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Messages - Walter Petorski

#1
I remember being told as a resident by a very senior mentor that I wouldnever have difficulty intubating an edentulous patient. I didn't believe him at the time, but in the years since, I must admit it has been true.

In fact I have often thought that if I ever get into a situation of "Can't ventilate, can't intubate" in someone with teeth, I would use the blunt, heavy end of the laryngoscope to knock the teeth out in order to save their lives. I think I would do this before slashingtheir necks open. Deparate times call for desparate measures.
#2
Regional Anesthesia / Unilateral spinals
January 19, 2005, 11:30:12 PM
I'm amazed more anesthesiologists do not use this more often. I have used it since my resident days.

Solution used is 0.5% heavy bupivacaine. Patinet positioned on injured side down. You may need a few mL of propofol to get the patient into this position. Needle is a pencil point with a side opening.  Once a dural puncture is acheived, orientate the opening of the needle down (the opening usually corresponds with a little tab on the flange). Then inject the LA SLOWLY to avoid a jet effect - just let the LA sink slowly down. Then, most important, keep the patient on the injured side down for at least 15 and preferably 30 minutes. Once the propofol wears off, the block is effective and the patient is comfortable.

Advantages: almost complete unilateral block. Less hypotension as half the sympathetics are preserved.
#3
General Discussion / Surgical face masks
January 05, 2005, 03:31:30 AM
I have never worn a surgical face mask in theatre. A few times I work with a new surgeon who asks me to put one on, and I refuse politely, and ask him to show me the evidence that they do any good. I have never been presented with this evidence.

Do others have any strong feelings on this issue.

I should point out that recently two of our surgeons have taken to not wearing face masks, although one had glasses for his own protection.
#4
General Discussion / Re: BIS vs Entropy
January 05, 2005, 03:27:04 AM
I have used BIS for over 3 years now and have a lot of experience with it. The Entropy monitor was introduced on a trial basis in our department just a efw months ago, so I have less experience with it.

I have found both monitors fairly redundant when using volatile anesthesia. They add nothing new to my clinical assessment of the patients depth of anesthesia as well as my end-tidal volatile reading. Where I do find it useful is in propofol infusion anesthesia. I think patients' propofol requriements vary enourmously and we cannot rely on the theoretical value given by the infusion pump when using TIVA. In this situation, I find both the BIS and Entropy useful - mainly in that they allow me to drop my target levels significantly while still maintaining a degree of confidence of lack of awareness. My patients then wake up quicker and cleaner at the end.

As for differences between the two monitors - not much between the two.
#5
Obstetric Anesthesia / Epidurals for VBAC
January 05, 2005, 03:18:11 AM
Does anybody change their epidural technique for woman having a trial of VBAC? I ask because recentlyI had an episode of uterine rupture in a woman who I had previously placed an epidural and using my usual epidural solution and dosing (0.125% bupivacaine with 5mcg/mL fentanyl on a 5mL PCEA). The rupture was picked up quickly because of a worsening CTG and an ultrasound on standby.
#6
Well, does anyone?

I must admit I still use it rarely for bronchoscopeis in children. I breath them down on halothane, get them very deep, spray the airway, and when deep enough, let the ENT guys at them. The long wash-out time enables the surgeon to do a lot of work before I have to re-dose the anesthetic. For adutls I use a propofol infusion (of course).

#7
Show me the other guy's wife and I'll consider it!