV meperidine 5 mg boluses or Tylenol with codeine syrup

For those knowledgable about the use of ketorolac (IV NSAID), what is the maximum IV dose.  Some of my colleagues give 60 mg IV, but I have been unable to find any literature supporting more than 30 mg IV (although 60 mg may be given IM).

Has anyone ever seen an allergic reaction to NMBD's (esp. rocuronium).  According to texts these are the most allergenic drugs anesthesiologists use on a regular basis, so I would assume that eventually one would see it (I have not).  If you have what are the most common manifestations, is there any routine preventive measure possible, and is it possible to distinguish from the other induction agents/abx given at the beginning of surgery?

Seems like you take all the right precautions.  I agree with the previous post that it is prudent to use smaller diameter ETT's (by .5 to 1 size); this can sometimes be problematic with peds as ETT is more prone to mucous plug.  Bleeding sometimes will still occur.

Interesting post,

I have a lot of experience with the pLMA, but have never used it for laparoscopic surgery.  Having said that of all the laparoscopic procedures I think lap BTL would be a good candidate (where allowed) as it commonly takes less than 10-15 minutes.  I would not attempt longer or more complicated procedures or non ideal patients unless there are major changes in the standard of care.

Strongly agree with last post to the point that I strictly use CSEA as opposed to spinal anesthesia even when I am not considering epidural analgesia postop.

preop High blood pressure without h/o HTN not uncommon: in my experience usually due to undiagnosed HTN or preop anxiety; after that less common causes of secondary HTN need to be looked at (these include drugs like NSAID's although I don't know any drugs causing acute HTN other than of course pressors)

Intraop high BP is much less common in my experience (with adequate anesthesia/analgesia) and I think would have to lead to consideration of causes of 2ndary HTN.  One situation I have seen which is sometimes associated with intraop HTN with seemingly adequate anesthesia is with use of tourniquets (when it is especially troublesome) although this resolves easily with antiHTN's

Interesting case, my opinion:

     obviously extreme bradycardia, would not take to OR until beta-blocker titrated up further (HR around 100 bpm).  Other differential diagnoses needing to be ruled out:

pheochromocytoma
iatrogenic/medication related
drug abuse (cocaine, methamphetamine)

may require Holter monitoring to see if HR always that high (situational) and /or if any irregular rhythms.

I was going to say that this is called transcranial herniation, but after a quick view on Wikipedia I found the correct term to be TRANSCALVARIAL HERNIATION.

Bone cement is made up of polymethyl methacrylate.  Different theories exist as to why there can be hypotension with cementing.  These include microemboli and reaction to the chemical in the cement.  I think it is also important to note that the process of cementing is also temporally related to the process of reaming (pounding the intramedullary cavity) which I have found to often trigger vagal response.

Many nurses seem to believe that a minimum PIV size of 20g is required for blood transfusion and in fact I was told this as well during training.

However, after a brief internet search I can not find any evidence to support this and further it does not appeal to common sense (a 7 micron RBC should fit through even the smallest PIV)

Comments?

A few comments:

1.  I don't routinely (or ever) do the clinical (modified) Allen's test before arterial cannulation because I've been told it is not a reliable test of collateral circulation to the hand.

2.  A CT surgeon once told me that Allen's test using doppler is a very good test of collateral circulation and in fact is necessary before taking a radial artery graft.

3.  I am used to using 20 g angiocaths for arterial cannulation; so I wonder if an 18g would be more prone to vascular occlusion.

4.  I read once that the ulnar a. is usually larger in diameter than the radial artery, and have found it to be a suitable site for ABP even after I had attempted to cannulate the ipsilateral radial a.

5.  I would imagine that this pt's underlying medical condition played a large part in her vascular insufficiency given the possibility of need for strong pressors (clamping down on the peripheral vessels) and possible hypercoagulability.

I recently had a nearly very bad situation when I repeated 1/2 a dose of succinylcholine (about 5 min after the original dose) to a healthy 23 y/o male.  Unknown to me, on further reading, I found this to be a well recognized complication of succinylcholine; especially because I have done this often in the past when managing difficult airways.

Does anyone else have similar experiences?

Does anyone have any experience using succinylcholine for very short term muscle relaxation when requested by the surgeon?

That ETT cuffs take on nitrous when used as an adjunct anesthetic (and hence ETT pressure goes up) was also taught to me during training.  However, I have never found any source which supports this view and the mechanism was never explained to me satisfactorily.

Of course N20 replaces air in enclosed spaces such as bowel, middle ear cavity although again the mechanism was never explained to me satisfactorily.  However, I can not imagine that the same process takes place in an ETT cuff which must be nonpermeable to gases or else how would it ever retain the air in the first place