While by no means an expert, I have given at least 2 successful spinals to women with Harrington rods . There were no issues, as the rods extended to the mid lumbar region, and I could easily get the needle in at L3/4.

I would expect that an epidural block would be patchy, not so much because of scar tissue, but because of the anatomical displacement of the cord and nerve roots due to the rods. The epidural space would be compressed on the previously concave side and may not come into contact with anesthetic solution.

I rencently had the challenging task of giving a single lung ventilation to a 5 year-old 25kg child who had been in a traffic accident and had a large hemothorax. The surgeons wanted to explore and repair on one lung if possible. The case was urgent enough for there to be no time to transfer to a dedicated pediatric hospital.

I managed to put a standard 5.5 ETT into the right main bronchus, with a big enough leak to allow the left lung to deflate. The surgeons were happy with their access and the bleeder was repaired.

My problems started when the surgeons requested repeated inflations and deflations of the left lung to identify persisting air leaks. I managed to pull the tube back and pass it down again several times, each time hoping it would go back into the right main bronchus. This worked well but was a very cumbersome technique.

I thought about putting in a Fogarty catheter as a bronchial blocker, but could not fit the catheter and bronchoscope together down the lumen. My smallest double lumen tube was a 32F - too big for this child.

Any other ways of tackling this situation?

I have recently become a convert to IT morphine. I am using 200mcg in 2.5mL heavy bupivacaine for my spinal Cesareans. The post-op analgesia is superb and rarely requires rescue narcotic in the forst 24 hours.

I am concerned that our glass morphine ampoules are not packaged sterile. What if I am introducing bacteria simply by contaminating the morphine solution when I crack the ampoule?

So I ran an informal, personal trial. I painted the outside of the morphine ampoule with sterile methylene blue, let it dry before cracking it. About one third of the morphine solutions showed some blue discoloration from the methylene blue, indicating that a small amount of whats outside the ampoule gets inside. I now get my assistant to wipe the ampoule with alcohol (and let it dry) before they crack it.

Any other ideas?

I am using parecoxib a lot since they tell me its the best thing since sliced bread.

But I am yet to be conviced that its as good as the old fashioned NSAIDS that we gave as suppositories.

I know we are supposed to wait 90 minutes for tis epak effect, even with IV administration, but I just getthe impression that patients were more confortable with my old regimen.

Anyone care to agree or argue?

That the subarachnoid space "herniates" through the nerve root foramina is well known. It is surprisingly easy to access the subarachnoid space at the level of the neck, especially in the thin patient. I am pretty sure this is what happened.

An intravascualr injection (carotid or vertebral) would cause an instant seizure followed by a relatively short coma.

It is well-known that intubating through poorly relaxed cords has a high incidence of cord damage.

>:D

For most longer head and neck work, when the airway is difficult to access, I think the most secure airway possible is the best. ie a ETT. I wouldn't risk anything less.

Does the screen separate from the LMA part or is it attached permanently? And if it separates, is it easy to attach? I'm thinking: Difficult airway, manage to get LMA in, squeak a bit of O2 in, patient borderline oxygenated, then have lots of trouble attaching the screen and alignining the connections properly to get a good view to intubate. May be mroe trouble than its worth.