Dogmas of Anesthesia - OANA / Oklahoma Association of ... · Anaphylaxis In the general population...

Dogmas of Anesthesia

Mike MacKinnon MSN, FNP CRNA

What gets us into trouble is not what we don't knowIt's what we know for sure that just ain't so.

- Mark Twain

Dogmas of Anesthesia

1. Ancef IV Test Dose with PCN Anaphylaxis

2. Most common cause of Anaphylaxis

3. Pump & Dump

4. Platelet level & OB Epidurals

5. Reversing Muscle Relaxant

6. Propofol & Soy/Egg Allergy

7. Supra Glottic Airways and Paralysis / PPV

8. Anesthesia in Pregnancy

9. Ortho’s are NOT smart

Dogma is a principle or set of principles laid down by an “authority” (or person) as

incontrovertibly true.

We will be using POLLEVERYWHERE today!

You should always give an IV test dose of ancef

to patients with anaphylaxis to PCN

IV Test Dose✓ The idea is that you will see a small area of reaction with a “~1cc”

IV test dose if there is true cross-reactivity with Ancef (cephlosporin). This will then guide you not to give the rest.

✓About 0.001% of patients treated with penicillins die from anaphylaxis.

✓ There are at least 300 deaths per year due to this complication of therapy.

✓About 70% of these patients have had penicillin previously. (Apter, 2006)

✓ The true cross reactivity with 1st generation cephlosporins is approximately 1% (Campagna, 2011)

✓Ancef (cefazolin) is a 1st gen cephlosporin

IV Test Dose

✓ PCN allergies are approx 25% IgE mediated and 75% non-IgE mediated (Haslan, 2012)

✓ IgE Mediated = anaphylaxis, urticaria (HIVES), angioedema

✓Current recommendations are not to give cephlosporins in patients with known IgE mediated reactions.

✓ The risk of giving them is ~1%.. But does that apply to Ancef?

IV Test Dose

So what is the right course of action?

✓Do not give a test dose, it will give NO useful clinical information

✓Anaphylaxis is an ALL or NOTHING proposition

✓ Therefore regardless of the dose you give, 1cc or the whole dose, the severity of the potential anaphylaxis is the same.

WHY?

ANCEF ?

WHY?

Verdict: Dogma

Ancef has no cross-reactivity to PCN. Test dose gives no useful

information. This is DOGMA!

RISK vs BENEFIT. Statistically there is no reason not to give 1st gen cephlosporins to patients with non IgE reactions and its a clinical call for those

WITH IgE mediated reactions.

The risk is 1%.

The Most Common Trigger in Anesthesia for

anaphylaxis are antibiotics

Anaphylaxis

In the general population the most common drug cause of anaphylaxis are antibiotics (particularly β-lactam ABX)

Anaphylaxis in anesthesia is estimated to occur between 1:4000 and 1:25000 patients

Mortality for anaphylaxis is estimated between 3.5-10% of those cases

In anesthesia 50-75% of all anaphylaxis events are caused by paralytics

Sadleir, P. H. M., Clarke, R. C., Bunning, D. L., & Platt, P. R. (2013). Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002 to 2011. British journal of anaesthesia, 110(6), 981-987.

Norred, C. L. (2012). Anesthetic-induced anaphylaxis. AANA journal, 80(2).

Anaphylaxis

Most paralytics directly stimulate histamine release

Steroid derived drugs may bind with biologic proteins creating a haptenmolecule that is recognized as an antigen

This reaction can happen the first time the paralytic is given due to cross-sensitization from similar quaternary ammonium ions in cosmetics, personal products (toothpastes, soaps, and shampoos), chemical additives in foods (metabisulfites, preservatives), and drugs (cough medicines).

Or the reaction can happen in subsequent administrations though not the first

Sadleir, P. H. M., Clarke, R. C., Bunning, D. L., & Platt, P. R. (2013). Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002 to 2011. British journal of anaesthesia, 110(6), 981-987.

Norred, C. L. (2012). Anesthetic-induced anaphylaxis. AANA journal, 80(2).

Anaphylaxis

The highest risk drugs are:

ROCURONIUM @ 56% of all cases

Succinycholine @ 21%

Vecuronium @ 11%

Verdict: Dogma

The evidence is clear that the highest risk for anaphylaxis in

anesthesia is from ROCURONIUM

This is DOGMA!

Women who are breast feeding should “Pump and Dump” 24 hours after a

general anesthetic

Pump & Dump

✓ The total doses of these drugs ingested by an infant is negligible, and intestinal absorption of these drugs by suckling infant is also negligible, which is why the advice of all experts is simply to continue breastfeeding after any operation (Howie 2006, Lang 2003).

✓ If a woman feels she is capable of breastfeeding her baby after an operation, she may do so in full knowledge that any anesthetic and analgesic drugs present in her blood will not affect her child.

✓Could potentially cause problems in infants who are premature or infants suffering from apnea. In this case consider waiting 24 hours.

Pump & DumpTotal dose of any drug ingested by an infant

The volume of milk produced by a lactating mother in the first few months after delivery is up to 500 ml per day.

Knowing the M/P ratios makes it possible to calculate the total dose of a drug present in the mother ingested by a suckling infant with the following formula.

Dose = C x (M/P) x V

Dose = Total dose of drug ingested by infant (mg)

C = maternal plasma concentration of drug during suckling (mg/l)

(M/P) = milk/plasma concentration ratio

V = volume of milk ingested by the infant (liters)

Pump & Dump

What concentrations of anesthetic drug in infant plasma can we REALLY expect?

• Resumption of normal mentation is a hallmark that these medications have redistributed from the plasma compartment (and thus generally the milk compartment)

•The calculation shows total dose of any suckling infant negligible

• Drugs ingested go through intestinal system which is slow and inefficient = Insignificant amount of any anesthetic drug present in a mother actually being absorbed into the blood a breastfeeding infant (Nitsun 2006)

Pump & DumpHow would I know an M/P ratio?

Verdict: Dogma

Women may restart breast feeding as soon as possible after surgery in normally developed infants

This is backed by both ACOG and Agency for Health and Research Quality

You cannot place an epidural OR Spinal unless the platelets are > 100K

Epidural with PLT < 100K

There is NO published data which suggests a platelet number which predicts risk of epidural hematoma. None.

There is a single report of an epidural hematoma in a pregnant woman occurring in the presence of thrombocytopenia (71K ) (Douglas, 2005)

Incidence of epidural hematoma is estimated at 1 per 160,000epidurals and 1 per 220,000 spinals. (Goswami, 2011)

Provided that a low count is clearly stable, maternal health is good, and there are normal fibrinogen levels, INR and APTT, then expert opinion is that neuroaxial blockade can be justified provided the platelet count is 50K or above. (Haematol, 2010)

Epidural with PLT < 100K

What about in Pre-eclampisa or HELLP?

Low grade activation of coagulation is accelerated

Increasing the risk of venous thromboembolism in the already prothrombotic pregnant circulation

Rarely CONSUMPTION is greater than ACTIVATION which results in depletion and widespread coagulopathy

Epidural with PLT < 100K

What about in Pre-eclampisa or HELLP?

Consider delaying epidural WHEN:

Abnormalities in coag screen

Falling plt count below 75K that is unstable

There is poor maternal health

On anticoags, anti-platelet agents

Have congenital coagulopathies or platelet function defects

Verdict: Dogma

Per all available data a PLT count of 75-80K is SAFE for placement of epidurals and 50K for

spinalsPatients between 50-75K for epidurals should decided on risk vs benefit

You do not have to reverse muscle relaxant if you have 4 strong

twitches

MR and Reversal✓ 70% of all anesthesia providers estimate residual paralysis at < 1%

✓ In a meta-analysis, Naguib et al. (2008) discovered providers estimates of the rate of residual paralysis based on a TOF ratio of <0.9 was 34.8%

✓ 65.2% of the time pts TOF ratio < 0.9.

✓Murphy et al. (2010) Volunteer studies have demonstrated that small degrees of residual paralysis (train-of-four ratios 0.7–0.9) are associated with impaired pharyngeal function and increased risk of aspiration, weakness of upper airway muscles and airway obstruction, attenuation of the hypoxic ventilatory response (approximately 30%), and unpleasant symptoms of muscle weakness. This suggests that residual blockade is a common cause of respiratory difficulties in the PACU

MR and Reversal✓ The train of four ratio is a ratio of the height of the 4th twitch

divided by the height of the first twitch.

✓Only 37% of anesthesia providers were able to detect fade visually and only 57% manually, ERGO assessment of TOF is unreliable

✓ Train of 4 ratio is clearly very SUBJECTIVE monitoring. Studies show that perioperative subjective monitoring does not significantly decrease the incidence of postoperative residual block (Brull, 2010)

✓ It is not possible by any clinical test or combinations hereof, nor by tactile or visual evaluation of the response to TOF, tetanic (50 or 100 HZ), or double-burst stimulation, to exclude clinically relevant postoperative residual paralysis. (Naguib, 2010)

MR and Reversal✓Only accurate way to determine 0.9 TOF ratio is with OBJECTIVE

EMG, MMG, or acceleromyography (AMG). Even then a % of patients will still display residual paralysis! (Brull, 2010)

AMG EMG MMG

MR and ReversalBut my case went “X” hours so its physiologically reversed…

✓Most clinicians believe that if it has been 1-4 hours no reversal is required

✓ The available data does NOT support this belief.

✓Caldwell et al. assessed the degree of neuromuscular blockade for up to 4 hours after a single dose of vecuronium (0.1 mg/kg). The TOF ratio was 0.75 in:

✓ 4 of 20 patients at 2 hours,

✓ 3 of 10 patients at 3 hours

✓ 1 of 20 patients at 4 hours

MR and Reversal

But my case went “X” hours so its physiologically reversed…

✓A large clinical study (n 526) examined the incidence of residual paralysis after a single intubating dose of an intermediate acting NMBD and no reversal. On arrival to the PACU, TOF ratios 0.7 and 0.9 were observed in 16% and 45% of patients, respectively.

✓ In the 239 patients tested 2 hours after the administration of the NMBD, TOF ratios 0.7 and 0.9 were noted in 10% and 37% of patients, respectively. (Debaene, 2003)

MR and Reversal

But my case went “X” hours so its physiologically reversed…

✓ Patients who are left to spontaneously recover from such blockade are SIX TIMES as likely to need reintubation within 48 hours of surgery (S. Devine1, G. Magee, D. E. Stein, G. S. Murphy, 2015)

✓ 2012 analysis (BMJ 2012;345:e6329) found that reintubation requiring admission to the ICU was associated with a 90-fold higher risk for in-hospital mortality

Verdict: Dogma

In the absence of an OBJECTIVE method of

determining TOF >0.9, it is not unreasonable to reverse all MR

with a clinically indicated dose of neostigmine.

Caveat: Reports of neuromuscular weakness with OD of neostigmine

Propofol should be avoided in patients who have an allergy to egg

yolks (Due to lecithin)

Propofol & Eggs

✓ The incidence of anaphylactic reactions has been reported as 1:60,000 (Hepner, 2003)

✓ RxN often blamed on previous Soy and Lecithin allergies b/c propofolis mixed in a liquid containing soybean oil and egg lecithin

What is the RISK of Propofol allergy?

Propofol & Eggs

✓ 1994: Bassett and colleagues reported pruritus after propofol in one patient who happened to be allergic to egg

✓ They suggested egg-allergy and propofol reactions were related

✓No testing was done

Where did this come from?

Bassett CW Talusan-Canlas E Holtzin L Kumar S Chiaramonte LT . Case report: an adverse reaction to propofol in a patient with egg hypersensitivity . J Allergy Clin Immunol 1994 ; 93 : 242

Propofol & Eggs

✓ 2001: Nishiyama reported bronchospasm in two patients after receiving propofol.

✓No testing for propofol or other allergy was performed.

✓ The authors surmised that soybean oil and yolk lecithin might have induced an allergic reaction, despite the only allergy reported by these patients being allergic rhinitis (hayfever)

Nishiyama T Hanaoka K . Propofol-induced bronchoconstriction: two case reports . Anesth Analg 2001 ; 93 : 645 – 6

Propofol & Eggs

✓ 2003: Hofer described hypotension and exacerbation of bronchospasm in ONE severely-asthmatic child after the administration of propofol and rocuronium

✓ Pt was known to be allergic to egg and peanut, but not soy. No allergy testing was performed to exclude (the more likely) anaphylaxis to rocuronium

✓ The authors did not test, ignored the much higher risk of allergy to Roc and concluded it was likely due to propofol.

Hofer KN McCarthy MW Buck ML Hendrick AE . Possible anaphylaxis after propofol in a child with food allergy . Ann Pharmacother 2003 ; 37 : 398 – 401

Propofol & Eggs

✓ 2016: Asserhøj did an 8 year retrioscpective study on 99 pts with confirmed egg or soy allergy who had propofol

✓ The 99 pts had a total of 171 propofol exposures between them

✓No patient developed clinical features suggestive of hypersensitivity during anaesthesia.

Asserhoj L Mosbech H Kroigaard M Garvey LH No evidence for contraindications to use of propofol in adults allergic to egg, soy or peanut Br J Anaesth 2016; 116: 77– 82

The Nail in the Coffin

Propofol & Eggs

✓ The majority of reports of anaphylaxis after propofol did NOT have soy or egg allergies

✓ The majority of patients who have egg allergy have had propofolwithout reaction

✓ In nearly EVERY CASE, Pts have received others drugs which are more likely to cause anaphylaxis

American Academy of Allergy, Asthma & immunology: https://www.aaaai.org/conditions-and-treatments/library/allergy-library/soy-egg-anesthesia

Verdict: Dogma

Though propofol can cause anaphylaxis on its own, there is no definitive evidence that it is related

to soy or lecithin

This is DOGMA!

It isn't safe to paralyze a patient with a

supraglottic device (SGA)

Paralysis & SGAs

The belief is that PPV under paralysis with an LMA will “force” any gastric contents which could come up INTO the trachea and

result in aspiration.

There is no evidence for this statement

It denfies the laws of physics.

Paralysis & SGAsWhat really happens?

When you inspire your diaphragm creates a negative intrathoracic ( sub atmospheric ) pressure gradient (-6 mmhg)

This causes a ‘pulling in’ of the air through the route of least resistance, the glottis. Like a suction catheter.

This pulling vacuum does not discriminate between air or fluid.

Think of your glottis as the end of your suction catheter during inspiration

Paralysis & SGAsWhat really happens?

LMAs never have a perfect seal

Therefore during inspiration anything sitting around the outside of the LMA (gastric contents / air) can be sucked in.

Especially during the START of inspiration after expiration has loosened the LMAs seal (removing suction effect which helps seat it).

Paralysis & SGAs

So physics dictates, the highest risk for aspirating gastric contents which come up around the LMA must be during the period of

“suction” (negative intrathoracic pressure) created by spontaneous inspiration.

Specifically: LaPlaces Law, Ideal Gas Law,

Paralysis & SGAsWhat happens under Paralysis

LMAs never have a perfect seal (Still!)

There is no ‘suction effect’ without negative intrathoracic pressure

Now there is only pressure during inspiration (air forced in) and pressure during expiration (air forced out).

Paralysis & SGAsWhat happens under Paralysis

As PPV occurs anything around the outside of the LMA gets FORCED away from it by air pressure. Not sucked in.

As expiration occurs anything around LMA also gets FORCED away from it during pressure

Paralysis & SGAsWhat Factors Decrease The Risk of Aspiration Under PPV?

Patient is paralyzed and active vomiting cannot occur only passive. Low pressure Low volume. (you can put pt into reverse T-berg)

Pressure on ventilation forces air out around LMA and pushes away gastric contents

Paralysis & SGAsWhat are the “CAVEATS”

This relies on patient selection and SGA type.

Patient selection:

With regular LMA keeping pressures under 20 mmhg to ventilate may be an issue with a large patient. Going over 20 mmhg may insufflate the gastrum increasing risk for passive regurgitation.

Might not be able to put them in reverse t-berg to decrease pressure depending on surgery

Paralysis & SGAsWhat are the “CAVEATS”?

SGA Type:

Regular LMA = PPV under 20 mmhg OR Proseal PPV up to 45 mmhg

New SGAs also have gastric ‘port’ where there is a path of least resistance for any gastric content to go or be suctioned out. Some allow the insertion of an OG tube as well.

Is there Evidence?Yes and its growing rapidly

1. Keller C, Brimacombe J. Spontaneous versus controlled respiration with the laryngeal mask. A review. Anaesthesist. 2001;50:187–191. [PubMed]

2. Bernardini A, Natalini G. Risk of pulmonary aspiration with laryngeal mask airway and tracheal tube: analysis on 65 712 procedures with positive pressure ventilation. Anaesthesia. 2009;64:1289–1294. [PubMed]

3. Keller C, Sparr HJ, Luger TJ, Brimacombe J. Patient outcomes with positive pressure versus spontaneous ventilation in non-paralysed adults with the laryngeal mask. Can J Anaesth. 1998;45:564–567. [PubMed]

4. Devitt JH, Wenstone R, Noel AG, O'Donnell MP. The laryngeal mask airway and positive-pressure ventilation. Anesthesiology. 1994;80:550–555. [PubMed]

5. Keller C, Sparr HJ, Luger TJ, Brimacombe J. Patient outcomes with positive pressure versus spontaneous ventilation in non-paralysed adults with the laryngeal mask. Can J Anaesth. 1998;45:564–567. [PubMed]

6. Brimacombe J, Keller C, Hörmann C. Pressure support ventilation versus continuous positive airway pressure with the laryngealmask airway: a randomized crossover study of anesthetized adult patients. Anesthesiology. 2000;92:1621–1623. [PubMed]

7. Riem N, Boet S, Tritsch L, Bould D. LMA with positive pressure ventilation is safe!. Korean J Anesthesiol. 2011 Jul;61(1):88-89

8. Keller C, Brimacombe J. [Spontaneous versus controlled respiration with the laryngeal mask. A review]. Anaesthesist. 2001 Mar;50(3):187-91. Review. . PubMed PMID: 11315492.

Is there Evidence?Yes and its growing rapidly

1. Heringlake M, Doerges V, Ocker H, Schmucker PA. Comparison of the cuffed oropharyngeal airway (COPA) with the laryngeal mask airway (LMA) during manually controlled positive pressure ventilation. J Clin Anesth.1999;11:590-595.

Brimacombe JR, Brain AIJ, Berry A. The Laryngeal Mask Airway. AReview and Practical Guide.London, England: WB Saunders; 1997.

Brimacombe J. The advantages of the LMA over the tracheal tube or face mask: a meta-analysis. Can J Anaesth.1995;42:1017-1023.

Graziotti PJ. Intermittent positive pressure ventilation through a laryngeal mask airway. Is a nasogastric tube useful? Anaesthesia.1992;47:1088-1090.

Heinrichs W, Weiler N, Latorre F, Eberie, B. Respiratory mechanics, gastric insufflation pressure and air leakage of the laryngealmask airway [abstract]. Anesthesiology. 1995;83A1227.

Joshi GP, Inagaki Y, White PF. Use of the laryngeal mask airway as an alternative to the tracheal tube during ambulatory anesthesia. Anesth Analg.1997;85:573-577.

Keller C, Sparr HJ, Luger TJ, Brimacombe J. Patient outcomes with positive pressure versus spontaneous ventilation in non-paralysed adults with the laryngeal mask. Can J Anesth. 1998;45:564-567.

Devitt JH, Wenstone R, Noel AG, O’Donnell MP. The laryngeal mask airway and positive pressure ventilation.Anesthesiology. 1994;80:550-555.

Natalini G, Facchetti P, Dicembrini MA, Lanza G, Rosano A, Bernardin A. Pressure controlled versus volume controlled venti lation with laryngeal mask airway. J Clin Anesth. 2001;13:436-439.

Frohlich D, Schwall B, Funk W, Hobbhahn J. Laryngeal mask airway and uncuffed tracheal tubes are equally effective for low flow or closed system anaesthesia in children. Br J Anaesth. 1997;79: 289-292.

Brimacombe J, Keller C, Brimacombe L. A comparison of the laryngeal mask airway ProSeal and the laryngeal tube airway in paralyzed anesthetized adult patients undergoing pressure-con trolled ventilation. Anesth Analg.2002;95:770-776.

Brimacombe J, Keller C, Boehler M, Puhringer F. Positive pressure ventilation with the ProSeal versus Classic laryngeal mask airway: a randomized, crossover study of healthy female patients. Anesth Analg. 2001;93:1351-1353.

Yoshino A, Hashimoto Y, Hirashima J, Hakoda T, Yamada R, Uchiyama M. Low-dose succinylcholine facilitates laryngeal mask airway insertion during thiopental anaesthesia. Br J Anaesth. 1999; 83(2):279-283.

Chui PT, Cheam EW. The use of low-dose mivacurium to facilitate insertion of the laryngeal mask airway.Anaesthesia. 1998;53(5):491-495

Verdict: Dogma

There is no data to suggest that patients are at more risk with an SGA paralyzed and on the vent as opposed to under spontaneous

ventilation AND evidence to suggest they are at higher risk of aspiration

under Spont. Ventilation. This is DOGMA!

There is a higher risk of Miscarriage & Birth

Defects if you have GA in the first trimester of

pregnancy

First Trimester GA

✓Of 720,000 pregnant women, there were 5405 non-obstetric operations, for an incidence of 0.75 percent.

✓ There are no randomized trials evaluating management of non-obstetric surgery in pregnant patients.

Risk of Miscarriage✓ First trimester background miscarriage rate is approximately 8 to

16 % in first trimester (Management of the pregnant patient undergoing nonobstetric surgery, Up to Date, 2015)

✓A literature review of studies of pregnancy outcome after non-obstetric surgical intervention reported an incidence of miscarriage within this range, 10.5 percent of patients in the first trimester (Management of the pregnant patient undergoing nonobstetric surgery, Up to Date, 2015)

✓ There is weak evidence of increased risk of spontaneous abortion in providers with exposure to unscavenged nitrous oxide, but notwhen scavenging equipment is used (Rowland AS, Baird DD, Shore DL, Weinberg CR, Savitz DA, Wilcox AJ, 1995), (Hemminki K, Kyyrönen P, Lindbohm ML, 1985)

Risk of Teratogenicity✓Currently used anesthetic agents have no known teratogenic

effects, and multiple large retrospective studies have not shown an increase in congenital defects in infants born to mothers who had surgery and anesthesia during pregnancy, including the 2252 pregnancies with first-trimester exposures (Visser BC, Glasgow RE, Mulvihill KK, Mulvihill SJ, 2008)

✓ Early reports suggested that diazepam use in early pregnancy may be associated with cleft palate; however, subsequent studies have failed to demonstrate this association or a definite risk of other anomalies, although a small increase in risk could not be excluded.

✓Commonly used benzodiazepines (such as midazolam) have neverbeen associated with congenital malformations.

2005 Systematic Review Findings

✓Miscarriage rate was 10.5%. Same range as general population

✓Major birth defect rate = 2%. Same range as general population

✓Commonly used benzodiazepines (such as midazolam) have neverbeen associated with congenital malformations.

✓ The rate of congenital malformations and unexplained stillbirths was similar for women who underwent non-obstetric surgery requiring anesthesia

(Cohen-Kerem R, Railton C, Oren D, Lishner M, Koren G, 2005)

Caveat……. Fetal Brain Development

✓ There is no clear evidence that any specific anesthetic agents are preferable to others during pregnancy to avoid effects on human fetal brain development.

✓ Laboratory and animal studies show increased neuronal apoptosis, and negative effects on neurodevelopment from inhalation anesthetics, propofol, and ketamine

✓ 2012 meta-analysis of studies of young children exposed to anesthetics and surgery suggests a modest increase in risk of developmental outcomes (DiMaggio C, Sun LS, Ing C, Li G, 2012)

✓Many studies being done BUT at present there is no compelling evidence that any specific anesthetic agent should be avoided during pregnancy

Caveat……. Fetal Brain Development

In 2016 the FDA released this statement:

“FDA is warning that repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect

the development of children’s brains.”

http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm533195.htm

Verdict: Dogma

There is no clear data to suggest that there is increased risk of

miscarriage or birth defects during 1st trimester undergoing General

Anesthesia. This is DOGMA!

Orthopods are not the sharpest tools in the

drawer….

Ortho’s are not SmartWhat is the evidence that Ortho’s are not smart?

Want to hide a $20 bill from an orthropod ….put it in a book

A double blind study is when 2 ortho’s are reading an EKG

Whats the heart for? Circulating Ancef to the bones..

Ortho’s are not SmartAnd lets not forget…

Ortho’s are not SmartBut then this came out in 2011

Ortho’s are not SmartWhat is the evidence that Ortho’s are not smart?

Verdict: Dogma

Based on all available evidence (one study done by orthopedists)

Ortho’s are both STRONGER and SMARTER than Anesthetists!

Questions?