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I’m not that good at US.like someone said above. the image helps. scan her ultrasound and go at low level. i wouldve attempted spinal even with that image
I’m not that good at US.like someone said above. the image helps. scan her ultrasound and go at low level. i wouldve attempted spinal even with that image
Were the pilgrims MH refugees from Europe? I don't remember ever seeing an MH susceptible patient and have never had to do a machine flush.I have taken care of many nervous MH susceptible patients (as I’m sure you all have) and been able to explain in broad terms a non-triggering anesthetic in a way that made them feel more comfortable (along with some versed).
That’s why I asked if anyone was co that this was done a year ago as well. Now she is returning and the surgeon plans more than an I&D. He was digging in than ass for a long time.Just do this prone with a propofol gtt and local by the surgeon as is done hundreds of times a day. Have the anesthesia circuit prepped for an MH case just in case....
That’s why I asked if anyone was co that this was done a year ago as well. Now she is returning and the surgeon plans more than an I&D. He was digging in than ass for a long time.
Boom, exactly. I had to start on the right side one inch from midline and direct the needle towards the left side And ended up about an inch from midline again. I made an effort to locate the intraspinal ligament and to stay in it. If I felt the needle leave the ligament then I stopped and redirected.The trick with scoli is to appreciate that there is twist in conjunction with the lateral curve. This means that you actually need to take an angle away from midline even though you are already starting off lateral to the midline. Counterintuitive, and doesn’t feel right the first time you do it, but that’s the key.
I guess you don’t care about her anxiety and wish not to go to sleep. Or maybe you don’t wield the force like Saltydog. Sometimes the pts desires can be as important as your own, Doctor!That's why I would have just put her to sleep and done a TIVA. Next.
I guess you don’t care about her anxiety and wish not to go to sleep. Or maybe you don’t wield the force like Saltydog. Sometimes the pts desires can be as important as your own, Doctor!
Boom, exactly. I had to start on the right side one inch from midline and direct the needle towards the left side And ended up about an inch from midline again. I made an effort to locate the intraspinal ligament and to stay in it. If I felt the needle leave the ligament then I stopped and redirected.
Any DO should have learned this in med schoolThe trick with scoli is to appreciate that there is twist in conjunction with the lateral curve. This means that you actually need to take an angle away from midline even though you are already starting off lateral to the midline. Counterintuitive, and doesn’t feel right the first time you do it, but that’s the key.
Yeah, I was taught to do the same. Helps a lot to look at available imaging.
View attachment 311101
I guess so, but you'd have to enter the skin a cm or two off midlinelook at this image, couldnt you have just gone straight in at plane of the back and gotten in as well... its like paramedian, except your needle isnt the one turning, the back is
I need a picture from back to front to see what it is I am supposed to appreciate.look at this image, couldnt you have just gone straight in at plane of the back and gotten in as well... its like paramedian, except your needle isnt the one turning, the back is
I guess so, but you'd have to enter the skin a cm or two off midline
I tried this a couple times but found that engaging the interspinous ligament was much more reliable.look at this image, couldnt you have just gone straight in at plane of the back and gotten in as well... its like paramedian, except your needle isnt the one turning, the back is
Really?Dude is this the first MH susceptible pt. you have had? I mean, they aren't a dime a dozen but there are enough of them out there (usually kids) that I have had a few discussions with mostly parents (who can be very nervous) that the risk is negligible if handled properly.
The trick with scoli is to appreciate that there is twist in conjunction with the lateral curve. This means that you actually need to take an angle away from midline even though you are already starting off lateral to the midline. Counterintuitive, and doesn’t feel right the first time you do it, but that’s the key.
Dude whatReally?
You know me better than that. What are you trying to accomplish, Mr Administrator?
Because to me it appears that you are Trying to instigate a confrontation. Not something An SDN administrator should be doing.
I recommend you change your approach. Otherwise, you are no better than the trolls you reign down on.
Thats interesting, im a little sceptical though. Can a supine CT done possibly months before be of any relevance to a seated position, hunched forward thoracic epidural attempt? Id like to see some literature on that if you had it! Thanks!Doing a fair number of thoracic epidurals these days and can't agree more. If you have a CT (done for whatever surgery) showing you the relevant levels, use it - can measure depth to LF, see rotation, etc. Sometimes you end up having to take crazy pseudo-parasagittal-but actually-midline needle angles you never would have otherwise.
Doing a fair number of thoracic epidurals these days
Thats interesting, im a little sceptical though. Can a supine CT done possibly months before be of any relevance to a seated position, hunched forward thoracic epidural attempt? Id like to see some literature on that if you had it! Thanks!
Same. We lost one of our few surgeons who did VATSWhat kinda cases? I feel like it's been a solid year since anyone in my group has placed a Thoracic epidural.
Really?
You know me better than that. What are you trying to accomplish, Mr Administrator?
Because to me it appears that you are Trying to instigate a confrontation. Not something An SDN administrator should be doing.
What kinda cases? I feel like it's been a solid year since anyone in my group has placed a Thoracic epidural.
Not the poster you replied to, but: Whipples, big surgical oncology/tumor debulking cases, certain open hepatobiliary cases if you don't anticipate coagulopathy postoperatively, etc.
There is no denying that thoracic epidurals provide gold standard analgesia for these kinds of cases. Whether they are worth the headache of managing them properly...YMMV
Thats interesting, im a little sceptical though. Can a supine CT done possibly months before be of any relevance to a seated position, hunched forward thoracic epidural attempt? Id like to see some literature on that if you had it! Thanks!
What kinda cases? I feel like it's been a solid year since anyone in my group has placed a Thoracic epidural.
ThisThere is no denying that thoracic epidurals provide gold standard analgesia for these kinds of cases. Whether they are worth the headache of managing them properly...YMMV
Lots of Whipples, open hepatic resections, open gyn onc, open thoracic, abdominal sarcomas, etc. Dedicated acute pain doc weekdays.
Vast majority of thoracic is VATS (surgeon does exparel intercostals) but we do enough volume to have several open lobes, decorts, meso cases a month.
Our hepatobiliary group has taken a sharp turn away from TEA toward either doing their own "4-point TAP" blocks with exparel, or asking us for same, for many open hepatobiliary cases whether midline or subcostal incisions. I was skeptical at first. After 6+ months, I can't say that skipping TEA is entirely wrong - a lot of these patients are pretty comfortable postop and obviously it's less hassle, calls, hypotension, fluid boluses, etc, for everyone.
Tsk tsk. You gotta double down and commit. Go for the throat; don’t back down!lol wut dude. No cupcakes or snowflakes here!
I think your approach is nuts. Not my jam. You got her through safely and comfortably, nice job!
Lots of Whipples, open hepatic resections, open gyn onc, open thoracic, abdominal sarcomas, etc. Dedicated acute pain doc weekdays.
Vast majority of thoracic is VATS (surgeon does exparel intercostals) but we do enough volume to have several open lobes, decorts, meso cases a month.
Our hepatobiliary group has taken a sharp turn away from TEA toward either doing their own "4-point TAP" blocks with exparel, or asking us for same, for many open hepatobiliary cases whether midline or subcostal incisions. I was skeptical at first. After 6+ months, I can't say that skipping TEA is entirely wrong - a lot of these patients are pretty comfortable postop and obviously it's less hassle, calls, hypotension, fluid boluses, etc, for everyone.
so is 4 point tap just bilateral TAP block and bilateral subcostals?? how much local do you use for that.. max 0.25% bupi?