very well said.

I would say it is uncommon to secure the airway before an IV is secured in the US. I spent six months at a children's hospital during residency and on chubby babies it might take five minutes to get an IV, maybe more, with more than one person working on IV access while still mask ventilating. If IV access is unsuccessful and the case warrants, the surgeon may modify the procedure, I.E. scheduled tubes and adenoids, he/she may just to tubes and cancel the adenoids.

Totally agree with you.

I don't alter my technique. My partners and I started doing combined spinal-epidurals (CSE) for labor analgesia several years ago and have never looked back. Arrow makes what I think is the best CSE kit. To the epidural space with the Tuohy, pop intrthecally with the 26 gauge spinal needle, inject ropivicaine 2mg and sufentanil 5 mcg, pull out the spinal needle, thread the catheter, and you're done! Just hook up the infusion. We use ropivicaine .2% with sufentanil .5 mcg/ml and run it at 12 ml/hr for just about every lady. Our redose rate is very, very low, unlike the bupivicaine/fentanyl stuff we used before.

Many advantages in my humble opinion. One does not have to dose the catheter which saves time, and is safer since there is virtually no chance of a high block. The intrathecal dose given isn't enough to give a high block, or at least I've never seen one in the 3 or 4 years I've been doing it. Redose rate is VERY low, yet another advantage for the busy practitioner. I've had one post-dural puncture headache in the last eight months and our delivery unit does between 175-200 deliveries a month.
Not to mention the superior safety profile of ropivicaine. One disadvantage is the women itch for about thirty minutes after the procedure from the sufentanil, but usually resolves on it's own. The delivery nurses love it and so do the patients. The CRNAs love it too because at my facility we have an OB CRNA who does the redosing. Drastically reduces their workload.

How compelling it is, the differences in practice in different countries! I practice in the US and I'd venture to say that there isn't an OR in the country that has personnel without facemasks, with the exception of urology cases. Whether or not its justified or not is not the issue here since alot of things are done for medico-legal purposes.

OK folks, heres another useless topic I'm going to propose. We have an old, ricketty orthopedic surgeon who insists we put all his total knees to sleep for whatever reason, even though we use regional with every other surgeon unless contraindicated. And he's one of those control freak- whiners who is constantly complaining- particularly about lack of muscle relaxation. He swears that once the tourniquet is up, our muscle relaxants don't do any good. Now as I see it, doesn't the non-depolarizer still work at the muscles origin ABOVE the tourniquet which would facilitate muscle relaxation? This guy is crazy, folks, and lord knows why he complains about muscle relaxation when every other ortho dude I've worked with hasn't. "HOW MANY TWITCHES DO YOU HAVE???", he'll ask the CRNA. blah blah blah. Was it my mom that told me a little knowledge is dangerous?

Is there any basis to his complaint? Or can I end this for good, drag him out into the parking lot and settle this gangster style? haha

Anyway, point me in the direction of a paper that'll refute this old dude and I'll buy you dinner in New Orleans.

Haven't seen a halothane vaporizer in years. Sevo rules in a fast paced practice. My previous practice (just moved to New Orleans eight months ago) had a surgery center doing an average of 30 cases a day. Some days we would do 20 child ENT cases. Using sevo instead of halo probably saved us an hour a day!!!

Yes, I see your point. I use it on all patients but have had equipment failure more than once (cable problem or whatever) and didnt worry about it. I could do knee scopes on young patients, C sections, etc all day long without an ECG and not bat an eye but as one of the posters indicated lawyers are sharks!!! haha

Anybody see patients cough after pushing generic propofol? Seems like I see it about 10% of the time. Maybe its the sulfites or something.?

No idea, dude.  Kind of an elementary question, but what is your propofol running at in mck/kg/min?

We started using Precedex for all hearts and carotids. really takes away the hemodynamic lability that seems to go hand in hand with CEAs. We started with the loading dose in holding followed by whatever infusion rate you pick. Usually see some hypotension very resposive to fluids or hespan. These patients are usually dry as you know because of their hypertension so fluids really evens them out. Intraoperatively the opiod requirement is low (50-150 mcg fentanyl) as well as volatile anesthetic requirement. Nice technique.
Same concept with CABGs and valves- we did about 475 pump cases in 2004. Precedex on every one. Usual fentanyl requirement 250 mcg or less. Because of the minimal opiod extubation times are quicker.

I respectfully disagree with Naveen's post. High 50s, low 60s in healthy patients having knee scopes, etc in my humble opinion is of no concern. In an 80 year old lady I'd be more vigilant, assist ventilations, turn the gas down, no more opioids, maybe 40mcg naloxone if you thought opioids were a factor, etc. It'd have to be pretty bad for me to pull a patent, well functioning LMA in a case to intubate. I think thats overkill. Of course I wouldnt've said that on my oral boards! haha

Thanks for your reply, Michael de Sousa. This was a question one of the other MDs and I had a friendly dispute over. I'm bummed to say I have now lost the bet! haha For some reason I received the impression in residency that sympathectomy was commensurate to local anesthetic strength, so I would typically use .25% bupivicaine in cases like AAAs where volume might become an issue. When I went into private practice, the group I joined always used .5% bupiv, hence the friendly dispute. Anyway I started doing what everybody else was doing (when in Rome do like the Romans) and never had a problem, but never could get a clear answer to my question. I wonder if there is any literature on this.?

While we're on the subject of epidurals,I tell you what, since we started doing thoracic epidurals for thoracotomies a few years ago I'm hooked (plus GA). Great band of analgesia at the surgical site and minimal volatile anesthetic and opiod requirement intraoperatively, not to mention nearly no pain postoperatively. We started working with a new heart surgeon a couple years ago and he was amazed how comfortable his patients were in the PACU and subsequent ICU stay.

Can anyone tell me if the degree of sympathectomy is commensurate with local anesthetic strength? For example, does .5% bupivicaine cause more of a sympathectomy than .25% bupivicaine?

Thanks

Yeah, I agree with Geoffrey's post. Have had four hematomas in eight years and without an ETT the results could've been catastrophic.