spinal anesthesia in the ASC

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Colba55o

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I'm a new grad and the "new guy" at my practice; trying to ruffle as few feathers as possible.

Did exactly this when I mentioned the possibility of doing a spinal for a knee scope at our ASC; nursing manager had a conniption as did some CRNAs and I heard a lot of "we don't do spinals here at the ASC".

Surely this is not the norm, or is it? Anyone have any cocktails for spinals that are suitable in an ambulatory setting they can recommend?
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Either is fine for a knee if the patient wants it, HOWEVER at the ASC one important goal is to move the patients through as quickly and safely as possible. Locking up a pacu bed for an hour or more unnecessarily will wreck the flow. On very busy days, pacu stay time is (should be) factored into the scheduling (OR and nurse staffing). If you have a few patients over stay their welcome your day is shot.
 
My reasoning was that the patient indicated on their pre-op visit that he was vehemently opposed to general anesthesia; had negative experience in the past.

I'm fully aware of the importance of flow in and out of the ASC. Nevertheless I have routinely offered (and documented such) that I discussed the option of a spinal for a knee scope along with GA. Of course I present the GA as the preferred option as it will allow the patient to go home faster, phrase spinal as "injection in the lower back" to make it sound unpleasant etc. But I always thought the best practice was to present the patient with an option. If a negative outcome occurs, cant you get nailed for not at least offering an alternative to GA?

Ive never done a lidocaine spinal in residency. Is the risk of TENS worth doing one?
 
Colba55o said:
My reasoning was that the patient indicated on their pre-op visit that he was vehemently opposed to general anesthesia; had negative experience in the past.

I'm fully aware of the importance of flow in and out of the ASC. Nevertheless I have routinely offered (and documented such) that I discussed the option of a spinal for a knee scope along with GA. Of course I present the GA as the preferred option as it will allow the patient to go home faster, phrase spinal as "injection in the lower back" to make it sound unpleasant etc. But I always thought the best practice was to present the patient with an option. If a negative outcome occurs, cant you get nailed for not at least offering an alternative to GA?

Ive never done a lidocaine spinal in residency. Is the risk of TENS worth doing one?
Click to expand...

http://www.anesthesiaanalgesia.org/content/103/1/234.full.pdf+html

Forget the Lidocaine Spinal. See the attached PDF.

Also, Ive done quite a few single shot Epidurals for Knee scopes with excellent results.
I use 15 mls of 1.5% Lidocaine or 2% Lidocaine.

Forget the Lidocaine spinal.

I have talked quite a few patients out of Regional Anesthesia at the ASC into a TIVA with Propofol and LMA. If they are ASA 1 or 2 the TIVA is faster in terms of discharge time.
 
BLADEMDA said:
http://www.anesthesiaanalgesia.org/content/103/1/234.full.pdf+html

Forget the Lidocaine Spinal. See the attached PDF.

Also, Ive done quite a few single shot Epidurals for Knee scopes with excellent results.
I use 15 mls of 1.5% Lidocaine or 2% Lidocaine.

Forget the Lidocaine spinal.

I have talked quite a few patients out of Regional Anesthesia at the ASC into a TIVA with Propofol and LMA. If they are ASA 1 or 2 the TIVA is faster in terms of discharge time.
Click to expand...

Blade, what is your recipe for a succesful propofol TIVA: 2 mg/kg bolus followed by LMA insertion and then start at 150 mcg/kg/min after spontaneous ventilation has returned and slowly wean down to 125 and then 100 mcg/kg/min after an hour? Do you mix in some fentanyl or ketamine and if so,what dose do you typically mix with the vial? Just curious.
 
Last edited:
painstop said:
Blade, what is your recipe for a succesful propofol TIVA: 2 mg/kg bolus followed by LMA insertion and then start at 150 mcg/kg/min after spontaneous ventilation has returned and slowly wean down to 125 and then 100 mcg/kg/min after an hour? Do you mix in some fentanyl or ketamine and if so, do you add 100 mcg (or 100 mg in the case of ketamine) to the bottle of Propofol? Just curious.
Click to expand...

For outpatient knee scopres in the 30-40 minute duration I use Propofol 2 mg/kg up front with 50 ug of Fentanyl. I turn on the Propofol at 150-180 ug/kg/min and titrate as needed.
If the patient shows signs that the Propofol isn't getting the job done then I'll add Ketamine into the mix. In my experience outpatient knee patients shouldn't get more than 100 mg of Ketamine for a short procedure. 50 mg is preferential. I've had a few woman complain after getting more than 100 mg of Ketamine following a knee scope. Hence, keep the Ketamine dosage LOW.

Finally, as the surgeon nears the end of the procedure I turn down the Propofol and then if no history of N/V I turn on the Nitrous Oxide (I limit this to 10-12 min usually). Remember, the Propofol needs time to redistribute from the brain so you can't just shut it off and expect a quick wake-up. A speedy wake-up with Propofol TIVA means you need to pay attention (It isn't Desflurane my friend).

99% of patients are happy with a Propofol TIVA and the 1% who aren't happy are likely crazy anyway.
 
+1 never do spinal at free standing ASC.

Too many downsides....urinary retention.....weakness....and GA or TIVA just too good, smooth, and easy. Talk em out of it for their own good.
 
BLADEMDA said:
For outpatient knee scopres in the 30-40 minute duration I use Propofol 2 mg/kg up front with 50 ug of Fentanyl. I turn on the Propofol at 150-180 ug/kg/min and titrate as needed.
If the patient shows signs that the Propofol isn't getting the job done then I'll add Ketamine into the mix. In my experience outpatient knee patients shouldn't get more than 100 mg of Ketamine for a short procedure. 50 mg is preferential. I've had a few woman complain after getting more than 100 mg of Ketamine following a knee scope. Hence, keep the Ketamine dosage LOW.

Finally, as the surgeon nears the end of the procedure I turn down the Propofol and then if no history of N/V I turn on the Nitrous Oxide (I limit this to 10-12 min usually). Remember, the Propofol needs time to redistribute from the brain so you can't just shut it off and expect a quick wake-up. A speedy wake-up with Propofol TIVA means you need to pay attention (It isn't Desflurane my friend).

99% of patients are happy with a Propofol TIVA and the 1% who aren't happy are likely crazy anyway.
Click to expand...


Blade,
Thanks for the quick reply. Your response made me think of something that's completely tangential to spinals at an ASC: why not use des when you are weaning off the propofol towards the end of the case. The main issue I could see is cost versus nitrous but the possible PONV factor is big in an ASC. Obviously I wouldn't use it to start an LMA case for inhalational induction but maintenance with it is fine. In Blade fashion, I found a journal article from A/A:

http://www.anesthesia-analgesia.org/content/96/3/701.full

27% of patients received desflurane concentrations in excess of MAC, and the incidence of coughing or breath holding in these patients was not increased, nor was the incidence decreased in patients given sevoflurane concentrations in excess of 1.85%
 
Colba55o said:
My reasoning was that the patient indicated on their pre-op visit that he was vehemently opposed to general anesthesia; had negative experience in the past.
Click to expand...

While I'd talk with the pt about what the negative experience was (hoarseness that could be addressed with an LMA? PONV that could be addressed in various ways?), I think it's reasonable to offer a spinal in this circumstance.

For the trainees out there: you would not want to add opiates to your intrathecal injection in this circumstance, because of the risk of delayed respiratory depression.
 
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I do most ga but some patients really want regional or want to watch the monitor. Yes do not add opioids or epinephrine to op spinal, 2CP 2% 2ml is all you need (especially because it is easy to remember). Btw approved for spinal in Europe but not USA.
 
Epidural idea is intriguing. 45-60min with 2%lido plain.

Neuraxial fentanyl wouldn't give you any problems but at the same time it doesn't give you any benefit either.

My knee scopes get lido 20-40, PPF 2mg/kg, LMA, then sevo 2.5-3%, zofran/ancef, toradol 30 IV. Keep gas up during painful part, then blow it off when surgeon alerts me (before he even starts closing). 15min. Surgeon shoots bupiv in the knee. Wake up, zero pain. PACU. Awake and ready to go.

For my slow arse surgeon, I use fent 25-50 due to more surgical trauma and poor local infiltration technique.

I might be tempted to say never do a spinal AND never use ketamine at a ASC (don't flame me 🙂
 
Spinals are less than an ideal choice at an outpatient surgery center for many reasons, but mostly just because it might slow down their PACU discharge.

But if it is in the patient's own best interest and that's what they want? Go for it. Patient is #1. Everybody else will get over it if it's truly what is best for the patient.
 
at our output centers the surgeon injects the knee with local and we do a propofol GA with Nasal cannula. very little pacu time, no N/V or post op pain
 
So out of curiosity for those that dont use spinals in ASC do you tube your cervical cerclages?
 
Tee Cell said:
So out of curiosity for those that dont use spinals in ASC do you tube your cervical cerclages?
Click to expand...

We did mepivacaine spinals for cerclages where I trained. 3 mL 1.5% mepivacaine and 2 mL D10, slick. Literature quotes a comparable incidence of TNS as lidocaine but my attendings' claim was that it wasn't a problem. (I'm not sure if that was a "we never followed up or asked, so we assume no problem" ...) I think there's no reason this couldn't be used in an ASC.


I'm not sure a tube is really necessary but I am sure you could easily find an expert witness to testify that GA with an unprotected airway in a pregnant supposedly-by-definition-full-stomach patient is malpractice. So yeah, I guess I'd intubate her.
 
The PLMA design includes a modified cuff to isolate the glottis from the oesophagus, and a drainage tube alongside the airway tube, allowing fluid from the stomach and oesophagus to bypass the pharynx and mouth or to be suctioned;9 10 the connection also equilibrates the stomach and atmospheric pressures, reducing gastric insufflation. The PLMA has several modifications that may protect against aspiration of regurgitated fluid. If properly placed, the drainage tube should be aligned with the oesophageal opening, and the distal cuff should be sealed against the hypopharynx

In cadavers, even with a clamped drainage tube, the airway was protected from retrograde injection of fluid from the oesophagus until pressures of 68–73 cm H2O were reached inside the bowl of the PLMA.12 In a study of 103 patients, methylene blue in saline was injected down the drainage tube to fill the hypopharynx. A fibre‐optic bronchoscope, passed down the airway tube at the beginning and end of each case, demonstrated no leakage of methylene blue into the bowl of the mask or the oropharynx in all but two cases. These exceptions were attributed to light anaesthesia and mask displacement.13 Although we used a fibre‐optic scope for confirmation of PLMA placement, this is not required in routine practice.

The PLMA was used effectively in a pregnant patient deemed to be at increased risk of aspiration. Rapid sequence induction and insertion of the PLMA allowed immediate control of ventilation. The PLMA may be considered in circumstances where rapid but brief control of the airway is required in pregnant patients.


http://bja.oxfordjournals.org/content/91/5/752.full

PLMA= ProSeal LMA
 
I'd do a Proseal LMA for a cerclage provided the patient was not obese and had no history of Gerd.
I certainly don't blame you for wanting to avoid a possible malpractice claim but I don't practice medicine purely on fear.
 
BLADEMDA said:
I'd do a Proseal LMA for a cerclage provided the patient was not obese and had no history of Gerd.
I certainly don't blame you for wanting to avoid a possible malpractice claim but I don't practice medicine purely on fear.
Click to expand...

I wouldn't. Spinal usually, geta otherwise.
 
Here is an excerpt from the package insert for the Proseal...

3. CONTRAINDICATIONS
Due to the potential risk of regurgitation and aspiration,
do not use the LMA ProSealTM as a substitute for an
endotracheal tube in the following elective or difficult
airway patients on a non-emergency pathway:
• Patients who have not fasted, including patients
whose fasting cannot be confirmed.
• Patients who are grossly or morbidly obese, more
than 14 weeks pregnant or those with multiple
or massive injury, acute abdominal or thoracic
injury, any condition associated with delayed
gastric emptying, or using opiate medication
prior to fasting.

Just saying, if the product says it in the package insert not to do something and you still do it.
 
sethco said:
Here is an excerpt from the package insert for the Proseal...

3. CONTRAINDICATIONS
Due to the potential risk of regurgitation and aspiration,
do not use the LMA ProSealTM as a substitute for an
endotracheal tube in the following elective or difficult
airway patients on a non-emergency pathway:
• Patients who have not fasted, including patients
whose fasting cannot be confirmed.
• Patients who are grossly or morbidly obese, more
than 14 weeks pregnant or those with multiple
or massive injury, acute abdominal or thoracic
injury, any condition associated with delayed
gastric emptying, or using opiate medication
prior to fasting.

Just saying, if the product says it in the package insert not to do something and you still do it.
Click to expand...

Where is the evidence for the 14 weeks? The textbook I quoted above says 18-20 weeks.
Package inserts without attached evidence doesn't mean much.

That's why we do clinical studies.
 
So the ProSeal LMA prevents aspiration except sometimes when it lets them aspirate because they got light or it wasn't seated correctly?

Also GA necessarily involves giving the fetus exposure to drugs that aren't necessarily safe for fetal development.



While there are lots of ways to skin a cat, for a cerclage, a good old spinal is simpler and safer than any method of GA.
 
Mman said:
So the ProSeal LMA prevents aspiration except sometimes when it lets them aspirate because they got light or it wasn't seated correctly?

Also GA necessarily involves giving the fetus exposure to drugs that aren't necessarily safe for fetal development.



While there are lots of ways to skin a cat, for a cerclage, a good old spinal is simpler and safer than any method of GA.
Click to expand...

I do 90 percent of those cases, cerclage, under SAB. But, I would consider doing the other 10 percent where the patient refuses SAB under LMA provided the following criteria were met:

I. Not obese
2. No Gerd
3. Less than 20 weeks Estimated Gestational age

For those of you refusing to use an LMA because of pregnancy what is your cutoff? 12 weeks? 14 weeks? Any evidence for that cutoff?
 
BLADEMDA said:
I'd do a Proseal LMA for a cerclage provided the patient was not obese and had no history of Gerd.
I certainly don't blame you for wanting to avoid a possible malpractice claim but I don't practice medicine purely on fear.
Click to expand...

Me neither. Just being cautious; if you choose not to be, that's on you.
 
BLADEMDA said:
For those of you refusing to use an LMA because of pregnancy what is your cutoff? 12 weeks? 14 weeks? Any evidence for that cutoff?
Click to expand...

A lack of evidence doesn't change what is probably widely considered standard of care. There's no evidence that I can't just give 200 mg bolus of propofol and mask them until the procedure is over, either, but that doesn't mean it's the right thing to do.
 
Why on earth would anyone want to place an LMA in a third trimester parturient for a cerclage?
If a patient refuses spinal anesthesia then just do what you do best: good old fashion GETA.
We live in a litigious society, and many of the people who are encouraging you to do a technique that is not seen as standard of care on this anonymous internet forum, will be glad to testify against you for a few dollars!
As for the question about knee scopes... I do 99% with an LMA GA but when I get an occasional crazy patient who wants regional anesthesia I do a low dose heavy Bupivacaine spinal (7.5mg) with a Propofol drip.
The right answer in medicine is always: keep it simple stupid!
 
Mman said:
A lack of evidence doesn't change what is probably widely considered standard of care. There's no evidence that I can't just give 200 mg bolus of propofol and mask them until the procedure is over, either, but that doesn't mean it's the right thing to do.
Click to expand...

I see you didn't respond to the quote from the textbook of Obstetric anesthesia on how many weeks a patient can be with child until an LMA is no longer acceptable. The textbook's author states " up to18-20 weeks" for an LMA. Is this considered "standard of care"? who get to decide this "standard"? Some author without any evidence for his/her statement?

Is this "standard of care" the same one which says I can't do U/S guided blocks on patients taking Plavix or use Decadron because it isn't FDA approved? Or, use PF Bupivacaine 0.5% to do a spinal?

I refuse to buy into the dogma. I prefer evidence based medicine.
 
BLADEMDA said:
I see you didn't respond to the quote from the textbook of Obstetric anesthesia on how many weeks a patient can be with child until an LMA is no longer acceptable. The textbook's author states " up to18-20 weeks" for an LMA. Is this considered "standard of care"? who get to decide this "standard"? Some author without any evidence for his/her statement?

Is this "standard of care" the same one which says I can't do U/S guided blocks on patients taking Plavix or use Decadron because it isn't FDA approved? Or, use PF Bupivacaine 0.5% to do a spinal?

I refuse to buy into the dogma. I prefer evidence based medicine.
Click to expand...

Good for you... but the rest of us have to practice here.. in the united states!
 
Are there LMA reps handing out pens and sandwiches someplace I don't know about?

I don't really get the attraction to the devices - attraction so strong that it goes so far as to look for reasons to use them in cases for which there is some controversy over their propriety.

Sure, they're great backup tools for airways, and I use them almost daily to simplify simple anesthetics, but I can't say I've ever found myself cursing the world because putting an ETT in was so inconvenient.

What's so horrid about a cerclage done with an ETT that you want to toe the line so badly and debate package inserts vs one textbook to justify an LMA?

What's the up side? What's the point?
 
BLADEMDA said:
I see you didn't respond to the quote from the textbook of Obstetric anesthesia on how many weeks a patient can be with child until an LMA is no longer acceptable. The textbook's author states " up to18-20 weeks" for an LMA. Is this considered "standard of care"? who get to decide this "standard"? Some author without any evidence for his/her statement?

Is this "standard of care" the same one which says I can't do U/S guided blocks on patients taking Plavix or use Decadron because it isn't FDA approved? Or, use PF Bupivacaine 0.5% to do a spinal?

I refuse to buy into the dogma. I prefer evidence based medicine.
Click to expand...


You ask "who get(s) to decide this "standard""?

That's easy. Legally it's the other people in the field of anesthesia. Standard of care in medicine is basically what everyone else in the field does.

You can do however many blocks you want on somebody that just got a 300 mg IV load of plavix, but if you have a complication you will be held liable for the damages. You can prefer evidence based medicine, but doing something against the standard of care that has no overwhelming scientific evidence to support it is not a wise decision IMHO.


Be a cowboy all you want and practice however you like, unfortunately many of us can't just do whatever we darn well please and damn the consequences.

For an LMA and a cerclage, there is at minimum some appreciable increase in risk. Nobody can quantify what that risk is exactly, but it is there. And what's the benefit? Miniscule at best.
 
I found another expert who says up to "20 weeks" for an LMA may be acceptable. Sounds like the "experts" aren't using the 12-14 weeks of 10-15 years ago.
For non obese Patients needing a short procedure under GA I'm thinking an LMA (supreme) looks like a solid choice up to 20 weeks gestational age.


After 20 weeks of gestation, caution regarding the unprotected airway should be exercised
 
pgg said:
Are there LMA reps handing out pens and sandwiches someplace I don't know about?

I don't really get the attraction to the devices - attraction so strong that it goes so far as to look for reasons to use them in cases for which there is some controversy over their propriety.

Sure, they're great backup tools for airways, and I use them almost daily to simplify simple anesthetics, but I can't say I've ever found myself cursing the world because putting an ETT in was so inconvenient.

What's so horrid about a cerclage done with an ETT that you want to toe the line so badly and debate package inserts vs one textbook to justify an LMA?

What's the up side? What's the point?
Click to expand...

Who decides 8 weeks? 12 weeks? If a woman needs a 15 min procedure why should I intubate her when it isn't necessary? You can "tube" them all as far as I'm concerned but the evidence doesn't support it being necessary.

Again, a woman who is 18 weeks pregnant, thin, healthy undergoing a 15 min procedure can safely receive either a SAB with 2% Chlorprocaine (not FDA Approved) or an LMA GA.

The Chlorprocaine and PF Isobaric Bupivacaine are perfect examples where the package insert doesn't mean squat.
 
BLADEMDA said:
I found another expert who says up to "20 weeks" for an LMA may be acceptable. Sounds like the "experts" aren't using the 12-14 weeks of 10-15 years ago.
For non obese Patients needing a short procedure under GA I'm thinking an LMA (supreme) looks like a solid choice up to 20 weeks gestational age.


After 20 weeks of gestation, caution regarding the unprotected airway should be exercised
Click to expand...

You can find "an expert" that will support almost anything, but that won't help support it as standard of care. Since hyperemesis peaks around week 10-15 in most women, not the type of patient I'm looking to have an LMA in as an LMA doesn't provide a benefit over an endotracheal tube. They still get a sore throat.
 
BLADEMDA said:
Who decides 8 weeks? 12 weeks? If a woman needs a 15 min procedure why should I intubate her when it isn't necessary? You can "tube" them all as far as I'm concerned but the evidence doesn't support it being necessary.

Again, a woman who is 18 weeks pregnant, thin, healthy undergoing a 15 min procedure can safely receive either a SAB with 2% Chlorprocaine (not FDA Approved) or an LMA GA.

The Chlorprocaine and PF Isobaric Bupivacaine are perfect examples where the package insert doesn't mean squat.
Click to expand...

🙄
 
Mman said:
You can find "an expert" that will support almost anything, but that won't help support it as standard of care. Since hyperemesis peaks around week 10-15 in most women, not the type of patient I'm looking to have an LMA in as an LMA doesn't provide a benefit over an endotracheal tube. They still get a sore throat.
Click to expand...

I've had both ETT and LMA. The LMA is far superior in terms of the sore throat issue. I found another "expert" recommending 16 weeks. I'm quite comfortable with 18-20 weeks as my cutoff in non obese, no GERD patients. You are free to use 10 weeks but I haven't used that "conservative" number in 2 decades. 15 years ago I used 14 weeks and sometime last year I increased it 16 weeks. Now, the data indicates up to 20 weeks is safe.
Hence, my new cutoff is 20 weeks. Like much of what we used to do over the decades this Dogma has no clothes.
 
Mman said:
You can find "an expert" that will support almost anything, but that won't help support it as standard of care. Since hyperemesis peaks around week 10-15 in most women, not the type of patient I'm looking to have an LMA in as an LMA doesn't provide a benefit over an endotracheal tube. They still get a sore throat.
Click to expand...

A textbook statement in a respectable book of that specialty will support "reasonable standard of care" in court slim. I know this for a fact.
 
Slightly off topic.. I had a surgeon in an ASC flip out because the PMD had suggested that the patient could "benefit from regional anesthesia" for her ankle fracture and I offered pt general with LMA. Didn't even bother talking to me, called my boss screaming "what if we cant get her off the ventilator???". Pt was know to me through related pain practice.. typical ASA2 pain disaster that tries to get up and walk away after 200mg of diprivan.

Long story short.. boss calls me up and says "just do the f'in spinal whats your problem", I offer to take my clear malpractice record elsewhere and while this went back and forth the surgeon got a new clearance without the "regional anesthesia" line from the PMD. Did the 40 minute case with an LMA, pt went home 45 minutes post op. Surgeon spent all of those 45 minutes lecturing me on how I know nothing since I haven't been sued as much as he has. Moral of the story.. I hate working in ASC's and your group sucks for sticking you there as a new grad.
 
Gasworks said:
Slightly off topic.. I had a surgeon in an ASC flip out because the PMD had suggested that the patient could "benefit from regional anesthesia" for her ankle fracture and I offered pt general with LMA. Didn't even bother talking to me, called my boss screaming "what if we cant get her off the ventilator???". Pt was know to me through related pain practice.. typical ASA2 pain disaster that tries to get up and walk away after 200mg of diprivan.

Long story short.. boss calls me up and says "just do the f'in spinal whats your problem", I offer to take my clear malpractice record elsewhere and while this went back and forth the surgeon got a new clearance without the "regional anesthesia" line from the PMD. Did the 40 minute case with an LMA, pt went home 45 minutes post op. Surgeon spent all of those 45 minutes lecturing me on how I know nothing since I haven't been sued as much as he has. Moral of the story.. I hate working in ASC's and your group sucks for sticking you there as a new grad.
Click to expand...

You're gonna get fired soon, trust me.
 
Gasworks said:
Slightly off topic.. I had a surgeon in an ASC flip out because the PMD had suggested that the patient could "benefit from regional anesthesia" for her ankle fracture and I offered pt general with LMA. Didn't even bother talking to me, called my boss screaming "what if we cant get her off the ventilator???". Pt was know to me through related pain practice.. typical ASA2 pain disaster that tries to get up and walk away after 200mg of diprivan.

Long story short.. boss calls me up and says "just do the f'in spinal whats your problem", I offer to take my clear malpractice record elsewhere and while this went back and forth the surgeon got a new clearance without the "regional anesthesia" line from the PMD. Did the 40 minute case with an LMA, pt went home 45 minutes post op. Surgeon spent all of those 45 minutes lecturing me on how I know nothing since I haven't been sued as much as he has. Moral of the story.. I hate working in ASC's and your group sucks for sticking you there as a new grad.
Click to expand...

In this life you have to learn how to choose your battles.
 
Southpaw said:
Gasworks, your group doesn't suck because they put you at the ASC. They suck for not backing your clinical decision making.



South
Click to expand...

+1.

This is what drives me nuts about anesthesia practice, and is probably one of the big factors keeping me in my current job, where the relations are collegial and supportive.
 
BLADEMDA said:
A textbook statement in a respectable book of that specialty will support "reasonable standard of care" in court slim. I know this for a fact.
Click to expand...

Thanks for recognizing my hard work with diet and exercise.

I'm still waiting to hear what benefit a pregnant patient gets from an LMA compared to an ETT....
 
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