pasgasser

I agree completely. Multiple studies have shown that EEG is not a reliable method of determining sedation level. BIS only measures frontal lobe in some way that the company will not divulge then puts in a machine, generates a random number that has no units and claims that sedation level is being measured. About two months ago in "Anasthesia and Analgesia" a case report indicated that a patient had recall because the BIS suggested appropriate sedation and the provider decreased th level of anesthesia.

pneumonics are ok, but Troy is correct. This is important and understanding the relationships is a must in practice. Few CRNA's or MDA's could quote these Laws but the magority should be able to derive them. After you understand them, they make sense.

Sprout, your second catherter may have not been intrathecal. After placing the toughy needle the first time if you bolused the needle (like many including myself do) then that fluid plus the fluid from the first leak would be in the epidural space. The positive aspiration could have been CSF and local anesthetic in the epidural space. A trick is to set the catheter down and see if fluid spontaneously comes from it. This is a gut feeling situation determined by the way the toughy felt going in and the flow of fluid coming out but at times a difference between epidural fluid and intrathecal CSF can be known, a test dose will confirm either. On another note you are in Birmingham. I did my anesthesia residency there and graduated in 2003 by your username I think I may know you. Send me PM.

The reason the provider changed the line is because at the onset of the case the pt descibed could easily need large bore access. A 4 lumen CVL is great for infusions but is a horrible volume line. If the 4 lumen line were new I would have likely left and it and also inserted the larger CVL. I can't imagine any provider not getting more access.

depending upon the pt's co-existing dzs it could (diabetes could cause the urinary retention to occur for several days). If the pt had not urinated after 72 hours I would investigate other causes. Also the type of local anesthetic is not mentioned here. If tetracaine or bupivicaine was used to help provide post-op pain the urinary retention could be longer. It is likely that the pt did not get a lidocaine SAB because 1) he was going to be an in-pt and no need for the SAB to wear off quickly 2) the incedence of transient neurologic syndrome associated with lidocaine has alot of providers avoiding it. I have started using bupivicaine for c-sections for the above reasons eventhough th OB's I work with rarely take longer than 15 minutes skin to skin on the procedure.

Urinary function is usually the last thing to return after SAB, this is lilkely the cause of your grandfather's issue. Nothing to worry about give it time. Because of this issue many providers including myself choose not to use SAB for out-pt procedures.

The reason for such a large ordeal is that if it the original intubation resulted in the pt being intubated with a combitube it can be assumed all other avenues were tried unsuccessfully. Combitubes are a last resort measure. The normal INR is 1 in nonanticoagulated pt's. An INR of 1.7 correlates to an INR in the 7th standard deviation from normal and a blind nasal technique would have had a high risk of bleeding. Also with this pt's sedation doses I assume she was not spontaneously ventilating which makes a blind technique very difficult.

The reason for such a large ordeal is that if it the original intubation resulted in the pt being intubated with a combitube it can be assumed all other avenues were tried unsuccessfully. Combitubes are a last resort measure. The normal INR is 1 in nonanticoagulated pt's. An INR of 1.7 correlates to an INR in the 7th standard deviation from normal and a blind nasal technique would have had a high risk of bleeding. Also with this pt's sedation doses I assume she was not spontaneously ventilating which makes a blind technique very difficult.

I'm curious. I am an anesthesiologist and at times I have sat with a pt in the PACU while waiting for the second on call RN to come in (I have also had the surgeon sit with the pt in the PACU while I have gone to the ER). Seriously is this a violation since I am not a PACU trained RN (nor was the surgeon). I am confident that pt care is not compromised but after reading the above I am curious if a violation has occurred.

Awareness during anesthesia is terrible but the BIS monitor is likely not the answer. Many times a full EEG has been used to attempt to determine depth of sedation and many times it has been ineffective. It is nonsensicle to believe that the BIS which only measures activity in the frontal lobes is superior to an EEG. I have strong anti-BIS feelings and can site more examples but the preceding to me is the most convincing.

This reply is to address pain on injection of propofol and not the original concern of chris. I have found two ways to help avoid pain on injection of propofol. 1)give 1 mg/kg of lidocaine 2 minutes proir to induction and stop the IV immediately after the injection (poor man's Beir block of the vein), 2)give 5-10mg of ketamine 1 minute prior to induction with propofol. These are not things that are from literature but have prove effective for me. I have found mixing lidocaine with propofol very ineffective in reducing pain upon injection of propofol.

The surgeon injects the scalp with local/epi and no further analgesic is necessary. At times colleages have needed low dose remi or propofol to aid with the anesthetic but I have not needed these to date.

The surgeon injects the scalp with local/epi and no further analgesic is necessary. At times colleages have needed low dose remi or propofol to aid with the anesthetic but I have not needed these to date.

My precedex use hs been limited to awake craniotomies. It works well because the sedation is good but respiratory drive is not decreased so no increase in PaCO2 and a intra-op neuro exam is easy to obtain. I agree with the hypotension with the loading dose to overcome this I don't load it. I use midazolam pre-op, turn the infusion on upon entry into the OR, and use propofol boluses for pinning and turning the bone flap. I have had great success with this routine. I have a partner who has successfully used a similar protocol for totoal hip arthroplasty in elderly pt's using a SAB.

My precedex use hs been limited to awake craniotomies. It works well because the sedation is good but respiratory drive is not decreased so no increase in PaCO2 and a intra-op neuro exam is easy to obtain. I agree with the hypotension with the loading dose to overcome this I don't load it. I use midazolam pre-op, turn the infusion on upon entry into the OR, and use propofol boluses for pinning and turning the bone flap. I have had great success with this routine. I have a partner who has successfully used a similar protocol for totoal hip arthroplasty in elderly pt's using a SAB.