Epidural/Spinal after the Patient is asleep?

[Zeffer]

What do you all think about this? I'll have an intresting case to post either Wednesday night or Thursday.

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[Noyac]

Generally, I don't do epidurals or spinals while the pt is under GA (except for caudals in kids). I don't have anything against the practice, its just how I was trained and so far I have not had a reason to do it. I think if you have the choice its better to do it awake. But if you don't really have a choice (not sure what cenario this would be but I'm sure there are many) and the pt would benefit tremendously from it then I wouldn't hesitate.
How's that?
Wishy Washy enough for you?

And if you are really nervous about it or against it, then I guess you could use ultrasound if there was no other way.

 

[UTSouthwestern]

Generally, I don't do epidurals or spinals while the pt is under GA (except for caudals in kids). I don't have anything against the practice, its just how I was trained and so far I have not had a reason to do it. I think if you have the choice its better to do it awake. But if you don't really have a choice (not sure what cenario this would be but I'm sure there are many) and the pt would benefit tremendously from it then I wouldn't hesitate.
How's that?
Wishy Washy enough for you?

And if you are really nervous about it or against it, then I guess you could use ultrasound if there was no other way.

One situation where I do put epidurals in after a GA is when a thoracoscopic procedure has to be converted to an open thoracotomy. I get consent for an ED for just such an occasion. After the surgery is done, the patient is already in a lateral position and I have access to do a TED quite readily.

 

[Noyac]

One situation where I do put epidurals in after a GA is when a thoracoscopic procedure has to be converted to an open thoracotomy. I get consent for an ED for just such an occasion. After the surgery is done, the patient is already in a lateral position and I have access to do a TED quite readily.

See, there is one cenario. I'd do that. But in the past I have done them in the recovery room.

 

[jetproppilot]

One situation where I do put epidurals in after a GA is when a thoracoscopic procedure has to be converted to an open thoracotomy.

Did one of these last week. Same scenerio.

 

[The_Sensei]

I wouldn't do it.....but that's just me. Check out the following link anyway:

http://www.asahq.org/Newsletters/2001/04_01/horlocker.htm

 

[nimbus]

How about the 90 year old for ORIF hip fx?

I give them fentanyl 50 mcg+Propofol 20-30mg before I flip them on their side for a spinal. I don't wait around for them to wake up before I put in the spinal. At that point, they are not under GA but I don't think they could tell me if I did something really bad to them.

I know a lot of others who do it the same way. Does anybody take issue with this?

Regarding thoracoscopies, the surgeons I work with have a good idea of which patients will be converted to thoracotomy. If there is a likelihood of conversion, I stick in an epidural ahead of time even if the case is booked as a thoracoscopy. Even the thoracoscopy patients benefit from a epidural, especially on the first postop day. Although I have put in asleep epidurals in the past, I haven't had to do so in the last 3 years.

 

[jetproppilot]

I wouldn't do it.....but that's just me. Check out the following link anyway:

http://www.asahq.org/Newsletters/2001/04_01/horlocker.htm

I totally agree concerning peripheral nerve blockade, but I feel very comfortable with driving a Tuohy under GA if their body habitus is acceptable. It is on rare occasion that this is necessary anyway.

And I do spinals on fractured-old-person-hips with a little propofol like described above.

 

[militarymd]

I agree with Jet and UT....It is very unlikely for a blunt, large needle like the Tuohy to injure nerves...


On the other hand, sharp tiny needles for spinals and nerve blocks seem a little scary.

The above is a non-evidence based opinion from the President of SARA.

 

[rainking]

One situation where I do put epidurals in after a GA is when a thoracoscopic procedure has to be converted to an open thoracotomy. I get consent for an ED for just such an occasion. After the surgery is done, the patient is already in a lateral position and I have access to do a TED quite readily.

just do it in the recovery room..

 

[rainking]

I agree with Jet and UT....It is very unlikely for a blunt, large needle like the Tuohy to injure nerves...


On the other hand, sharp tiny needles for spinals and nerve blocks seem a little scary.

The above is a non-evidence based opinion from the President of SARA.

quite the contrary...

a smalll tiny 25 g whitacre can do little damage if you are extremely careful while placing it.... I think a epidural needle can do more damage

 

[militarymd]

quite the contrary...

a smalll tiny 25 g whitacre can do little damage if you are extremely careful while placing it.... I think a epidural needle can do more damage

Large dull needles tend to push structures out of the way....reason for using a Tuohy needle....pushes dura away to find epidural space.

Reason for B-bevel needles....the duller tip is more likely to push nerves away during attempts to get near nerves rather than cutting them.


Whereas very small regular tipped needles are more likely to cut and/or pierce nerves.

I believe that is the rationale behind the designs of the needles.

Otherwise, why would we have different types of needles specifically for nerve blocks.

 

[jetproppilot]

quite the contrary...

a smalll tiny 25 g whitacre can do little damage if you are extremely careful while placing it.... I think a epidural needle can do more damage

I disagree.

The anatomy of epidural placement is conducive to being able to construct a 3-D picture in your head of where you are placing the needle...spinous processes above and below...after experience you "know" what approximate depth to place the needle, and develop a tactile sense which is just as valuable....

...interscalenes, axillary blocks, etc are less exact and typically require more "probing".

 

[Noyac]

I disagree.

The anatomy of epidural placement is conducive to being able to construct a 3-D picture in your head of where you are placing the needle...spinous processes above and below...after experience you "know" what approximate depth to place the needle, and develop a tactile sense which is just as valuable....

...interscalenes, axillary blocks, etc are less exact and typically require more "probing".

True. Epidurals and even spinals are the only ones I'd consider doing asleep. Peripheral blocks are much more risky. With that being said, I will do a 3-in-1 block with the pt asleep.

 

[UTSouthwestern]

just do it in the recovery room..

Why? They're already in position in the OR, usually already prepped, although I prep additionally, they don't sway too and fro, and they don't have to wake up with any sensation of pain from the beginning.

Transporting them to the PACU, having them turn to the side or worse, sit on the edge of a bed with their chest tubes tugging at skin, coughing from the chest tube irritation of the diaphragm/phrenic nerve, etc., seems to be adding a lot of wasted time and effort to it.

 

[rainking]

Why? They're already in position in the OR, usually already prepped, although I prep additionally, they don't sway too and fro, and they don't have to wake up with any sensation of pain from the beginning.

.

Because grasshopper, you dont wanna explain to the law firm of cohen, shapiro, rabinowitz and shchwartz, Ltd. from the big city why you put in a regional anesthetic while the patient was asleep..( and there will be plenty of your colleagues on the witness stand saying, " I never do it asleep" Its all about LIMITING your LIABILITY DUDE. I know I know its a pain in the ass to do it in the recovery room but it will help you.. Or just do it before he or she goes to sleep.

 

[UTSouthwestern]

Because grasshopper, you dont wanna explain to the law firm of cohen, shapiro, rabinowitz and shchwartz, Ltd. from the big city why you put in a regional anesthetic while the patient was asleep..( and there will be plenty of your colleagues on the witness stand saying, " I never do it asleep" Its all about LIMITING your LIABILITY DUDE. I know I know its a pain in the ass to do it in the recovery room but it will help you.. Or just do it before he or she goes to sleep.

Well cricket, since, as stated previously, I explain the risks to the patient before the case and have them sign a consent which contains all information about the risks and benefits of the procedure and states that I am more than happy to wake them up first and do it after the case, I'd say I'm reasonably well covered.

But that's just me. I would rather not have my patients feeling a thoracotomy incision then having them jump through hoops to get an epidural I can place in 3 minutes after the end of the case. Unless they want to.

Given the volume of thoracic cases my group covers, an ED for every thoracoscopy would be serious overkill.

 

[rainking]

Well cricket, since, as stated previously, I explain the risks to the patient before the case and have them sign a consent which contains all information about the risks and benefits of the procedure and states that I am more than happy to wake them up first and do it after the case, I'd say I'm reasonably well covered.

But that's just me. I would rather not have my patients feeling a thoracotomy incision then having them jump through hoops to get an epidural I can place in 3 minutes after the end of the case. Unless they want to.

Given the volume of thoracic cases my group covers, an ED for every thoracoscopy would be serious overkill.

DUDE

informed consent doesnt mean anything.. the patient doesnt understand, you forced her, she was anxious etc... theyll say anything... Limit your liability and do it while the patient is awake.. I dont see anything wrong with it.. however.. a lawyer will if ANYTHING bad happens.. and there will be your colleagues testifying against you as expert witnesses.. Just info..

 

[UTSouthwestern]

DUDE

informed consent doesnt mean anything.. the patient doesnt understand, you forced her, she was anxious etc... theyll say anything... Limit your liability and do it while the patient is awake.. I dont see anything wrong with it.. however.. a lawyer will if ANYTHING bad happens.. and there will be your colleagues testifying against you as expert witnesses.. Just info..

A lawyer will sue you even if everything goes perfectly, awake or asleep. I've put everything down in writing and I document everything in my notes. Included in those notes is a narrative that clearly states that the patient's choice and reaffirmation on the day of surgery. Lawyers dictate that I have to spell everything out in simple English to all of my patients but they do not dictate the way I practice.

 

[rainking]

Lawyers dictate that I have to spell everything out in simple English to all of my patients but they do not dictate the way I practice.

oh yes they do.. I bet you there is a lawyer behind every single protocol going in the hospital ..LOL

dude dont fight it.. just accept it...

 

[militarymd]

oh yes they do.. I bet you there is a lawyer behind every single protocol going in the hospital ..LOL

dude dont fight it.. just accept it...

soooo....what were your previous usernames?

 

[jetproppilot]

soooo....what were your previous usernames?

haha....youre probably spot on, Mil.

Mil FBI Profiler....

hmmmmm....

has a certain ring to it....

 

[rainking]

haha....youre probably spot on, Mil.

Mil FBI Profiler....

hmmmmm....

has a certain ring to it....

I already told him i was banned several times from the forum...

 

[UTSouthwestern]

oh yes they do.. I bet you there is a lawyer behind every single protocol going in the hospital ..LOL

dude dont fight it.. just accept it...

Funny, I thought TREATMENT protocols were driven by evidence based medicine. I could give a rat's ass about ADMINISTRATIVE protocols.

 

[UTSouthwestern]

haha....youre probably spot on, Mil.

Mil FBI Profiler....

hmmmmm....

has a certain ring to it....

Come on, we all know its Justin 456390210 whatever.

 

[cloud9]

Come on, we all know its Justin 456390210 whatever.

or stephend1977 / davvid2600 (or whatever the handles were). My money's on this guy.

 

[s204367]

My 2 cents.
I think you walk a very dangerous line placing a thoracic epidural in an asleep patient. A tuohy needle that advances too far will take a punch biopsy of the cord, whereas a 25 or 27g whitacre may cause damage, but damage that may be recoverable..
Now, I do do thoracic epidurals on asleep kids WITH flouro, a simple c-arm when I do Pectus repairs....Otherwise, my thoracic epidurals are all done awake with a little bit of sedation...sometimes havin em awake can guide you midline in a fat phuker. If its a VATS and i think the risk of opening is high..epidural, only takes a few minutes, and most of the COPDers are thin..

The 90 yr old with a hip fracture...now, this gets a little ethical, but at least 50% of the hip fractures we do, the pt will never walk again. Their hip is getting repaired so that they can be elligible for SNF placement, and perhaps to decrease pain. Versed/Fent, sometimes prop, if they are real fragile, a combo of 1mg Versed with some ketamine....you can sit the pt right up without a moan....it all really depends. Even if you drove a 22 quinke right into the conus, most likely you would never hear about it again....Don't jump on me for that, I am just saying each pt has their own risks and choose them wisely...I don't do regional blocks on psych patients either.

Despite the consent, if you ever had a complication from placing an epidural on an asleep pt, your ass is fried. It is probably fried on an awake pt too, but not if your documentation is excellent. Look at the closed claims results and the number of settled cases from even lumbar epidurals...I would say they cause more trauma...

 

[rainking]

agree 103 percent

thats what i was telling UT southwestern.. BUt he thinks its defendable practice.. even after he "takes a punch biopsy of the cord"

 

[militarymd]

agree 103 percent

thats what i was telling UT southwestern.. BUt he thinks its defendable practice.. even after he "takes a punch biopsy of the cord"

Hey, what did he get banned for? I searched his last few posts....doesn't seem unreasonable....

Was it PM's?

 

[UTSouthwestern]

agree 103 percent

thats what i was telling UT southwestern.. BUt he thinks its defendable practice.. even after he "takes a punch biopsy of the cord"

You must speak from experience because I have no clue how you can be that bad at placing epidurals. Certainly you can get a wet tap, but to punch through the cord? It's no wonder that you have so many problems in your career, Justin4563.

For the record, I contacted the president of our local anesthesia society and asked him specifically about defending an asleep epidural with consent signed and he is aware of two successfully defended epidurals under anesthesia (for incomplete analgesia and a dermatomal neuropathy that developed after the ED was removed).

He also pointed out that he routinely placed epidurals in asleep pedi patients, caudal, lumbar, and thoracic. He doesn't recommend it, but in certain circumstances, such as in a rescue analgesic situation (thoracoscopy converted to thoracotomy, rib fractures in the ER in a patient heavily sedated and/or intubated, etc.), he agrees it can be done and is defensible and he, like me, consents his thoracoscopy patients for just those situations with extreme words of warning about complications.

Unlike some people, both he and I will abandon the procedure if any difficulty is anticipated or BEGINS to be encountered, as opposed to forcing it and getting a biopsy of the cord.

 

[s204367]

Now first, I place thoracic epidurals on asleep kids..with c-arm. Suppose however, you are placing an epidural on an asleep pt at the end of the case. You turn the pt sideways, just as you are advancing the tuohy the pt either bucks on the tube, or more likely responds to the pain of an epidural and jumps. Or, just suppose, everything goes well, but you end up with nerve damage. Now, most regional Gurus I know would voluntarily sit on a stand to fry your ass. As a resident I sat on the ASA committee of standards of care. THis came up at one of our meetings at the Vegas national meeting. Every member of the committee, attending members, considered it not the standard of care. Certain circumstances, where the risk outweighs the benefit sure. But just because everything so far has gone well...if you have one complication from an asleep epidural EVEN if things go well and you are certain you did everything well, place that epidural asleep and just open up your wallet. I don't care WHAT you have them consented to. I have testified before, in almost every malpractice case....failure to consent is named in the suit even WITH fully written signed dated consents......practice however you want, but I try to limit my risks because **** does happen...

 

[militarymd]

Now first, I place thoracic epidurals on asleep kids..with c-arm. Suppose however, you are placing an epidural on an asleep pt at the end of the case. You turn the pt sideways, just as you are advancing the tuohy the pt either bucks on the tube, or more likely responds to the pain of an epidural and jumps. Or, just suppose, everything goes well, but you end up with nerve damage. Now, most regional Gurus I know would voluntarily sit on a stand to fry your ass. As a resident I sat on the ASA committee of standards of care. THis came up at one of our meetings at the Vegas national meeting. Every member of the committee, attending members, considered it not the standard of care. Certain circumstances, where the risk outweighs the benefit sure. But just because everything so far has gone well...if you have one complication from an asleep epidural EVEN if things go well and you are certain you did everything well, place that epidural asleep and just open up your wallet. I don't care WHAT you have them consented to. I have testified before, in almost every malpractice case....failure to consent is named in the suit even WITH fully written signed dated consents......practice however you want, but I try to limit my risks because **** does happen...

I have refrained on posting because I am the president of SARA (Society Against Regional Anesthesia).

However, having said that....I HAVE placed thousands of epidurals in various levels along the spine....and in my limited experience....the consciousness of the patient did not affect how the epidural was placed.

Despite that experience, I do not place neuraxial cathethers in unresponsive patients......why? because I'm a *****.

On the other hand.....we SHOULD NOT allow non-physicians (lawyers) alter how we practice medicine......

 

[UTSouthwestern]

So basically, awake or asleep, you can get screwed. So practice the way you are comfortable practicing. Just don't punch biopsy the spinal cord because you're too stupid to know when to stop.

 

[s204367]

Jones is definitely now a bitch. He was shakin like Matty Z gettin ready to head into a liver tx with HT on the day of his wedding..

I agree though. How many times have you talked to a pt who claims they have had back pain ever since they had a spinal years ago???

PS-ordered the RS4.