Clinical issues?

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This board and the NA.org board has become a bulletin board for anesthesia training programs.

There has got to be some clinical questions and dilemmas that folks face in their training that they may want an opinion on apart from their clinical instructors. Or maybe not. That is a great testament to training programs as they exist today.

But...if there is something that someone said or did in your clinical setting that you want to vet in an anonymous setting, or present an easy or difficult case...do it here. You'd be surprised at how many anesthesia residents peek in looking for the right way to do things in a "safe" way of taking advantage of CRNA's knowledge and experience...SRNA's should too!

Anesthesia is such a technical, skill based specialty, I'm so surprised that on line forums, pretty much across the board, have so little clinical conversations.

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I'm not far in my program (graduate in 2019) but I'll have a lot of questions. One that came up last week though is epidural placement in obese patients. Is there any ultrasound technology or something for spirals/epidurals when it's not possible to palpate bony prominences?

[offlabel]

I'm not far in my program (graduate in 2019) but I'll have a lot of questions. One that came up last week though is epidural placement in obese patients. Is there any ultrasound technology or something for spirals/epidurals when it's not possible to palpate bony prominences?

Yes, there is, and there are folks that use it and promote it, but I can tell you that I've never met anyone that uses u/s for that with any regularity at all. Not being able to palpate landmarks is not an impediment to placing a neuraxial block for a routine case (ie, elective surgery or labor epidural). Now, chronic pain management is another story that presents unique challenges, but that isn't what we're talking about here. It's just the typical obese patient for an elective procedure.

Being able to see and palpate everything is no guarantee of an easy block either The largest patient I ever put an epidural in was around 560 pounds and needed a lot of help staying still. That was with a normal length touhy needle.

More than u/s, excellent positioning, lining up the base of the neck with the top of where the gluteal cleft should be and simply asking the patient where he feels the needle going and redirecting based on that is the most efficient way of putting these blocks in, imo.

Another caveat would be to go a little higher for placement in someone you desired a lumbar epidural, around T11-12.

One last trick that works for me...an epidural needle is far more maneuverable than a spinal needle, so on occasion, I'll find the epidural space with that and use it for an introducer for a long spinal needle for a spinal anesthetic.

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Thank you so much. I am still in the stage of being petrified holding a rather large Tuohy needle and shoving it into someone's back without visibility. I like the idea of using the Tuohy as an introducer for a spinal--I'll keep that in my back pocket for the future.

Next question from today: we were taught to never use desflurane or isoflurane for inhaled inductions d/t risk of laryngospasms. I saw someone today give an induction dose of propofol (not RSI) and while preoxygenating she turned her desflurane gas on. I asked her if she always did this and she said yes, regardless of the gas. She said this was acceptable because desflurane can't be used for inhaled INDUCTIONS but it wasn't a problem at this point, and it's only a problem if the patient is awake to feel the airway irritation. Overall that sounds scary to me, but again just a few months into the program with a lot to learn still. Is this safe/acceptable practice?

[offlabel]

Thank you so much. I am still in the stage of being petrified holding a rather large Tuohy needle and shoving it into someone's back without visibility. I like the idea of using the Tuohy as an introducer for a spinal--I'll keep that in my back pocket for the future.

Next question from today: we were taught to never use desflurane or isoflurane for inhaled inductions d/t risk of laryngospasms. I saw someone today give an induction dose of propofol (not RSI) and while preoxygenating she turned her desflurane gas on. I asked her if she always did this and she said yes, regardless of the gas. She said this was acceptable because desflurane can't be used for inhaled INDUCTIONS but it wasn't a problem at this point, and it's only a problem if the patient is awake to feel the airway irritation. Overall that sounds scary to me, but again just a few months into the program with a lot to learn still. Is this safe/acceptable practice?

Confusing... you said she gave an anesthetic dose of propofol, but then you said she turned the vaporizer on while preoxygenating. We preox patients while still awake. She turned the des on while the patient was awake? Or after the propofol? We always turn the agent on at some point after the induction agent. If she did it right after the induction, there is no risk of spasm.

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Sorry, she gave the propofol and was turned on the vaporizer. It was my first time that we didn't use sevo so I wasn't sure if this was standard or not.