would you consider a cut down?

[urge]

For an epidural in a morbidly obese pt if you really wanted one for whatever reason?

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[bostonblaz]

would take them to the pain clinic and do it with fluro before i tried to do a cut down

 

[Planktonmd]

For an epidural in a morbidly obese pt if you really wanted one for whatever reason?

I can't think of a situation where I could want an epidural bad enough to consider that.
If I can't get an epidural in you the conventional way this means you don't get an epidural.

 

[isoman2000]

What would you need an epidural so badly for? Has anyone ever done it?

 

[jennyboo]

Ever consider looking with an ultrasound? Not sure if you can really do it "ultrasound guided" but I once had a lady with BMI 70 for urgent c-section (active labor, fetal macrosomia) -- took the ultrasound, used it to approximate midline, then put the probe down and proceeded to place the epidural the regular way in the spot where I saw midline on the ultrasound.

Hard to imagine getting these patients to lie on their stomachs for fluoro (ehm, even less so if pregnant and in labor).

 

[dfk]

Hard to imagine getting these patients to lie on their stomachs for ...

...and for what got them here in the first place

 

[DrRobert]

What would you need an epidural so badly for?

The only surgery that I would consider an epidural mandatory is for lung volume reduction surgery - you'd never get them extubated without one. Usually these patients are cachectic rather than morbidly obese. I would do the epidural under fluoro regardless of whether or not it would be easy because in this case the epidural MUST work.

 

[jetproppilot]

For an epidural in a morbidly obese pt if you really wanted one for whatever reason?

No.

 

[periopdoc]

...and for what got them here in the first place

I once took care of one of these patients. The baby daddy was equally obese...I mean a REALLY MASSIVE couple.

Finally, one of the L&D nurses had the balls to pop the question.

Apparently, they invited the neighbors over. Mom to be laid down on the kitchen table. The neighbors stepped in and each of them held a leg up while baby daddy did the deed.

Thankfully she delivered vaginally.

Ultrasound is not particularly good for epidurals because the people you would need it for are too big for ultrasound to work effectively. Because you need such a steep angle with your needle, it is difficult to visualize on ultrasound. However, ultrasound can be helpful in determining midline, depth to the spinous processes, and identify interspaces prior to inserting the needle.

If I was desperate and failed to place the epidural in the usual fashion, hard to imagine, I would use fluoro.

-pod

 

[potentagent]

For an epidural in a morbidly obese pt if you really wanted one for whatever reason?

Nope

 

[dfk]

Apparently, they invited the neighbors over. Mom to be laid down on the kitchen table. The neighbors stepped in and each of them held a leg up while baby daddy did the deed.

Thankfully she delivered vaginally.

with friends like those, who needs enemies?!

 

[geogil]

I once took care of one of these patients. The baby daddy was equally obese...I mean a REALLY MASSIVE couple.

Finally, one of the L&D nurses had the balls to pop the question.

Apparently, they invited the neighbors over. Mom to be laid down on the kitchen table. The neighbors stepped in and each of them held a leg up while baby daddy did the deed.


-pod

 

[jetproppilot]

with friends like those, who needs enemies?!

i just threw up a little in my mouth...

 

[Monty Python]

..... and coming soon to your neighborhood bariatric surgery center :troll:




.

 

[Jalopycat]

I didn't know they made undies that big!

 

[Trisomy13]

I didn't know they made undies that big!

it's a tablecloth.

now leave my gal alone!

 

[Trisomy13]

I once took care of one of these patients. The baby daddy was equally obese...I mean a REALLY MASSIVE couple.

Finally, one of the L&D nurses had the balls to pop the question.

Apparently, they invited the neighbors over. Mom to be laid down on the kitchen table. The neighbors stepped in and each of them held a leg up while baby daddy did the deed.

I have heard of this technique, which means either: it is urban legend (but it sounds legit), we are at the same institution (unlikely), you are me (disturbing), or this is an accepted method of fatty reproduction (most likely).

Ew.

 

[periopdoc]

I have heard of this technique, which means either: it is urban legend (but it sounds legit), we are at the same institution (unlikely), you are me (disturbing), or this is an accepted method of fatty reproduction (most likely).

Ew.

Johns Hopkins?

-pod

 

[Trisomy13]

Johns Hopkins?

-pod

nope, must be a recognized method of blubberlust.

 

[urge]

I can't think of a situation where I could want an epidural bad enough to consider that.
If I can't get an epidural in you the conventional way this means you don't get an epidural.

I was thinking about a 700 lbs pregnant fibromyalgia pt with a bunch of "allergies" to any pain medication. Patient is adamant about an epidural because she "cannot" get anything else. You can do it...you know it... but you know you might strugle for a while.... and might not be successful.

Why go through all that agony? I don't need to prove I can do epidurals 1 foot below skin level. Why not just do a cut down? This should be standard of care.

 

[jetproppilot]

I was thinking about a 700 lbs pregnant fibromyalgia pt with a bunch of "allergies" to any pain medication. Patient is adamant about an epidural because she "cannot" get anything else. You can do it...you know it... but you know you might strugle for a while.... and might not be successful.

Why go through all that agony? I don't need to prove I can do epidurals 1 foot below skin level. Why not just do a cut down? This should be standard of care.

Sounds foolhardy to me.

Doing a cutdown (I don't know how you'd accomplish this) sounds like a surgical procedure with an incision to me....then say you're successful...

big lady then lays on her back (surgical site) for hours on end with fluid, pee, and poo poo stuff on the pad she's laying on....and you've got a direct conduit to the epidural space via your catheter?????

I'll pass.

Thanks.

 

[militarymd]

I was thinking about a 700 lbs pregnant fibromyalgia pt with a bunch of "allergies" to any pain medication. Patient is adamant about an epidural because she "cannot" get anything else. You can do it...you know it... but you know you might strugle for a while.... and might not be successful.

Why go through all that agony? I don't need to prove I can do epidurals 1 foot below skin level. Why not just do a cut down? This should be standard of care.

fluoro

 

[Gern Blansten]

Sounds foolhardy to me.

Doing a cutdown (I don't know how you'd accomplish this) sounds like a surgical procedure with an incision to me....then say you're successful...

big lady then lays on her back (surgical site) for hours on end with fluid, pee, and poo poo stuff on the pad she's laying on....and you've got a direct conduit to the epidural space via your catheter?????

I'll pass.

Thanks.

What he said!

Does anyone take into consideration in these situations the weight limit of the MRI scanner? What would you do if you placed an epidural in one of these "big boned" patients and they began to have neurologic symptoms consistent with an epidural hematoma or abscess? You are then told that she cannot have an MRI because of the weight limit for the insurance policy on the MRI scanner. What then? Let's just suppose that you are not near a Sea World park where you could use Shamu's MRI scanner.

 

[Gern Blansten]

This should be standard of care.

Seriously!? If someone suggested that to my loved one, first I would say, "Baby, in case the fact that we had to invite friends over to help us have sex wasn't enough of a clue, this should be a sign that you gotta lose some damned weight!" Then I would say "Hell no you are not going to do a cut down epidural!"

 

[Arch Guillotti]

When I hear "cut down" and epidural in the same sentence I assume it is a joke. I have never even thought about it until this thread.

 

[huktonfonix]

i guess its done for scoliosis surgery, but thats because theyre there already.

 

[Fastrach]

How bout a cut down for an a-line?

(Other than 'You g*dd@m freakin radial artery, your mom's an idiot!'... cut down, get it.. tee hee..)

But seriously, especially on those vasculopaths where you KNOW the artery is RIGHT THERE, and you just can't thread the damn wire... is it not unreasonable after you've tried on both sides as well as been unsuccessful with a brachial stab?

I've seen a-line cutdowns twice over my residency, and both times involved calling in a surgeon... is this standard for everyone else?

 

[huktonfonix]

not standard, but also useful in lil tiny babies needing lil tiny arterial lines

 

[Gern Blansten]

How bout a cut down for an a-line?

(Other than 'You g*dd@m freakin radial artery, your mom's an idiot!'... cut down, get it.. tee hee..)

But seriously, especially on those vasculopaths where you KNOW the artery is RIGHT THERE, and you just can't thread the damn wire... is it not unreasonable after you've tried on both sides as well as been unsuccessful with a brachial stab?

I've seen a-line cutdowns twice over my residency, and both times involved calling in a surgeon... is this standard for everyone else?

Ultrasound or doppler can be very helpful in these cases before trying a cutdown.

 

[Planktonmd]

Ultrasound or doppler can be very helpful in these cases before trying a cutdown.

Doppler?
How do you do a Doppler of the epidural space?

 

[Planktonmd]

Doppler?
How do you do a Doppler of the epidural space?

Never mind, you are actually talknig about A lines.

 

[TheSandMan]

Right now I am on a pediatric cardiothoracic rotation, where we do cut down a-lines routinely. Its so easy that it almost a joke.

Why dont we do this on adults with impossible to get a-line eg. that multiple gunshot wound trauma with no blood pressure?

How bout a cut down for an a-line?

(Other than 'You g*dd@m freakin radial artery, your mom's an idiot!'... cut down, get it.. tee hee..)

But seriously, especially on those vasculopaths where you KNOW the artery is RIGHT THERE, and you just can't thread the damn wire... is it not unreasonable after you've tried on both sides as well as been unsuccessful with a brachial stab?

I've seen a-line cutdowns twice over my residency, and both times involved calling in a surgeon... is this standard for everyone else?

 

[Arch Guillotti]

Right now I am on a pediatric cardiothoracic rotation, where we do cut down a-lines routinely.

!

I did 4 months of hearts during residency and never saw one despite being in the peds room pretty frequently.

 

[urge]

fluoro

Does a 700lbs pt fit in the C-arm? Especially if they are pregnant. I don't know.

Cut down, my friend. That is the answer. I'll bring it up to attendings active at the SOAP.

 

[urge]

Sounds foolhardy to me.

Doing a cutdown (I don't know how you'd accomplish this) sounds like a surgical procedure with an incision to me....then say you're successful...

big lady then lays on her back (surgical site) for hours on end with fluid, pee, and poo poo stuff on the pad she's laying on....and you've got a direct conduit to the epidural space via your catheter?????

I'll pass.

Thanks.

You are so negative. Relax dude. It will be all right.

 

[Gern Blansten]

Why do I get the feeling that urge is just jacking with us? Have we been punked.

 

[dfk]

Does a 700lbs pt fit in the C-arm? Especially if they are pregnant. I don't know.

Cut down, my friend. That is the answer. I'll bring it up to attendings active at the SOAP.

i'm sure you couldn't even tell they're pregnant. as for weight issue, hell, with 700 pounds, what does a handful more make? not that much in the scheme of things. put 'er in the C-arm and give 'er a biggun hug!

 

[lobelsteve]

Fluoro is likely out.

2 problems from a technical standpoint.
Table capacity limited to 500 pounds.
Bari tables - too cumbersome for the C.

C-arm power- even the "aggressive OEC 9800's" cannot penetrate that amount of tissue to give an image that would be useful.

I have done an ESI using an OEC 9400, a 500 pound rated table, and a 412lb patient. THe bones were slightly grayer than the surrounding snow. I thought I was looking at an oscilloscope screen. A 17G 6" Tuohy was down to the hub and I applied 2" pressure on the surrounding skin to get it in.

Additional problem: patient would need to be sidelying- a baby would not survive in the prone fatty position.

 

[urge]

Why do I get the feeling that urge is just jacking with us? Have we been punked.

I'm just trying to advance anesthesia into the 21st century. We didn't do cut downs because we didn't have 700lbs patients. Times have changed. So should our approach.

 

[dhb]

I'm just trying to advance anesthesia into the 21st century. We didn't do cut downs because we didn't have 700lbs patients. Times have changed. So should our approach.

now that's funny.

Anyway 21th century will see food prices go through the roof, fat people won't be able to sustain their diet and will lose weight

 

[Gern Blansten]

now that's funny.

Anyway 21th century will see food prices go through the roof, fat people won't be able to sustain their diet and will lose weight

Before that happens, they will eat all of the skinny people.

 

[dhb]

If they can catch them

 

[cloud9]

For an epidural in a morbidly obese pt if you really wanted one for whatever reason?

Epidural is elective.

That being said we have had find longer epidural needles as the space can be at 12 or 13 cm. So far never been unable to get one.

always a good time

 

[9french]

I'd consider pre-epidural, emergency liposuction first.

 

[Planktonmd]

I'd consider pre-epidural, emergency liposuction first.