Yes, a well exploited drug this Katamine is. Even in our regular use, standard sedation dose contains 25 mg Ketamine in addition to Medazolam and Pentazocine or  Fentanyl combination.
     It has a good analgesic property and above all it sort of dissociates the patient and reduces chances of awareness.
     At times even with spinal or Epidural, we add IV Ketamine as sedation along with other IV sedatives.
     I have used as mentioned a PK regime 50 mg in 20 ml of Propoflo with a syringe pump.
      Thanks for sharing the info with all of us.

Gas Embolism.
I know that this word can dilate our sphincters.
I had a case of Fistula in ano under GA with LMA.
Standard induction with Fentanyl, Medazolam, Glycopyrolate, Pre oxygenation, Propofol, Vecuronium, and intubation with LMA. All parameters normal till at about 20 mins after starting surgery things started happening.
I have  group of 4 qualified anaesthesiologists. One of them was on the pulse. Multi paramonitor was connected. Second anaesthesiologist was writing notes and drug list etc. I was just around in the OT.
First assistant started making movements. ON inquiring she said " No Radial"
Monitor took next NIBP reading:50/20mmBP.
SpO2 started dropping. N2O stopped. Quickly LMA removed and endotracheal tube put. 100% O2 with venti given.
No change. SpO2 now 70%. BP not recordable. Vaso Pressures given.
No improvement.
I went to surgeons trolly. Asked the sister about what is in the bowls. She said one is Savlon, Betadine, and Hydrogen Paroxide.
I asked the assistant to auscultate. She said air entry was equal on intubation. I asked for murmur, she said there was no murmur preop.
I asked her to re auscultate. She said there is some funny loud murmur. In a fluke I said this is called a Mill Wheel Murmur. I had never heard it before.
The surgeon had injected 10ml of Hydrogen Paroxide to find the internal opening of the Fistula in ano.
The murmur vanished in about a min and SpO2 was about 52%.
It was not possible to give  Durrant's position from lithotomy possision.  nor was it possible to put in a central line.
We were just waiting for the fate. Suddenly the SpO2 started rising. BP came up till 120 systolic. And Patient was fully conscious at reversal.
Was discharged on third day and he had no clue about the diagnosis.
Any one can throw some light on this case.
any easier way to manage this crisis.
Any one with a simillar experience?

In majority part of India where I practice, that Includes major city like Bombay ( Now Mumbai), Halothane is still counted as a modern drug. Ether is still used in many parts. Though Sevo and Iso are available in major institutions, I wonder if that is used by even 5 % of total Anaesthesioloigsts here. This is opinion of an anaesthesioloigist in Private practice who also works in corporation general hospital.
But gradually use of Sevo is increasing in Mumbai. Rest of the country, Halothane is still the best.

Sir,
Good list of Journals given by you.
     I am interested in some kind of Protocol for Anaesthesia in C. Section. I wish to present it  in the court of law for a case against one of our Anaesthesiologist coleague. He had a mortality following a Mendelsons' Syndrome.
     The court has asked him to present some protocol based aproach to Anaesthesia.
I found some practice guide lines in ASA journal.
      In India we have no such protocol as per my knowledge. You have some in any country?
Please let me know.

There are times that there is a wet tap. As a reflex an an anaesthesiologist removes the needle. This does not prevent the leak. In my group the protocol is to first put the styllet back in the needle. Wait and think. Was it easy to give epidural in the first place? Will the patient allow again at another space?
If no, then we push the catheter inside and accept it as a continuous spinal. The dose for Epidural labour analgesia is 0.2 ml of 0.5 % Bupivacain Heavy, plus 25 mcg of Fentanyl. One has to keep in mind that when we are injecting such a small volume, catheter capacity also matters. But keep your concentration same and keep injecting as per need.
I read some where, not to remove the catheter on the same day. The protein in the CSF that keeps leaking around the catheter forms a coagulum around the catheter and prevents PDPH ( Post Dural puncture headache)  later on when the cath is removed 2 days later. Yes, we do lock up the catheter and make it non functional, so by error, no one injects something for pain. We keep it inside to prevent the PDPH and if required for some emergency later on.
Remember the PDPH  is really bad, specially after a labour analgesia, as there is  a leak of CSF, every time uterine contraction takes place.

How oftern one encounters a segmental block in Epidural.
One of my patient recently was given Epidural Labour Analgesia. She did very well and was very comfortable till she was taken up for a section. She was a qualified nurse. She had pain on incision only on the right side of midline, with a total lack of action of block. The left side was perfect. Another for a Vag Hyst, same way only one side acted. Second no action at all.
Any light on this issue? Any suggestions to improve the block?

Hi,
IN India we do not get 0.75 % Bupivacain. Only choice is 0.5 %. Our group uses only 2.2 ml of 0.5% as a protocol Only variation is allowed if a patient is very short or very tall. That is 1.8 to 2.5 ml as justified.

Hi,
It is right to adjust the dose of spinal as per the height of the patient. But weight? Does it really matter? The nerve roots of a pt of 50 kg and other of 100 kg will be of the same size, logically needing the same amount of the Spinal drug. Can more ppl throw light on the same?

In an elderly  or severly malnourished patient, try using a running saline drip for locating the epidural space. Just connect a saline drip after entering the skin. keep advancing. In htese patients generally no FEELs are felt. The drip does not go till you enter the space and here the drip starts running. Even the onlookers are amazed.

Since it is printed on the literature of the multidose vial that this should not be used for Epidural, it makes it even more difficult to use as some one may file a suit taht even the manufacturer also mentions that local anaesthetic with preservative should not be used for Epdural.
One teaching institution in Mumbai, India, now recommends to use Preservative free ampuoles available for spinal and dilute it to your need and use in Epidural space.
I have also done that and now quite happy to do it on regular bases.

Logically if lumber puncture can be done many times a day for diagnostic purpose, one can do LP for spinal also or repeat spinal also on the same day. As for the drug effect in spinal for repeatation, we all now know that we can put continuous spinal cath and give it as often as needed.

Yes, We have performed Spinal Anaesthesia in three patients, where it was very difficult to give spinal due to technical difficulties. For example, two were very obese and could not get any bearings to give spinal and one was a case of Polio deformity. We used a C- arm TV and under vesion we could give it.

color=blue]Normally by default our group of Anaesthesiologists are supposed to use NS in LOR syringe. We have a group of 12 Anaesthesiologists.
But in an elderly or poorly nourished patients, who are very thin or all calcified ligaments, it is easy to get false give way sensations. At times saline also flows freely and catheter also goes in. Epidural does not act because it is no where near epidural space. It has entered a false pocket created by us.
Here we use a sterile I V set connected to NS bottle. Only when the NS  flows freely we accept it as a right placement of catheter.
It is very reliable in this kind of patients.
Try it out in your next case to succeed in a next bad patient, where an epidural has to act.[/color][/size][/size][/size][/size][/size]