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Topics - Russell Coupland

I have an old-fashioned surgeon who likes me to check the patient's vocal cords after thyroid and parathyroid surgery to look for recurrent laryngeal nerve palsy. Despite having done this list for many years, I am yet to find a consistently successful way fo doing this.

The techniques that I use are:
1. Pull the ETT while the patient is deeply anesthetized and look using direct laryngoscopy.
2. Insert laryngoscope as the patient emerges, and when they are ready to extubate, pull ETT while looking at cords.
3. replace ETT with LMA while patient is deep and check crods with a fibreoptic bronchoscope.

None of these works all the time, and I am too often reassuring my surgeon despite NOT having had a good look at the cords.

Any other suggestions?
Regional Anesthesia / How do you do your Epidurals?
January 26, 2005, 02:13:20 AM
Not that it means anything, but I am wondering how people do their epidurals?
General Discussion / ECGs for everybody?
January 06, 2005, 02:57:59 AM
I do not use ECGs monitoring routinely during anesthesia. In fact, I would estimate less than 50% of my patients warrent ECG monitoring. If the patient is young (less than 50) with no cardiac history and no history of arrhythmia, then I do not use ECG monitoring. I have it available if needed, but rarely have I had to apply it at a later stage. My pulse oximeter gives me all the info I need regarding heart rate and rhythm.

I find that I sometimes have to argue the point strongly with my assistant or resident. Yet, when I ask them to justify ECG use in every patient, they are at a loss.

I am interested to hear how many others do NOT use ECG routinely.
General Discussion / Reliability of pulse oximetry
January 06, 2005, 02:54:26 AM
Today, we would never be without our SPO2 monitor. We are taught they sometimes read false low due to artefacts, but never read false high.

We had a case a few days ago where the pulse oximeter was reading a steady 99% with a heart rate of 76beats/min. We then noticed that the EKG was obviously faster than 76 - probably in the low 100's. We checked the monitor - the heart rate was set to read from the oximeter (- I often do this as a default as I often do not apply EKG to young healthy patients). We then checked the finger probe - it was STILL CLIPPED TO THE STAINLESS STEEL ANESTHETIC MACHINE TROLLEY! yet it gave a perfect waveform, a rate of 76 and a saturation of 99%.

We placed the probe on the patient and instantly the saturation reading changed to the actual value of about 96% and the heart rate showed about 100/min.

How could a non-applied probe give such a falsely reassuring reading? I have my suspicions that it was an incompatibility of the probe (Nelcor) with the monitor (Datex-Ohmeda). Any other ideas?
Regional Anesthesia / Nerve blocks under GA
January 06, 2005, 02:42:42 AM
I was recently reprimanded (by my resident!) for putting in a femoral nerve block while the patient was asleep. It has been standard practice of mine for many years to do this for femoral shaft fractures, knee surgery etc. I use a nerve stimulator, a short bevel needle and do not inject if there is any resistance at all. In all my years I have never had a problem.

Do others condone this? Are there any blocks that are justified for insertion while under a GA (patient, not practitioner!)?