Alex Ronenson 👨🇷🇺

obstetric anesthesiologist once, obstetric anesthesiologist forever

[Updates in Medicine @medic_updates]

Peripheral vasopressors may be safer than we thought — only 1 major adverse event across 29,596 short PIV catheters in this meta-analysis of 49 studies.

[Dr. Chacón-Lozsán F .'. @franciscojlk]

💉🩺Rapid sequence intubation in 2026: we are no longer “protecting the airway.”
We are managing physiology under extreme stress.

The latest evidence challenges one of the oldest dogmas in critical care.

RSI was designed to prevent aspiration.
But today, the real enemy is often hypoxemia and cardiovascular collapse.

1. Aspiration is no longer the central problem

For decades, RSI was built around one fear: aspiration.

But emerging data suggest:

RSI may not significantly reduce aspiration

It may increase hypoxemia and hemodynamic instability

The paradigm is shifting:

👉 From aspiration avoidance → to physiologic optimization

2. First-pass success is everything

Every additional attempt increases:

Hypoxia

Hemodynamic collapse

Mortality

Modern RSI is built around one goal:

Get it right the first time.

That means:

Videolaryngoscopy first-line

Stylet routinely

Team choreography, not improvisation

3. Preoxygenation is now a therapeutic intervention

Not just a step—a determinant of survival

NIV > face mask

HFNO as adjunct

Semi-upright positioning

And one key shift:

👉 Gentle ventilation is no longer taboo

Done correctly, it reduces hypoxemia without increasing aspiration risk.

4. Hemodynamics matter more than ever

Up to 40–50% of patients experience peri-intubation instability.

The modern approach:

Avoid propofol in unstable patients

Favor etomidate or ketamine

Consider prophylactic vasopressors

Fluid loading?
Not routinely beneficial.

5. Cricoid pressure: from dogma to doubt

No clear benefit in preventing aspiration

May worsen laryngoscopy and ventilation

Current thinking:

👉 Use selectively, or not at all

6. RSI is no longer a rigid protocol

It is now:

Patient-specific

Physiology-driven

Team-dependent

With tools like:

Gastric ultrasound

POCUS-guided decisions

Structured airway protocols

7. The real determinant of success: human factors

Preparation, communication, and coordination matter as much as drugs.

Because in critical care:

The airway is not just anatomy.
It is a moment of systemic vulnerability.

🤓Final message

RSI has evolved:

From speed → to precision

From protocol → to physiology

From individual skill → to team performance

And ultimately:
The goal is no longer just to intubate.
It is to intubate without killing the patient.

📃Reference
Boulos NM et al. Anaesth Crit Care Pain Med. 2026. https://t.co/KWUfUtAMyP

[British Journal of Anaesthesia @BJAJournals]

🤢 Nausea and vomiting during caesarean delivery are not trivial. Multimodal antiemetic prophylaxis, especially combination therapy, can reduce complications, improve comfort, and support smoother recovery.
Read more: https://t.co/Bqj13i6fU7

[𝘈𝘯𝘢𝘦𝘴𝘵𝘩𝘦𝘴𝘪𝘢 @Anaes_Journal]

This one is for all the obstetric anaesthetists out there!

Some new guidelines - "Pain management after elective caesarean section under neuraxial anaesthesia"

#anaesthesia #obstetrics #regionalanaesthesia #regionalanesthesia #MedTwitter

https://t.co/nI3VpQo3BL

[AJOG @AJOG_thegray]

AJOG Expert Review: The Stark (Misgav Ladach) cesarean delivery—a streamlined surgical technique: development, rationale, and clinical outcomes https://t.co/1zWvHVJlYN

[𝘈𝘯𝘢𝘦𝘴𝘵𝘩𝘦𝘴𝘪𝘢 @Anaes_Journal]

You all heard about the new breastfeeding guidelines at #WSM2026!

Now the conference fun is behind us, take some time to have a quick read and refresh your understanding of how to care for breastfeeding patients!

#anaesthesia #breastfeeding #MedTwitter

https://t.co/zcPdhnCamu

[𝘈𝘯𝘢𝘦𝘴𝘵𝘩𝘦𝘴𝘪𝘢 @Anaes_Journal]

Here is some really useful information on transfer to breastmilk of medicines used peri-operatively.

Of note are drugs to:
⚠️ use with caution - tramadol, oxycodone, codeine and pethidine
❌ avoid - aspirin in analgesic doses

#anaesthesia #breastfeeding #MedTwitter #obstetrics

https://t.co/Ln9DlKAQQs

[AJOG @AJOG_thegray]

AJOG Expert Review in Cesarean: I feel pain, not pressure: a personal and methodological reflection on pain during cesarean delivery https://t.co/afcjbgv8mj

[𝘈𝘯𝘢𝘦𝘴𝘵𝘩𝘦𝘴𝘪𝘢 @Anaes_Journal]

High-flow nasal oxygen in obstetric practice – where do we stand?

"... it would be premature to conclude that HFNO represents a superior method of pre-oxygenation to facemask oxygen in obstetric practice."

@YavorRM #anaesthesia #medicine #obstetrics #respiratory

https://t.co/yIRIt8VGQi

[AJOG @AJOG_thegray]

Closed- or open-glottis pushing for vaginal delivery: a planned secondary analysis of the TRAnexamic Acid for Preventing postpartum hemorrhage - Pathophysiological hypotheses illustrating effects of pushing mode on obstetrical events https://t.co/7nHDxG2M1C

[Heart_BMJ @Heart_BMJ]

National Institute for Health and Care Excellence guidelines for lipid management 💯

[𝘈𝘯𝘢𝘦𝘴𝘵𝘩𝘦𝘴𝘪𝘢 @Anaes_Journal]

🔓Interpreting evidence on ‘failed intubation’: are we losing airways or losing our minds?

"Airway safety is less about a first-past-the-post system and more about making sure that no patient is left behind."

🔗https://t.co/uoVhugjstI

[𝘈𝘯𝘢𝘦𝘴𝘵𝘩𝘦𝘴𝘪𝘢 @Anaes_Journal]

🔓"We have identified areas for quality improvement, particularly in the management of spinal anaesthesia and obstetric haemorrhage."

#OpenAccess @RCoANews #NAP7

@noolslucas @emirakur @doctimcook @adk300 @drrichstrong @NAPs_RCoA @jas_soar

🔗https://t.co/UYdrFbnmgH

[𝘈𝘯𝘢𝘦𝘴𝘵𝘩𝘦𝘴𝘪𝘢 @Anaes_Journal]

🔓Emergency treatment of peri-operative anaphylaxis: Resuscitation Council UK algorithm for anaesthetists👇

@jas_soar @LouiseSavic @Assoc_Anaes @RCoANews @BSACI_Allergy @britsocimm @ResusCouncilUK

🔗https://t.co/Kps7l8RYLt

[Dr. Ron George 🇨🇦 #Anesthesiologist @Ron_George]

High-volume patient-controlled epidural vs. programmed intermittent epidural bolus for labour analgesia: a randomised controlled study.
https://t.co/yFj4NhvW4W

“PCEA is non-inferior to PIEB if equal volumes of PCEA are used to maintain labour analgesia”

#OBAnes

[CDC Division of Reproductive Health @CDC_DRH]

#MaternalMortality is a tragedy that no one should have to endure. Maternal Mortality Review Committees (MMRCs) identify prevention opportunities.

CDC has a guide to help turn #MMRC data to action to prevent future deaths: https://t.co/qHRmmW0n4K.

[Critical Care Reviews @CritCareReviews]

Today's paper of the day is on fluids and early vasopressors in the management of septic shock: do we have the right answers yet?
https://t.co/JKgcYjlUQ5

Join us to read 1 paper per day and stay up-to-date as we cover the spectrum of critical care across 2023

[AJOG @AJOG_thegray]

Is magnesium sulfate therapy warranted in all cases of late postpartum severe hypertension? Algorithm for the evaluation and management of late postpartum severe hypertension with gastrointestinal, cardiac, or pulmonary symptomshttps://ow.ly/C9pQ50QaZFO

[AJOG @AJOG_thegray]

Is magnesium sulfate therapy warranted in all cases of late postpartum severe hypertension? A suggested approach to a clinical conundrum https://t.co/lfBi25Q9sT

[Alicia Dennis @AliciaTDennis]

MBRRACE-UK 2023 released reporting maternal deaths and morbidity 2019-2021

https://t.co/o8YIaqF4yQ