Illustration contrasting the 4 major stimuli to breathe, vs the 4 major responses taken to increase oxygen delivery

Don’t Withhold Oxygen From That CO2 Retainer

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There is often a great deal of confusion about how to manage the care of a patient with COPD because of concern about inducing CO2 retention. This fear of causing CO2 retention sometimes causes providers to withhold or withdraw oxygen inappropriately. Understanding some of the respiratory physiology behind CO2 retention will allow you to make more informed decisions. This discussion will explain why withholding or withdrawing oxygen from a sick CO2 retainer may, or may not, be the wrong thing to do. Read More …

What’s The Difference Between Oxygen Saturation And PaO2?

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Many people confuse the important distinction between arterial partial pressure of oxygen (PaO2) and oxygen saturation (O2 sat). This is such a key concept that we all must take pains to ensure our staff understands how to use pulse oximetry to identify hypoxemia and hypoxia. 
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Ventilate and Intubate But Don’t Forget Communicate

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Many years ago I was participating in a volunteer medical mission to Kenya when I learned a valuable lesson in communication which I often share with my students. It involves a failure to communicate on multiple levels that almost caused some major problems. Read More …

Illustration during percutaneous jet ventilation of using the jet to ventilate while holding the catheter hub securely at the skin

Don’t Be Afraid To Use Percutaneous Jet Ventilation In An Emergency

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Needle cricothyrotomy or percutaneous transtracheal jet ventilation (PCJV) can truly be a life saving procedure. It is a fast, effective way of providing oxygen to a patient with an obstructed airway who does not respond to more conventional means of opening the airway. The “can’t intubate-can’t ventilate” scenario is a good example. PCJV is faster to perform than a surgical airway. It will buy you time to establish a more permanent airway such as an intubation or surgical airway if the patient is hypoxic.

However, PCJV carries some rare though potentially serious risks of worsening airway obstruction and cardiovascular collapse if the catheter is not correctly positioned within the trachea. Fear may prevent us from using it. In addition, most of us have never had to use PCJV in an emergency or even seen it used. Lack of familiarity with the equipment and simple lack of comfort may make us hesitate to try. We may not even think about it in the moment of crisis. So let’s look at some of the ways we can use PCJV safely. Read More …

Photo of pedunculated laryngeal polyp at its furthest position above the vocal cords at the end of exhalation

Awake Intubation With The GlideScope

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One of the most challenging scenarios to face is a tumor in the airway. Working closely with your surgeon is important. In these days of advanced technology, we often avoid awake intubate because of concern of causing the patient pain or distress. However, sometimes awake intubation is the safest way to proceed and if you are gentle and prepare the patient well, it can be comfortable as well. The Glidescope is another tool you can use for awake intubation. Read More …

Graduation Address School of Nurse Anesthesia

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Below is the text of a graduation address I gave a few years ago at the Kaiser Permanente School of Nurse Anesthesia in Pasadena, California. I came across it the other day and I thought that it might be worth sharing with all of those of you who are recent graduates, as well as those of you who taught those graduates. I have always felt that we who have the honor of training the next generation must always strive to inspire the best that that generation has to offer. I hope you enjoy. Read More …

Avoiding Medication Errors

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Humans are fallible and medication errors are very easy to permit’s easy to give a medication error if you aren’t constantly vigilant. Presented are a series of steps to perform every time a medication is administered that will help prevent medication error. Read More …

Photo of nasal airway with an endotracheal tube connector inserted to allow use to manually ventilate a patient, or to insufflate anesthetic

Use Of A Nasal Airway To Assist Ventilation During Fiberoptic Intubation

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Attaching a nasal airway to a breathing circuit as a tool to assist or control ventilation is a very helpful trick to have in challenging airway management situations. This technique is particularly helpful during blind nasal intubation or fiberoptic intubation in young children after induction of general anesthesia for surgery, although it can be used in adults. Here we discuss use of this technique for a case of accidental extubation of a patient with Ludwig’s Angina.
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How Does Hypoventilation Cause Hypoxemia?

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I often find that my students sometimes confuse oxygenation and ventilation as the same process. In reality they are really very different. Ventilation exchanges air between the lungs and the atmosphere so that oxygen can be absorbed and carbon dioxide can be eliminated. Oxygenation is simply the addition of oxygen to the body.Why do we need to understand this? Let’s look at some common examples. Along the way we will painlessly use the Alveolar Gas Equation to explain two common scenarios:
how hypoventilation causes hypoxia,
why abruptly taking all supplemental oxygen away from a carbon dioxide retainer will hurt them. Read More …

Photo of tongue necrosis from Laryngoscope. 2010 July; 120(7): 1345–1349.

Tongue Necrosis From Endotracheal Tube Compression

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Tongue necrosis from compression by an endotracheal tube or oral airway is a rare, but devastating complications when it occurs. It can occur with poor endotracheal tube positioning, flexed head and neck positioning, impaired blood flow, and shock. It is important to familiarize ourselves with this entity so that we as anesthesia providers can minimize the risks.
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Plastic In the Airway: An Unsuspected Aspiration Hazard

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I saw a potential aspiration hazard in the OR today. How many times a day do we routinely peel plastic wrappers off of airway equipment? If I’m at the surgicenter, I might need 7 face masks, a variety of LMAs and endotracheal tubes and an oral airway or two. Take a look Read More …

A Case of Endotracheal Tube Obstruction

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Normally we view patients who are intubated as being protected in terms of ventilatory support. However, being intubated makes the patient vulnerable to a variety of potential problems. Rapid deterioration of an intubated patient can be a challenging and frightening scenario because the providers must rapidly troubleshoot the causes as well as treat. Here a case of endotracheal tube obstruction and its management is described. Read More …

photo of simulated cardiac arrest in the OR

Cardiac Arrest In The OR

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Cardiac arrest in the OR is challenging both to recognize as well as to treat. You must be able to work the causal diagnosis in the face of some potentially complex anesthetic, surgical and comorbid combinations. At the same time you must perform a resuscitation, often in the face of ongoing surgery. Getting prepared for rare events is often more challenging than preparing for regular events. When a rare event happens the shock and fear induced by the event can erase protocol from the most prepared mind. This article shares learnings from my years of experience attending to emergency resuscitations and management of cardiac arrests in the OR. Read More …

Photo of Glidescope intubation with the blade midline while the jaw is being lifted for intubation.

Glidescope: Tricks For Successful Intubation

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Glidescopes are very easy to use, but intubation with the Glidescope is very different than direct laryngoscopy. I have seen many novice Glidescope users struggle to intubate, despite having great views of the larynx. Failure to recognize the differences of using the Glidescope can make intubation not only frustrating but also hazardous to your patient. Beginners almost always make the same few easy to correct mistakes. This article discusses those mistakes and how to correct them. Read More …

Our Procedural Cast Offs Can Place Our Patients at Risk of Pressure Injury

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Health care workers are sometimes careless when it comes to leaving discarded odds and ends that come with our needles and catheters in patient beds. These objects can cause pressure sores and nerve injuries, especially inpatients who are at high risk of pressure injury. We must always be alert to safeguard our patients. Read More …

Protect Yourself From Infection In The Workplace

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There are several animal and avian viruses that show the potential of becoming easily transmissible to humans. MERS, H7N9 and H5N1 are already spreading in humans, although not easily. The last major jump from animal to human occurred with the 1918 flu pandemic where an estimated 40 million people died. Mortality from MERS is currently 330-40% in the Middle East and 10% in South Korea. As health care workers, how we approach infectious disease precautions will have a lot to do with how safe we and our patients are in the workplace. Read More …

The Bougie: Use Wisely To Avoid Rare But Serious Complications

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One of the simplest and most valuable devices to help with a difficult intubation is the bougie. The primary use is a difficult intubation, when you cannot see the larynx well but are able to predict where the glottic opening should be based on anatomy. This article discusses techniques as well as potential complications. Bougies must be used with care to avoid patient injury. Read More …

Illustration showing endotracheal tube cuff above the cords

Risks of Placing Your Endotracheal Cuff Too High

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When intubating, we all know to check the depth of the endotracheal tube. Most people believe this is just to ensure that the tube is not too deep and therefore causing a mainstem intubaton: intubating just one bronchus and therefore only one lung. However, there are significant risks with having the tube too shallow as well, risks such as accidental extubation and potentially causing permanent damage to the recurrent laryngeal nerves. Here we discuss some of the warning signs that the cuff is too high and what to do about it. Read More …

How To Excel In Your Field

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One of my students recently asked me what traits he should develop to become an excellent anesthesia provider. This is an interesting question, because in reality, being an excellent provider of any specialty takes more than just knowing the dosages of the medications, or how to technically perform a procedure. Let Read More …

Picture LMA Supreme

LMA Supreme: Great Invention But Insert It Gently

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Ease of insertion, presence of a gastric port, and the option for using higher ventilatory pressures make the LMA Supreme more versatile and applicable for use in higher risk patients. This article will discuss the differences between the LMA Supreme and The Classic LMA, detail how to insert the Supreme to optimize positioning in the oropharynx and provide guidance on how to avoid patient injury. Read More …