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Anyone do adult epidurals under GA?

Discussion in 'Anesthesiology' started by sevoflurane, Jun 14, 2008.

  1. sevoflurane

    sevoflurane Ride 10+ Year Member

    Jul 16, 2003
    Clearly it's better to do them awake... while under GA you loose your best monitor. But what about that post gastric bypass panniculectomy or ex-lap that turns into a huge incision in the patient that could benefit from an epidural vs. pca? I do them all the time in peds (epi under ga)… but rarely in adults. What is the standard (if any) in private practice? Preemptive epidural based on surgeons that are likely to make a bigger whack? Or.. wait until they wake up in the pacu and then place it- academic style? Do you have the time to do that when you are running 3-4 rooms?
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  3. dr doze

    dr doze To be able to forget means to sanity Lifetime Donor Classifieds Approved 10+ Year Member

    Dec 6, 2006
    Last edited: Mar 10, 2009
  4. goodoc

    goodoc Banned

    Jan 28, 2008
    Place pre-op. You will know what cases need it which one do not.
  5. urge

    urge 10+ Year Member

    Jun 23, 2007
    On the same token, don't pediatric oncologist take kids to the OR for a spinal all the time? I don't see how a lumbar epidural is different. For thoracic epidurals it's another story.
  6. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Nov 2, 2006
    The South
    Unfortunately, you always have to consider what the people who would testify against you are going to say if something goes wrong and you get sued.
    Unfortunately, the people who will testify against you are usually the academic guys, and if they say it's wrong to do it asleep then it doesn't matter what you think, the jury will believe them because they are the authority.
  7. 2win

    2win 7+ Year Member

    Apr 25, 2008
    yes - under fluoroscopy. Not very often due to the risk stated by other posters. The time to get the C arm in the room is another consideration. If the reason is clearly explained in your note and the procedure done well (identification of the epidural space with contrast) the risk for an eventual malpractice are minimized.
  8. Intubate

    Intubate ASA Member 10+ Year Member

    Dec 9, 2006
    you don't see how an epidural is different from a lumbar puncture? really?
  9. Noyac

    Noyac ASA Member SDN Advisor 10+ Year Member

    Jun 20, 2005
    If the situation calls for it.
  10. Arch Guillotti

    Arch Guillotti Senior Member Administrator Physician Lifetime Donor Classifieds Approved 10+ Year Member

    Aug 8, 2001
    It's different for the kids that get LP's because they may have to be under GA to perform the procedure. Also, usually these kids are usually getting chemo/cell counts and it really isn't an "elective" procedure. Epidurals in adults are elective procedures and can be safely done under sedation or wide awake if one chooses to do so. This is not the case in kids.
  11. BIS40

    BIS40 7+ Year Member

    Jul 19, 2007
    Im a peds fellow and do them asleep with consent. I wouldn't do it on adult, to much risk. One of my seasoned attendings told me your getting good, but next year on your own you need to decide if you have the balls to do it, because many people actually consider it malpractice, and it would be no problem to find people to testify against you with an occurrence.
  12. drccw

    drccw ASA Member 7+ Year Member

    Jan 20, 2008
    have you ever seen a lumbar drain put in?

    Where I trained: 14 G tuohy needle. done after induction. L3-4 or L4-5....

    Since seeing one of those I havent had any qualms about doing Lumbar epidurals asleep... thoracic maybe but lumbar no....

    though pre-op is always my preference...
  13. Dinkyconductor

    Dinkyconductor 10+ Year Member

    Sep 27, 2006
    I agree with most posters here, I only put them in awake, although several of my colleagues put them in adults under GA routinely. They also do interscalene blocks in adults under GA routinely. Can't say I agree with that.

    In fact, I'm the one person in my group who won't even do a femoral block in an asleep patient or a patient with a spinal. You could be injecting intraneurally and the patient is unable to give feedback.
  14. Arch Guillotti

    Arch Guillotti Senior Member Administrator Physician Lifetime Donor Classifieds Approved 10+ Year Member

    Aug 8, 2001
    I have put a lumbar epidural in under GA in a child only once. Surgery was sort sort of a big whack and the benefits outweighed the risks, though I am sure some would arue to the contrary. One time I watched another resident put a thoracic epidural in a 4 year old under GA. He was nervous as a ***** in church and his hands were a shakin'.
  15. Arch Guillotti

    Arch Guillotti Senior Member Administrator Physician Lifetime Donor Classifieds Approved 10+ Year Member

    Aug 8, 2001
    I can only remember putting one lumbar drain in and quite honestly I don't remember if it was awake or asleep. I don't think it really matters for this kind of case. I just remember the tremendous size of that 14 gauge Touhy.
  16. Gern Blansten

    Gern Blansten Account on Hold 10+ Year Member

    Jun 20, 2006
    As a resident, we used to put blocks in asleep patients. Never had a bad outcome, though I have heard of many horror stories. The following case report by Benumof describes 4 such cases of permanent spinal cord injury following interscalene blocks done under GA:

    These case reports were pretty much the end of blocks under GA except in the cases of pedi patients where the benefits would outweigh the risks. If a peripheral nerve block is done under GA in a pedi patient here, it is always with ultrasound.
    I disagree that morbid obesity is an instance where it would justify placing it asleep. If they are too big to place it awake, I am not sure I want them to have one anyway (if there was any problem, would they even fit in the scanner??).
    So, for the original question, no, I never do it.
    Last edited: Jun 16, 2008
  17. dhb

    dhb Member Lifetime Donor Classifieds Approved 10+ Year Member

    Jul 12, 2006
    If echo becomes the gold standard for regional procedures then GA shouldn't be a contraindication for regional since you see where you're injecting the local.
  18. Gern Blansten

    Gern Blansten Account on Hold 10+ Year Member

    Jun 20, 2006
    It would certainly seem to increase the safety, but I am not sure it would eliminate it. Having done a fair number of blocks with Ultrasound, sometimes the picture is crystal clear, other times it is not clear at all.

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