Rotator cuff repair that is a bit unusual.

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What does the vascular surgeon or whoever... do to get the case under way? 😉
 
Doesn't he/she map out LE venous structures...

Starts up at the femoral vein and work his/her way down the leg... with an USD.

Then, once the patient is asleep, he places a 18g/20g until he gets a flash... then wires it in with a .21/.25g wire.... Kinda like a venous a-line.

I'm pretty sure most anesthesiologists trained with USD can run circles around most vascular surgeons with USD skills.

No neck lines for me on this case. Chubby neck, carotid, plavix, awake, etc.

No femoral lines with big fat pannus and placement of CVP in the outpatient setting either.

Stepping a little outside of the box here. 🙂

(actual picture from friday)

6827377302_e52b5b2f60.jpg
[/url]
IMG_2180 by Crazyhorse75, on Flickr[/IMG]
 
sevoflurane said:
Need an IV for a ISB/SCB and LMA.... 🙄
Click to expand...

So? I do anticoagulated patients frequently for central line placement. This is no big deal. Plavix and aspirin? So what? I do INRs of 2.5-5 and Fully heparinized patients. Previous Carotid surgery is no big deal when you use U/S.

Use your U/S stud. Find a large IJ greater than 10 mm preferably on the opposite side of the surgery. If the IJ is small go Femoral as you only need the line for a few hours.

For those ultracautious types on here place a Femoral venous line and be done with it.
Get an orderly or nurse to hold up her big belly while you find the vein.
 
6973495055_ecb674b9b1.jpg
[/url]
IMG_2184 by Crazyhorse75, on Flickr[/IMG]


Unusual place for an IV.

Love USD.

The technology makes things easier and safer.

(sorry 'bout the tape job... a little OCD when it comes to securing a foot/leg line in the sitting position)
 
ssmallz said:
I am the expert but it certainly can't hurt to have in the cards note something about risks of bleeding vs benefits of regional anesthesia. If he states something along the lines of the benefits of RA (stable hemodynamics) outweigh the risks (hematoma, bleeding), then it makes our case for choosing RA stronger if we had to defend it to some lawyer at a later time. This is especially important IMO b/c our ASRA guidlines state we should wait 7 days before placing a block and if we are disagreeing with the published literature we should have a very strong case for doing so. IMO another opinion on this will only strengthen our case
Click to expand...

Sorry for bringing this up again, but I have issues with people having cardiology, or whomever, making decisions for them.

The way I see it YOU think regional is more hemodynamically stable but want to be able to BLAME cardiology if something goes wrong with your approach. "He made me do it".

If I were the cardiologist I would give 3 flying f.... for how you anesthetize the pt. My recommendations are continue the dual antiplatelet, avoid hypoxia, hypotension, and tachycardia. It's your field, your problem.
 
urge said:
You just share the responsibility, i.e. both get screwed. Cardiology notes, writing "discussed risk, benefits, alternative", and all that nonsense people focus on don't mean anything. What matters is the outcome. And, in case of a bad outcome, did you follow standard of care?

I'm sure the plaintiff will have no problem finding anyone to testify you did not follow standard of care by stopping the plavix.
Click to expand...

I don't stop plavix...ever. That's up to Cards and the surgeon. I wont hit anything but net when placing the ISB under U/S. I've done thousands and thousands of these with nothing but a ****ty NS. Under U/S this is a lay up.

If you don't have confidence in yourself or your ability then keep working at it. We are asked to step up to the plate daily where I work. Daily.

One last thing I'm very familiar with our legal system especially in Florida. I know what to expect from our J.D. friends.
 
sevoflurane said:
Doesn't he/she map out LE venous structures...

Starts up at the femoral vein and work his/her way down the leg... with an USD.
Click to expand...

Mine does it a bit different. Marks the veins preop with the patient standing. Scans after induction. Does mostly stab phlebectomies, sometime endovascular. They're pretty good with the US.

But doing an IJ with ASA and Plavix is no big deal. Just use the US and don't hit the carotid. If really fancy then do an ISB at the same time.
 
BLADEMDA said:
So? I do anticoagulated patients frequently for central line placement. This is no big deal. Plavix and aspirin? So what? I do INRs of 2.5-5 and Fully heparinized patients. Previous Carotid surgery is no big deal when you use U/S.

Use your U/S stud. Find a large IJ greater than 10 mm preferably on the opposite side of the surgery. If the IJ is small go Femoral as you only need the line for a few hours.

For those ultracautious types on here place a Femoral venous line and be done with it.
Get an orderly or nurse to hold up her big belly while you find the vein.
Click to expand...

Have you ever had a femoral CVL kink in the sitting position? Do you like trouble shooting under the drapes with someone holding the panus?

Do you want to charge the patient for a CVL on the oupatient side?

What if you put her in t-burg and she gets combative with her fat belly pushing up on her diaphragm... right as you are sticking her non-existant 2 inch neck....?

My room time was 7:20am. Patient intubated and turned over at 7:35am.

Most central lines are butter easy. Sometimes they are not. 🙂
 
urge said:
Sorry for bringing this up again, but I have issues with people having cardiology, or whomever, making decisions for them.

The way I see it YOU think regional is more hemodynamically stable but want to be able to BLAME cardiology if something goes wrong with your approach. "He made me do it".

If I were the cardiologist I would give 3 flying f.... for how you anesthetize the pt. My recommendations are continue the dual antiplatelet, avoid hypoxia, hypotension, and tachycardia. It's your field, your problem.
Click to expand...

Agreed. I'd just ask if it was "safe" or "okay" to stop the Plavix for 3 days. If the answer is "yes" re-schedule. If "no" just do the case after making a note in the chart about your conversation with the Cardiologist (proceeding at 6 months following DES while cont. dual anti-platelet therapy; Cardiologist aware and agrees with Ortho to proceed.)
 
sevoflurane said:
Have you ever had a femoral CVL kink in the sitting position? Do you like trouble shooting under the drapes with someone holding the panus?

Do you want to charge the patient for a CVL on the oupatient side?

What if you put her in t-burg and she gets combative with her fat belly pushing up on her diaphragm... right as you are sticking her non-existant 2 inch neck....?

My room time was 7:20am. Patient intubated and turned over at 7:35am.

Most central lines are butter easy. Sometimes they are not. 🙂
Click to expand...

Thanks for the lecture on central lines. You do realize how many I have placed, right? Now you are telling me the risks? Nice. I fully understand the risks here and I'm extremely confident that a large IJ greater than 10mm is a lay-up under U/S. (I've placed them in 500 pounders for Bariatric surgery)

And I've placed them in outpatient centers before without U/S. Yes, I have no issues with charging this patient for any and all necessary procedures.

I'm glad you got the vein with U/S. Nice shot.
 
sevoflurane said:
6973495055_ecb674b9b1.jpg
[/url]
IMG_2184 by Crazyhorse75, on Flickr[/IMG]


Unusual place for an IV.

Love USD.

The technology makes things easier and safer.

(sorry 'bout the tape job... a little OCD when it comes to securing a foot/leg line in the sitting position)
Click to expand...

Looks good.. do you have longer angiocaths? I always find the deep veins I find with our standard IVs never work as well as I would like...

That's why I prefer a central line.. imagine if the IV stops working during the case...

drccw
 
The purpose of this case was just to show a different way to do things.

I thought about doing a neck line on her...

I choose another route.

That's all. Just sharing a different way.
 
sevoflurane said:
The purpose of this case was just to show a different way to do things.

I thought about doing a neck line on her...

I choose another route.

That's all. Just sharing a different way.
Click to expand...

Nice shot. Funny how you are worried about the FEMORAL Line kinking under the drapes but not about the loss of the IV. To each his own I guess.
 
Now... regarding the bleeding with plavix and a rotator cuff.

#1 rule for me is:


KNOW YOUR SURGEON!


When my orthopod buddy says he's gonna be in and out in 20 minutes and it's a small tear and it won't be bloody....

HE MEANS IT... not all are like that. This one is.

ISB....? Yeah... sure

I coulda done it.

But I didn't.

I listend to him.... and believed him. I can always do the block post-op.

Here is the incision for our rotator cuff repair that took 20 minutes.

6973494161_53c019b0da.jpg
[/url]
IMG_2178 by Crazyhorse75, on Flickr[/IMG]


I encouraged 20cc's of .5% with 1:200k epi (for potential bleeding).

and...

she woke up very comfortable.

ISB would have just put some $$$ in my pocket and given her a motor/analgesic block for 24hrs.

Not necessary here. Not this time.
 
Last edited:
BLADEMDA said:
Nice shot. Funny how you are worried about the FEMORAL Line kinking under the drapes but not about the loss of the IV. To each his own I guess.
Click to expand...

That IV had 4 nurses with AR's protecting it... 😉

It was a VERY secure line.
 
sevoflurane said:
Now... regarding the bleeding with plavix and a rotator cuff.

#1 rule for me is:


KNOW YOUR SURGEON!


When my orthopod buddy says he's gonna be in and out in 20 minutes and it's a small tear and it won't be bloody....

HE MEANS IT... not all are like that. This one is.

ISB....? Yeah... sure

I coulda done it.

But I didn't.

I listend to him.... and believed him. I can always do the block post-op.

Here is the incision for our rotator cuff repair that took 20 minutes.

6973494161_53c019b0da.jpg
[/URL]
IMG_2178 by Crazyhorse75, on Flickr[/IMG]


I encouraged 20cc's of .5% with 1:200k epi (for potential bleeding).

and...

she woke up very comfortable.

ISB would have just put some $$$ in my pocket and given her a motor block for 24hrs.

Not necessary here. Not this time.
Click to expand...


Nice job. The only thing different I would have done is the ISB. In about 4 hours that local is going to wear off. I bet the block would offer potential advatages to decreasing her "stress" and possible risk of a thrombus.
 
Good job.

How long are those IV's?
 
BLADEMDA said:
Thanks for the lecture on central lines. You do realize how many I have placed, right? Now you are telling me the risks? Nice. I fully understand the risks here and I'm extremely confident that a large IJ greater than 10mm is a lay-up under U/S. (I've placed them in 500 pounders for Bariatric surgery)

And I've placed them in outpatient centers before without U/S. Yes, I have no issues with charging this patient for any and all necessary procedures.
Click to expand...

Don't take me the wrong way Blade. I was not lecturing YOU. You have more experience than most on this forum and as such I appreciate your clinical contribution... 👍

I've also placed plenty of central lines in the outpatient setting. I liked the method above. It was easy, cheap, safe and lightning fast. All things we like in medicine.

I'm just showing a different way for others to THINK about next time they get in these scenarios... which they will get into.

That is what this forum is 'bout right? 🙂
 
sevoflurane said:
Don't take me the wrong way Blade. I was not lecturing YOU. You have more experience than most on this forum and as such I appreciate your clinical contribution... 👍

I've also placed plenty of central lines in the outpatient setting. I liked the method above. It was easy, cheap, safe and lightning fast. All things we like in medicine.

I'm just showing a different way for others to THINK about next time they get in these scenarios... which they will get into.

That is what this forum is 'bout right? 🙂
Click to expand...

Like I said "good job." I've got NO ISSUES how you handled this case. None. I'd glady have you place that IV for me then I'd do the ISB.😉

The evidence behind Regional improving outcome is weak. Would it reduce the patient's stress response? Reduce inflammation? Lower C Reactive protein post op?


http://bja.oxfordjournals.org/content/107/suppl_1/i90.full.pdf
 
How about SEVO mask induction for this patient then deal with the IV? It makes things easier to find that thumb vein or ventral wrist vein after a little vasodilation/venodilation.

If you can't get the IV then place the IJ under U/S with the patient asleep. I've done it before and will do it again.
 
BLADEMDA said:
How about SEVO mask induction for this patient then deal with the IV? It makes things easier to find that thumb vein or ventral wrist vein after a little vasodilation/venodilation.

If you can't get the IV then place the IJ under U/S with the patient asleep. I've done it before and will do it again.
Click to expand...

I'm a big fan of the mask induction... I like to place a LMA once they are deep enough... makes things a little easier when you don't have any help...

The caveat is while I don't mind mask inducing adults, I tend to think of myself as crazy not stupid...

From the description of this patient, she doesn't sound like a good candidate for mask induction..

That brings up another can of worms-> regional under GA...

I've done it... it's not my preference (especially for NS ISB) but I've done it...

drccw
 
USD is da bomb.

Femoral n. b. under GA in the right patient IS A PIECE OF CAKE. I've had "0" complicationns this way. N = easily over 100.

Good topic.

I'm not sure I'd ever do an ISB or any other block under GA though...
 
Well, actually... I should say that I have had one last >30 hrs. 😱

But it wasn't intraneural.... that is for sure.
 
sevoflurane said:
Well, actually... I should say that I have had one last >30 hrs. 😱

But it wasn't intraneural.... that is for sure.
Click to expand...

when I have a block last longer than 20 hours, I tell patients

"great, you won the lottery! that's some great pain control"

while on the inside

"Oh poop.. sure hope it wears off soon"

That all being said, with the US I find some nerves are easier to visualize than others...

For example, upper extremity blocks are a chip shop... Interscalane, supra and infra clav are all easy to visualize the nerves.... no stimulator required.

With the femoral, I feel like sometimes I see it and sometimes I don't.. I always have to stim the femoral.

drccw
 
I always use both. Stim and USD. Under GA, I never take anything under .6 ma.
 
A prospective analysis of interscalene brachial plexus blocks performed under general anesthesia


  • Gary Misamore, MD
    • Affiliations
    • Methodist Sports Medicine / The Orthopedic Specialists, Indianapolis, IN, USA
    • icon_authorInfo.gif
      Reprint requests: Gary Misamore, MD, Methodist Sports Medicine / The Orthopedic Specialists, 201 Pennsylvania Pkwy, Ste 325, Indianapolis, IN 46280.
    ,
  • Brian Webb, MD
    • Affiliations
    • Methodist Sports Medicine / The Orthopedic Specialists, Indianapolis, IN, USA
    ,
  • Sherman McMurray, MD
    • Affiliations
    • Anesthesia Consultants of Indianapolis, Indianapolis, IN, USA
    ,
  • Peter Sallay, MD
    • Affiliations
    • Methodist Sports Medicine / The Orthopedic Specialists, Indianapolis, IN, USA
published online 16 August 2010.
Background

The purpose of this prospective study was to assess the safety and efficacy of interscalene brachial plexus block anesthesia when performed on patients who were anesthetized with a general anesthetic prior to the performance of the block.
Methods

Patients were assessed postoperatively through surveys, interviews, and physical examinations to document block success, duration of anesthesia, block side effects, and persistent neurological complications. Nine-hundred fifty-one patients were available for the analysis.
Results

The overall block success rate was 97% and the mean duration of anesthesia provided by the blocks was 23.9 hours. Immediate postoperative block side effects occurred in 16% (142 of 910), persistent neurological complications occurred in 4.4% (40 of 910) of patients, and long-term neurologic complications occurred in 0.8% (8 of 910).
Conclusion

Our study results suggest that the rates of success and complications associated with the performance of interscalene block regional anesthesia performed after induction of general anesthesia are similar to the results demonstrated in prior studies in which brachial plexus block was performed on nonanesthetized patients. Although significant complications were not common, this procedure is not without risk and can result in long-term neurologic complications.
 
Last edited:
We believe serious consideration should be given to performing brachial plexus blockade in the awake or lightly sedated patient. In addition to a perceived reduction in risk of spinal cord and peripheral nerve damage, this reduces the intensity of observation required for the patient at a time when the anaesthetist is occupied with other matters. Furthermore, complications such as i.v. injection should be detected at an earlier stage.


http://ceaccp.oxfordjournals.org/content/6/2/71.full
 
If you receive a single-shot nerve block, you can expect up to 4-24 hours of pain relief after surgery; however, the exact duration of analgesia depending on many factors. For adults, single-shot nerve blocks are a one time injection of local anesthesia given typically under sedation but before general anesthesia is started. A single-shot nerve block may also be given to children to help with pain control after surgery but in most cases, your anesthesiologist will perform the block while your child is already asleep (after general anesthesia has started). Single-shot nerve blocks are often used for pain control after orthopedic (bone and joint) surgery.

ASRA

http://www.asra.com/patient-info-pain-relief-after-surgery.php
 
Literature Review


Figure 8. Injection of local anesthetic in lateral approach to popliteal block with in-line monitoring of the injection pressure to avoid pressures >20 psi which may be associated with intraneural injection.
No study has compared the risk of neurologic complications in awake versus anesthetized patients, and it is unlikely that such studies will ever be done. A review of published reports of injury after PNBs indicates that significant neurologic injury after PNBs in awake patients occurs at a rate of 0.2%-0.4%.97 Most of these reports included brachial plexus blocks only, probably because these techniques are used more frequently than lower extremity nerve blocks.20 In a recent similar prospective evaluation by Bogdanov and Loveland, none of 548 patients who received an interscalene brachial plexus block after induction of GA developed permanent or long-term neurologic complications.81 Similarly, in a report presented at the 2005 Annual ASRA Spring Meeting, Tsai et al presented the data on 226 PNBs of both upper and lower extremities, all performed in heavily sedated or anesthetized patients, none of whom developed neurologic complications. Bogdanov et al. used a modified classical approach to interscalene block proposed to reduce complications whereas Tsai et al. used objective assessment of injection pressures to reduce the risk of intraneural injection during PNBs of both upper and lower extremity, Figure 8.98 While the relatively small number of patients in these reports do not allow accurate comparison, these studies at least indicate that the risk of complications of PNBs after GA may not be substantially more common than complications reported in other similarly powered studies in awake patients.99 In fact, performance of PNBs in heavily premedicated patients or after induction of GA is undoubtedly a common practice, and a routine in the pediatric anesthesia practice. A recent informal poll conducted during the ASRA 2005 session on complications of PNBs indicated that approximately half of the present attendees performed blocks in heavily sedated or anesthetized patients.

NYSORA.com
​
 
In our opinion, the importance of patient feedback to the safe application of the interscalene brachial plexus block has been underestimated, particularly in the case of the nonexpert. Although the experience of Bogdanov and colleagues was complication-free, a series of 548 patients is inadequate to define the incidence of rare complications compared to that incidence in an awake patient population. As the outcome of these rare complications has the potential to be catastrophic, we feel the standard of practice for the performance of an interscalene block should incorporate all measures which can minimize risk, including maintaining communication with the patient.
Department of Anesthesiology, New York Presbyterian Hospital, Columbia University Medical Center, New York, USA
 
BLADEMDA said:
Literature Review


Figure 8. Injection of local anesthetic in lateral approach to popliteal block with in-line monitoring of the injection pressure to avoid pressures >20 psi which may be associated with intraneural injection.
No study has compared the risk of neurologic complications in awake versus anesthetized patients, and it is unlikely that such studies will ever be done. A review of published reports of injury after PNBs indicates that significant neurologic injury after PNBs in awake patients occurs at a rate of 0.2%-0.4%.97 Most of these reports included brachial plexus blocks only, probably because these techniques are used more frequently than lower extremity nerve blocks.20 In a recent similar prospective evaluation by Bogdanov and Loveland, none of 548 patients who received an interscalene brachial plexus block after induction of GA developed permanent or long-term neurologic complications.81 Similarly, in a report presented at the 2005 Annual ASRA Spring Meeting, Tsai et al presented the data on 226 PNBs of both upper and lower extremities, all performed in heavily sedated or anesthetized patients, none of whom developed neurologic complications. Bogdanov et al. used a modified classical approach to interscalene block proposed to reduce complications whereas Tsai et al. used objective assessment of injection pressures to reduce the risk of intraneural injection during PNBs of both upper and lower extremity, Figure 8.98 While the relatively small number of patients in these reports do not allow accurate comparison, these studies at least indicate that the risk of complications of PNBs after GA may not be substantially more common than complications reported in other similarly powered studies in awake patients.99 In fact, performance of PNBs in heavily premedicated patients or after induction of GA is undoubtedly a common practice, and a routine in the pediatric anesthesia practice. A recent informal poll conducted during the ASRA 2005 session on complications of PNBs indicated that approximately half of the present attendees performed blocks in heavily sedated or anesthetized patients.

NYSORA.com
​
Click to expand...

I wonder how many of these blocks were done under USD back in 2005?

I'd like to get our pediatric attendings and fellows in on this one...

Or anybody that works at a children's hospital with an active acute pain service...
 
sevoflurane said:
USD is da bomb.

Femoral n. b. under GA in the right patient IS A PIECE OF CAKE. I've had "0" complicationns this way. N = easily over 100.

Good topic.

I'm not sure I'd ever do an ISB or any other block under GA though...
Click to expand...

If they want the block from me it won't be under GA.

Blade
 
sevoflurane said:
I wonder how many of these blocks were done under USD back in 2005?

I'd like to get our pediatric attendings and fellows in on this one...

Or anybody that works at a children's hospital with an active acute pain service...
Click to expand...

ASRA says its safe for PEDS but not for Adults. Evidence? none. But, when and if you get a complication you are toast here.
 
As I said, femoral n.b.'s are easy in the RIGHT patient.

Anything else (sciatic, politeal, brachial plexus, lumbar plexus).. is out. Never even considered these blocks under GA.

I still do 99% of my blocks awake. But now and again, the right patient, the right circumstance... a femoral or fascia illiaca is butter.

The femoral nerve is EXTREMELY resiliant btw.

Just watch out for tourniquet pressures above 275mmhg... anything above that... they don't get a fem. nerve block under GA.
 
If you receive a single-shot nerve block, you can expect up to 4-24 hours of pain relief after surgery; however, the exact duration of analgesia depending on many factors. For adults, single-shot nerve blocks are a one time injection of local anesthesia given typically under sedation but before general anesthesia is started. A single-shot nerve block may also be given to children to help with pain control after surgery but in most cases, your anesthesiologist will perform the block while your child is already asleep (after general anesthesia has started). Single-shot nerve blocks are often used for pain control after orthopedic (bone and joint) surgery.

http://www.asra.com/patient-info.php
 
sevoflurane said:
As I said, femoral n.b.'s are easy in the RIGHT patient.

Anything else (sciatic, politeal, brachial plexus, lumbar plexus).. is out. Never even considered these blocks under GA.

I still do 99% of my blocks awake. But now and again, the right patient, the right circumstance... a femoral or fascia illiaca is butter.

The femoral nerve is EXTREMELY resiliant btw.

Just watch out for tourniquet pressures above 275mmhg... anything above that... they don't get a fem. nerve block under GA.
Click to expand...

I've got no issues with blocks under GA...none. I'm not a malpractice lawyer nor do I play one on TV.😀 If and when a patient gets a long term complication from one of your blocks under GA then you have given the attorney the angle he needs to collect money from your insurance company. You are on the DEFENSIVE here trying to justify your technique while academic geeks testify against you.

BTW, studies have shown that the Sciatic nerve is extremely resilient as well.😉
 
sevoflurane said:
Just watch out for tourniquet pressures above 275mmhg... anything above that... they don't get a fem. nerve block under GA.
Click to expand...

Man, my orthopods never ever go that low. maybe for like hand surgery...

350 mmhg is standard
skiny folk get 300...

fatties 400...

we're seeing a lot of 400...

drccw
 
drccw said:
Man, my orthopods never ever go that low. maybe for like hand surgery...

350 mmhg is standard
skiny folk get 300...

fatties 400...

we're seeing a lot of 400...

drccw
Click to expand...


Agree. I see 300 all the time. That's why I don't add any Epi to my Sciatic blocks; I just use plain Bup or Rop (no additives for a sciatic block).
 
BLADEMDA said:
I've got no issues with blocks under GA...none. I'm not a malpractice lawyer nor do I play one on TV.😀 If and when a patient gets a long term complication from one of your blocks under GA then you have given the attorney the angle he needs to collect money from your insurance company. You are on the DEFENSIVE here trying to justify your technique while academic geeks testify against you.

BTW, studies have shown that the Sciatic nerve is extremely resilient as well.😉
Click to expand...

I hear you blade. I hope that never happens to neither you or me. I hate practicing defensive medicine though.

Sometimes you look at the field and say to yourself...

"DANG!!!! that is gonna hurt...." In those rare circumstances, I elect to try and help my patient... under GA. The circumstances have to be right though.

No biggens and a USD scan that looks easy.

Easily see the nerve. Document a picture via USD.

Deposit LA. Document via USD picture.

Good topic to bring up though...

Have you ever had any permanant n. damage from a femoral n. b.? I'm sure you've done thousands.
 
400mmhg

Jesus Christy.

Bargain with them... tell them you'll keep the b.p. around 100 systolic if they come down on their T. pressure.
 
sevoflurane said:
I hear you blade. I hope that never happens to neither you or me. I hate practicing defensive medicine though.

Sometimes you look at the field and say to yourself...

"DANG!!!! that is gonna hurt...." In those rare circumstances, I elect to try and help my patient... under GA. The circumstances have to be right though.

No biggens and a USD scan that looks easy.

Easily see the nerve. Document a picture via USD.

Deposit LA. Document via USD picture.

Good topic to bring up though...

Have you ever had any permanant n. damage from a femoral n. b.? I'm sure you've done thousands.
Click to expand...

No. If you want specifics about my complications then post in the Private forum. I'm happy to discuss them all..in detail.
 
sevoflurane said:
I hear you blade. I hope that never happens to neither you or me. I hate practicing defensive medicine though.

Sometimes you look at the field and say to yourself...

"DANG!!!! that is gonna hurt...." In those rare circumstances, I elect to try and help my patient... under GA. The circumstances have to be right though.

No biggens and a USD scan that looks easy.

Easily see the nerve. Document a picture via USD.

Deposit LA. Document via USD picture.

Good topic to bring up though...

Have you ever had any permanant n. damage from a femoral n. b.? I'm sure you've done thousands.
Click to expand...

No good deed goes unpunished. Be careful out there.
 
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