Spinal anesthesia for Total Knee arthroplasty

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You can go paramedian with a 25 without an introducer. We had one old timer staff in residency that would do all his spinals paramedian with a 25 Whit with no introducer and no skin local.
Are you calling me an “old timer”?
I routinely do paramedian without introducer. I actually nearly never use an introducer. Our kits changed the all metal one to a yellow plastic one and some partners were talking about how they didn’t like it. I never noticed the change happened.

The key to using a 25or 27g without an introducer is to drive the needle with your nondominant hand just beyond the skin. For example, I grab the needle with my right hand and apply gentle pressure from the back of the needle while also pinching the needle about 1cm from the skin and pushing it in from this point. My fingers contact the skin and I grab it again another cm back. The tissues act as your introducer by not allowing the needle to bow. I had an attending that loved to give you just one 27g whit to do your spinal at the VA. Then he would have you dose it with 25mg of isobaric marcaine.

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Are you calling me an “old timer”?
I routinely do paramedian without introducer. I actually nearly never use an introducer. Our kits changed the all metal one to a yellow plastic one and some partners were talking about how they didn’t like it. I never noticed the change happened.

The key to using a 25or 27g without an introducer is to drive the needle with your nondominant hand just beyond the skin. For example, I grab the needle with my right hand and apply gentle pressure from the back of the needle while also pinching the needle about 1cm from the skin and pushing it in from this point. My fingers contact the skin and I grab it again another cm back. The tissues act as your introducer by not allowing the needle to bow. I had an attending that loved to give you just one 27g whit to do your spinal at the VA. Then he would have you dose it with 25mg of isobaric marcaine.

I wasn't referring to you, but if the shoe fits. . . .

The technique you describe is exactly how this other old-timer did it. I'd say 80-85% of the time he nailed it first pass, and the lack of skin local didn't seem to matter. The other 15-20% when he had to redirect one or more times it was clearly not so comfortable for the patient. This guy did pretty much his whole career at a women's hospital doing nothing but L&D and GYN cases. Watching him do an epidural (actually CSE all comers) was truly an exercise in elegance, beauty, and speed. Watching him do a GA was, well . . . not so elegant, beautiful, or quick.
 
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I actually nearly never use an introducer.

I'll add this to the list of things @Noyac doesn't believe in/thinks are for p*ssies. So far, the list reads:

1) Ultrasound
2) Stylets
3) Introducers
4) Preoxygenation
5) Remi
 
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I wasn't referring to you, but if the shoe fits. . . .

The technique you describe is exactly how this other old-timer did it. I'd say 80-85% of the time he nailed it first pass, and the lack of skin local didn't seem to matter. The other 15-20% when he had to redirect one or more times it was clearly not so comfortable for the patient. This guy did pretty much his whole career at a women's hospital doing nothing but L&D and GYN cases. Watching him do an epidural (actually CSE all comers) was truly an exercise in elegance, beauty, and speed. Watching him do a GA was, well . . . not so elegant, beautiful, or quick.
I feel like the only reason I inject local is to put a hole in the skin. I use Pencan needles and they don’t always puncture the skin so elegantly.
 
I'll add this to the list of things @Noyac doesn't believe in/thinks are for p*ssies. So far, the list reads:

1) Ultrasound
2) Stylets
3) Introducers
You have me pegged. But there are more. All in due time young Jedi.
 
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I thought one of the main ideas of the introducer was to avoid picking up skin commensals and leaving them IT?
 
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