Let’s do another case

[Noyac]

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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.

 

[Southpaw]

given your interview with the patient this is a spinal, even with that X-ray.

 

[dannyboy1]

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....

 

[okayplayer]

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).

 

[dhb]

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).

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.

 

[Noyac]

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.

 

[deleted162650]

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.

 

[Arch Guillotti]

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.

That's why I would have just put her to sleep and done a TIVA. Next.

 

[Noyac]

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.

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.

 

[Noyac]

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!

 

[Arch Guillotti]

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!

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.

 

[banister]

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.

Yeah, I was taught to do the same. Helps a lot to look at available imaging.

 

[abolt18]

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.

Any DO should have learned this in med school 🙂

The vertebrae rotate the opposite direction of the bend.

See for example, Fryette's Laws.
" Principle I: When the spine is in neutral, sidebending to one side will be accompanied by horizontal rotation to the opposite side.[2] This law is observed in type I somatic dysfunction, where more than one vertebra is out of alignment and cannot be returned to neutral by flexion or extension of the vertebrae. The involved group of vertebrae demonstrates a coupled relationship between sidebending and rotation. When the spine is neutral, side bending forces are applied to a group of typical vertebrae and the entire group will rotate toward the opposite side: the side of produced convexity[3] Extreme type I dysfunction is similar to scoliosis. "

 

[anbuitachi]

Yeah, I was taught to do the same. Helps a lot to look at available imaging.
View attachment 311101

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

 

[banister]

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

 

[chocomorsel]

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 need a picture from back to front to see what it is I am supposed to appreciate.

 

[deleted162650]

I guess so, but you'd have to enter the skin a cm or two off midline

You often have to do that as well angle away from midline with significant scoli.

 

[Noyac]

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 tried this a couple times but found that engaging the interspinous ligament was much more reliable.

 

[Noyac]

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.

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.

 

[fakin' the funk]

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.

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.

 

[fakin' the funk]

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.
I recommend you change your approach. Otherwise, you are no better than the trolls you reign down on.

Dude what

 

[deleted697535]

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.

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!

 

[deleted162650]

Doing a fair number of thoracic epidurals these days

What kinda cases? I feel like it's been a solid year since anyone in my group has placed a Thoracic epidural.

 

[Hoya11]

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!

Yes. As a pain fellow we would often look up old imaging to see what we are getting into.. no literature but it is done commonly

The imaging gives you a sense of how easy it is to get in overall.. they usually fall into 2 categories:

1. Holy crap look at that spine its so arthritic and twisted, no visible openings I can see to the epidural space this is going to be tough!
2. This isn't going to be so bad its mostly preserved and several reasonable visible openings

 

[Twiggidy]

What kinda cases? I feel like it's been a solid year since anyone in my group has placed a Thoracic epidural.

Same. We lost one of our few surgeons who did VATS

 

[Arch Guillotti]

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.

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!

 

[Urzuz]

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

 

[anbuitachi]

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

a lot of these cancer cases that may benefit from thoracic epidural, the surgeons here like to give lovenox around induction. and yes the risk of epidural bleeding is low, however it still goes against asra guidelines about using lovenox shortly after epidural placement

 

[fakin' the funk]

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!

Anecdotal answer: yes
Scan usually done only a few weeks prior
Levels you are looking at (T6-10) not likely to be distorted by the disease process (eg pancreatic ca)
There seems to be impressive variation in the ant-post depth of the posterior column and thickness of soft tissue even in normal nonobese patients in the thoracic spine
Compression of posterior thoracic soft tissue in supine issue is a consideration, yes
So is the fact that when you measure skin to LF depth it is a strictly axial measurement, not a paramedian cephalad+medial-angulation path that your needle actually takes
Can also look at sagittal cuts to confirm

Point is, in this difficult procedure, readily available imaging of your specific patient may make the difference between a successful procedure and 30 minutes of flail

 

[fakin' the funk]

What kinda cases? I feel like it's been a solid year since anyone in my group has placed a Thoracic epidural.

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.

 

[fakin' the funk]

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

This

 

[deleted162650]

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.

Wow, you guys are doing a lot of big cases.

 

[MoMoGesiologist]

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!

Tsk tsk. You gotta double down and commit. Go for the throat; don’t back down!

 

[anbuitachi]

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?

 

[fakin' the funk]

so is 4 point tap just bilateral TAP block and bilateral subcostals?? how much local do you use for that.. max 0.25% bupi?

Tbh I have no idea what they do. I think that's the intent, yes, bilateral classic+subcostal TAPs.

When I do these for a midline laparotomy on the bigger side, I'll do 20 exparel + 60 0.25% bupi + 10 saline. 25 in each subcostal tap, 20 in each classic tap. All hand waving obviously but it seems to have some efficacy and can be done quickly after patient is asleep.