Case #7 : Emergency Obstructed Hernia, 300 Ibs with HT and DM - what shoud've done more?

DrAmir0078

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Dear SDN Anesthesiologists,

I hope you are doing well, yesterday night, I had a tough 24 hours emergency surgeries’ shift, my call then started at 0530 PM with Knee injury and the vascular team required to do popliteal veins exploration and this operation lasts 4 hours plus orthopedic intervention, the total cases I gave anesthesia with the help of my PGY1 and our team leader (CA3) were 8 cases, 3 appendectomies (20 male one with history of epilepsy, 16 years heavy smoker, and one child 11 years old with a weight of 125 Ibs), two other perianal abscesses (one child 11 months old, one female heavy smoker 30 years old), last case was posterior hip dislocation – pregnant 7 miss periods – this case ended up my shift at 0200 AM.



The case I am talking about was obstructed umbilical vs para umbilical hernia, 55 years old female, weight around 300 Ibs if not more) with a past medical history of diabetes and hypertension. Patient obesity was more central, on examination in the operating theatre, once supine her sat O2 was less than 95%, her Bp was 177/104 mmhg, her pulse was like 90s. The bed elevated from her head side about 30 degrees, her sat became 97%, clear chest no added sounds.



After getting the consent till (death) from their family, I called my CA3 Senior resident – the team leader, to come and to provide me with opioids, you know we have shortages.



Induction:

Patient placed head – bed up, preoxygenated with Nasal Cannula 6 Lt, and Ventilator mask for more than 3 minutes, the induction done with multimodal analgesia as follows (with anesthetics):

  • Lidocaine 100 mg
  • Fentanyl 50 mcg
  • Pethidine 25 mcg
  • Paracetamol 1000 mg with Nefopam (infusion)
  • Dexamethasone 8 mg
  • Ketamine 50 mg
  • Propofol with sleeping dose 125 mg
  • Another dose of Fentanyl 50 mcg
  • Scoline 200 mg RSI procedure (crush like induction)
ETT was 7.5 (barely difficult), Mallampati grade prior was 3, I believe, I put her on PCVG with vT 475 ml + Peep 6 and RR sets on 12, her sat was 96%, Peak Pressure 25 to 27 cmH2O, maintained with Isoflurane 2% (1.5 MAC)



Patient woke up from scoline around 10 minutes later, with high Peak Pressure 40 cmH2O, then given atracurium 30 mg (long operation), patient relaxed, but blood pressure went up to 180s/110s mmhg, then given another Fentanyl 50 mcg with Pethidine 25 mcg.



Fluid was given 2 liters during the operation, but the Bp kept up, I tried to give her Angisid (GTN) 10 mcg, but she desaturated to 92% briefly, then went up to 95%, I didn’t have good emergent Beta blockers unfortunately except Metoprolol, but I decided to give her 1 mg of it prior to extubation and I did.



Prior to closure of the subcutaneous tissue after removing 3 pounds of fat and omentum stuck with the sac plus skin (they did lower umbilical transverse incision – wide enough like over 10 inches, could’ve more, same as the incision of pfannenstiel incision), I prepared my Lidocaine in two syringes, each one with 10 ml, 2% diluted to 12 ml (>1.5%) and gave her TAP petit triangle block, using regular needle and could manage the depth with skin stretching and feeling the first pop of the skin (I blunted out the tip) and the second pop of external oblique.



Operation finished, and I woke her up with SIMV/PC Ventilation, then PSVPro mode, and did suction, the patient with her ETT in, was able to protrude her tongue out and elevate her neck, beside opening her eyes. I extubated her and put her on Nasal Cannula 6 Liter and saturation was 98% and didn’t drop, the patient was amazingly saying “did you do the operation”, I tried to touch the wound dressing and without pain noticed, she was able to speak, elevate her head and she moved herself to the next stretcher without pain, I sent her with face mask 10 Lt oxygen to the surgical ward, and semi stting position 45 degrees, patient in the morning is well, feeling better.



What should’ve done more according to the limited resources I have, rate my approach 0 – 10 😊, did I pass this challenging case? Were something needs to be addressed? This is my first multimodal analgesia - surgical anesthesia!



Love and Peace,



Dr Amir Al Shimmarii, PGY3 aka CA2

Iraqi Board in Anesthesia and Intensive Care,

Al Imamain Al Kadhimain Medical City

North of Baghdad / Iraq
 
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Very nice job Dear Amir, it's actually challenging case for both the anasthetist & the surgeon, & the fact that she wake up free of pain is great.
You couldn't do best than this & if you let me I have question.
You mentioned that she was Diabetic, what about her Blood sugar prior to, during & post op. ? What kind of fluid you gave her?Did you approach her on sliding scale for controlling her sugar as she's an emergency case.
Another question, what about the surgery, was there any diseased bowel ?, resection? , did the surgeon use mesh? , & if not , why??
Regards
Dr. Salah Salih
General & Laparoscopic Surgeon
 
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DrAmir0078

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Very nice job Dear Amir, it's actually challenging case for both the anasthetist & the surgeon, & the fact that she wake up free of pain is great.
You couldn't do best than this & if you let me I have question.
You mentioned that she was Diabetic, what about her Blood sugar prior to, during & post op. ? What kind of fluid you gave her?Did you approach her on sliding scale for controlling her sugar as she's an emergency case.
Another question, what about the surgery, was there any diseased bowel ?, resection? , did the surgeon use mesh? , & if not , why??
Regards
Dr. Salah Salih
General & Laparoscopic Surgeon
Dear Dr. Salah,
Thanks for the words, and to regarding your question, she wasn't that elevated high blood sugar, her last RBS was like 230 based on finger tip glucose measuring per residents. I used 2 ringer lactate + 2 NS; there were no diseased bowel, except entrapped omentum, but due to the huge sac created over 15 years per patient talk, they resected part of skin and subcutaneous fat and unfortunately, I did not have glucose monitoring in the theater, I asked for it, and didn't get it !
Per surgery resident said, she is very well in the morning and didn't require ICU admission as I instructed them to closely monitor her.

Our resuscitation regarding blood glucose range from giving blouses of insulin subcutaneously and support with fluid, sometimes we use sliding scale, but requires infusion that we do not have handy except at the ICU!
It was very challenging to me and the teams !
The way she woke up, I honestly felt the happiness!
 
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Again, I said it was great job & the majority of the hard work is yours, the Anasthetist.
Thanks for sharing this nice case.
 
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Planktonmd

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Very nice Dr. Amir, and the fact that you are doing the old fashion TAP block based on anatomy and without ultrasound is probably something many of the young guys here never heard of :)
On the other hand I can't help but saying that your induction cocktail was a bit too complicated, I am not sure you really needed all these things you gave to do a rapid sequence induction on a bowel obstruction. Also 1 mg of Metoprolol is a very small dose and you could give a little bit more.
 
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DrAmir0078

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Very nice Dr. Amir, and the fact that you are doing the old fashion TAP block based on anatomy and without ultrasound is probably something many of the young guys here never heard of :)
On the other hand I can't help but saying that your induction cocktail was a bit too complicated, I am not sure you really needed all these things you gave to do a rapid sequence induction on a bowel obstruction. Also 1 mg of Metoprolol is a very small dose and you could give a little bit more.
Thanks Dr Planktonmd,
The fact that I used such cocktail, derived from my experience with the ENT electives of multiple analgesia with induction, and the other fact, she was not considered obstructed bowel, otherwise I would be aggressive on fluid and third space loss!
Our brilliant Anesthesiologist and a board supervisor Dr. Haider Abbass who taught me the triangle of petit TAP from his OBs work experience with him at this training center. I called him to thank him for his teaching, he was much happier than me. Yes Metoprolol was very low dose, I could've give more, but based on her PR was Okay like upper 80s.
The way I woke up the patient recently also taught in my early 3rd year residency from our brilliant Anesthesiologist too Dr. Ali Hassan, both Gentlemen taught me a lot and sharpened my knowledge.
From your perspective, what to delete from what mentioned induction dosages?
 
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Planktonmd

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Thanks Dr Planktonmd,
The fact that I used such cocktail, derived from my experience with the ENT electives of multiple analgesia with induction, and the other fact, she was not considered obstructed bowel, otherwise I would be aggressive on fluid and third space loss!
Our brilliant Anesthesiologist and a board supervisor Dr. Haider Abbass who taught me the triangle of petit TAP from his OBs work experience with him at this training center. I called him to thank him for his teaching, he was much happier than me. Yes Metoprolol was very low dose, I could've give more, but based on her PR was Okay like upper 80s.
The way I woke up the patient recently also taught in my early 3rd year residency from our brilliant Anesthesiologist too Dr. Ali Hassan, both Gentlemen taught me a lot and sharpened my knowledge.
From your perspective, what to delete from what mentioned induction dosages?
The title of your post was "emergency obstructed hernia" means bowel obstruction, and bowel obstruction requires a true rapid sequence induction: Preoxygenate, then (Propofol + Succinylcholine) followed by tube in few seconds as soon as the fasciculations stop. You basically want to first secure the airway before the patient starts vomiting.
Your approach is not wrong but it's more of an elective artistic induction.
 

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The title of your post was "emergency obstructed hernia" means bowel obstruction, and bowel obstruction requires a true rapid sequence induction: Preoxygenate, then (Propofol + Succinylcholine) followed by tube in few seconds as soon as the fasciculations stop. You basically want to first secure the airway before the patient starts vomiting.
Your approach is not wrong but it's more of an elective artistic induction.
Understood now - but then you would cover her with Fentanyl blouses if you were in my situation and to TAP her !
 
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Induction: propofol 200 sux 200

decadron 8 later

pethidine, lidocaine, ketamine, tylenol, fentanyl are all unnecessary. I would tap at the beginning to limit opioids for this fatty and when she started breathing i'd probably put her on pressure support right there because they don't need relaxation. With the right patient and a good block you don't need any opioids except maybe for the tube. 50 at the beginning and 50 around thirty minutes prior to extubation is what I'd do. Zofran 8 at the end as well.
 
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DrAmir0078

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Absolutely, and maybe stay away from the Ketamine if you are having trouble controlling the BP :)
Yes, I considered not to give to be honest, but seeing her blood pressure isn't over 180 / 110 (I put in my mind in assumptions - her blood pressure was related to the pain she had and her EKG was a bit normal no LV issues or ischemic changes either), and I needed Ketamine analgesia effects in this multimodal - I was glad that I didn't give her Midazolam otherwise will go into severe hypotension!
If she was presented with much elevated blood pressure and an emergency, I would discard Ketamine for sure!
Many thanks Dr. Planktonmd
 

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in these obese patients with DM, i skip dex, because its super long lasting and ive seen many times having it plus having surgery, causing glucose to run up out of control and patient had to be placed on insulin infusion for manage the glucose. imo, risk of poor would healing and increased risk of infection and other hyperglycemia complications, is > than benefit of giving dex in these patients
 
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DrAmir0078

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Induction: propofol 200 sux 200

decadron 8 later

pethidine, lidocaine, ketamine, tylenol, fentanyl are all unnecessary. I would tap at the beginning to limit opioids for this fatty and when she started breathing i'd probably put her on pressure support right there because they don't need relaxation. With the right patient and a good block you don't need any opioids except maybe for the tube. 50 at the beginning and 50 around thirty minutes prior to extubation is what I'd do. Zofran 8 at the end as well.
Wow,
That looks awesome, I actually spoke before with Dr. Haider Abbass about a plan to TAP pregnants before CS to reduce opioids or analgesia if any...
You proved it with your suggestions.
I am so glad and thankful!
VERY SMART!
Next time as always there is Next Time to learn from all of you!
 

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Why would she have "severe hypotension" with Midazolam?
A brilliant top Anesthesiologist (RIP - due to covid complications last year - a great loss to the Country) in Iraq Dr Khalid Ali with 6 volumes textbooks he wrote - unpublished, he was the head Anesthesiologists at the ENT OR at Baghdad Medical City Complex surgical specialities said and I have the recording of that - never mix Midazolam with opioids as it induces severe hypotension!
I uploaded the conversation for you... It is back in November 2019 in the anesthesia induction room....

Just a second to make it youtube
 

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A brilliant top Anesthesiologist (RIP - due to covid complications last year - a great loss to the Country) in Iraq Dr Khalid Ali with 6 volumes textbooks he wrote - unpublished, he was the head Anesthesiologists at the ENT OR at Baghdad Medical City Complex surgical specialities said and I have the recording of that - never mix Midazolam with opioids as it induces severe hypotension!
I uploaded the conversation for you... It is back in November 2019 in the anesthesia induction room....

Just a second to make it youtube
That's simply inaccurate Amir, Midazolam is used with opiates very frequently everywhere.
 
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DrAmir0078

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in these obese patients with DM, i skip dex, because its super long lasting and ive seen many times having it plus having surgery, causing glucose to run up out of control and patient had to be placed on insulin infusion for manage the glucose. imo, risk of poor would healing and increased risk of infection and other hyperglycemia complications, is > than benefit of giving dex in these patients
That is correct, and I agree, but I gave her for a reason to enhance pulmonary function if I would encounter, beside it works on PONV, and not to forget the airway manipulation due to a bit difficult intubation, two tries!

I have only metoclopramide, no Zofran unfortunately (in regard of PONV)

Many Thanks Dr. Anbuitachi
 
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Usually midaz is fine for most people. We gave up to 10 in residency for blocks at an ortho center which I now realize is way too much. But I have seen a few cardiac cripples/vasculopaths get hypotensive from midaz only. I just eliminate it for most general anesthetics because it's not necessary. I give it for sedation for blocks mostly.
 
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DrAmir0078

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Thanks for this info, I will keep it in mind when I will master USGRA one day!
Usually midaz is fine for most people. We gave up to 10 in residency for blocks at an ortho center which I now realize is way too much. But I have seen a few cardiac cripples/vasculopaths get hypotensive from midaz only. I just eliminate it for most general anesthetics because it's not necessary. I give it for sedation for blocks mostly.
 
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DrAmir0078

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By the way Moderators and Admins, I made a YouTube video just few minutes ago visiting the patient and she was very comfortable and didn't even got any pain medication till now, it has been almost 20 hours post op...
She was praying for me and saying NO I have no pain.
If you agree to share it here, I am glad to do so according to the policy and guidelines of SDN, and I had her full verbal consent to share this video!

Your opinion matters!
 
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When Versed was first becoming popular in the early 1990s, there were some widely circulated news accounts of patients dying in endoscopy suites after receiving the drug. Turns out that people thought it was equipotent to Valium and frail elderly patients were getting 5-10mg. That may be where the story of versed causing hypotension originated.

As an aside, a standard cardiac anesthetic in those days was Versed 20mg and fentanyl 2-3mg with some pavulon. No vapor/no propofol.
 
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DrAmir0078

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When Versed was first becoming popular in the early 1990s, there were some widely circulated news accounts of patients dying in endoscopy suites after receiving the drug. Turns out that people thought it was equipotent to Valium and frail elderly patients were getting 5-10mg. That may be where the story of versed causing hypotension originated.

As an aside, a standard cardiac anesthetic in those days was Versed 20mg and fentanyl 2-3mg with some pavulon. No vapor/no propofol.
Very informative history of Versed!
Thanks Dr. Nimbus.

Well if giving that much of 20 mg Versed + Fentanyl that much 2 mg - wow!

I am actually doing a research of intrasurgical linea semilunaris block after delivering the baby in CS, and yesterday the surgical field was disrupted (trying to locate linea semilunaris and wasnt there and wouldn't do blind injections), but courageously with extra caution, I did Triangle of petit TAP block, the interesting part is that the amount I gave in such plan block was minimal 12 ml, that brings hope to me, and my mentor Dr. Haider Abbass who taught me how to do it, was always telling me that controlling acute pain post op is the most important goal.

Next post, will post a case of Hysterectomy I did that intrasurgical linea semilunaris block before closing the rectus sheath - the outcome was amazing too!
 
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dipriMAN

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The fact that you did a blind TAP in this size of a patient and it worked is a miracle. Very impressed.
 
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DrAmir0078

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The fact that you did a blind TAP in this size of a patient and it worked is a miracle. Very impressed.
Thanks Dr dipriMAN

... From my mentor experience Dr. Haider Abbass in OBs C/Ss, he said "single pop after the skin pop is effective", I personally tried in C/S cases twice and with one time single pop in a pregnant patient with a history of cardiomyopathy - it worked very well and patient woke up free of pain.... I am not sure about the distance in triangle of petit towards the EQ in different patients weights with or without stretching of the skin and pushing the skin against the tissues like a probe!
 
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abolt18

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What do you use to blunt your needle?
 
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woopedazz

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Alright, I respect your opinion too and will manage to give Midazolam next time too and monitor blood pressure!

Peace

Thanks for this amazing discussion.
Midazolam will attenuate sympathetic outflow in virtuality all patients, but this is rarely an issue as the vasoplegia (minimal in the doses we currently use) and mild brady is offset by the baroreceptor reflex.

However, it's a massive issue in the maximally sympathetically charged/compensated trauma patient; the cohort your boss was probably referring to?

Either way you shouldn't use it in this case at it's an RSI for bowel obstruction, so I agree good choice on not using it.
 
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DrAmir0078

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What do you use to blunt your needle?
I use kidney dish filled with antiseptic and digging the tip of the needle until it has a curve or hook like... Like ten times is enough perpendicular force or you can use it on clean vial sponge the same procedure or on the shaft of new plastic needle... It is easy... It will create a resistance to enter the skin and you can feel the pop easily...
 

DrAmir0078

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Midazolam will attenuate sympathetic outflow in virtuality all patients, but this is rarely an issue as the vasoplegia (minimal in the doses we currently use) and mild brady is offset by the baroreceptor reflex.

However, it's a massive issue in the maximally sympathetically charged/compensated trauma patient; the cohort your boss was probably referring to?

Either way you shouldn't use it in this case at it's an RSI for bowel obstruction, so I agree good choice on not using it.
Thanks for the info.
Will be more considered next time with such amazing information I am getting.
Thanks Dr. Woodepazz
 
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nimbus

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Thanks Dr dipriMAN

... From my mentor experience Dr. Haider Abbass in OBs C/Ss, he said "single pop after the skin pop is effective", I personally tried in C/S cases twice and with one time single pop in a pregnant patient with a history of cardiomyopathy - it worked very well and patient woke up free of pain.... I am not sure about the distance in triangle of petit towards the EQ in different patients weights with or without stretching of the skin and pushing the skin again the tissues like a probe!

I would think you need 2pops after skin. First pop being EO/IO interface and second pop being IO/TA. But I’ve never done a blind TAP.
 
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DrAmir0078

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I would think you need 2pops after skin. First pop being EO/IO interface and second pop being IO/TA. But I’ve never done a blind TAP.
Yup, I do understand that, but I said even one pop works - why? Could've the IQ is stretched enough, don't know, but tried it so many times!

There is an interesting research from South Korea, but for the old 2 cm medial to ASIS 2cm above and do the same TAP and they found miracles - if the spread just beyond EQ would block Ilioinguinal-iliohypogastric and iliohypogastric but if it was deep to between IQ/TA could do femoral block and would delay discharge the patients from the outpatient clinic!
But lateral TAP petit triangle, don't know!
I need to do research, could've the speed of injection would diffuse to the IQ? Who knows?

The link (carefully read)
 
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nimbus

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Yup, I do understand that, but I said even one pop works - why? Could've the IQ is stretched enough, don't know, but tried it so many times!

There is an interesting research from South Korea, but for the old 2 cm medial to ASIS 2cm above and do the same TAP and they found miracles - if the spread just beyond EQ would block Ilioinguinal-iliohypogastric and iliohypogastric but if it was deep to between IQ/TA could do femoral block and would delay discharge the patients from the outpatient clinic!
But lateral TAP petit triangle, don't know!
I need to do research, could've the speed of injection would diffuse to the IQ? Who knows?

The link (carefully read)

If it works, it works! It would be interesting to check the needle position with an ultrasound after one pop.
 
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DrAmir0078

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If it works, it works! It would be interesting to check the needle position with an ultrasound after one pop.
Can you please do it a paper mini research, mention my name, it would be helpful
 
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woopedazz

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Can you please do it a paper mini research, mention my name, it would be helpful
Someone wrote a dodgy paper on this at one of my hospitals. We do these blind "TAP" blocks in GA crash cesareans at the end of the case.

Typically diluted to 20mL each side.
Injected in divided doses of 10mL/10mL after pop 1 and 2 respectively.

I.e. left side --> skin --> pop 1, stop, inject 10mL --> pop 2, stop, inject 10mL
Repeat for right side.

Most work, some fail
 
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DrAmir0078

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Someone wrote a dodgy paper on this at one of my hospitals. We do these blind "TAP" blocks in GA crash cesareans at the end of the case.

Typically diluted to 20mL each side.
Injected in divided doses of 10mL/10mL after pop 1 and 2 respectively.

I.e. left side --> skin --> pop 1, stop, inject 10mL --> pop 2, stop, inject 10mL
Repeat for right side.

Most work, some fail
Original dodgy paper for review - If any?

Very interesting....
 

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The EO at that level is usually thin or absent and the needle could be entering the IO when you enter the skin, this makes the the first pop you feel is the needle exiting the the IO into to the TAP.
 
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I mean I have concerns about going through peritoneum and making a hole in something that doesn't need a hole even when I have ultrasound.
 

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The EO at that level is usually thin or absent and the needle could be entering the IO when you enter the skin, this makes the the first pop you feel is the needle exiting the the IO into to the TAP.
Dr. Planktonmd, at what level you mean, lateral? Triangle of petit? If yes, please cite it, it truly help me a lot... It answer lots of questions!
 

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I mean I have concerns about going through peritoneum and making a hole in something that doesn't need a hole even when I have ultrasound.
I did this TAP on a kid with appendix, before closure, I asked the resident to direct his hand fingers towards triangle of petit and I inject from outside and feel his fingers and he said I feel you are close by.
I was fearing the peritoneum, and it works...
This technique was created by me, the bi manual triangle of petit block!
 

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Dr. Planktonmd, at what level you mean, lateral? Triangle of petit? If yes, please cite it, it truly help me a lot... It answer lots of questions!
When you get closer to the inguinal ligament the external oblique muscle starts getting thinner and ends with the aponeurosis of the EO.
If you are truly lateral and posterior in the triangle of petit then the EO is basically absent and the first muscle you hit is the IO.

1617990845331.png 1617990870762.png
 
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DrAmir0078

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When you get closer to the inguinal ligament the external oblique muscle starts getting thinner and ends with the aponeurosis of the EO.
If you are truly lateral and posterior in the triangle of petit then the EO is basically absent and the first muscle you hit is the IO.

View attachment 334464 View attachment 334465
Wow Dr Planktonmd
It explained it so cool those pictures, and I used to go to the mid axillary line and will try to go to posterior axillary line, that is for sure the petit triangle, I was always thinking it is the top of iliac crest, but what I am seeing is the most top towards the posterior axillary line or in between - this is the possibility!
I am very impressed now!
So thankful!
 
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