Is the CSF leaking out of the skin

How did this tract develop so easily
How long was the catheter insitu

I think you now have a subarachnoid - cutaneous fistula. Through this tract CSF has a continuous channel to come out and so conversely infection must have a continuous channel to get in.
Very scary thought.

I have never heard of anything like this.
but 2 previous surgeries would have made the dura scared, fibrosed and incapable of further healing. The same may be true for all the ligaments and subcutaneous tissue.

I would get a neurosurgeon consult and explore the options of surgical closure of the tract.
Broad spectrum antibiotics till then

My 2 bits on the problem
but do keep me posted on how you all managed this rare, but really scary problem

regs

Chest wall rigidity is common to all phenopiperidine group of narcotics which includes all the nil's - Fenta, Sufenta, Alfenta and remifenta.
So theorotically similar rigidity can occur with all agents in the susceptible patient. this can be minimized by administration in a diluted form.
Theorotically there is no advantage of starting with fentanyl and switching to remifentanyl.
Thankfully both are mu receptor agonists and can be compatibly  used.
Cases have been documented were chest wall rigidity led to inability to ventilate and also to hypoxic cardiac arrest.
although rare it can be a very dangerous complication.

On the converse when you work with remifentanyl you need to worry about post-op analgesia. As soon as you stop remi( which is done to allow the patient to awaken from anaesthesia) the patient will experience the full pain. To take care of this, longer acting narcotic must be started much before Remi is stopped. This longer acting could be Morphine or Fenta

I have no working experience with Remi but theorotically this seems to be the take on these drugs

regs

Dear Dr Sandi

One of the complications of deep cervical plexus block is Phrenic nerve palsy and hence unilateral paralysis of diaphragm.
This complication is also seen in interscalene approach to Brachial plexus

Hence for very obvious reasons bilateral cervical plexus block cannot be recommended as safe anaesthetic practice.
You might end up with a non-ventilating patient.

Similarly it is better to avoid CVC attempts on both sides at the same sitting.
Bilateral botched up attempts could mean a potential for bilateral pneumothorax and that again is deemed as unsafe anaesthetic practice.

regs

I also think it was volutrauma
They got the small ETT way too in to produce endobronchial intubation
The tight bag was mistaken for Bronchospasm
Vigorous ventilation then lead to production of the iatrogenic pneumothorax

The subsequent persistent collapsed lung was due to intraluminal bronchial obstruction by inspissated secretions which needed removal under FOB guidance

Thankfully the patient made a complete recovery

regs

Presenting a case report and hoping to arrive at some answers from your knowledgeable inputs.

35 year old lady posted for laprotomy for growth ascending colon.
No significant past history or co-morbid illness.
Effort Tolerance > 4 mets (can climb 3 floors without any dyspnoea)
No allergy / drug intake

examination was all normal including resp system
Cxr was normal
Breath holding test > 25 secs
Assessed as ASA 2 due to malignancy and increased risk of peri-op DVT and Type C surgery requirements

In OT got all standard things done
Patient received a thoracic epidural to site the catheter tip at T9 for post-op analgesia.
Patient then received a GA consisting of Fentanyl 2 mcg/kg + Lignocaine 1.5 mg/kg + Thiopentone 5 mg/kg + Vecuronium 0.1 mg/kg
Ventilated for 3 mins
Laryngoscopy showed a class 2 Cormack Lehane but the laryngeal aditus appeared narrow
7mm ETT tried could not be passed
6.5 attempted - still not passing
Patient larynx finally accepted a 6 mm ETT

Connected to machine and IPPV started.
Bag a little tight
Auscultation showed ? wheeze
All anti-bronchospasm interventions undertaken
Meanwhile patient starting to desaturate and there is decreased airentry on right side
Diagnosis of Pneumothorax suspected.
Needle thoracostomy reveals air in pleural space
ICD inserted and surgery proceeds without any further event.

I saw this case post-operatively in the ICu with the ETT insitu and working ICD
24 hours later lung not re-expanded.
We continue checking ICD and Nebulized brochodilators  for another day
48 hours later - lung still collpased

We did a FOB and found right bronchus blocked with secretions.
We did a thorough suction
12 hours later CXR showed good expansion
24 hours later repeated FOB inspection and suction.
successful extubation was acheived later.

UNANSWERED DOUBTS
1. How did a normal lung develop pneumothorax? Where did we go wrong? Remember CXR - no bullae and resp reserve excellent
2. Did the secretions and intraluminal obstruction contribute to the pneumothorax in any way
3. Any better way of dealing with this case.

This drug is in clinical use in Europe
But there are some problems.
The intially recommended dose is not effective and the current dosage recommendations are much higher that what they used to be.
Also some hypotension and arrythmias is causing concerns.
If you want the details I will provide the link in my next reply

regs

The problem is GA- you still have to give it. There lies the problem
So how does the block actually help

Also
Would you do these blocks bilaterally for Total Thyroidectomy

regs

I find that a lot of Anaesthesia residents quoting use of IM adrenaline for intra-op Anaphylaxis when there is a good IV line in existence. In my opinion intra-op we should prefer the IV than any other route for administration of drugs because the absorption of the drugs can never be assured by any other route
Would just like to know what the general opinion is

regs

Surgical exploration is not mandatory for asymptomatic patient.
Surgeon and patient just has to be informed and documentation
Close monitoring for neurological deficit.

If problem arises MRI should be OK followed by surgical exploration

Catheters get severed when we try and withdraw them through the needle and not in toto as a set. All of us know this complication but it is so rare that we seldom follow it ( ME INCLUDED).
Rarely when we get into trouble after years of practice like this we indeed realise that it was all written in the textbooks in the first place.

I wonder why inspite of knowing what is safe, sometimes we ( ME INCLUDED) never follow it

Would like to hear your views on it

regs

Both Roc and Propofol produce pain on injection. But not in everybody - huge inter-individual variability.
I have seen it even after giving Fent and lignocard
as a routine i usually premix 1.5 mg/kg of lignocard with the necessay dose of propofol
I see no purpose in giving Roc before propofol because its onset matches Suxa

Slow onset drugs like Vec and Atra are either given completely before induction ( Timing technique) or atleast after a partial induction dose ( Priming technique) because since onsets are slow we save the induction agents to ensure adequate plane of anaesthesia during induction.

regs

Theorotically low flow is not permitted in Mapleson D - Bain is the coaxial version
Mapleson circuits are eliminate CO2 by using adequate FGF to push it out of the APL valve to atmosphere or scavenging system if you have one.
Recommended FGF to prevent rebreathing is 2 to 2.5 times MV
But if you have an ETCO2 monitor you can reduce the flow and permit rebreathing and make sure that ETCO2 remains within acceptable limits. Still flows have to be relatively high.

Yes i use low flow with circle absorber.
N2O 1 L + 500ml of O2.

Advantages
Less use of IA -- cost containment
Conserves heat -- Decreases hypothermia
Humidification - decreases POPC
Decreased OT contamination  - lesser effects on all OT personnel
Conserves gas usage -- again cost effective

Esp with newer costly IA like sevoflurane - it is cost effective
2% sevo with flow rate of 1.5L uses lesser liquid agent than the same sevo 2% with flows of 4L or more litres
With low flow actual cost of using sevo is reduced

For details kindly refer the Exponential function of Lowe vs. the Linear function of Lin for low flow anaesthesia

Low flow also has its disadvantages esp with Sevo. Low flow has more incidence of Compound A production but that happens when flows are below 1 litre.

regs

If hyponatremia is suspected

TREATMENT RECOMMENDATION is
0.9% NaCl
Restrict Free water
Loop Diuretics
K correction
If symptomatic – 3% NaCl 100 ml B.D at 10 ml / hour

HYPERTONIC SALINE USAGE GUIDELINES
The required sodium is calculated as
Na Requirement = (Desired Na – Actual Na) X 0.6 X Body Weight

TARGETED CHANGES IN PLASMA Na should be around
Hourly   0.5 – 1 mmol / L / Hr
1st Day   < 10 - 12 mmol / L
2nd Day   ≤ 18 mmol / L
Do Not exceed over 24 hrs   ≤ 12 mmol / L

Severe Symptomatic Hyponatremia
< 115 mmol / L   correct at rate of 1 – 2 mmol / L / Hr  For 3- 4 hours

1 LITRE OF 3% NaCl WILL RAISE Na BY
(Infusate Na/L – Serum Na) / ( Total Body water + 1)
Total Body water = 0.6 X Body Weight
BTW 3% NaCl contains 513 mmol of sodium

ACUTE CORRECTION INTERRUPTION is recommended if
Symptoms Abolished
Safe plasma Na Level 125 mmol / L
Total Magnitude of Correction > 20 mmol / L

OSMOTIC DEMYELINATION SYNDROMEmust be monitores for. It presents with
Flaccid Paralysis
Dysarthria
Dysphasia

I guess NaHCO3 can be used it has almost 1500 mmol of sodium/ litre
But it unfortunately also produces
hyperosmolarity
CO2 production whosw elimination must be ensured
Paradoxical CNS acidosis which is difficult to treat

These are the prectice guidelines and we have had good results in the few patients we have handled

regs

If sterility can be assured and monitoring can be guaranteed I guess it can be done.
Also one needs to rememeber that during transport to OT, alterations in position may add to the hypotension. This needs to be aggressively monitored and treated.
For a recent urology workshop we did the SAB in the adjacent OT had the patient stabilized and just wheeled him in to the OT where the set up was made. It really reduced turnover times
Those are my thoughts

regs

Have done 2 studies with clonidine


STUDY 1
Oral clonidine (2 mcg/kg) pre-op night and 3 hrs before surgery as adjunct to intra-op hypotensive anaes in patients undergoing FESS surgery with balanced GA with Isoflurane at 1%.
Super good rate and BP control
Never needed intra-op esmolol or NTG
MAP between 60 to 70 mm Hg

Problems - delayed recovery due to deep sedation. Ramsay scale 4 or 5 / 6
2 cases needed overnight admission because yhey did not meet PADCS score discharge criteria.

We compared this with ATENOLOL 25 mg same dosage timing
equally good haemodynamics and good recovery

In fact as a routine if there is no CI for betablockers I use it as premedication for all patients needing intra-op hypotensive anaesthesia
Polderman's study supports it.
But there is recent work questioning routine beta blockade esp in old people.

STUDY 2

Low dose bupivacaine and clonidine for SAB for lower limb surgeries
We started with 150 mcg as adviced in literature. Ended up with severe hypotension. reduced to 75 mcg and finlly we are happy giving 1/4 cc which is 37.5 mcg.
apart from prolonging duration, it provides sedation and also decreases incidence of peri-operative shivering. Haemodynamics at this dose are stable
Don't know if it is merely intrathecal effect of clonidine or also systemic absoption and central effect on CNS as demonstrated by IT opioids.
We are thinking of looking at the effect of IV clonidine on analgesia produced by epidural anaesthetics + narcotics

FINAL WORD
Clonidine's deep sedation is quite scary in some patients
If you are planning to  start - go intitally with lower doses until you work out your comfort zone

regs

I remember reading in some journals that 3 deaths have been reported due to aspiration during the use of Cobra PLA. I will try and search for the link. Meanwhile it may be a better idea to stick with PLMA.
It is vry important to use these supraglottic airway devices with great care ensuring all safety, plane of anaesthesia and adequate monitoring

regs