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sivatrainees.bsky.social

@sivatrainees.bsky.social
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Rob Fleming @robjimfleming.bsky.social · 28/11/2025
Ahead of my talk today at #SIVA25, I have packaged up some #PERUSEbeforeYouInfuse posters, for anyone convinced by what I'm saying, who then wants to use the check. The right things happen more often if you make them easy. Providing posters (and Blu Tack) is very much in the spirit of the talk.
A "PERUSE before you Infuse" poster, resting on top of a stack of pre-packaged bundles of posters, each containing 20 posters and some Blu Tack, for putting them on walls. It is all about incentivising the good, innit?
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Reposted by @sivatrainees.bsky.social
Society for Intravenous Anaesthesia @sivanaesthesia.bsky.social · 28/11/2025
Morning folks! We hope that those who attended the dinner last night had a splendid time and have woken up bright and refreshed, ready for today's #SIVA25 content! Those who have registered for the workshop, please note it starts at 0900. The first session of talks starts at 0915. See you soon!
Timetable for the morning of day 2 of SIVA's Annual Scientific Meeting, 2025.
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Reposted by @sivatrainees.bsky.social
Society for Intravenous Anaesthesia @sivanaesthesia.bsky.social · 28/11/2025
First up in the main session today at #SIVA25 we have Professor Gavin Kenny, one of the key architects of the Diprifusor TCI system. It is no exaggeration to say modern TCI and TIVA would not exist without him. In the first of two talks he is giving today, he tells us how Diprifusor was created.
Professor Kenny at the lectern, in front of a slide titled "Diprofusor Design Features".
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Society for Intravenous Anaesthesia @sivanaesthesia.bsky.social · 27/11/2025
Getting ready for the second start of the day. To the folks who attended a workshop this morning, hello again! To the folks just arriving, welcome to Liverpool and #SIVA25! Our next talks are focussed around some of the practicalities of TIVA, in the "how I do it" session.
Agenda for the first half of this afternoon's SIVA ASM.
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Society for Intravenous Anaesthesia @sivanaesthesia.bsky.social · 26/11/2025
Nice view of the famous Liverpool skyline from up here! Both cathedrals, and the Radio City tower are visible. Bit chilly right now though. Liverpool is a brilliant city. We are looking forward to welcoming our delegates at tomorrow's Annual Scientific Meeting #SIVA25. See you there!
Liverpool skyline after dark. The two cathedrals are visible at the horizon, with the Radio City tower to the right.
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Society for Intravenous Anaesthesia @sivanaesthesia.bsky.social · 26/11/2025
Hello Bluesky! Ahead of our Annual Scientific Meeting, which starts tomorrow, we thought we would get this account up and running. It will be curated by @robjimfleming.bsky.social for the next couple of days at least. Hopefully we will see some of you in sunny Liverpool!
SIVA - 27th & 28th November, Liverpool.
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Reposted by @sivatrainees.bsky.social
Anaesthesia @anaesjournal.bsky.social · 01/10/2025
"... a ‘RSI–TCI’ mode with a pre-programmed manual bolus offers a pragmatic solution for those who wish to preserve an intact pharmacokinetic model for accurate propofol delivery, while allowing the rapid induction clinicians expect from a manual bolus." #AnSky #MedSky doi.org/10.1111/anae...
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sivatrainees.bsky.social @sivatrainees.bsky.social · 09/08/2025
What would you like? I'll see what we can cobble together!
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sivatrainees.bsky.social @sivatrainees.bsky.social · 08/07/2025
0.2mg/kg bolus has no EEG effect (See image) 0.3mg/kg may have an effect but I feel clinically un likely 0.5mg/kg often will induce EEG changes that are associated with an rise in BIS index If bolusing and concerned about rise in BIS value, give during a period of surgical stability
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sivatrainees.bsky.social @sivatrainees.bsky.social · 06/07/2025
Likewise have a similar recipe. I am enjoying comparing my bolus infusion technique to intermittent boluses
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sivatrainees.bsky.social @sivatrainees.bsky.social · 06/07/2025
After modelling do you have any thoughts on how useful TCI ketamine is Vs bolus infusion? Ie any circumstances you might choose TCI first?
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sivatrainees.bsky.social @sivatrainees.bsky.social · 23/06/2025
Brilliant, thank you. Caveats noted!
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sivatrainees.bsky.social @sivatrainees.bsky.social · 23/06/2025
7x more failures!? Do you have a study I can look at?
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Reposted by @sivatrainees.bsky.social
British Journal of Anaesthesia @bjajournals.bsky.social · 13/06/2025
Eleveld et al.'s #pharmacokinetic - #pharmacodynamic model of #remimazolam begins to pave the way for its widespread use in #sedation and anaesthesia. #BJA #model #simulation www.bjanaesthesia.org/article/S000...
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sivatrainees.bsky.social @sivatrainees.bsky.social · 08/06/2025
If performed by a second person, the cost isn't their salary. It's the time that could be spent elsewhere. Helping with turnover, prepping for the next case etc If performed by airway assistant - disagree with this practice - The cost is attention divided between multiple important tasks.
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sivatrainees.bsky.social @sivatrainees.bsky.social · 08/06/2025
If performed by a second person, the cost isn't their salary. It's the time that could be spent elsewhere. Helping with turnover, prepping for the next case etc If performed by airway assistant - disagree with this practice - The cost is attention divided between multiple important tasks.
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sivatrainees.bsky.social @sivatrainees.bsky.social · 08/06/2025
Completely agree with this point about us not necessarily being great at predicting who has a full stomach, especially in the era of comorbid disease and GLP1s
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sivatrainees.bsky.social @sivatrainees.bsky.social · 08/06/2025
Aspiration has an incidence of between 1:900 - 1:10,000 (NAP4) Perioperative cardiac arrest has an incidence of 1:3000 (NAP7) - Arguably equally catastrophic so should every patient have defib pads put on at the start of a case?
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sivatrainees.bsky.social @sivatrainees.bsky.social · 08/06/2025
But I think your question is less about having cricoid as an absolute but maybe where are we drawing a line as to who to use it on?
media.tenor.com
a man in a robe is standing in a dark room with the words `` only sith deal in absolutes '' written on the screen .
ALT: a man in a robe is standing in a dark room with the words `` only sith deal in absolutes '' written on the screen .
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sivatrainees.bsky.social @sivatrainees.bsky.social · 08/06/2025
Every intervention in healthcare has an opportunity cost. Cricoid force should be performed by a team member with no other role. Cricoid time x No of anaesthetics/ per hosp/ per year = large number Aspiration low incidence in general anaesthetic pop. Cricoid becomes non cost effective.
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sivatrainees.bsky.social @sivatrainees.bsky.social · 05/06/2025
That is a great study! One to be kept in the bank of interesting papers.
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Reposted by @sivatrainees.bsky.social
Nicholas Chrimes @chrimesy.com · 04/06/2025
I don’t think anyone considers thio part of RSI anymore but I’m certain most who’ve abandoned cricoid are still using sux/roc & many aren’t FMV. It’s definitely singled out. Again, I qtn whether the rationale for RSI is sound. This is my fav evidence FOR cricoid. journals.lww.com/anesthesia-a...
journals.lww.com
The Effectiveness of Cricoid Pressure for Occluding the... : Anesthesia & Analgesia
al entrance with and without CP in anesthetized and paralyzed adult patients. METHODS: One hundred seven, nonobese ASA physical status I and II patients were recruited for the study. A cricoid forc...
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sivatrainees.bsky.social @sivatrainees.bsky.social · 05/06/2025
No thats fair. And perhaps RSI is not the answer to making us take more care. But we're not always careful for a variety of human factor-ey reasons... Fine you've convinced me! But can I replace it with another fun acronym instead?
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Nicholas Chrimes @chrimesy.com · 04/06/2025
Interestingly while cricoid pressure gets mocked by those wanting to practice EBM, there’s no more evidence for any other aspect of RSI? Why has cricoid been singled out as the component to ditch when the whole thing is entirely rationale-based & incls many opportunities to cause harm.
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sivatrainees.bsky.social @sivatrainees.bsky.social · 05/06/2025
Interesting! So can I gas induce them? Arguably 8% sevo can be reasonably quick... I joke of course but I think if you're being really careful in frail patients you can reach an accidental plane of 'excitability' If I'm honest I don't disagree with your points
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sivatrainees.bsky.social @sivatrainees.bsky.social · 05/06/2025
Then again, here I am arguing about the term rather than the substance of what an RSI is. Perhaps we do need to be rid of the term...
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sivatrainees.bsky.social @sivatrainees.bsky.social · 04/06/2025
There were several cases of cardiac arrest in NAP7 related to TIVA use where anaesthetists didn't change their practice in sick patients. The term RSI serves as a warning 'This patient is sick, Take care' - Use roc not vec, have the suction under the pillow, think about asking for that NG prior
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sivatrainees.bsky.social @sivatrainees.bsky.social · 04/06/2025
By your other point do you mean that our usual practice has changed ie we should preox and sit up every patient? I'd argue that a lot of the PUMA recommendations we don't do for all Pts - or at the very least we aren't scrupulously careful. In a patient who 'needs' an RSI We take time to prepare.
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sivatrainees.bsky.social @sivatrainees.bsky.social · 04/06/2025
Good points! I would agree, deeply paralysed and anaesthetised pt before instrumentation is key But I think the 1st part - rapid - is important. Risk of aspiration is not proportional to length of time without a protected airway, but does this mean I can take as long as I want with my induction?
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sivatrainees.bsky.social @sivatrainees.bsky.social · 04/06/2025
The only way to be safe 🤣
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Nicholas Chrimes @chrimesy.com · 04/06/2025
Background reading for this week’s debate - this excellent editorial by @sthjournalclub.bsky.social & Craig Lyons in @anaesjournal.bsky.social associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/epdf/10....
associationofanaesthetists-publications.onlinelibrary.wiley.com
Rapid sequence induction: a modern‐day example of Theseus' Paradox?
You have to enable JavaScript in your browser's settings in order to use the eReader.
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sivatrainees.bsky.social @sivatrainees.bsky.social · 04/06/2025
Interestingly there were several aspiration events peri-EXTubation. Does this mean we need an RSE as well as RSI?
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sivatrainees.bsky.social @sivatrainees.bsky.social · 04/06/2025
NAP4 had an overrepresentation of junior anaesthetists involved in aspiration events. I'd argue that teaching a 'standardish' RSI technique to your less experienced team members gives them a baseline of safety; alone, in a theatre, in the middle of the night.
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Dr Mary-Ann Fox BMBS FANZCA GChPOM @maffygirl.medsky.social · 04/06/2025
Ok it’s time for the very first Midweek #AnSkyMedSkyDebate, which I will call the #VortexDebate after the wonderful @chrimesy.com. Come on let’s get our opinions out and have a good robust discussion. See next comment for the topic. #AnSky #MedSky
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sivatrainees.bsky.social @sivatrainees.bsky.social · 04/06/2025
I (personal opinion) like the term RSI. As an indicator of someone who needs 'a tube stuck in quickly' The term is less about the recipe, more as a reminder to the team to be careful. Certainly in anaesthetic practice where 'RSI' is not done for every pt.
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sivatrainees.bsky.social @sivatrainees.bsky.social · 07/12/2024
References for all of this. [1] doi.org/10.1097/ALN.... [2] doi.org/10.1213/ane.... [3] doi.org/10.1093/bja/... 12/12
doi.org
Clinical Electroencephalography for Anesthesiologists: Part I: Background and Basic Signatures
Abstract. The widely used electroencephalogram-based indices for depth-of-anesthesia monitoring assume that the same index value defines the same level of unconsciousness for all anesthetics. In contr...
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sivatrainees.bsky.social @sivatrainees.bsky.social · 07/12/2024
Ketamine has a VERY different EEG effect than propofol or the vapours To avoid confusion, wait for a period of surgical / anaesthetic stability before giving a bolus If you're really worried you could always give less - 0.2mg/kg appears to have no effect on BIS values. [3] 11/12
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sivatrainees.bsky.social @sivatrainees.bsky.social · 07/12/2024
BIS drops to <60 over several minutes (can takes 1h !) As the bolus fades, propofols alpha/ delta pattern returns So If you give ketamine as analgesia under GA - The EEG may change significantly - BIS may >60 - Just because BIS >60 doesn't mean the patient is 'waking up' 10/12
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sivatrainees.bsky.social @sivatrainees.bsky.social · 07/12/2024
Post Ketamine bolus - BIS goes up (unsurprisingly) DSA Shows Propofol alpha / delta pattern -> Fast oscillations in the high-beta / low-gamma range (Initial theta wave activity too) Slow rising BIS, >60 after 4.4 minutes Peak BIS 10 minutes after bolus 9/12
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sivatrainees.bsky.social @sivatrainees.bsky.social · 07/12/2024
Let's look at what the EEG does with a small Ketamine bolus under GA Example small observational study Single ketamine bolus - 0.56mg/kg (via TCI) Mastectomy Pts (n=14) GA, LMA, TIVA Median propofol (Eleveld) Ce 2.75 mcg/mL Median remifentanil (Minto) Ce 3 ng/ml 8/12
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sivatrainees.bsky.social @sivatrainees.bsky.social · 07/12/2024
And that's exactly what we see with a low dose bolus. Activity in the high beta - low gamma range (25 - 32 Hz) Under anaesthesia, this high frequency activity can be interpreted by the BIS as a lighter plane of anaesthesia 7/12
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sivatrainees.bsky.social @sivatrainees.bsky.social · 07/12/2024
If the pt was awake, they might have hallucinations, mod. dissociation, eu/ dysphoria, - There's a reason people take it recreationally. So we're expecting a more active EEG, but not necessarily one that's indicative of more awake conscious state. 6/12
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sivatrainees.bsky.social @sivatrainees.bsky.social · 07/12/2024
Ketamine is anaesthetically weird Low doses act on NMDA receptors that inhibit inhibitory interneurons (double negative) This activates excitatory neurons - Not in a nice coordinated manner - Cortex, amygdala, hippocamp etc talk to one another but information is garbled. 5/12
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sivatrainees.bsky.social @sivatrainees.bsky.social · 07/12/2024
Disclaimer - I do not recommend looking just at a number pEEG is more than a single number. It's a beautiful wibbly wobbly squiggle. BUT - Numbers are easy to write down... 4/12
media.tenor.com
a man is saying that he is not a number and is a person
ALT: a man is saying that he is not a number and is a person
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sivatrainees.bsky.social @sivatrainees.bsky.social · 07/12/2024
Summary up front - 0.5mg/kg causes stereotypical EEG changes that manifest as a high BIS number - If you bolus intraop, do it when everything is stable - <0.2mg/kg probably won't have too much effect on the EEG 3/12
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sivatrainees.bsky.social @sivatrainees.bsky.social · 07/12/2024
If only you knew what ketamine does to the EEG, you could ignore that pesky BIS box So lets have a look at the Ketamine EEG and what happens when you give pts low / sub dissociative doses under anaesthesia. 2/12
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sivatrainees.bsky.social @sivatrainees.bsky.social · 07/12/2024
1st SIVATrainee - BlueSky Thread! pEEG and ketamine If youve spent any time around TIVA and EEG You'll know that ketamine can increase the BIS number - Perhaps you never use ketamine because every time you do your processed EEG keeps telling you the patient's 'awake' 1/12
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Kaspar Bachmann @kasparbachmann.bsky.social · 03/12/2024
Are you interested in #Sustainability in #Anesthesiology and how reusing TIVA lines could help reduce greenhouse gas emissions? Per Werner Moller, originally an expert in #AppliedPhysiology and #VenousReturn, discusses their environmental paper on the #EJA podcast. open.spotify.com/episode/2RCa...
journals.lww.com
Bacterial contamination and greenhouse gas emissions: A... : European Journal of Anaesthesiology | EJA
roorganisms, and eliminating the risk for patient-to-patient cross-contamination. However, infusion-set contamination from compromised aseptic handling could affect quality of care. INTERVENTIONS T...
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sivatrainees.bsky.social @sivatrainees.bsky.social · 02/12/2024
SALG Patient Safety Update has released One case reports stood out Relevant after our 'TIVA in a hyperbaric chamber' by Craig Holdstock #SIVA24 One of the few NHS funded indications for hyperbaric oxygen therapy. Delaying can be detrimental 🔗 tinyurl.com/5564rezu #salgpatientsafety @RCoANews
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sivatrainees.bsky.social @sivatrainees.bsky.social · 02/12/2024
Goat brains on bypass If you know...you know #SIVA24 @chronotrope.bsky.social
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