About the ads

Jet's TOP TEN

Discussion in 'Anesthesiology' started by jetproppilot, Apr 23, 2012.

  1. SDN is a nonprofit organization. Services are made possible through the generous support of SDN members and sponsors. Thank you.
  1. jetproppilot

    jetproppilot Turboprop Driver

    Joined:
    Mar 12, 2005
    Messages:
    5,831
    Location:
    level at FL210
    SDN 7+ Year Member

    SDN Members don't see this ad. (About Ads)
    10) you don't need to be sterile to place an A line.

    9) giving an asymptomatic asthma patient a breathing treatment pre op is a waste of time.

    8) Using etomidate for induction because you're scared to use propofol because of hemodynamic instability has no basis in fact....actually, etomidate has been shown to INCREASE mortality....moral of the story? USE PROPOFOL. Just use less. Or if the situation is that dire, use scopolamine or midazolam.

    7) There is only ONE situation where I'd want a pulmonary artery catheter intraoperatively so WHY ARE YOU PUTTING SO MANY IN?

    6)Giving blood? Yes. You can mix it with Lactated Ringers. Yeah I know. Doesn't matter. Academic, perpetuated dogma.

    5) Combined spinal epidural for OB analgesia is superior to, and safer than current day accepted epidural care.

    4) There exists no superior laryngoscopy blade. The best blade is the one you yield THE FORCE with.

    3) If you're coming off bypass and you experience asystole or a brady arrhythmia, give 2mg atropine IMMEDIATELY.

    2) Don't accept OBSTRUCTIONALISTIC NURSE BEHAVIOR. Move past it. Use your status to keep the OR moving.

    AND THE NUMBER ONE JET TOP TEN:

    1) Don't wait for ventilation to give succinylcholine. Give it as soon as the patient is unconscious. If the chips are down, assuming you are giving an appropriate dose, waiting to ventilate is burning precious seconds off your airway clock. This by far is one of the stupidest dogmas perpetuated by the "doctors" teaching you.
    FFP likes this.
  2. Coastie

    Coastie Junior Member

    Joined:
    Oct 17, 2005
    Messages:
    2,551
    Status:
    Resident [Any Field]
    SDN 7+ Year Member
    Good list. Except, coming off bypass, I'd check the pacing wire connections and capture before the 2 mg of atropine.

  3. WholeLottaGame7

    WholeLottaGame7

    Joined:
    Jul 10, 2005
    Messages:
    1,291
    Location:
    Right here.
    Status:
    Fellow [Any Field]
    SDN 7+ Year Member
    Just finished the 5-hour repeat C/S from hell. At one point the OB attending looked over the drape and said "thank goodness for CSEs." Amen to that.
  4. drkkt

    drkkt

    Joined:
    Apr 15, 2012
    Messages:
    1
    Status:
    Resident [Any Field]
    You must be joking. 5-hour CS with the patient lying 'still' on the table??????
  5. MTGas2B

    MTGas2B Sunny and 70

    Joined:
    Sep 22, 2004
    Messages:
    870
    Location:
    San Diego, CA
    Status:
    Attending Physician
    Physician Faculty Navy SDN 7+ Year Member
    While I feel your pain, and recall the days of training in a place where CSE's for c-sections were the standard of care I think Jet was referring to labor CSE's.
  6. MRW

    MRW AA-C

    Joined:
    Jan 8, 2009
    Messages:
    137
    Location:
    FL
    Status:
    Non-Student
    SDN 5+ Year Member
    I am eager for wisdom, so please share your reasons. So, you are saying knowing you are able to ventilate is not a requirement for the administration of paralytics? I have done it both ways as my attendings are often the ones pushing the induction agents, but I was taught a very specific order of things and sux comes after you have succesfully mask ventillated. Of course, that seems to go out the window when the BMI is high, the neck is thick and the jaw is not able to open very wide...
  7. PMPMD

    PMPMD 4G MD

    Joined:
    Oct 15, 2001
    Messages:
    1,423
    Status:
    Attending Physician
    Physician Faculty SDN 10+ Year Member
    From the BJ of A

  8. PMPMD

    PMPMD 4G MD

    Joined:
    Oct 15, 2001
    Messages:
    1,423
    Status:
    Attending Physician
    Physician Faculty SDN 10+ Year Member
    Editorial on the subject.

    Anaesthesia, 2008, 63, pages 113–115

  9. cchoukal

    cchoukal Senior Member Moderator

    Joined:
    Jul 10, 2001
    Messages:
    1,879
    Location:
    SF, CA
    Status:
    Attending Physician
    SDN 10+ Year Member
    Interesting editorial. Admittedly, I generally achieve FMV prior to NDMBs, be it with a mask or LMA (we get a lot of ZZ top beards here), but if I'm using succ I'll give it with induction. I agree that waking up a morbidly obese, unmaskable, desaturating patient after an induction dose of propofol (particulular if adjuncts like opiates and benzos were included) is pretty unrealistic. I'd add that the right-sided tail of apneic periods after 1 mg/kg of succ stretched up to 9 minutes (saw this paper in residency in Anesthesiology, but didn't take the time to look it up again), suggesting that the traditional dose of succ for RSI may not achieve the desired effect of "wearing off before they get hypoxic."

    I think the important aspect is to assess the airway and history with an eye toward 1) whether they'll be difficult to mask (kheterpal's paper is a great read for this), and 2) whether they'll be difficult to intubate so that you can have a plan in place before having to make a decision when you induce and learn that they're tough to mask.

    That and get comfortable with "awake" intubations (FOB, glide, AND DL). I do lots and I've never regretted one.
  10. PMPMD

    PMPMD 4G MD

    Joined:
    Oct 15, 2001
    Messages:
    1,423
    Status:
    Attending Physician
    Physician Faculty SDN 10+ Year Member
    [​IMG]

    Of course the drummer (the guy in the middle) is named Frank Beard.
  11. Gern Blansten

    Gern Blansten Account on Hold

    Joined:
    Jun 20, 2006
    Messages:
    1,953
    Location:
    Northeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    Yes. I always loved it that Frank Beard was the only one without a beard. Classic band.
  12. Gern Blansten

    Gern Blansten Account on Hold

    Joined:
    Jun 20, 2006
    Messages:
    1,953
    Location:
    Northeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    [​IMG]
  13. jwk

    jwk AA-C ASA-PAC Contributor

    Joined:
    Apr 30, 2004
    Messages:
    2,949
    Location:
    Atlanta, GA
    SDN 10+ Year Member
    Love em, especially 1,2,4, and 8, although we all know a MAC 3 is the best ;) for gravid fire ants.

    Respectfully (of course) agree to disagree on #5 though. Nearly 20k deliveries a year in our system and nary a CSE to be found.
  14. Noyac

    Noyac SDN Advisor SDN Advisor

    Joined:
    Jun 20, 2005
    Messages:
    4,949
    Status:
    Attending Physician
    SDN 7+ Year Member
    I would have agreed with you JWK until I went to my current gig. Now I have to say the CSE is da bomb. But it's not necessarily better. How's that for confusing? I like it cuz it I can leave he room as soon as the catheter is placed. No need to stay and assess the situation.
  15. pie944

    pie944 ASA Member

    Joined:
    Feb 4, 2009
    Messages:
    213
    Status:
    Attending Physician
    SDN 5+ Year Member
    How long do you monitor the BP after the spinal dose?
  16. Noyac

    Noyac SDN Advisor SDN Advisor

    Joined:
    Jun 20, 2005
    Messages:
    4,949
    Status:
    Attending Physician
    SDN 7+ Year Member
    I have the nurse take a BP before I start while she is sitting up and then every 5 min after that. Th next BP is after the IT dose and then one more as I'm walking out of the room. I am typically in the room less than 15-20 minutes. I haven't been called back in years.
  17. pie944

    pie944 ASA Member

    Joined:
    Feb 4, 2009
    Messages:
    213
    Status:
    Attending Physician
    SDN 5+ Year Member
    What's your intrathecal dose? Do you co-load with 500mL? We do the 500, dose for multip/nullip>4cm is 2.5 mg 0.5% Bupivicaine/15 mcg FTL, nullip<4cm is 25 mcg of FTL. We are instructed at minimum to stay until the blood pressure stabilizes, threshold to treat I'm sure varies, not sure the frequency at which I need to treat with something other than fluid, seems rare.
  18. pgg

    pgg Laugh at me, will they? Moderator

    Joined:
    Dec 14, 2005
    Messages:
    7,220
    Location:
    Home Again
    Status:
    Attending Physician
    Navy SDN 7+ Year Member
    I'm a big fan of the labor CSE and it's all I do now.

    I use 1 mL 0.25% bupiv + 15 mcg fentanyl, and ALMOST never see any hypotension afterwards ... I do think you still need to make sure patients have had at least some fluid bolus, especially the pre-e ones who may be dry. I've thought about changing to a fentanyl only IT dose but I'm not sure the itching would be worth getting rid of the local.
  19. Noyac

    Noyac SDN Advisor SDN Advisor

    Joined:
    Jun 20, 2005
    Messages:
    4,949
    Status:
    Attending Physician
    SDN 7+ Year Member
    Why are you guys making it so difficult?

    I tell the OB to have the nurse call when the bolus is in. I don't care what the bolus is really. Then I Do a one size fits all ( sort of like a crna with a general anesthetic) bupiv 2.5 mg and Fent aprox 20mcg.
  20. bullard

    bullard Senior Member

    Joined:
    Oct 15, 2005
    Messages:
    409
    Status:
    Attending Physician
    SDN 7+ Year Member
    Agreed. I haven't done a single CSE in private practice because our OB volume is low and so there's never a rush. But in residency where we did about 12000 deliveries a year and 95% got epidurals...I had to put CSEs in everybody because by the time I got LOR on one epidural, they'd be paging me about the next one...
  21. pie944

    pie944 ASA Member

    Joined:
    Feb 4, 2009
    Messages:
    213
    Status:
    Attending Physician
    SDN 5+ Year Member
    With the 25mcg of fentanyl people frequently complain about itching while I'm finishing the charting. It's tempting to ask if it's worse than the prior discomfort? Do you think the intrathecal dose sets up high expectations? The pure fentanyl ones rarely seem to complain(re doses, etc), but the ones that get the 2.5 mg of bupivicaine + 15 mcg fentanyl end up having more complaints of pain and that 'it isn't as good as it was at first.'

    The blood pressure usually consistently drops with our full dose, people vary in threshold for treating, RN concern vs <100 SBP vs symptomatic etc.
  22. Noyac

    Noyac SDN Advisor SDN Advisor

    Joined:
    Jun 20, 2005
    Messages:
    4,949
    Status:
    Attending Physician
    SDN 7+ Year Member
    It all depends on your nursing staff.
  23. bullard

    bullard Senior Member

    Joined:
    Oct 15, 2005
    Messages:
    409
    Status:
    Attending Physician
    SDN 7+ Year Member
    Try 1.25 mg of bupivicaine with 15 mcg fentanyl.
  24. Mman

    Mman Senior Member

    Joined:
    Mar 22, 2005
    Messages:
    1,682
    Status:
    Attending Physician
    SDN 7+ Year Member
    what I dislike about CSEs is getting a patient comfy for 90 minutes with the spinal and then finding out after that the epidural catheter blows and can't keep them comfy. If I'm going to have to redo the epidural, I'd rather find out within 15 minutes than 90 minutes later when they are potentially significantly more uncomfortable and it becomes a more difficult task.

    The only time I do a CSE is if I think there is a decent chance the patient will deliver before the spinal wears off.
  25. ssmallz

    ssmallz California Dreamin

    Joined:
    Sep 25, 2008
    Messages:
    630
    Location:
    SoCal
    Status:
    Fellow [Any Field]
    SDN 5+ Year Member
    Agree completely. I usually just place my epidural, then inject the remaining 3 cc of test dose lido and add 5 cc of pump solution (usually .2% ropi w/fent or .125% bupi). I stick around for 5 minutes to finish my paperwork and by the time I'm done the pt is nice and comfy.
  26. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

    Joined:
    Nov 2, 2006
    Messages:
    4,932
    Location:
    Florida
    Status:
    Attending Physician
    SDN 7+ Year Member
    Agree with every item on the list especially the one about not wasting precious time on attempting ventilation before giving SUX.
    I am not sure why people don't understand that the ability to ventilate before sux does not mean you will be able to ventilate after SUX and also that sometimes when you cant ventilate before Sux ventilation becomes possible after Sux.
    Basically proving that you can ventilate before giving SUX does not prove anything it only wastes precious time.
  27. sevoflurane

    sevoflurane Ride

    Joined:
    Jul 16, 2003
    Messages:
    3,426
    Status:
    Attending Physician
    SDN 10+ Year Member
    Exactly plank. Especially that last part.

    To be honest... I hardly ever test ventilation... and in most cases I give the ROC and the Propofol in the same syringe... but only if they have a narcotic load upfront + some lido as ROC also burns.

    For me, it's prop/roc or prop/sux then tube w/o testing for ventilaiton OR Awake fiberoptic/glidescope/DL or mask induction.

    As mentined... ventilation more often than not improves after muscle relaxation.

    Of course there are the head and neck radiation cases, tracheal stenosis, mediastianal and AW masses, facial trauma, AW burns... these require critical thinking and are case dependant. Mask inductions with preservation of SV vs Prop/sux/tube vs trach vs. awake FO or the like.


    Good to see you posting jet. :thumbup:
  28. IlDestriero

    IlDestriero Ether Man

    Joined:
    Nov 24, 2007
    Messages:
    4,055
    Location:
    The ivory tower.
    Status:
    Attending Physician
    Physician Faculty SDN 5+ Year Member
    That's a good top ten, but I place my a lines with sterile technique. Chlorhex bath, sterile gloves. The drape is optional, though policy requires it. If the fellow is struggling on one side, I usually don't drape the other, maybe one drape to put the wire on. Shhh, don't tell.;)
  29. MRW

    MRW AA-C

    Joined:
    Jan 8, 2009
    Messages:
    137
    Location:
    FL
    Status:
    Non-Student
    SDN 5+ Year Member
    How are you dosing the Roc, .6mg/kg or 1.2mg/kg?

    In the surgery center for shorter cases, we often use a small dose of Roc and mask the patient down with Sevo for ~90 seconds. Clearly ventilation is tested that way, but your points regarding not testing ventilation are well made.

    At what point do you typically tape the eyes? The corneal abrasion thread had me wondering what common practice is elsewhere as I will not even mask the patient until their eyes are taped (urgent circumstances excepted)...
  30. sevoflurane

    sevoflurane Ride

    Joined:
    Jul 16, 2003
    Messages:
    3,426
    Status:
    Attending Physician
    SDN 10+ Year Member
    You are not testing ventilation if u already gave the paralytic. Mask inductions are fine, but prop inductions are more predictable, nicer and faster for adults. Kids are by far the exception.
    My roc dose depends on the case. Spine case gets full dose and then some. Lap chole = much smaller, but also depends on comorbid conditions and age. I tape the eyes after the tube is in. I've never had a corneal abrasion.
  31. MRW

    MRW AA-C

    Joined:
    Jan 8, 2009
    Messages:
    137
    Location:
    FL
    Status:
    Non-Student
    SDN 5+ Year Member
    We do propofol inductions, we just mask with Sevo while the small dose of roc takes effect which is ~90 seconds
  32. sevoflurane

    sevoflurane Ride

    Joined:
    Jul 16, 2003
    Messages:
    3,426
    Status:
    Attending Physician
    SDN 10+ Year Member
    You describe a standard induction. If you are going with a smaller dose of roc, turning on the sevo while the paralytic takes effect is wise as it takes longer to get adequate relaxation. (bigger dose of propofol +/- fent accomplishes the same thing).

    You get negative style points if the patient bucks or gags during laryngoscopy. ;)
  33. Bertelman

    Bertelman Maverick!

    Joined:
    Feb 11, 2006
    Messages:
    4,213
    Location:
    Had a Cooch
    Status:
    Attending Physician
    SDN 7+ Year Member
    Right after I push the drugs. But not because I care about abrasions with a mask. Mostly because otherwise I will sometimes forget. Plus I've got plenty of time to do so while the relaxant takes effect.

    And I probably used to do it to piss my attendings off just a little bit, like "Here I am taping the eyes shut- don't worry I'll mask 'em in just a second!"
  34. pie944

    pie944 ASA Member

    Joined:
    Feb 4, 2009
    Messages:
    213
    Status:
    Attending Physician
    SDN 5+ Year Member
    You guys do MEPs at all? Or even with your larger doses is it absent by the time you go prone/prep/etc?
  35. sevoflurane

    sevoflurane Ride

    Joined:
    Jul 16, 2003
    Messages:
    3,426
    Status:
    Attending Physician
    SDN 10+ Year Member
    Some of our surgeons do. The surgeon I worked with today during a five level percutaneous fusion uses mep's/ssep's 40% of the time. Another one uses it 100% of the time. Always on scoliosis cases.
  36. pie944

    pie944 ASA Member

    Joined:
    Feb 4, 2009
    Messages:
    213
    Status:
    Attending Physician
    SDN 5+ Year Member

    In terms of the intrathecal(opioid vs LA/opioid) based on source of pain, visceral vs somatic pain, and the rate of progression thru the visceral component into the somatic.

    In terms of the co-loading...I thought one thing but because of your points I started looking into it and now am not so sure...so thank you.
  37. urge

    urge

    Joined:
    Jun 23, 2007
    Messages:
    1,968
    Status:
    Attending Physician
    SDN 7+ Year Member
    I'm curious about the physiologic basis for this one. Too much vagal stimulation coming off bypass?
  38. RocurWorld

    RocurWorld

    Joined:
    Jul 10, 2010
    Messages:
    81
    Status:
    Resident [Any Field]
    SDN 2+ Year Member
    I havent decided yet if I like CSE vs epidural for labor better yet. We rotate through 2 hospitals, one everyone gets an epidural only, the other, CSE for all. The nurse calls after the pt has received a fluid bolus. Every pt gets 1mg of bupivicaine + 15mcg fentanyl. As a resident, i like the CSE because it sometimes confirms im in the right space. Occasionally i get a not so great loss, and if my spinal needle returns csf, im more confident im the right space, and if it doesnt...ill likely replace the touhy. On the other hand, like it was said above, it might take 90 minutes before i realize my catheter isnt working. And they are heading back for a section. blergh.
  39. jetproppilot

    jetproppilot Turboprop Driver

    Joined:
    Mar 12, 2005
    Messages:
    5,831
    Location:
    level at FL210
    SDN 7+ Year Member
    Great

    to see such interest!

    We've got a lot to talk about.

    I encourage all pre meds, med students, residents, attendings:


    Let it out man.

    There's soooooooooo many
    VOYEURS OUT THERE
    dudes.
    Chime in.
    I wanna hear from the
    Scared med students
    the
    Humble residents
    the
    Quiet Attendings
    out there
    I've quoted some s h it I've learned over the last sixteen years of my private practice life.

    Here's the thing:

    ITS OK TO LIKE OR DISLIKE

    A.K.A. tell Jet to go €#€k himself


    It's

    all ok man.

    Here's what I've learned:

    I've learned that anesthesiology is a practice of medicine where you can do

    ONE THING

    Several different ways so it is


    IMPORTANT TO LISTEN TO EVERY BODY ELSE.

    That includes

    You, Slim.

    Show me whatcha got. :D
  40. jetproppilot

    jetproppilot Turboprop Driver

    Joined:
    Mar 12, 2005
    Messages:
    5,831
    Location:
    level at FL210
    SDN 7+ Year Member
    No man. I'm talking about
    WAYYYyYYYYY ahead of pacing
    I'm suggesting that aggressive atropine use in the presence of bradyarrythmia
    during that immediate moment can


    Make pacing unneeded.

    2mg.

    Atropine.

    Seriously.

    Try it next time during separation where you see bradycardia

    Slam in 2mg atropine and wait a cuppla minutes.

    You can always pace.

    I'm suggesting that atropine at the right time can make pacing unnecessary.
  41. urge

    urge

    Joined:
    Jun 23, 2007
    Messages:
    1,968
    Status:
    Attending Physician
    SDN 7+ Year Member
    Is pacing a bad thing?
  42. jetproppilot

    jetproppilot Turboprop Driver

    Joined:
    Mar 12, 2005
    Messages:
    5,831
    Location:
    level at FL210
    SDN 7+ Year Member
    Indeed not.

    If you come off pacing, tho, and it doesn't work, where do you go?

    You go back on bypass.

    You have no safety net.

    That's why I'm suggesting exhausting your pharmacologic armamentarium before pacing.

    Because you are leaving yourself a safety net.

    If you're able to separate from bypass without pacing,

    you've got another weapon in your holster if things go awry.

    Being ahead of the game pays dividends.

    Use everything you know when doing a difficult case.

    I've done the Atropine trick many times, dudes.

    I wouldn't suggest it if it didn't work.

    Volume coming in, venous line clamped, bradycardia,

    BOOM.

    Atropine 2mg.

    A lotta times pacing unneeded.

    I don't have time to make a randomized double blinded study.
    Last edited: Apr 25, 2012
  43. Nooblet

    Nooblet

    Joined:
    Aug 1, 2007
    Messages:
    347
    Status:
    Resident [Any Field]
    SDN 5+ Year Member
    Cool thanks for these teaching points -

    Can you guys explain why giving sux doesn't make ventilating easier? It just seems to me that once sux is given and all the muscles are relaxed, resistance to ventilation is now lower. So it would logically follow that if you are able to ventilate them when they aren't paralyzed yet, you should definitely be able to afterwards
  44. doctor712

    doctor712

    Joined:
    Nov 14, 2008
    Messages:
    1,871
    SDN 2+ Year Member
    I hope an attending will follow up this post to correct my errors and omissions, but in the spirit of Jet mentioning pre-meds and med students do some thinking here as well...I'll take a stab here based upon reading everyone's prior sux posts on SDN and time having my ears open in the OR...

    Nooblet, I don't think anyone said that sux doesn't make ventilating easier per se. I think the (I said I think twice so I know I'm outta my league but still, I think, I can answer this. 3X) idea is that testing ventilation without sux is not necessary/time wasting etc. I think (4x) what's being argued here is, "Why test ventilation prior to giving a muscle relaxant, when, if you cannot easily ventilate, you are going to use a muscle relaxant anyway...so why not a) give the muscle relaxant and NOW see where things stand, or, don't, find out that you cannot ventilate without it, and then give it." Point is, somewhere along the line you may use sux, so, what use carrying out an experiment that is really not giving you any pertinent information?

    I think it is safe to say (for me at least, and I stopped counting I thinks) that sux will make the patient easier to ventilate. It's kind of the whole point why you wouldn't test ventilate prior to its use.

    In other words, scenario 1: patient induced, you mask ventilate, it's not happening...(I imagine the algorithm brings you to) using a muscle relaxant. So what was the point of testing before sux? You're here now anyway... Testing ventilation without sux is a test to see if you can do something without all the ingredients of what you will ultimately use in case you fail (your test). scenario two: you mask ventilate after using sux/roc, ventilation not happening so, a) TOTAL GUESS - you give more sux to make sure they are fully relaxed? b) instead of using sux in the first place you used (past tense) a non-depolarizing relaxant so you reverse and back out, but why would you do that because you want to facilitate ventilation, with nice relaxed muscles, preferably muscles that weren't relaxed by hypoxia, so TOTAL GUESS, can you give sux after Roc? (If not actually, patient is still relaxed, so, we're theoretically where sux would get us). All of the above get you to: having used sux, which I think is the quickest, most effective paralytic (as it's used in RSI). So why test without it, if, should the HITSAY hit the ANFAY, you're going to use it anyway?

    I don't know if I thought through this out loud well enough, so I do hope an Attending will follow up with what I'm missing! :thumb up:

    Applying flame retardant as we speak...

    D712
  45. DrN2O

    DrN2O

    Joined:
    Sep 17, 2007
    Messages:
    159
    Status:
    Fellow [Any Field]
    SDN 5+ Year Member
    CSE is my default. Maybe I'm in minority, but I am MORE CONFIDENT about an epidural with CSE than without. The only thing better than LOR to confirm epidural space is to advance a spinal needle through the tuhoy and get CSF back. The spinal will have kicked in by the time you taped in the catheter and laid the patient back down. A study out of Brigham showed dural puncture (without drugs) results in more symmetric block and better sacral spread of epidural analgesia. As for "spoiling" the patient with the spinal, it's all about setting reasonable expectation. I tell all of them that after the more dense block wears off, they are going to feel more, but that doesn't mean something is wrong. They just need to be checked and most likely the baby is coming soon.

    A randomized trial of dural puncture epidural technique compared with the standard epidural technique for labor analgesia.

    Cappiello E, O'Rourke N, Segal S, Tsen LC.
    Source

    Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.

    Abstract

    BACKGROUND:

    We designed this prospective, double-blind, randomized study to examine whether a dural puncture without intrathecal drug administration immediately before epidural drug administration would improve labor analgesia when compared to a traditional epidural technique without prior dural puncture.
    METHODS:

    Eighty nulliparous parturients with cervical dilation less than 5 cm were randomly assigned to receive a standardized epidural technique, with or without a single dural puncture with a 25-gauge (G) Whitacre spinal needle. After successful placement of the needle(s) and the epidural catheter, 12 mL of bupivacaine 2.5 mg/mL was administered through the epidural catheter and a patient-controlled epidural infusion of bupivacaine 1.25 mg/mL + fentanyl 2 mug/mL was initiated. The presence of sacral analgesia (S1) and pain scores were compared between groups.
    RESULTS:

    In demographically similar groups, parturients with prior dural puncture had more frequent blockade of the S1 dermatome (absolute risk difference [95% confidence interval] 22% [6-39]), more frequent visual analog scale scores <10/100 at 20 min (absolute risk difference 20% [1-38]), and reduced one-sided analgesia (absolute risk difference [95% CI] 17% [2-330]). The highest median sensory level (T10) was no different between groups.
    CONCLUSIONS:

    Dural puncture with a 25-G spinal needle immediately before the initiation of epidural analgesia improves the sacral spread, onset, and bilateral pain relief produced by analgesic concentrations of bupivacaine with fentanyl in laboring nulliparous patients.
  46. RocurWorld

    RocurWorld

    Joined:
    Jul 10, 2010
    Messages:
    81
    Status:
    Resident [Any Field]
    SDN 2+ Year Member
    So in my previous post i agreed with you. However, i just placed a CSE. I used LOR with saline, got a fantastic loss. Placed my spinal needle, no pop, no CSF. So now, rather than making me feel confident, i am unconfident (is that a word?). So I ended up advancing the touhy like 3/4 of a centimeter, and then i finally got csf. but it made me uneasy! Anyways, now i am concerned it went intravascular. Aspiration was negative, but we dont give a test dose with our CSE's. I guess ill find out soon enough. blergh.
  47. WholeLottaGame7

    WholeLottaGame7

    Joined:
    Jul 10, 2005
    Messages:
    1,291
    Location:
    Right here.
    Status:
    Fellow [Any Field]
    SDN 7+ Year Member
    There's a good diagram in Chestnut that illustrates reasons you might not get CSF even with good loss, one of which being the spinal needle isn't long enough to reach the dura or just dents the dura.

    Another alternative being you're at an angle and you're sliding the needle past the CSF, which I think had happen to me on a particularly difficult CSE.

    On the flip side, if you do get CSF, I do feel like that's pretty good reinforcement that the Tuohy's in the epidural space.
  48. Bertelman

    Bertelman Maverick!

    Joined:
    Feb 11, 2006
    Messages:
    4,213
    Location:
    Had a Cooch
    Status:
    Attending Physician
    SDN 7+ Year Member
    Why are you giving such a large dose of atropine? That's double the code dose. You ever get a brisk response >100?

    Also, you have any thoughts on what you're treating? I'm concerned that acute bradycardia immediately after separation may be from air down the RCA.

    I'm all for trying out various techniques to get me to the ICU, but if we have an issue coming off pump, I want to make sure that pacer is working. If it's not, you've got to troubleshoot that, especially if the patient has demonstrated a tendency to brady down. Atropine or not, you gotta get that **** working.

    You ever use ephedrine coming off?
  49. dr doze

    dr doze Neocon Gold Donor

    Joined:
    Dec 6, 2006
    Messages:
    2,295
    Status:
    Attending Physician
    SDN 7+ Year Member
    I am also going to come down against the CSE for labor.

    While I agree that the analgesia from a standard labor epidural is second best as compared to a CSE. An ("A" grade versus "A+"). As someone who supervises residents and CRNAs who place these catheters. (I would add that we typically supervise 3-4 rooms). I have seen more than one patient get comfortable with the intrathecal injection. Never activate the epidural catheter. Roll back for a STAT C-sec only to find out that the epidural s*cked. Two times on a challenging airway that we struggled on. I have since modified my belief on why epidural catheters get placed in my practice:
    Providing outstanding labor analgesia as opposed to very good labor analgesia is a secondary priority compared to making certain that I have a quick, reliable method of administering regional anesthesia for a Csec. If I placed all the catheters myself or only supervised very experienced CRNAs that I have complete confidence in, my opinion would probably be different.
  50. BLADEMDA

    BLADEMDA SDN Gold Donor Gold Donor

    Joined:
    Apr 22, 2007
    Messages:
    11,397
    Location:
    Southeast
    Status:
    Attending Physician
    SDN 7+ Year Member
    I've done them both ways. CSE or standard. Yes, the CSE is faster but in my hands it works out to about 3-4 minutes longer for a standard Epidural and I don't nick the dura.
    By the time I finish the paperwork and leave the room the patient is comfortable plus I know the Epidural is fully functional.

    The CSE is a great technique and it may even improve the quality of the Epidural block itself; but, I still prefer my old fashioned standard epidural where I avoid puncturing the dura.

Share This Page


About the ads