Another Typical Night On Call

[jetproppilot]

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Last night was pretty typical.

Finished up around 9pm, went home.

Called for labor epidural at 0030. On the way to the hospital, girlfriend calls and says shes on the way in to to a lap appy.

Throw the CSE in. Another satisfied preggo customer.

Start Hotties case at 0124.....she TURNS AND BURNS....

skin-to-skin 19 minutes.😱

We get back home around 0240.

Labor epidural call at 0330.

Ya gotta hate it when the epidurals are spaced out just right to ruin your night, huh? i think its a newborn conspiracy....

This time I just stay at the hospital and catch a few Zs in wanna the recliners in the doctors lounge.

Help with a cuppla 0730 starts.

Walk outta the hospital at 0800.

I've been screwing off all day....tooka nap, did some laundry.

Girlfriend still doing office even though she was up in the middla night last night......she gets a little NIMBLY BIMBLY watching me walk outta the hospital post call while she heads to her office to see thirty-some-odd patients....

Don't hate the player, Honey. Hate the game.😀

 

[Gardner]

Jet, it is common in the gas business to get post-call day off? Or is this a practice-by-practice arrangement that is widely variable?

 

[fakin' the funk]

Called for labor epidural at 0030.

Throw the CSE in. Another satisfied preggo customer.

Why a CSE for labor?

 

[jetproppilot]

Jet, it is common in the gas business to get post-call day off? Or is this a practice-by-practice arrangement that is widely variable?

Kinda variable, Gardner.

Alotta places you dont have to come in post call, and I'd say most of the other places, if you do have to come in post call its just for an hour or two.

Of course there are practices that are trying to absolutely-maximize their income in which case the partners may elect to run the biz a haffa-man to a full-man short which results in post-call day work but more money-per-partner.

 

[jetproppilot]

Why a CSE for labor?

1)very quick onset

2)almost zero chance of high spinal since you don't dose the epidural catheter after the spinal dose (currently I use 2.5mg bupivicaine/25ug fentanyl)...ya just hook up the infusion

3)no increase in post dural puncture headache incidence

4)very uncommon to haffta give ephedrine since the small intrathecal local-anesthetic dose doesnt cause much hemodynamic drop

5)saves me about 15 minutes

 

[videolectures]

Was also on call lastnight.

Had a surgeon shopping in the ER for B.S I&D cases to bring to the O.R till 12:30 am.

Then after that, I had to manage a 31 y.o female in the PACU with an unfortunate IUFD due to placenta abruptio oozing during her STAT C/S now presenting with DIC. Get Heme consult and begin the infusion ( 4 PRBC, 4 FFP, 10 units Cryo, 1 unit single donor platelets)

Get MICU consult..patient gets accepted...patient "about" to be transferred. Then the OB attending covering the service refuses to send her to "MICU" but would allow SICU or PACU management.

sidenote: SICU intern was prob not experienced enough to cover this patient without proper senior supervision (who was covering trauma)

Battle between anesthesia attending and OB attending. Our chair as called in middle of the night along with hospital administrator.

was an interesting political call night

 

[jetproppilot]

Was also on call lastnight.

Had a surgeon shopping in the ER for B.S I&D cases to bring to the O.R till 12:30 am.

Then after that, I had to manage a 31 y.o female in the PACU with an unfortunate IUFD due to placenta abruptio oozing during her STAT C/S now presenting with DIC. Get Heme consult and begin the infusion ( 4 PRBC, 4 FFP, 10 units Cryo, 1 unit single donor platelets)

Get MICU consult..patient gets accepted...patient "about" to be transferred. Then the OB attending covering the service refuses to send her to "MICU" but would allow SICU or PACU management.

sidenote: SICU intern was prob not experienced enough to cover this patient without proper senior supervision (who was covering trauma)

Battle between anesthesia attending and OB attending. Our chair as called in middle of the night along with hospital administrator.

was an interesting political call night

OK, Dude.

You win.

Thats a pretty rough nite!

 

[camkiss]

Sunday call. New attending in PP. Go in @ 7am and do pain rounds on 6 patients. All tucked in nicely. Fart around on the internet reading the "status of this forum" debate unfold. Enjoy it tremendously. C/S @ 11am followed by labor epidural @ 1230pm. Eat lunch. Read...watch tv...nap...internet...etc. Call room at 2100 and sleep until 0430 Monday morning when they call for labor epidural. Sign out at 0645. In car by 0700. 24 hour in house call for 2 hours worth of work. Of course there are those calls when OB kills you all night. Oh well, I'll take these calls when I can get 'em.

 

[2ndyear]

Same here, Sunday call, new in PP-land. I have a CRNA until 5pm:
8 am D&C- quick & healthy, NPO, elective.
9am appy- not bad, goes quick. Place 1 labor epidural.
10am VATS- sick dude with fluid in the chest, cancelled earlier in the week for fluid overload, thrombocytopenia. Art line, double lumen. Goes fine, but I have to reintubate at the end. Whatever. But I have to do vent/med orders in the ICU...and check the x-ray for tube placement on the weekends. I never understood why it is sooo important to check that x ray after an intubated patient is brought to the ICU. I write "OK to Use ETT" in the orders just because it's dumb. I think I placed 2 labor epidurals during this case.
Get some lunch, almost send CRNA home.
1 pm, ortho calls with 3 cases, appy is added.
15 year old elbow fracture. Yawn.
90-something hip fracture. S/p MI and CABG, EF 30's. Touch of ketamine for the roll lateral and throw in an isobaric bupivacaine spinal. See a few pain patients (PCA and epidural). I'm in the room solo at 5. Make sure to have coffee beforehand.
Next up is a IM rod femur. Motorcycle accident. Big guy with a big beard, but intubated easily. Had thoughts of fiberoptic, but besides being fat he had no other real predictors of difficult intubation. Propofol sux tube. Still getting used to being totally 100% alone with marginal airways.
Appy, done by 9:30 pm. Sleep in call room.
00:30 section..failure to progress. I take my time getting there and getting the patient into the OR.
01:30 section in recovery, notice L&D board full of elective inductions of labor. On a weekend. Interesting.
03:30 epidural. Hmm...cranked up the pit all day and NOW an epidural? I'd have been happy to do it earlier. I still do get a fair amount of satisfaction from placing the catheter, bolusing, and then doing my chart. By the time I'm done they've gone from screaming to 'what contraction?' Makes the job worthwhile.
Sleep
07:00 Go to holding and help with preops. Place a thoracic epidural to help a colleague get the morning going. Offer to cover the ECT's but they don't need me.
08:00 out the door. Smell of the new BMW leather reminds me that being up most of the night is kinda worth it. Hit the couch at home. Still on the beeper until noon post call. Not called back in.

 

[bigeyedfish]

2ndyear, how do you cover OB and sit in an OR? What if there's an abruption or something?

 

[Trisomy13]

Sunday call. .. Of course there are those calls when OB kills you all night.

My Sunday call two days ago...
24 yr old for c-section for failure to progress (my favorite catch-all excuse).
New OB attending right out of residency, but usually skin-to-skin in the <40 minute range so I'm not too bummed when we start at 12:30 a.m. Nothing in the main ORs so I wander up to help the CA-1 and hang out with the attending.
Prior epidural still working well enough to get started.
Some extra tugging on the baby at delivery.
Then the bleeding. Pitocin. More bleeding. More Pitocin.
Bleeding. Bleeding.
Methergin. Bleeding. Hemabate.
Bleeding. Bleeding.
OB looks unhappy. Calls in backup from home. MFM on the way. Bleeding.
Mom having some discomfort despite the epidural being dosed repeatedly.
Fentanyl gets worked in. Along with some midazolam.
More bleeding. More Hemabate. More Methergin.
Eventually we achieve lift off with ketamine, but she still comes back to earth and feels some pain.
Leftover precedex from an earlier case is started and evens out the rest of the case, which obviously had turned into a c-hyst.

By the end of the case at 5 a.m., we have three OB attendings mucking around with what might have been an accreta vs. percreta, with the argon beam coagulator in the room (do these guys even know how to use that? i might lose my eyes), 3.5 liters EBL, a couple extra large bore IVs in the pt, some empty bags of RBCs, FFP, and Plts, and one exhausted CA-1 who was welcomed to his first 24 hr call in a most unpleasant manner. I told him that at least he saw how nasty OB can get early in the year, and to have respect for the angry uterus.

And a perfectly adequate, if not ideal, 5 hour c-hyst anesthetic on 2L nasal cannula.

 

[videolectures]

My Sunday call two days ago...
24 yr old for c-section for failure to progress (my favorite catch-all excuse).
New OB attending right out of residency, but usually skin-to-skin in the <40 minute range so I'm not too bummed when we start at 12:30 a.m. Nothing in the main ORs so I wander up to help the CA-1 and hang out with the attending.
Prior epidural still working well enough to get started.
Some extra tugging on the baby at delivery.
Then the bleeding. Pitocin. More bleeding. More Pitocin.
Bleeding. Bleeding.
Methergin. Bleeding. Hemabate.
Bleeding. Bleeding.
OB looks unhappy. Calls in backup from home. MFM on the way. Bleeding.
Mom having some discomfort despite the epidural being dosed repeatedly.
Fentanyl gets worked in. Along with some midazolam.
More bleeding. More Hemabate. More Methergin.
Eventually we achieve lift off with ketamine, but she still comes back to earth and feels some pain.
Leftover precedex from an earlier case is started and evens out the rest of the case, which obviously had turned into a c-hyst.

By the end of the case at 5 a.m., we have three OB attendings mucking around with what might have been an accreta vs. percreta, with the argon beam coagulator in the room (do these guys even know how to use that? i might lose my eyes), 3.5 liters EBL, a couple extra large bore IVs in the pt, some empty bags of RBCs, FFP, and Plts, and one exhausted CA-1 who was welcomed to his first 24 hr call in a most unpleasant manner. I told him that at least he saw how nasty OB can get early in the year, and to have respect for the angry uterus.

And a perfectly adequate, if not ideal, 5 hour c-hyst anesthetic on 2L nasal cannula.

Major hemorrhage...along with massive transfusion...vitals were stable enough not to need an A-line nor intubation? (although I know she is still considered full stomach)

Asking not from a challenge standpoint...but rather so I can learn...thanks!

 

[jwk]

Major hemorrhage...along with massive transfusion...vitals were stable enough not to need an A-line nor intubation? (although I know she is still considered full stomach)

Asking not from a challenge standpoint...but rather so I can learn...thanks!

All my fun comes in threes - actually had three accretas in two weeks in July, two planned C/Hyst, and one surprise. One of the planned ones actually flew with her epidural the whole time, the other two were epidural for the C/S, then off to sleep after some quick bonding time. None of the three got an A-Line. All got 6+ units of blood, FFP, cryo, platelets.

THE KEY - Type and cross x4-6, and at least 4 units IN THE OR before the incision. No blood, no incision. The moment you see your surgeon called the accreta correctly, call for FFP, cryo, +/- platelets.

 

[Planktonmd]

All my fun comes in threes - actually had three accretas in two weeks in July, two planned C/Hyst, and one surprise. One of the planned ones actually flew with her epidural the whole time, the other two were epidural for the C/S, then off to sleep after some quick bonding time. None of the three got an A-Line. All got 6+ units of blood, FFP, cryo, platelets.

THE KEY - Type and cross x4-6, and at least 4 units IN THE OR before the incision. No blood, no incision. The moment you see your surgeon called the accreta correctly, call for FFP, cryo, +/- platelets.

So you guys are putting epidurals and doing epidural anesthesia in patients with known placenta accreta and anticipated major blood loss and coagulolpathy?
Is epidural anesthesia OK when you are expecting major hemodynamic changes and hypovolemia?
Even in the cases where you started with epidural then put them to sleep for the hysterectomy did you wait until the epidural anesthetic resolved? what did you do with the epidural catheter when the patient got coagulopathic and required "FFP, platelets and cryo"?

 

[dfk]

My Sunday call two days ago...
24 yr old for c-section for failure to progress (my favorite catch-all excuse).
New OB attending right out of residency, but usually skin-to-skin in the <40 minute range so I'm not too bummed when we start at 12:30 a.m. Nothing in the main ORs so I wander up to help the CA-1 and hang out with the attending.
Prior epidural still working well enough to get started.
Some extra tugging on the baby at delivery.
Then the bleeding. Pitocin. More bleeding. More Pitocin.
Bleeding. Bleeding.
Methergin. Bleeding. Hemabate.
Bleeding. Bleeding.
OB looks unhappy. Calls in backup from home. MFM on the way. Bleeding.
Mom having some discomfort despite the epidural being dosed repeatedly.
Fentanyl gets worked in. Along with some midazolam.
More bleeding. More Hemabate. More Methergin.
Eventually we achieve lift off with ketamine, but she still comes back to earth and feels some pain.
Leftover precedex from an earlier case is started and evens out the rest of the case, which obviously had turned into a c-hyst.

By the end of the case at 5 a.m., we have three OB attendings mucking around with what might have been an accreta vs. percreta, with the argon beam coagulator in the room (do these guys even know how to use that? i might lose my eyes), 3.5 liters EBL, a couple extra large bore IVs in the pt, some empty bags of RBCs, FFP, and Plts, and one exhausted CA-1 who was welcomed to his first 24 hr call in a most unpleasant manner. I told him that at least he saw how nasty OB can get early in the year, and to have respect for the angry uterus.

And a perfectly adequate, if not ideal, 5 hour c-hyst anesthetic on 2L nasal cannula.

leftover precedex during hemorrhage?

 

[jwk]

So you guys are putting epidurals and doing epidural anesthesia in patients with known placenta accreta and anticipated major blood loss and coagulolpathy?
Is epidural anesthesia OK when you are expecting major hemodynamic changes and hypovolemia?
Even in the cases where you started with epidural then put them to sleep for the hysterectomy did you wait until the epidural anesthetic resolved? what did you do with the epidural catheter when the patient got coagulopathic and required "FFP, platelets and cryo"?

Virtually all our C/S patients get epidurals and keep them post-op for pain control, which is covered by our acute pain service, so we wouldn't usually be pulling the catheter at the end of the case anyway. If they do become coagulopathic, they can keep the catheter an extra day or two as needed. Many of these patients are still out the door on post-op day 4 just like most of the other C/S patients.

I'm not sure why we would need to wait for the epidural to "resolve" before putting the patient to sleep. I don't see the issue there.

Major blood loss cases aren't necessarily a contraindication for epidurals, although we would usually be using them primarily for post-op pain, not the actual case. We do them all the time for elective AAA's, revision THR's, etc.

 

[Planktonmd]

Virtually all our C/S patients get epidurals and keep them post-op for pain control, which is covered by our acute pain service, so we wouldn't usually be pulling the catheter at the end of the case anyway. If they do become coagulopathic, they can keep the catheter an extra day or two as needed. Many of these patients are still out the door on post-op day 4 just like most of the other C/S patients.

I'm not sure why we would need to wait for the epidural to "resolve" before putting the patient to sleep. I don't see the issue there.

Major blood loss cases aren't necessarily a contraindication for epidurals, although we would usually be using them primarily for post-op pain, not the actual case. We do them all the time for elective AAA's, revision THR's, etc.

If you think a case could involve major blood loss to a point that you are asking for blood products in the room before incision, would you still do this case under epidural anesthesia?
There is a difference between epidurals for post op pain and starting a case that could eventually turn into a massive blood bath under epidural anesthesia or while an epidural block is still causing a sympathetic block.

 

[jwk]

If you think a case could involve major blood loss to a point that you are asking for blood products in the room before incision, would you still do this case under epidural anesthesia?
There is a difference between epidurals for post op pain and starting a case that could eventually turn into a massive blood bath under epidural anesthesia or while an epidural block is still causing a sympathetic block.

We will do known accreta's with probable C/Hyst under epidural only or epidural for the C/S and convert to GA shortly after the baby is out. Whether general or epidural, as soon as it becomes obvious we're going the C/Hyst route, we replace the volume loss and clotting factors early and aggresively and tend to stay out of trouble to begin with rather than dig our way out after actually getting into trouble.

 

[Planktonmd]

We will do known accreta's with probable C/Hyst under epidural only or epidural for the C/S and convert to GA shortly after the baby is out. Whether general or epidural, as soon as it becomes obvious we're going the C/Hyst route, we replace the volume loss and clotting factors early and aggresively and tend to stay out of trouble to begin with rather than dig our way out after actually getting into trouble.

What does that mean? Are you going to transfuse them before they start bleeding?
And if you think that you will be able to avoid a hemodynamic collapse despite the sympathetic block then why would you want to give GA on top of the epidural for the hysterectomy? why not just do all of them under epidural anesthesia?
I am not trying to give you hard time but I just find the approach a little unusual, but maybe this is how it's done these days and I am a little behind.

 

[jwk]

What does that mean? Are you going to transfuse them before they start bleeding?
And if you think that you will be able to avoid a hemodynamic collapse despite the sympathetic block then why would you want to give GA on top of the epidural for the hysterectomy? why not just do all of them under epidural anesthesia?
I am not trying to give you hard time but I just find the approach a little unusual, but maybe this is how it's done these days and I am a little behind.

We won't transfuse them before they start bleeding, but we won't wait until they're down 1500cc with ongoing blood loss before we start to transfuse them either.

The accretas seem to be much more common than they used to be, probably because of the number of repeat C/S we do and limited VBAC's. Our usual C/S patient gets a type and screen only. With the accreta's, we go ahead and make sure they are crossmatched, PRBC's in the room prior to incision, and order the clotting factors early.

I'll admit general on top of epidural might be unusual, but we just don't see any hemodynamic "collapse" with these cases. Granted, it doesn't take much of a general anesthetic at this point. The epidural patients are usually well pre-hydrated, and both hypotension and hypovolemia are treated early and aggressively. We have done these exclusively under epidural, but the moms tend to get a little antsy after a while - it's easier to put them to sleep at that point, which also allows us to concentrate on the more pressing physiological issues at hand.

 

[Planktonmd]

We won't transfuse them before they start bleeding, but we won't wait until they're down 1500cc with ongoing blood loss before we start to transfuse them either.

The accretas seem to be much more common than they used to be, probably because of the number of repeat C/S we do and limited VBAC's. Our usual C/S patient gets a type and screen only. With the accreta's, we go ahead and make sure they are crossmatched, PRBC's in the room prior to incision, and order the clotting factors early.

I'll admit general on top of epidural might be unusual, but we just don't see any hemodynamic "collapse" with these cases. Granted, it doesn't take much of a general anesthetic at this point. The epidural patients are usually well pre-hydrated, and both hypotension and hypovolemia are treated early and aggressively. We have done these exclusively under epidural, but the moms tend to get a little antsy after a while - it's easier to put them to sleep at that point, which also allows us to concentrate on the more pressing physiological issues at hand.

I tend to think that if I am expecting massive bleeding I would rather not have a neuraxial anesthetic limiting the patient's ability to maintain hemodynamic stability.
But it seems I am old fashion here.

 

[pushthesux]

1)very quick onset

2)almost zero chance of high spinal since you don't dose the epidural catheter after the spinal dose (currently I use 2.5mg bupivicaine/25ug fentanyl)...ya just hook up the infusion

3)no increase in post dural puncture headache incidence

4)very uncommon to haffta give ephedrine since the small intrathecal local-anesthetic dose doesnt cause much hemodynamic drop

5)saves me about 15 minutes

A few questions...

Air or saline? Why (other than it takes 43 seconds less per epidural with air??)
I'm assuming you use 1/2cc of 0.5% bupi and 1/2 cc of fentanyl?
Do you feel rushed threading the catheter?
If the catheter doesn't thread, then what?
What's the dose/rate of your infusions?
Do you stay in house for running epidurals?
If you hafta go to section, what do you use?

Thanks Jet.

 

[jetproppilot]

A few questions...

Air or saline? Why (other than it takes 43 seconds less per epidural with air??)
I'm assuming you use 1/2cc of 0.5% bupi and 1/2 cc of fentanyl?
Do you feel rushed threading the catheter?
If the catheter doesn't thread, then what?
What's the dose/rate of your infusions?
Do you stay in house for running epidurals?
If you hafta go to section, what do you use?

Thanks Jet.

1)Air. Was taught by wanna my deft attendings that way and always did it that way. You could look at it the other way and say "why use saline?" 43 seconds is 43 seconds. Either way is fine I'm sure but if you learn little tricks here and there, all the sudden all your little tricks save more and more time. The stuff you're taught about air causing a problem in the epidural space is BS. Its not like youre gonna blow up the space..I pull the plunger back to the 2mL mark every time. Why 2mL? I dunno. Cudda been 3...4....but the 2 mark puts the plunger on my thumb in a comfortable position....AND if you use the same mark every time your feel will become very refined after a while....an epidural is a tactile procedure....once the Tuohy is initially buried and the syringe is attached you (after 100s/1000s of placements) could literally close your eyes and still have the same success rate.

2) 1 cc of .25% bupiv and 1/2 cc fentanyl. A haffa mL of .5% would work too (obviously).

3)rushed threading the catheter? If you're referring to because-I-just-gave-a-spinal-dose, no. Remember 2.5 mg isnt much so youre not gonna see a big hemodynamic drop even if they're sitting up. But it doesnt take long to thread the catheter anyway, as you know.

4)Theres alotta tricks to try if the catheter doesnt thread...the best for me is to push the Tuohy JUST A MILLI FRACTION more. You're taught to push some saline thru, or rotate the Tuohy 180 degrees, but since I've tried both of those many many times, yeah sometimes it works, but advancing the Tuohy works better. You've gotta really focus your vision on the Tuohy...ya see those black bands on the Tuohy, focus on the one closest to the skin..helps you gauge very tiny movement...

5) .125%bupiv with fentanyl (can't remember if its .5ug or 1ug per mL at the moment) at 16mL per hour.

6)No. We have a CRNA in house so I come in, put it in, and leave.

7)2% lidocaine 10-20mL. Start with 10....sometimes thats enough....if not another 5-10mL.

 

[Trisomy13]

leftover precedex during hemorrhage?

to clarify - had a case earlier (spine) and used precedex that i had split into two syringes. this was the syringe that was not used during that case. i guess leftover was a poor choice of words.

 

[Consigliere]

Same here, Sunday call, new in PP-land. I have a CRNA until 5pm:
8 am D&C- quick & healthy, NPO, elective.
9am appy- not bad, goes quick. Place 1 labor epidural.
10am VATS- sick dude with fluid in the chest, cancelled earlier in the week for fluid overload, thrombocytopenia. Art line, double lumen. Goes fine, but I have to reintubate at the end. Whatever. But I have to do vent/med orders in the ICU...and check the x-ray for tube placement on the weekends. I never understood why it is sooo important to check that x ray after an intubated patient is brought to the ICU. I write "OK to Use ETT" in the orders just because it's dumb. I think I placed 2 labor epidurals during this case.
Get some lunch, almost send CRNA home.
1 pm, ortho calls with 3 cases, appy is added.
15 year old elbow fracture. Yawn.
90-something hip fracture. S/p MI and CABG, EF 30's. Touch of ketamine for the roll lateral and throw in an isobaric bupivacaine spinal. See a few pain patients (PCA and epidural). I'm in the room solo at 5. Make sure to have coffee beforehand.
Next up is a IM rod femur. Motorcycle accident. Big guy with a big beard, but intubated easily. Had thoughts of fiberoptic, but besides being fat he had no other real predictors of difficult intubation. Propofol sux tube. Still getting used to being totally 100% alone with marginal airways.
Appy, done by 9:30 pm. Sleep in call room.
00:30 section..failure to progress. I take my time getting there and getting the patient into the OR.
01:30 section in recovery, notice L&D board full of elective inductions of labor. On a weekend. Interesting.
03:30 epidural. Hmm...cranked up the pit all day and NOW an epidural? I'd have been happy to do it earlier. I still do get a fair amount of satisfaction from placing the catheter, bolusing, and then doing my chart. By the time I'm done they've gone from screaming to 'what contraction?' Makes the job worthwhile.
Sleep
07:00 Go to holding and help with preops. Place a thoracic epidural to help a colleague get the morning going. Offer to cover the ECT's but they don't need me.
08:00 out the door. Smell of the new BMW leather reminds me that being up most of the night is kinda worth it. Hit the couch at home. Still on the beeper until noon post call. Not called back in.

Dude,

Your job blows. For a gig like this, you should be getting $500k MINIMUM.

 

[militarymd]

Dude,

Your job blows. For a gig like this, you should be getting $500k MINIMUM.

I concur

 

[ozzie20]

I think you may have enough days that people listed for someone to sticky this in the "what is call like" in the faq.

 

[2ndyear]

2ndyear, how do you cover OB and sit in an OR? What if there's an abruption or something?

Weekends have 1 CRNA coverage until 5pm, weeknights until 8. So I am free to do epidurals, pain rounds, post ops, intubations on the floor, spinal taps in the ER, 'emergency' central lines because the hospitalists or surgeons won't do them etc. After that I'm solo.

Should a c-section be called when there is a case in the OR, the CRNA is in the room. I have to call in my backup call from home who has to be there in the 30 minute decision to incision time. As far as I know I can't assume care for the section patient on a 1:1 basis while there is a case I am signed into in the OR that the CRNA is in. This would be a violation of hospital by-laws stating that CRNA's can't do cases uncovered.

Question to those who have been out longer than me: We do VBAC's, multiple births, and seem not to turn away the preeclamptics. Chances of stat section are high. Why some of these people don't seek care at one of the many top rated academic centers down the road as opposed to my community hospital is way beyond me, but it's not my place to judge. But if a true stat section was needed and a CRNA was in the OR, what would be the ramifications of starting the case myself? It may be against hospital by-laws, but if the OR patient were stable as far as I can tell the surgeon would become the physician supervisor.

 

[Planktonmd]

Weekends have 1 CRNA coverage until 5pm, weeknights until 8. So I am free to do epidurals, pain rounds, post ops, intubations on the floor, spinal taps in the ER, 'emergency' central lines because the hospitalists or surgeons won't do them etc. After that I'm solo.

Should a c-section be called when there is a case in the OR, the CRNA is in the room. I have to call in my backup call from home who has to be there in the 30 minute decision to incision time. As far as I know I can't assume care for the section patient on a 1:1 basis while there is a case I am signed into in the OR that the CRNA is in. This would be a violation of hospital by-laws stating that CRNA's can't do cases uncovered.

Question to those who have been out longer than me: We do VBAC's, multiple births, and seem not to turn away the preeclamptics. Chances of stat section are high. Why some of these people don't seek care at one of the many top rated academic centers down the road as opposed to my community hospital is way beyond me, but it's not my place to judge. But if a true stat section was needed and a CRNA was in the OR, what would be the ramifications of starting the case myself? It may be against hospital by-laws, but if the OR patient were stable as far as I can tell the surgeon would become the physician supervisor.

First of all to answer your question: These patients with high risk OB situations come to your hospital because your OB Docs want them to come and because they are not smart enough to know better.
Second: Dude, You are working way too hard!
I can't believe you are doing LP in the ER 😱
I hope they are paying you enough.

 

[Planktonmd]

First of all to answer your question: These patients with high risk OB situations come to your hospital because your OB Docs want them to come and because they are not smart enough to know better.
Second: Dude, You are working way too hard!
I can't believe you are doing LP in the ER 😱
I hope they are paying you enough.

And I forgot to say: If the OB says it's a stat C section then you should be OK leaving the CRNA in the OR and going to do the C Section regardless of what the hospital policy is.

 

[dfk]

7)2% lidocaine 10-20mL. Start with 10....sometimes thats enough....if not another 5-10mL.

hey jet,
are you concerned at all with TNS or cauda equina syndrome developing with the use of lidocaine?
i was under the assumption this was "taboo".. more so for SABs (with hyperbaric lido), but also with epidurals.

 

[Planktonmd]

hey jet,
are you concerned at all with TNS or cauda equina syndrome developing with the use of lidocaine?
i was under the assumption this was "taboo".. more so for SABs (with hyperbaric lido), but also with epidurals.

TNS and cauda equina were reported after intrathecal Lidocaine not epidural.
And to be specific after using Lidocaine 5 % intrathecally through an intrathecal micro catheter.

 

[treasurefull2]

No, I think we need a few more...well, maybe, maybe not, but I like reading these....

 

[deleted126335]

.

 

[jetproppilot]

hey jet,
are you concerned at all with TNS or cauda equina syndrome developing with the use of lidocaine?
i was under the assumption this was "taboo".. more so for SABs (with hyperbaric lido), but also with epidurals.

2% lidocaine is used frequently in an epidural to achieve a surgical plane of anesthesia. I'm not familiar with any correlation between epidural lidocaine and cauda equina syndrome.

Lidocaine SABs are OK too even though I dont use lidocaine....I think you are thinking of long ago when intrathecal microcatheters were used...I think cauda equina syndrome was the issue with the microcatheters but I never used one.......not sure what you're referring to...

 

[jetproppilot]

2% lidocaine is used frequently in an epidural to achieve a surgical plane of anesthesia. I'm not familiar with any correlation between epidural lidocaine and cauda equina syndrome.

Lidocaine SABs are OK too even though I dont use lidocaine....I think you are thinking of long ago when intrathecal microcatheters were used...I think cauda equina syndrome was the issue with the microcatheters but I never used one.......not sure what you're referring to...

Just saw Planks post.

Thanks Plank.

 

[Planktonmd]

Just saw Planks post.

Thanks Plank.

Got you covered 😎

 

[dfk]

thanks for the clarification

 

[ZA_Gasman]

I tend to think that if I am expecting massive bleeding I would rather not have a neuraxial anesthetic limiting the patient's ability to maintain hemodynamic stability.
But it seems I am old fashion here.

I agree.👍 And I'm definitely NOT old fashioned. Why make life harder than it needs to be. Put in a tube, tell the mom she can see the baby when she wakes up. Have good control over haemodynamics. Less sweating, fewer grey hairs.

 

[militarymd]

TNS and cauda equina were reported after intrathecal Lidocaine not epidural.
And to be specific after using Lidocaine 5 % intrathecally through an intrathecal micro catheter.

uhh...no......any lidocaine subarachnoid block is associated with TNS..

and NO...not just with 5%....any concentration.....

this is old news

 

[Planktonmd]

uhh...no......any lidocaine subarachnoid block is associated with TNS..

and NO...not just with 5%....any concentration.....

this is old news

Yes, there are a few case reports here and there.
the majority of cases of TNS were reported with Lido 5 % which was the most common of Lido used for intrathecal injection.
And the couple of cases of Caudas equina were reported were in microcatheters and Lido 5%.

 

[militarymd]

Yes, there are a few case reports here and there.
the majority of cases of TNS were reported with Lido 5 % which was the most common of Lido used for intrathecal injection.
And the couple of cases of Caudas equina were reported were in microcatheters and Lido 5%.

uh...no ....it's been studied specifically ....concentration doesn't matter.

 

[militarymd]

Since you don't know Plank...I would recommend reading some of Julia Pollock's stuff...

she works at Virginia Mason...and is kind of an advocate for lidocaine subarachnoid block.

 

[Planktonmd]

Since you don't know Plank...I would recommend reading some of Julia Pollock's stuff...

she works at Virginia Mason...and is kind of an advocate for lidocaine subarachnoid block.

You obviously got that audio digest lecture by her ( a few months ago?) and memorized a few parts, good job.


In clinical practice the overwhelming majority of TNS happened after INTRATHECAL 5% LIDO.
And Cauda equina happened almost exclusively after 5 % Lido through microcatheter.
Are you still confused?
And we were discussing epidural lidocaine.
So now you can go ahead do an internet search and come with another argument.

 

[militarymd]

TNS and cauda equina were reported after intrathecal Lidocaine not epidural.
And to be specific after using Lidocaine 5 % intrathecally through an intrathecal micro catheter.

Yes, there are a few case reports here and there.
the majority of cases of TNS were reported with Lido 5 % which was the most common of Lido used for intrathecal injection.
And the couple of cases of Caudas equina were reported were in microcatheters and Lido 5%.

In clinical practice the overwhelming majority of TNS happened after INTRATHECAL 5% LIDO.
And Cauda equina happened almost exclusively after 5 % Lido through microcatheter.
Are you still confused?
And we were discussing epidural lidocaine.
So now you can go ahead do an internet search and come with another argument.

Your head is so far up your as s that you don't even know what you've posted.....

Beardsley was one of my attendings when I was a resident...I have no confusion about any of this.

 

[Planktonmd]

Your head is so far up your as s that you don't even know what you've posted.....

Beardsley was one of my attendings when I was a resident...I have no confusion about any of this.

😀

No, I actually think that you have zero idea what you are talking about.
Do I always have to keep telling that you are just an idiot regardless of how highly you think of yourself??
How many times do I need to remind you that I actually know how shallow your knowledge is and that the B.S. that you pull on the others does not work with me?
I know exactly what you know and what you don't, and I don't buy your B.S. so go try it on someone else.
Now go think of more teenager type of cussing words to say.

 

[militarymd]

Here's what I posted:

1) I noted your error
2) I gave you new information
3) I gave you the author of the new information
4) I told you where this author works
5) I told you that I was one of the author's references (Bearsdley- who you obviously never heard of) when I was a resident when he was developing the in vitro spinal model for lidocaine toxicity

and all you have is:

1) you are confused
2) you have zero idea
3) you are an idiot
4) you have shallow knowledge
5) you are pulling bs
6) you cuss like a teenager

Geogil ...how would you score that round?

😀

No, I actually think that you have zero idea what you are talking about.
Do I always have to keep telling that you are just an idiot regardless of how highly you think of yourself??
How many times do I need to remind you that I actually know how shallow your knowledge is and that the B.S. that you pull on the others does not work with me?
I know exactly what you know and what you don't, and I don't buy your B.S. so go try it on someone else.
Now go think of more teenager type of cussing words to say.

 

[Monty Python]

Yes, there are a few case reports here and there.
the majority of cases of TNS were reported with Lido 5 % which was the most common of Lido used for intrathecal injection.
And the couple of cases of Caudas equina were reported were in microcatheters and Lido 5%.

This is from very rusty and old memory, so here goes with a grain of salt:

Weren't most of these cases with lido associated with lithotomy position?

 

[Planktonmd]

Here's what I posted:

1) I noted your error
2) I gave you new information
3) I gave you the author of the new information
4) I told you where this author works
5) I told you that I was one of the author's references (Bearsdley- who you obviously never heard of) when I was a resident when he was developing the in vitro spinal model for lidocaine toxicity

and all you have is:

1) you are confused
2) you have zero idea
3) you are an idiot
4) you have shallow knowledge
5) you are pulling bs
6) you cuss like a teenager

Geogil ...how would you score that round?

I think it's clear that I crushed you as usual.

 

[Brian Fantana]

Good topic, I have gone thru said articles and now the answer is clear. This reminds me of

as Plank searches for the mouthpiece...