Thoracic epidurals

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Do you tend to do these alot in private practice? The one attending that would readily do these with us has left our program and I dont forsee me getting alot of experience with these.

Also do lumbar epidurals work well for chest procedures?

 

[militarymd]

Do you tend to do these alot in private practice? The one attending that would readily do these with us has left our program and I dont forsee me getting alot of experience with these.

Also do lumbar epidurals work well for chest procedures?

yes, for thoracotomies...and lumbars work, but you need to use morphine.

 

[jetproppilot]

Do you tend to do these alot in private practice? The one attending that would readily do these with us has left our program and I dont forsee me getting alot of experience with these.

Also do lumbar epidurals work well for chest procedures?

Thoracic epidurals are great for thoracotomies like Mil said....more effective than lumbars IMHO...

thoracics enable you to inject local anesthetic at the level of the surgery...providing a "band" of anesthesia a cuppla levels above and below the level where the epidural is...so when using local anesthetic, you obtain "regional numbness", in contrast to a lumbar epidural where the patients whole lower body is numb.

Local anesthetic volumes are much less as well...say five mL .5% bupivicaine initially, with 3-5 mL every 60-90 minutes. Postoperatively an epidural PCA works well with bupivivaine.125% with some opiod mixed in (since the LA concentration is low), with a basal rate of around 3mL/hr and around 2mL every twenty minutes available to the patient via PCA.

Superior to central opiate receptor agonism via lumbar epidural for chest cases in my opinion.

 

[nitecap]

My experience in managing post-op pain post TAAA with thoracoabdominal inscisions as well as thoracotomy are mixed. It seemed most of the time it went 50/50. Half the time them working great half the time them working sometimes not at all. Usually it was fent, bupivicaine mix. Would come out at basal rate of at least 3 and when pts were extuabted they used the epidural PCA usually at .5-1ml q 10-20 minutes. We titrated up to a max total of 10ml/hr if that didnt work pain mgmt services usually pulled it and started IV opiods. I found for the TAAA they worked rather poorly being that the thoracic inscision often extended at least 4 inches above the level of the block in the back. So they would have no adb. pain but very bad pain in upper back near scapula. Couldnt give them enough IV opiods to treat the back pain without dropping pressures ect. Also many times they didnt work at all. would be maxed out and get serveral boluses administered but with marginal results. Possibly it was because usually they didnt put the block in until after the pt was asleep so maybe it was poor placement. They however didnt want to cause any acute HTN preop placing the blck when awake for fear of rupturing the anyeursm. The pts that it did work well I mean did great. They kept it in a few days post op, ambulated with it and what not. But many times they were highly uneffective. I found that for post op pain the lumbar epidurals for lower ext. periph bypass surg worked much better than the high thoracic epudurals did. Actually a few in this group are currently doing research I believe been going on for about 3 yrs now on out comes post CABG and TAAA surg with those that received thoracic epidurals vs. IV opiods. Pretty sure its still in progress.

 

[jetproppilot]

My experience in managing post-op pain post TAAA with thoracoabdominal inscisions as well as thoracotomy are mixed. It seemed most of the time it went 50/50. Half the time them working great half the time them working sometimes not at all. Usually it was fent, bupivicaine mix. Would come out at basal rate of at least 3 and when pts were extuabted they used the epidural PCA usually at .5-1ml q 10-20 minutes. We titrated up to a max total of 10ml/hr if that didnt work pain mgmt services usually pulled it and started IV opiods. I found for the TAAA they worked rather poorly being that the thoracic inscision often extended at least 4 inches about the level in the back. So they would have no adb. pain but very bad pain in upper back near scapula. Couldnt give them enough IV opiods to treat the back pain without dropping pressures ect. Also many times they didnt work at all. would be maxed out and get serveral boluses administered but with marginal results. Possibly it was because usually they didnt put the block in until after the pt was asleep so maybe it was poor placement. They however didnt want to cause any acute HTN preop placing the blck when awake for fear of rupturing the anyeurism. The pts that it did work well I mean did great. They kept it in a few days post op, ambulated with it and what not. But many times they were highly uneffective. I found that for post op pain the lumbar epidurals for lower ext. periph bypass surg worked much better than the high thoracic epudurals did. Actually a few in this group are currently doing research I believe been going on for about 3 yrs now on out comes post CABG and TAAA surg with those that received thoracic epidurals vs. IV opiods. Pretty sure its still in progress.

HOLY S HIT!!!!!

Geez, Nite,

ya see how easy that is? Post, post, post away. The more clinicians we get opinions from, in a constructive fashion, the better we'll all become as anesthesia providers.

I dont know everything. You dont know everything. Mil doesnt know everything (that being said, Mil knows more science than anyone on this board, bar none, and if you [and me for that matter] don't tap his knowledge, you are truly missing ALOTTA anesthesia/CCM info). So if we continue interacting, we'll all benefit. As will our patients.

Nice post. 👍

 

[jetproppilot]

My experience in managing post-op pain post TAAA with thoracoabdominal inscisions as well as thoracotomy are mixed. It seemed most of the time it went 50/50. Half the time them working great half the time them working sometimes not at all. Usually it was fent, bupivicaine mix. Would come out at basal rate of at least 3 and when pts were extuabted they used the epidural PCA usually at .5-1ml q 10-20 minutes. We titrated up to a max total of 10ml/hr if that didnt work pain mgmt services usually pulled it and started IV opiods. I found for the TAAA they worked rather poorly being that the thoracic inscision often extended at least 4 inches about the level in the back. So they would have no adb. pain but very bad pain in upper back near scapula. Couldnt give them enough IV opiods to treat the back pain without dropping pressures ect. Also many times they didnt work at all. would be maxed out and get serveral boluses administered but with marginal results. Possibly it was because usually they didnt put the block in until after the pt was asleep so maybe it was poor placement. They however didnt want to cause any acute HTN preop placing the blck when awake for fear of rupturing the anyeurism. The pts that it did work well I mean did great. They kept it in a few days post op, ambulated with it and what not. But many times they were highly uneffective. I found that for post op pain the lumbar epidurals for lower ext. periph bypass surg worked much better than the high thoracic epudurals did. Actually a few in this group are currently doing research I believe been going on for about 3 yrs now on out comes post CABG and TAAA surg with those that received thoracic epidurals vs. IV opiods. Pretty sure its still in progress.

My feeling on Nite's post is operator dependent...I believe a thoracic epidural in the RIGHT place provides superior analgesia to a lumbar approach for CHEST cases, not chest/abd cases.

Thoracic epidurals are tricky...you FEEL alotta false loss-of-resistance when placing the catheter....so a clinician may fall for said false-loss-of-resistance...hence the hefty reliance on operator dependency, to sort out which is false (not epidural space) and which is real (epidural space).

Once you've got the Tuohy to the point where you pull the stylette and attach the glass syringe, whether lumbar or thoracic, the procedure, from this point on, is all FEEL. Something your hands-to-brain connection appreciates. You could turn the lights off at this point without affecting success rate. And settling for a loss-of-resistance less than what FEELS right, at this point, is what, I think, leads to misplacement of catheters.

Reached a LOR that feels "kinda funny?"

Don't settle.

If it doesnt FEEL EXACTLY like you think it should, retract the Tuohy and try again. Chances are you're right.

And therein lies the art of anesthesia.

 

[quark]

My feeling on Nite's post is operator dependent...I believe a thoracic epidural in the RIGHT place provides superior analgesia to a lumbar approach for CHEST cases, not chest/abd cases.

Thoracic epidurals are tricky...you FEEL alotta false loss-of-resistance when placing the catheter....so a clinician may fall for said false-loss-of-resistance...hence the hefty reliance on operator dependency, to sort out which is false (not epidural space) and which is real (epidural space).

Once you've got the Tuohy to the point where you pull the stylette and attach the glass syringe, whether lumbar or thoracic, the procedure, from this point on, is all FEEL. Something your hands-to-brain connection appreciates. You could turn the lights off at this point without affecting success rate. And settling for a loss-of-resistance less than what FEELS right, at this point, is what, I think, leads to misplacement of catheters.

Reached a LOR that feels "kinda funny?"

Don't settle.

If it doesnt FEEL EXACTLY like you think it should, retract the Tuohy and try again. Chances are you're right.

And therein lies the art of anesthesia.

What's your opinion about using paravertebral blocks instead of epidurals? I've seen both used but haven't had enough experience yet to decide if one is better than the other for post-op pain.

 

[jetproppilot]

What's your opinion about using paravertebral blocks instead of epidurals? I've seen both used but haven't had enough experience yet to decide if one is better than the other for post-op pain.

Paravertrebral nerve blocks are used therapeutically to address radicular pain at a specific level. The local anesthetic dose needed to address each nerve root at the levels affected by the surgery makes it unuseable in the perioperative setting.

Hence the epidural-space approach, which affects, concominantly, several nerve-root levels, whilst staying within accepted local-anesthetic-dosage guidelines.

 

[davvid2700]

My experience in managing post-op pain post TAAA with thoracoabdominal inscisions as well as thoracotomy are mixed. It seemed most of the time it went 50/50. Half the time them working great half the time them working sometimes not at all. Usually it was fent, bupivicaine mix. Would come out at basal rate of at least 3 and when pts were extuabted they used the epidural PCA usually at .5-1ml q 10-20 minutes. We titrated up to a max total of 10ml/hr if that didnt work pain mgmt services usually pulled it and started IV opiods. I found for the TAAA they worked rather poorly being that the thoracic inscision often extended at least 4 inches above the level of the block in the back. So they would have no adb. pain but very bad pain in upper back near scapula. Couldnt give them enough IV opiods to treat the back pain without dropping pressures ect. Also many times they didnt work at all. would be maxed out and get serveral boluses administered but with marginal results. Possibly it was because usually they didnt put the block in until after the pt was asleep so maybe it was poor placement. They however didnt want to cause any acute HTN preop placing the blck when awake for fear of rupturing the anyeursm. The pts that it did work well I mean did great. They kept it in a few days post op, ambulated with it and what not. But many times they were highly uneffective. I found that for post op pain the lumbar epidurals for lower ext. periph bypass surg worked much better than the high thoracic epudurals did. Actually a few in this group are currently doing research I believe been going on for about 3 yrs now on out comes post CABG and TAAA surg with those that received thoracic epidurals vs. IV opiods. Pretty sure its still in progress.

nitecap

Ive had it with you and I wish you would go to your nursing forum and interact over there. They probably will welcome you with open arms. You have caused too much of a stir here with denegrading physicians in general and your threatening private messages in my mailbox to have nothing but contempt for you. If you were working with me once again I would restrict your practice considerably. You definitely would not even come near a thoracic epidural while my name was on the chart. So if you wanna put in thoracic epidurals go to backwardsville, ND and you can go to town. Hope you dont murder anyone.

With that being said.. i dont like thoracic epidurals for descending aneurysms.. too big of a case.. Once extubated.. sit him/her up and put one in. Never after asleep. thats borderline practice. Ive seen it done though.

A well placed epidural will almost always work. If it doesnt after sufficient meds.. Its not in the right place.

I disagree with jet.. The above post was written by an amateur and i disagree with almost everything nitecap wrote. Just proves that he is a nurse in training and does not have an understanding of the real issues/

 

[davvid2700]

Reached a LOR that feels "kinda funny?"

Don't settle.

If it doesnt FEEL EXACTLY like you think it should, retract the Tuohy and try again. Chances are you're right.

And therein lies the art of anesthesia.

I use hanging drop method for my thoracic epidurals.

The LOR to air.. too equivical

No question with the hanging drop method..

hanging drop not necessary for lumbar epidurals

I agree with Jet.. IF it feels kinda not right.. DO it again until it feels right.. That should be with everything in anesthesia..

 

[jetproppilot]

nitecap

Ive had it with you and I wish you would go to your nursing forum and interact over there. They probably will welcome you with open arms. You have caused too much of a stir here with denegrading physicians in general and your threatening private messages in my mailbox to have nothing but contempt for you. If you were working with me once again I would restrict your practice considerably. You definitely would not even come near a thoracic epidural while my name was on the chart. So if you wanna put in thoracic epidurals go to backwardsville, ND and you can go to town. Hope you dont murder anyone.

With that being said.. i dont like thoracic epidurals for descending aneurysms.. too big of a case.. Once extubated.. sit him/her up and put one in. Never after asleep. thats borderline practice. Ive seen it done though.

A well placed epidural will almost always work. If it doesnt after sufficient meds.. Its not in the right place.

I disagree with jet.. The above post was written by an amateur and i disagree with almost everything nitecap wrote. Just proves that he is a nurse in training and does not have an understanding of the real issues/

constructive post, which is all we can ask for...

that being said, a thoracic epidural placed in the "right" place by a skilled clinician benefits the thoracotomy patient.

No ifs, ands, or buts.

Believe me.

No doubt.

Do you wanna awake from your anesthetic, cancerous lobe removed from you, with a "band" of anesthesia, covering the site where your stud-surgeon removed the cancerous lobe,

no if's and's

or butt's????

A thoracic epidural, placed by a confident clinician, will ameliorate said patient's post-operative course...since a thoracic epidural will give them superior pain relief..allowing said patient to take part in the all-important-post-op-lets-not-allow-post-op-atelectasis-play-a-role-in-post op-morbidity role...

thoracic epidurals placed appropriately by skilled clinicians may influence post-op morbidity/mortality....but as of now, the numbers are too few...

 

[nitecap]

nitecap

Ive had it with you and I wish you would go to your nursing forum and interact over there. They probably will welcome you with open arms. You have caused too much of a stir here with denegrading physicians in general and your threatening private messages in my mailbox to have nothing but contempt for you. If you were working with me once again I would restrict your practice considerably. You definitely would not even come near a thoracic epidural while my name was on the chart. So if you wanna put in thoracic epidurals go to backwardsville, ND and you can go to town. Hope you dont murder anyone.

With that being said.. i dont like thoracic epidurals for descending aneurysms.. too big of a case.. Once extubated.. sit him/her up and put one in. Never after asleep. thats borderline practice. Ive seen it done though.

A well placed epidural will almost always work. If it doesnt after sufficient meds.. Its not in the right place.

I disagree with jet.. The above post was written by an amateur and i disagree with almost everything nitecap wrote. Just proves that he is a nurse in training and does not have an understanding of the real issues/

Again your professionalism shining at its brightest. I have not put in any thoracic epidurals put cared for many pts as yes a RN. Id say at least a couple of hundred. You guys put in the epidural and bolus a few times. We manage the post-op issues increasing and decreasing infusions rates to pain control, side effects ect. Sorry man unless you are working pain mgmt or critcal care you have no clue what your intra op epidural does a few days later and my post was extremely acurate. Not sure where you work but I can promise you I as a Nurse for more than 3 yrs prob. cared for more pts (no not inserting the block) than you still have at your point in your career dave. You are a freaking joke and just when all seems like it may chill out a little bit here you go and open your ignorant mouth. You are prob such a freaking tool too. DAVE 2 words that I want you to think about when you get into your bed alone tonight as usual. BLOW ME.

Sorry Jet, oldmandave and a few others for my come back. I think more than anything chilling some of your fellow anesthesiologist would calm this forum down. You cant expect anything more from dave though, class less to say the least.

You can go ahead and shut down a pretty decent thread now. Appreciate it dave you tool. And my threatening PM's, you must be smoking crack man I have a box full from you as well. Still waiting for you to step up to the plate man.

 

[VolatileAgent]

Paravertrebral nerve blocks are used therapeutically to address radicular pain at a specific level. The local anesthetic dose needed to address each nerve root at the levels affected by the surgery makes it unuseable in the perioperative setting.

Hence the epidural-space approach, which affects, concominantly, several nerve-root levels, whilst staying within accepted local-anesthetic-dosage guidelines.

i disagree. if you are doing a single-sided thoracotomy, you can effectively block only that side. this helps you in two ways. first, it is pretty much impossible to block the contralateral sympathetics (very problematic with thoracic epidurals) so you preserve sympathetic tone and are therefore less likely to develop hemodynamic instability (i.e., hypotension). second, you don't effect chest wall excursion on the non-operative side and patients report being able to often breathe better post-operatively. i think this correlates well objectively with better lung function, less atelectasis, less fever, etc.

we do pre-op, and have even seen intra-op placed under direct vision by CT surgery, paraverterbrals all the time here for VATS and other thoracostomies. it's a very good techinique, but does have a high failure rate. typically we'll run 1/4% lido with epi into the space and it works well. i've even seen this technique done effectively on a 6-year-old. maybe not suitable for private practice, but it's a good techinque. as well, we've got some unique approaches to introducing the catheter that are likely going to be published.

 

[militarymd]

since a thoracic epidural will give them superior pain relief..allowing said patient to take part in the all-important-post-op-lets-not-allow-post-op-atelectasis-play-a-role-in-post op-morbidity role....

Sorry jet, but I got to pull the

on this one. The datas was published in Thorax in the late 90's and has been repeated.

Here is the link: article

 

[quark]

i disagree. if you are doing a single-sided thoracotomy, you can effectively block only that side. this helps you in two ways. first, it is pretty much impossible to block the contralateral sympathetics (very problematic with thoracic epidurals) so you preserve sympathetic tone and are therefore less likely to develop hemodynamic instability (i.e., hypotension). second, you don't effect chest wall excursion on the non-operative side and patients report being able to often breathe better post-operatively. i think this correlates well objectively with better lung function, less atelectasis, less fever, etc.

we do pre-op, and have even seen intra-op placed under direct vision by CT surgery, paraverterbrals all the time here for VATS and other thoracostomies. it's a very good techinique, but does have a high failure rate. typically we'll run 1/4% lido with epi into the space and it works well. i've even seen this technique done effectively on a 6-year-old. maybe not suitable for private practice, but it's a good techinque. as well, we've got some unique approaches to introducing the catheter that are likely going to be published.

We've been placing paravertebral blocks (both single shots and catheters, unilateral or bilateral) preoperatively in cases where an epidural is typically used...e.g. thoracotomies, nephrectomies, ex laps. We also use them for inguinal hernia repairs, mastectomies, prostatectomies, and hystertomies. Most of the patients seem really happy with the blocks and we do round on them everyday to adjust the infusion rates. I haven't seen studies comparing both PVB vs epidurals head-to-head, hence my question in the previous post.

 

[militarymd]

We've been placing paravertebral blocks (both single shots and catheters, unilateral or bilateral

) preoperatively in cases where an epidural is typically used...e.g. thoracotomies, nephrectomies, ex laps. We also use them for inguinal hernia repairs, mastectomies, prostatectomies, and hystertomies. Most of the patients seem really happy with the blocks and we do round on them everyday to adjust the infusion rates. I haven't seen studies comparing both PVB vs epidurals head-to-head, hence my question in the previous post.

I Don't know how to do them.

 

[Noyac]

Paravertebrals work well. Thats all about that.

I place epidurals and I use the paramedian approach for thoracics. Its much easier to place IMHO. I also use .0625% Bupiv with .1% Meperidine. The Meperidine has a local anesthetic effect along with narcotic effect (I also use meperidine for spinals, anothertpic). These pts do well in my opinion. Extubated at the end of the case and completely comfortable. I never put them in asleep, if I had to for some reason I would put a lumbar in and run morphine and it wouldn't work as well.

Nitecap, I gotta disagree with your post. It sounds like the ones placing them in your practice were not very good at it, if only 50% worked. They also were putting them in at the wrong level if the abd was covered but the thoracic area was not. The thoracotomy hurts more so you cover it first and the benefits are greater there. Then you use morphine for greater spread of the narcotic (if yo are worried about the abd incision) and give them a IVPCA for abd pain. As far as the research, I believe its been shown already that there is no difference in recovery of CABG pts with or without Th. Epi. I can't imagine our hearts doing any better. They are out of the ICU the next morning ambulating, eating a full diet and minimal pain without any epidural.

 

[bullard]

As far as the research, I believe its been shown already that there is no difference in recovery of CABG pts with or without Th. Epi.

Yeah, I think there was an article in Anesthesiology last month saying just that. So I have two questions:

1. Are we still waiting for the definitive study on the subject?
2. If not, why are people putting in thoracic epidurals?

 

[2Deep]

If your unsure of your LOR and the patient's spontaneously breathing, you can attach a short piece of IV tubing and a stopcock filled with saline to the Tuohy. Raise it higher than the needle and look for the saline to easily run in, especially with inspiration. The negative intrathoracic pressure should be transmitted to the epidural space at this level. This is not a 100% specific test but it is sensitive. If the column of saline doesn't drop, it's probably not in.

 

[davvid2700]

If your unsure of your LOR and the patient's spontaneously breathing, you can attach a short piece of IV tubing and a stopcock filled with saline to the Tuohy. Raise it higher than the needle and look for the saline to easily run in, especially with inspiration. The negative intrathoracic pressure should be transmitted to the epidural space at this level. This is not a 100% specific test but it is sensitive. If the column of saline doesn't drop, it's probably not in.

sounds like hanging drop to me..

 

[davvid2700]

Again your professionalism shining at its brightest. I have not put in any thoracic epidurals put cared for many pts as yes a RN. Id say at least a couple of hundred. You guys put in the epidural and bolus a few times. We manage the post-op issues increasing and decreasing infusions rates to pain control, side effects ect. Sorry man unless you are working pain mgmt or critcal care you have no clue what your intra op epidural does a few days later and my post was extremely acurate. Not sure where you work but I can promise you I as a Nurse for more than 3 yrs prob. cared for more pts (no not inserting the block) than you still have at your point in your career dave. You are a freaking joke and just when all seems like it may chill out a little bit here you go and open your ignorant mouth. You are prob such a freaking tool too. DAVE 2 words that I want you to think about when you get into your bed alone tonight as usual. BLOW ME.

Sorry Jet, oldmandave and a few others for my come back. I think more than anything chilling some of your fellow anesthesiologist would calm this forum down. You cant expect anything more from dave though, class less to say the least.

You can go ahead and shut down a pretty decent thread now. Appreciate it dave you tool. And my threatening PM's, you must be smoking crack man I have a box full from you as well. Still waiting for you to step up to the plate man.

I dont know where you are.. but where i am if i put in a thoracic epidural I round daily on the patient and make necessary changes.. I will not let any of the nursing staff touch or make adjustments.. In fact I make big signs that say "DONT TOUCH".

And nitecap I think you should be banned for the last time for making innuendos about your genitals. I will petition the moderators for this. Sorry sir. We can have a disagreement about how poor your training is but you cant use sexual innuendos.. ANd dont log back in under a different name. Just go to your nursing forums,, champ. add a U to that

 

[nitecap]

I dont know where you are.. but where i am if i put in a thoracic epidural I round daily on the patient and make necessary changes.. I will not let any of the nursing staff touch or make adjustments.. In fact I make big signs that say "DONT TOUCH".

And nitecap I think you should be banned for the last time for making innuendos about your genitals. I will petition the moderators for this. Sorry sir. We can have a disagreement about how poor your training is but you cant use sexual innuendos.. ANd dont log back in under a different name. Just go to your nursing forums,, champ. add a U to that

Dave there you go again. dave the black sheep of the ASA that discredits all it has achieved. You prob dont even belong to your prof. org. You seem like someone that would complain about everything but not have the balls to step up to the plate and be a leader. Thats b/c dave I actually worked in a top notch world reknown facility not the podunct places where you trained and pracitice. You already even admitted that. So until you get out the woods and goto a place that sets the benchmarks you have no clue man. Sexual innuedos yeah right. Again dave please quit trying to ruin the thread that actually is informative. If you want to get crushed again go ahead and start your own thread man so I can again display to the internet world how very weak you are with your childish come backs and lack of ability to keep your temper under control. Again man the fact that you are alone in this world is very evident, dont know what to tell you man. Try getting a life and then a few peeps might actually give a damn about you.

 

[davvid2700]

Dave there you go again. dave the black sheep of the ASA that discredits all it has achieved. You prob dont even belong to your prof. org. You seem like someone that would complain about everything but not have the balls to step up to the plate and be a leader. Thats b/c dave I actually worked in a top notch world reknown facility not the podunct places where you trained and pracitice. You already even admitted that. So until you get out the woods and goto a place that sets the benchmarks you have no clue man. Sexual innuedos yeah right. Again dave please quit trying to ruin the thread that actually is informative. If you want to get crushed again go ahead and start your own thread man so I can again display to the internet world how very weak you are with your childish come backs and lack of ability to keep your temper under control. Again man the fact that you are alone in this world is very evident, dont know what to tell you man. Try getting a life and then a few peeps might actually give a damn about you.

I graduated from an US medical school and an accredited residency that is top notch enough for me.. amnd furthermore I have my boards under my belt. so there.. I call you out constantly because of the false information you spew on here. WHy would anyone let a nurse titrate epidural infusions. Every hospital that I have been to strictly prohibits that. But you were saying that so everyone can think you are competent when the first few lines of everything you say I can tell you are inexperienced nurse who thinks they can take over the specialty. You think by being in the room where a procedure takes place you automatically get credit for performing that procedure.. It that case I would be an expert in general surgery etc. I wouldnt have to do a residency.. The point is.nursing is nursing.. I dont care if you spent 10 years as an icu nurse.. It doesnt matter. Unless you are a physician and spent formal training in the icu making rounds and making medical decisions all your letters ccrn bsn ccsasda means nothing when it comes down to making MEDICAL DECISIONS>. WHy cant you understand that?

Medicine is Medicine and NUrsing is NURSING. 2 totally different mindsets..

 

[nitecap]

I graduated from an US medical school and an accredited residency that is top notch enough for me.. amnd furthermore I have my boards under my belt. so there.. I call you out constantly because of the false information you spew on here. WHy would anyone let a nurse titrate epidural infusions. Every hospital that I have been to strictly prohibits that. But you were saying that so everyone can think you are competent when the first few lines of everything you say I can tell you are inexperienced nurse who thinks they can take over the specialty. You think by being in the room where a procedure takes place you automatically get credit for performing that procedure.. It that case I would be an expert in general surgery etc. I wouldnt have to do a residency.. The point is.nursing is nursing.. I dont care if you spent 10 years as an icu nurse.. It doesnt matter. Unless you are a physician and spent formal training in the icu making rounds and making medical decisions all your letters ccrn bsn ccsasda means nothing when it comes down to making MEDICAL DECISIONS>. WHy cant you understand that?

Medicine is Medicine and NUrsing is NURSING. 2 totally different mindsets..

It is in a RN's scope of practice to titrate epidural infusions but not bolus epidurals. At least we are on the same page about something. You are right Doctors practice medicine and CRNA's practice nursing. I guess anything that may overalap just does so and thats where the cloudyness is. If I am working in a rural setting with no anesthesiologist around. I develop the plan for my anesthetc and administer it safely and the pt does great. I did everything withn my scope of practice as a CRNA practicing nursing. SO did I just do a few things that are also within the scope of practice as a anesthesiologist. Sure I did. Yet legally, regulatory ect the 2 practices are different yet may do some of the same things. So what do we call it? Thats the real issue that causes the problems. If a CRNA is practicing independently as a contractor in rural america and calling all the anesthesia related shots he is still practicing nursing even though a anesthesiologist in the next town may have a similar operative role as that CRNA and he is practicing medicine Nurse anesthesia is the practice of Nursing though things may overlap. SO be it. I can live with that as long as I have a good profession and great job Im damn content.

Sorry for the "propaganda" guys chill your boy out and like I promised I will stop also. He keeps coming at me and I just cant help but hit back sorry. I prefer doing it via PM's but he is chicken butt.

 

[davvid2700]

It is in a RN's scope of practice to titrate epidural infusions but not bolus epidurals. At least we are on the same page about something. You are right Doctors practice medicine and CRNA's practice nursing. I guess anything that may overalap just does so and thats where the cloudyness is. If I am working in a rural setting with no anesthesiologist around. I develop the plan for my anesthetc and administer it safely and the pt does great. I did everything withn my scope of practice as a CRNA practicing nursing. SO did I just do a few things that are also within the scope of practice as a anesthesiologist. Sure I did. Yet legally, regulatory ect the 2 practices are different yet may do some of the same things. So what do we call it? Thats the real issue that causes the problems. If a CRNA is practicing independently as a contractor in rural america and calling all the anesthesia related shots he is still practicing nursing even though a anesthesiologist in the next town may have a similar operative role as that CRNA and he is practicing medicine Nurse anesthesia is the practice of Nursing though things may overlap. SO be it. I can live with that as long as I have a good profession and great job Im damn content.

Sorry for the "propaganda" guys chill your boy out and like I promised I will stop also. He keeps coming at me and I just cant help but hit back sorry. I prefer doing it via PM's but he is chicken butt.

in rural america you are practicing medicine without a license.. regardless of what the laws say. Seriously, because unless you have a schedule license (like I do and every physician does) narcotic dea license you are perpertrating a fraud. Unless the surgeon is allowing you to use his license to dispense narcotics. no way around it.. In order to prescribe medicine you have to be a physician. So flex your muscles all you want that wont make you a physician.

 

[nitecap]

in rural america you are practicing medicine without a license.. regardless of what the laws say. Seriously, because unless you have a schedule license (like I do and every physician does) narcotic dea license you are perpertrating a fraud. Unless the surgeon is allowing you to use his license to dispense narcotics. no way around it.. In order to prescribe medicine you have to be a physician. So flex your muscles all you want that wont make you a physician.

CRNA's can obtain DEA #'s in some states. Here is the big difference we may order anything relevant to manage the pt within our scope of practice, yet prescriptive authority is more limited Say a post-op pt on the floor is hurting,we may go to the floor and order meds ect as long as consulted by say his surgeon. And in rural podunct this is alot of times the case. And no we are not under the surg.liscense doing such. In most states as far as prescribing goes their are limitations to what a CRNA can prescribe. One couldnt write a script for oxycotin or loratab for the pt to be discharged with to take at home. BUt one could order oxycotin/loratab while the pt was in the hospital to manage his post op pain as long as you have been consulted. OB can consult us for pain mgmt of their laboring pt ect. Dave please do your research b/f you start trash talking. You are ignorant and serely malinformed about scope of practice differences b/t providers. THe way you talk seems like you would know it all.

SO if a PA for a orthopod or CT thoracic surgeon harvests venous grafts or closes after or total hip or even as I have witnessed reem the femur as the orthopod holds it is he practicing medicine even though he is practicing under his PA scope of practice. as well its also the Surgeons scope too. Dave you are a looser man, grow up. You passed your boards congrats now its time to start learning about different aspects and issues relevant to your profession.

THe law is the law man. And if its says that a CRNA in podunct is practicing nursing and not medicine than thats the final word man. Thats what stands up in court. Now I guess you are a law maker too now.

 

[davvid2700]

CRNA's can obtain DEA #'s in some states. Here is the big difference we may order anything relevant to manage the pt within our scope of practice, yet prescriptive authority is more limited Say a post-op pt on the floor is hurting,we may go to the floor and order meds ect as long as consulted by say his surgeon. And in rural podunct this is alot of times the case. And no we are not under the surg.liscense doing such. In most states as far as prescribing goes their are limitations to what a CRNA can prescribe. One couldnt write a script for oxycotin or loratab for the pt to be discharged with to take at home. BUt one could order oxycotin/loratab while the pt was in the hospital to manage his post op pain as long as you have been consulted. OB can consult us for pain mgmt of their laboring pt ect. Dave please do your research b/f you start trash talking. You are ignorant and serely malinformed about scope of practice differences b/t providers. THe way you talk seems like you would know it all.

SO if a PA for a orthopod or CT thoracic surgeon harvests venous grafts or closes after or total hip or even as I have witnessed reem the femur as the orthopod holds it is he practicing medicine even though he is practicing under his PA scope of practice. as well its also the Surgeons scope too. Dave you are a looser man, grow up. You passed your boards congrats now its time to start learning about different aspects and issues relevant to your profession.

THe law is the law man. And if its says that a CRNA in podunct is practicing nursing and not medicine than thats the final word man. Thats what stands up in court. Now I guess you are a law maker too now.

the only people who can prescribe medicine are doctors of medicine, doctors of dental medicine, doctors of podiatric medicine, and doctors of optometry.. everyone else who does it is practicing medicine without a license and I dont care what the law states

 

[nitecap]

the only people who can prescribe medicine are doctors of medicine, doctors of dental medicine, doctors of podiatric medicine, and doctors of optometry.. everyone else who does it is practicing medicine without a license and I dont care what the law states

Fine by me. Dont have the need to prescribe as long as I can order what drugs I need to manage my patient in the OR. That would make me not practicing medicine which I have no desire to do so.

You are just malignant man. I see you dogging DO's here to. I have met several DO's that have passed your beloved boards as well. SO are they not equal to you.

This is over man, grow some Balls and PM me if you have a problem. We have officially ruined this thread by your provoking.

 

[VolatileAgent]

Here is the big difference we may order anything relevant to manage the pt within our scope of practice

that's a loose term, "manage". iow, you don't "manage" a patient anymore than a lpn "manages" an iv insertion site. whatever you do - i don't care how you slice it - someone else is ultimately responsible for it. period.

 

[davvid2700]

Fine by me. Dont have the need to prescribe as long as I can order what drugs I need to manage my patient in the OR. That would make me not practicing medicine which I have no desire to do so.

You are just malignant man. I see you dogging DO's here to. I have met several DO's that have passed your beloved boards as well. SO are they not equal to you.

This is over man, grow some Balls and PM me if you have a problem. We have officially ruined this thread by your provoking.

thats what im saying to you

if you prescribe anything you are practicing medicine without a license

and doing anything without a license is dangerous

I dont care what the legislatures are saying.

I never dengrate DOs ... why dont you go through my posts.. I support them and they are another group that can prescribe medicine.. (doctors of osteopathic medicine)

I knew you would see it my way.. go home nitecap

and things would be fine if you just went out and found your own forum in the nursing lounge and fight with the lpns or the associate degree rns or the anesthesiology assistants..

 

[rn29306]

Anybody ever seen those "Toughman" Contests in towns / cities?

Seems we gots two contenders RIGHT HERE.

 

[TofuBalls]

I just finished my Acute Pain rotation and we placed an average of 4 thoracic epidural a day, mostly for thoracotomies. They are by far the most gratifying epidurals IMHO. The next day when I get a patient to sit up so that I may look at the catheter site, they just pop up with little or no discomfort!

I just wanted to add what we have been doing to confirm a working epidural before the pt rolls to the O.R. For the test dose, we give the entire 5mL vial of 1.5% Lido w/ Epi in two divided doses (3mL then 2mL). Anyway, after taping up the catheter, we take an exam glove filled with ice and run it up and down the pt's back. A pt with a working epidural will almost always have a sympathectomy and notice a change in cold sensation over the blocked dermatomes.

We started doing this due to the sometimes iffy LOR's. Of course if you have a great hanging drop and the catheter feeds effortlessly, that will work too.

Anyway, great thread! I also wanted to ask about using morphine at a lumbar level for thoracic surgery. Any of you guys do this? If so, what dose, rate, etc?

As for the two individuals trying to take this thread down the crapper, please go and start your own thread. Perhaps you could title it: Brokeback Call Room

 

[zippy2u]

Zip's down and dirty technique: Slip some spinal duramorph 0.5mgs before going asleep. Intraop, tell surgeon under direct visualization to do 3-4 intercostals with 0.5%marcaine. Throw guy in unit and surgeon uses PCA IV. Nurses in unit monitor for resp. depression. Oh, he's got some pain the next day? Run over to the unit with 20 cc syringe of 0.5% marcaine and do 3-4 intercostals; don't worry about a pneumo 'cause the guy still has chest tube-- take ya 5 minutes. All geared for minimal headaches. Regards, ---Zip

 

[Noyac]

Zip's down and dirty technique: Slip some spinal duramorph 0.5mgs before going asleep. Intraop, tell surgeon under direct visualization to do 3-4 intercostals with 0.5%marcaine. Throw guy in unit and surgeon uses PCA IV. Nurses in unit monitor for resp. depression. Oh, he's got some pain the next day? Run over to the unit with 20 cc syringe of 0.5% marcaine and do 3-4 intercostals; don't worry about a pneumo 'cause the guy still has chest tube-- take ya 5 minutes. All geared for minimal headaches. Regards, ---Zip

I was done with this thread after those two *****s took it over until I saw that Zippy had a responce.
I like your style zip but I have seen a pt seize after intercostal blocks (but they can seize from anything). That doesn't mean that I think they are bad. I do them all the time for zoster and they work for a short period of time but in thoracotomies they do better with Th. Epi's in my hands. About the intrathecal duramorph, I'm also a big fan. But I limit it at 400mcg b/c a few years back it was shown that 400mcg was the limit of analgesic effects and that anything over that just added SE's. Thats when I stopped using 1 mg doses. 😱 Honestly, I only used the 1 mg dose twice for a couple of long bloody rad. prostates in training. Those guys didn't need any form of pain relief for 3 days and interestingly they didn't itch that much either.

 

[cloud9]

I was done with this thread after those two *****s took it over until I saw that Zippy had a responce.

I was going to finally use the IGNORE (haven't used it on anyone yet) but this is just too funny. Cheap entertainment, gotta love it.

 

[jetproppilot]

I disagree with jet.. The above post was written by an amateur and i disagree with almost everything nitecap wrote. Just proves that he is a nurse in training and does not have an understanding of the real issues/

Dont misunderstand my post...

Was just complimenting the dude on interacting on a clinical level, regardless of the accuracy of the post...at least he's trying to interact on a non-propaganda level, and you gotta give him credit for that.

I'd much rather see posts that I clinically disagree with than the propaganda crap thats been dominating this forum lately.

 

[jetproppilot]

Sorry jet, but I got to pull the

on this one. The datas was published in Thorax in the late 90's and has been repeated.

Here is the link: article

HAHAHAHAHHAHAHAHAHAHHAHAHAHAH

Dude, your inserts are f ukking hilarious!!!

And I really dont give a s hit what the literature says. I've seen post-op thoracotomy patients with, and without thoracic epidurals. And in my book theres no comparison. Call it anecdotal all you want, but if I ever need a thoracotomy, your oriental, intellectual, superbike ridin' a ss better put a thoracic cath in me!!!!!!

 

[jetproppilot]

HAHAHAHAHHAHAHAHAHAHHAHAHAHAH

Dude, your inserts are f ukking hilarious!!!

And I really dont give a s hit what the literature says. I've seen post-op thoracotomy patients with, and without thoracic epidurals. And in my book theres no comparison. Call it anecdotal all you want, but if I ever need a thoracotomy, your oriental, intellectual, superbike ridin' a ss better put a thoracic cath in me!!!!!!

AND DONT GIVE ME YOUR LITERATURE S HIT ON THIS!!!

MilMD: "Hooooooooooooo, Jet, Riterature show no difference in outcome. Mushi mush!"



thats funny!! i dont care who you are, thats funny!!!

 

[militarymd]

AND DONT GIVE ME YOUR LITERATURE S HIT ON THIS!!!

MilMD: "Hooooooooooooo, Jet, Riterature show no difference in outcome. Mushi mush!"



thats funny!! i dont care who you are, thats funny!!!

I would want one too, and i put them in all the time for thoracotomies....I'm just saying it appears that good pain relief does not decrease post thoracotomy atelectasis.

 

[jetproppilot]

I would want one too, and i put them in all the time for thoracotomies....I'm just saying it appears that good pain relief does not decrease post thoracotomy atelectasis.

Agreed. Just intuitively doesnt make sense, know what I mean? S/P rib fractures, one worry is low tidal volumes secondary to pain will lead to low tidal volumes and potential atelectasis and consolidation, correct? And thats where incentive spirometry comes in, right?

Seems someone more comfortable would perform pulmonary stuff better....incentive spir., coughing, moving around, etc, and hence have less pulmonary sequalae.

The top of that paper says there is alot of controversy on this topic....what do the papers on the other side of the controversy say?

 

[davvid2700]

I was done with this thread after those two *****s took it over until I saw that Zippy had a responce.
I like your style zip but I have seen a pt seize after intercostal blocks (but they can seize from anything). That doesn't mean that I think they are bad. I do them all the time for zoster and they work for a short period of time but in thoracotomies they do better with Th. Epi's in my hands. About the intrathecal duramorph, I'm also a big fan. But I limit it at 400mcg b/c a few years back it was shown that 400mcg was the limit of analgesic effects and that anything over that just added SE's. Thats when I stopped using 1 mg doses. 😱 Honestly, I only used the 1 mg dose twice for a couple of long bloody rad. prostates in training. Those guys didn't need any form of pain relief for 3 days and interestingly they didn't itch that much either.

I give consistently .2 mg for my c sections.. what do yalll think about that dose of duramorph.. I am afraid of increasing my dose just a little bit for fear of side effects.. Namely itching..

 

[militarymd]

Agreed. Just intuitively doesnt make sense, know what I mean? S/P rib fractures, one worry is low tidal volumes secondary to pain will lead to low tidal volumes and potential atelectasis and consolidation, correct? And thats where incentive spirometry comes in, right?

Seems someone more comfortable would perform pulmonary stuff better....incentive spir., coughing, moving around, etc, and hence have less pulmonary sequalae.

The top of that paper says there is alot of controversy on this topic....what do the papers on the other side of the controversy say?

I believe the controversy is the common belief that it should work...as everyone (including myself) believe...hoever desproved by data.

I had a patient today with a thoracoabdominal incision crossing the thorax and abdomen....one lung vent for 3 hours...for a tumor resection that crossed the diaphragm....

I put the epidural in post op....night and day difference....10/10 pain before, no pain afterwards....but the data would suggest that CT graded atelectasis would be no different.

 

[Noyac]

I give consistently .2 mg for my c sections.. what do yalll think about that dose of duramorph.. I am afraid of increasing my dose just a little bit for fear of side effects.. Namely itching..

Nice post David. Now that wasn't so hard, was it?
Don't be affraid in the OB population. I give .4mg routinely and they are happy. The Obstetricians love it and so does the OB nursing staff. Maybe one in five itch but they are more comfortable than with .2 mg. Plus nubain really works well for the pruritis. I reserve the .2 mg dose for the elderly.

 

[jetproppilot]

I believe the controversy is the common belief that it should work...as everyone (including myself) believe...hoever desproved by data.

I had a patient today with a thoracoabdominal incision crossing the thorax and abdomen....one lung vent for 3 hours...for a tumor resection that crossed the diaphragm....

I put the epidural in post op....night and day difference....10/10 pain before, no pain afterwards....but the data would suggest that CT graded atelectasis would be no different.

This is where I have a problem with "studies". I mean, gimme a break, Mil. I think it should make a difference. MilMD, Mr. Dude that has so many degrees we should call him thermometer thinks it should make a difference. Then the "literature" puts out a cuppla "well done" studies, and, thats that . The scientific method has been proven and replicated.

I wish I had the statistical prowess to dissect these studies that have "proven" something that, anecdotally, myself, and many other clinicians find the end-result hard to believe.

I've done hundreds of thoracic epidurals for thoracotomies, as has every other cutting-edge clinician who has been in the anesthesia biz for ten years. No big feat. Just a factor of time. We've seen the clinical differences in our patients...those that cant have an epidural for a thoracotomy for whatever reason, and those that we place them in. No comparison, as Mil pointed out in his recent case. I differ NONE in Mil's description of a thoracotomy patient with a pain score of 10/10 before-epidural, and no-pain/10 post-epidural. With a well placed catheter by a skilled clinician, those are the facts.

Then factor in your knowledge of respiratory physiology, the advantages of being able to breathe "normally" after a surgeon cuts your ribcage open, verses "not being able to breathe normally after a surgeon cuts your ribcage open", i.e...without a thoracic epidural.

I again digress back to your run-of-the-mill patient with multiple rib fractures in the ER, S/P MVA...one of the significant worries about this dude is that he's not gonna respire normally because of the pain, and resultant of that, he is at risk of atelectasis and potential pulmonary consolidation.

Said ER dude differs little from a post-op thoracotomy patient. Suggested pulmonary sequelae are the same.

SO MIL, are these studies GOOD enough to establish a precedence? Good enough to defer the perioperative placement of a thoracic epidural, which you, me, and many other clinicians have witnessed, albeit anecdotally, the clinical advantages of??

Lemme divulge my statistical knowledge and see if I can find, along with you, any weaknesses in said studies...lets be the devil's advocates here...

are they multi-center studies? Are their n values big enough to warrant clinical precedence? Are their p values low enough to warrant clinical precedence?

I think this is where the money is...if the n value is high enough, and the p value is low enough, for clinicians who practice every day to alter their clinical practice because of the results of said study.

Can you say, with confidence, that we should alter our clinical practice because of said studies???

 

[Noyac]

I'm with you Jet, but I think there may be something we are not measuring here in the private world that is measured in the research (indirectly). How many times do you get a chance to see the incentive spirometer used before the epidural is placed and then again after. For example, I just had a lady come in the ER after taking a wrong turn on her snowmobile and driving it off a 50ft cliff and tumbling 150 ft. Among many of her injuries, all of which were remarkably not life threatening, she fractured 3 ribs and had a pneumothorax. She was admitted to the ICU for obs and 2 days later I was asked to put a thoracic epidural in her for pain control. She was pulling 1300mls with the IS b/4 placement and then after placement she was still just pulling 1300 mls totally pain free. So I checked her the next day after 24hrs pain free and still 1300mls. Therefore, in the research this may explain the lack of evidence to improve outcome, either b/c of atelectasis or pneumonia, etc. What do you think? Mil? Anybody?

 

[mick2003]

[

 

[militarymd]

Here is something to chew on with respect to studies looking at things that we intuitively know to be true.


Prior to year 2001, Lopressor was contraindicated for use in patients with low ejection fractions. Reason being a beta blocker is a negative inotrope, and for years clinicians saw that using lopressor in low ef patients resulted in worse symptoms and subsequent hospital admissions....

However, in 2001, the FDA re-labeled the package insert from "contraindicated" to "INDICATED" for decreased ejection fraction.

The reason, a number of studies published in the 1990's showed that despite increased symptoms, etc....patients with low EFs had better survival when placed on Lopressor....go figure.

There are other examples of this....things just make sense one way, but when studied vigorously...ie pooled data from multiple clinicians....the results go the other way...

inotropes in heart failure
regional anesthesia and MIs
efficacy of zofran vs anzemet
the list goes on....

What do you all say?

 

[OldManDave]

HAHAHAHAHHAHAHAHAHAHHAHAHAHAHCall it anecdotal all you want, but if I ever need a thoracotomy, your oriental, intellectual, superbike ridin' a ss better put a thoracic cath in me!!!!!!

Jet has nailed this one on the head! But, let me be a little more blunt - if I ever have a thoracotomy & someone doesn't give an epidural...or make a damned good effort to try...IF I survive the operation, I will promise to open an entire crate of whoop-ass on them!

Furthermore, just to add fuel to the fire - CSEs have never been demostrated to improve/alter outcomes vs plain labor epidurals. But, from a purely quality of experience, rapidity of comfort, patient satisfaction & public relations - I most always opt for the CSE...unless there are compelling reasons not to do so.

Literature is meant to serve as a guide to best practice(s). I did not bust my balls in medical school & now residency to merely mindlessly follow the latest publication. For most topics, if you follow the literature in sufficient depth or over time, you can find bodies of data to support most any position on most any topic. Fundamentally, I think the lack of concensus or the circuitous wax/wane of what "best" is reflects the fact that medicine is truly many many generations from truly understanding how the body works. Until we can claim...if we ever can...that level of insight, our literature will be frought with playing the statistics game.

 

[militarymd]

Fundamentally, I think the lack of concensus or the circuitous wax/wane of what "best" is reflects the fact that medicine is truly many many generations from truly understanding how the body works..

I hear this all the time from residents, "don't let the evidence confuse me, based on my experience, I know what to do."

 

[OldManDave]

I hear this all the time from residents, "don't let the evidence confuse me, based on my experience, I know what to do."

That is not what that phrase implies. As someone with a mere 19 or so months of experience, I am not so brash as to proffer the assertion you have made. My statement applies to medicine, including clinical medicine, as a whole. Face it - much of what is taught in med school is still based upon prokaryotes & eukaryotes - not on organ systems as complex as a hominid.