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Jet's TOP TEN

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

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  1. pgg

    pgg Laugh at me, will they? Moderator

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    Interesting perspective - not sure what I'll do if I end up at a place with residents in a few years. I spent some time at Brigham (where the above study was done) as a guest resident doing OB only, and they were big believers in CSEs, especially for residents just learning how to place epidurals. Part of the rationale was that inexperienced hands would be fooled less often by an equivocal LOR, and get fewer 17 ga wet taps, if they could pop a spinal needle through the and "probe ahead" a little. They felt, on the whole, that newbies got better and more reliable epidurals with the CSE technique.

    Presently I don't supervise/direct CRNAs and there are no residents around. Easier to have faith in a catheter I've placed than some unknown.
  2. Mman

    Mman Senior Member

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    Completely agree. While I tell patients the risk of PDPH is the same, I think you have to be at least a little less likely to get a HA if you never make a hole in the dura. And knowing that the epidural is working well is my main priority. With a CSE, you never know until the spinal is gone. And I've had to replace plenty of epidurals from my colleagues that do CSEs despite their claims that their epidurals always work after they get CSF (and they've been doing them for 20+ years so inexperience isn't a factor).
  3. sevoflurane

    sevoflurane Ride

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    I'm with you guys... I often get my OB patients complaining of little, if any, pain after a straight epidural. Bolus test dose, give some left over lido and 100mcgs of fentanyl... and I've got a COMFY epidural patient by the time I'm out the door.

    One thing is for sure though... the ones coming in dilated at 7-9cm or the 15 y/o that is in "excruciating pain" or the mentally challanged patients that somehow got pregnant.... they get a CSE every single time.

    For residents and med students out there:

    A CSE tuohy needle is a GREAT choice to get CSF in the difficult spinals either cuz they have scoliosis, are too fat, have calcified ligaments or a diagnosis of ankylosing spondylitis or any other condition that makes placement of a spinal difficult with the little introducer that comes in the spinal kit.

    Using the tuohy gives you a lot more feedback. It makes spinals easy in an otherwise challenging intrathecal anesthetic.

    Had a 22 y/o severely mentally retarded get pregnant some time ago. You could hear the screams from outside of the hospital. She got a CSE and calmed down within a minute. A little crazy... but yeah... it worked great.

    [​IMG]
  4. Bertelman

    Bertelman Maverick!

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    Only did a few CSEs in residency, but I've done it for the above. Totally worth it.
  5. Substance

    Substance

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    Severely mentally retarded pregnant girl? That's fishy.
  6. Mman

    Mman Senior Member

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    and unfortunately all too common
  7. dhb

    dhb Member Lifetime Donor

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    I am truly amazed by the doses you guys use for your epidurals and CSE, i feel like i'm giving bigger and bigger doses with unsatisfactory results.
    Even with 5mg bupivacaine + 5 sufenta i don't get 100% good results for CSE
    For strait epidurals i've been giving 15cc of 1.5% lido with mixed results :shrug:
  8. Mman

    Mman Senior Member

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    Loading with lidocaine for the epidural? Big no no in my book. When it wears off and they no longer have a surgical anesthetic level they are almost guaranteed to be unhappy. I load with 0.25% bupivicaine. 5-10 mls is usually all it takes to give them pain relief within 10-15 minutes.
  9. sevoflurane

    sevoflurane Ride

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    Tachyphylaxis with lidocaine is commonly described.

    2-3 cc's after test dose + some fentanyl will give you a good idea of how your epidural is working. Loading up with 15cc's of lido (usually 2%) is for the emergent C/S that has a working epidural.

    I wouldn't use it to load up an epidural I just placed. .2% rop with fentanyl is our cocktail... and it works great.
  10. sevoflurane

    sevoflurane Ride

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    Typically start it @ 10-12 cc's/hr. Up to 16cc's/hr. The fent, test dose and 3cc's of lido left over from my skin weal keeps 'em happy until I get to steady state with my rop infusion.
  11. IlDestriero

    IlDestriero Ether Man

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    When I did CSEs for everyone, I would give 2.75Mg bupi with 15 or 20mcg fentanyl and 100mcg epi. Worked every time, and quickly. I cautioned them up front that the initial relief would be more than with the epidural. They didn't complain.;) I don't do them anymore, but my patient population is unusual. Now I just want a functional epidural every time with no surprises. I dose it with 12-15 cc of 0.2% Ropiv. And start the pcea. It also works fine, but it takes a little while to get them comfortable.

    Cheers!
  12. dhb

    dhb Member Lifetime Donor

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    I know this is waht you all do but in my experience it has been insufficient.
  13. dr doze

    dr doze Neocon Gold Donor

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    This makes sense if the issue is correctly identifying the epidural space. This is but one reason for failed epidurals. Another slightly less common reason is that inexperienced personnel often thread these catheters too far, achieving a single sided block. THis doesn't get identified unless you activate the catheter.
  14. DrN2O

    DrN2O

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    Not getting CSF with spinal after a LOR happens. If LOR was "fantastic" and was difficult to get, I would just tread the epidural catheter, assuming I'm off midline and chance the block will be a little asymmetric. If LOR was iffy, or the distance or angle felt weird, I would come out and redo the LOR. I would not advance the tuhoy anymore after loss.

    I know some people don't do test doses for CSE or even plain epidural, but I do. The 2.5mg of bupiv is not going to give you a complete motor block and the intravascular test is still valid. Just because "we don't do" something routinely, doesn't mean it "can't be done" for special situations.
  15. behindthadeuce

    behindthadeuce Junior Member

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    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.

    Jet-

    Respect your opinion and love your contributions, as always.

    Although I actually agree with you that etomidate isn't necessarily REQUIRED as an induction agent in any circumstance, your above comment has severely undersimplified the data regarding this issue.

    Etomidate has been shown to increase mortality in critically ill patients (retrospectively, keep in mind)...and when patients in septic shock are removed from analysis, there is actually no difference in mortality.

    So...a critically ill trauma patient who is bleeding out in the ED would not appear to have an increased mortality rate if etomidate were used to induce anesthesia.

    Deuce :thumbup:
  16. amyl

    amyl ASA Member

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    regarding cse... nurses here know to fluid bolus them when they call us. our obgyns also typically order a dose of nubain for pain when they start getting uncomfortable... which is nice 'cause with it on board i haven't seen any itching w 25mcg IT fentanyl.
    i always set up expectations that they are gonna get a deep block and the second phase, that will allow them to push, wont be the same level of relief. after the spinal i tell them, this is as good as its going to get so i suggest tv off, family quiet and let her take a nap.... usually by the time they wake up, its time to push.... a nap makes a less bit--y mom later -- makes everyone happy.
    most women that have had both prefer the CSE.... and thats a pretty good arguement for it.
    -- agreed w use too much etomidate, agreed no vent before sux....
    thanks jet -- good input as always
  17. countingdays

    countingdays SDN Bronze Donor Bronze Donor

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    Nobody else likes bolusing through the Tuohy then infusing through the catheter? Kinda like a single shot epidural followed immediately by a continuous epidural without the need to place the needle twice. Kinda like a cse without the need to puncture the dura?
    I know it isn't popular these days, but it works well and works fast with no pdph and no wasting time wasting narcotics and no itching.
    I know, I know...
  18. Magoun

    Magoun

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    We have one attending who routinely doses 15 cc's through the needle -- and it's the Cadillac of epidurals. Patients are very happy. For whatever reason, this attending doesn't have a lot of failed catheters, even though they are untested. (Maybe the large volume increases the likelihood that the catheter will stay midline?) Although, one of my buddies had the pleasure of a babysitting a high spinal in the OR after doing this...

    I'm a big fan of just local through the catheter. I want to know it works, and they are comfortable before I've left the room. I'll do a CSE for the screaming early nullip (usually a teen) or the 8cm multip, but otherwise give me a tested catheter, please.
  19. Sonny Crocket

    Sonny Crocket ASA Member

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    What about testing a level after a spinal for c section. I think this is usually not needed. I mean monitors, prep, spinal, lie the patient down, hypotension, nausea, guess what? Your spinal is working!
  20. Noyac

    Noyac SDN Advisor SDN Advisor

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    Can I add #11

    You don't need to apply the monitors and get a set of vitals before placing a spinal ( unless of course you have no idea what the vitals are). I can see putting a pulse of on a little old lady your gonna sedate bc of a broken hip.
  21. h2oriderz

    h2oriderz ASA Member

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    I'm a big fan of starting a phenylephrine gtt immediately after a spinal for C/S -- avoiding the hypotension and nausea makes the overall experience more pleasant. It only takes a second to check the level.
  22. AirBubble

    AirBubble

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    The benefit of checking a level is that you can control the level assuming you are using a hyperbaric local anesthetic solution. Place the patient in trendelenburg if the level is too low for surgical anesthesia or reverse trendelenburg if it is spreading too high too quickly. Checking a level may be unnecessary most of the time if an appropriate dose of local anesthesia is administered but I've been surprised.
  23. fakin' the funk

    fakin' the funk CA-2

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    I do like labor CSE's, but like everything else, you gotta select your patients when you do it.

    For me this is ladies with impeding delivery, or ones in extreme pain, or ones where you really wanna know your Tuohy's in the right spot (equivocal loss, giant fatty).

    Fentanyl alone raises the risk of fetal bradycardia independent of BP...and no one likes fetal bradycardia.

    Bupiv only might make 'em hypotensive...and no one likes hypotension.

    I like a combination of around 1.25mg bupiv and 10-15mcg fentanyl as others have said.
  24. fakin' the funk

    fakin' the funk CA-2

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    Seems like total overkill. I'm all for being proactive right after spinal for C/S but usually by the time you lay 'em down, maybe 1-2 doses phenylephrine/ephedine, and polish off a liter or so, they're fine.

    Nausea -- you should be prophylactically giving ondansetron preop.
  25. fakin' the funk

    fakin' the funk CA-2

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    This is a fantastic idea.
  26. dhb

    dhb Member Lifetime Donor

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  27. Mman

    Mman Senior Member

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    might be overkill, but babies have better blood gases when mom is started on a phenylephrine infusion after placement of the spinal compared to bolus doses. I'm all for better fetal outcomes.
  28. Bertelman

    Bertelman Maverick!

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    So you're all for better blood gases, or better fetal outcomes?
  29. IlDestriero

    IlDestriero Ether Man

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    Statistically significant differences are not the same as clinically significant differences.

    Cheers!
  30. Noyac

    Noyac SDN Advisor SDN Advisor

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    I just squirt a 10cc syringe of neo in the liter of LR and place the spinal. Then open the puppy up all the way. No nausea, no hypotension, all is good, usually.
  31. Mman

    Mman Senior Member

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    For something with a risk of 0, a cost difference of 0, and a potential benefit to the baby of anything (as small as you can imagine) and a benefit of less nausea to mom, the risk/benefit analysis is clearly on the side of using the infusion.

    Unless our getting to be lazy is a consideration.
  32. Bertelman

    Bertelman Maverick!

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    You call it lazy, I call it only doing what is indicated for the patient. And I think your assertions are misleading. It actually does cost something, and some of that is passed on to the patient. They are charged for the drug, charged for the pump.

    And I'm not sure you can make a claim that your infusion is any different than timely boluses, or that it provides any measurable clinical difference in outcomes. And there are at least ten other things we could be doing that might provide some small benefit to 1:10000 patients, but you aren't doing all of those.
  33. Mman

    Mman Senior Member

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    I'm too lazy to link it, but there are several fairly good studies (if small) that show measurable improvements in maternal outcomes like nausea/vomiting. And the patient gets charged nothing for the pump. It's already in the room. And they are already getting charged for the phenylephrine whether you give it as boluses or as an infusion. The cost should be the same.

    So it's the same cost and an actual benefit. You do the math.
  34. fakin' the funk

    fakin' the funk CA-2

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    I think this (simple, titratable, one step) but isn't 1mg of phenylephrine over 10-15 minutes too much? How about 500mcg instead?
  35. fakin' the funk

    fakin' the funk CA-2

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    My take is this is a setting with a patient population group at very, very high risk of perioperative N/V and you have an opportunity to give a very effective low-risk antiemetic prophylactically. So, I do it.
  36. Noyac

    Noyac SDN Advisor SDN Advisor

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    Usually start turning it down about 500cc into the bag or so. But all need to do is turn the IV up or down as needed according to BP.

    The single best way to avoid nausea is controlling the BP. This method for me is the easiest and best one I've come up with. It's faster than setting up a pump and faster than changing the rate on the pump. And the BP is much more steady and consistent when compared to boluses.
  37. epidural man

    epidural man ASA Member

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    There is more than just data in septic patients.

    Adrenal supression is a real thing...and plenty of data to show that it happens with single dose - in normal people.

    The point is...is hemodynamically compromised patients (the ones you would use etomidate on anyway), etomidate actually has shown to have MORE hypotension than in propofol patients. Also, in that same vein, in really critically ill patients, even if you give NOTHING, the act laryngoscopy causes hypotension in a significant number of patients.

    Given this - why in the hell would anyone ever use that crappy drug?

    I hate it. Everytime I get talked into using it (by a resident), the patient has a pressure of 220/120, plus they are twitching all over the place from myoclonus.
  38. pgg

    pgg Laugh at me, will they? Moderator

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    This was an interesting thread http://forums.studentdoctor.net/showthread.php?t=850129

    I pretreat all my c-section spinals with Zofran.

    Think I'm going to try Noyac's phenylephrine-spiked LR technique a few times too.
  39. drccw

    drccw

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    I go with 300 mcg of phenylephrine and 20 mg of ephedrine in a liter of LR before spinal placement. Everyone also gets a dose of metoclopramide and odansetron (the only setting I use metoclopramide). Some say it's a lot of work.. I say it beats dealing with puke (which is my goal...)

    drccw
  40. epidural man

    epidural man ASA Member

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    Nice list.


    Here is a cool editorial (too bit go attach) that discusses some of the dogma you mention as well as some others. I especially like the dogma about keeping CO2 on the lowish side, and intubating/extubating with 100%. Cool discusion I think.
    http://www.ncbi.nlm.nih.gov/pubmed?... and Shibboleths: Barriers to Patient Safety?

    Attached are two articles that show evidence against your #1 point. I think the dogma here is that a-lines DONT get infected. They apparently do, and at a similar rate as CVC's. I think the take home message is to use a chlorhexadine patch ($4) if you think the a-line will stay in longer than a day or two.

    Actually, i guess your point is you don't put them in sterile conditions. I guess I don't either, so in that sense, I agree with you.

    (My ICU bro gave me the a-line articles - thanks bro).

    Attached Files:

  41. Mman

    Mman Senior Member

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    I would bet there is a stronger correlation between the rates of blood stream infections from arterial lines and peripheral IVs than there is correlation between central lines and arterial lines.

    For infectious purposes, an arterial line is the exact same thing as a peripheral IV. In fact it's probably even less because IVs are carrying lots of fluids to inside the patient. Arterial lines don't have a fluid carrying potential pathogens into the body aside from the very low rate of flush from the pressure bag.
  42. Bertelman

    Bertelman Maverick!

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    For something with a risk of 0, a cost difference of 0, and a potential benefit to the patient of anything (as small as you can imagine) and a benefit of less infection to the patient, the risk/benefit analysis is clearly on the side of using a sterile field.

    Unless our getting to be lazy is a consideration.
  43. Mman

    Mman Senior Member

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    Do you work in a magical land where they give out sterile drapes for free? I know I don't. Our "kits" that have the hole 9 yards for an arterial line including a drape cost roughly 10x the amount of grabbing an individual chloraprep and an individual arrow catheter, and the patient gets charged an even higher amount for it.
  44. Bertelman

    Bertelman Maverick!

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    No, I live in a land where OB patients don't come to the OR with a pump, and to get one requires time. My land comes with ready access to sterile towels, however. And there is no difference in charge to the patient based on the kit used, whether it is the arrow or just a simple 20 g catheter.

    Back to my original point, before you call others lazy, understand we all work in different situations, and what seems so simple and cost-effective to you may not be so in another practice environment. I had ready access to phenylephrine syringes galore, but drips were harder to come by. Our OB suites were a block away from the main hospital and pharmacy, far enough for it to be a hassle to arrange some of these things.
  45. jetproppilot

    jetproppilot Turboprop Driver

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    Great comments and interaction on this thread, dudes.

    Not convinced there's a right way to do most things in our business.

    I've got my way, you've got yours.

    In the end, if it works and our outcomes are good,

    it's all good man.


    It's fun and educational to see everyone's spin on how others perform our profession.

    Plus I love debates.:D

    Nicely done.

    :thumbup::thumbup:
  46. Noyac

    Noyac SDN Advisor SDN Advisor

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    Thanks Coach!
  47. jetproppilot

    jetproppilot Turboprop Driver

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    hahahahahahahahahahahahaha
    Last edited: May 6, 2012
  48. Mman

    Mman Senior Member

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    we just stick our syringe of phenylephrine on a syringe pump that is in every OR (alaris pumps with both IV tubing or syringe pump setups). And maybe you should reread my post. I didn't call anybody else lazy. I said we. As in all of us. And I was trying to point out that it shouldn't be a consideration for any of us.
  49. h2oriderz

    h2oriderz ASA Member

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    Not really overkill, a simple 20cc syringe and a syringe pump is pretty easy to put together. Prophylactic Zofran won't do a whole lot when the nausea is a result of the hypotension from the spinal.
  50. Ignatius J

    Ignatius J

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    I just start up the fluids when I start cleaning the back. Pop it in. Inject slowly. Lay down. Hit 'em with a cc or two of phenylephrine and we're off to the races. There's more than one way to skin a cat, but that seems like just one more thing to set up and put together. Plus not all my spinals blood pressures behave nearly the same way. Some barely have a noticeable drop, some plummet. I don't feel like titrating a vasopressor while starting the case up. I do the KISS method.

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