Dear Dr. Amit Shah,
   When we use NS in a LOR syringe, no matter how much you try, the pressure exerted on the piston can never be the same. Even after a  feel developed over 25 years of practice, I have entered dura. The tissue resistance in poorly nourished or elderly or cachectic patients is so low, that at every level you will be able to push the piston of LOR syringe, even when filled with NS.
    When you use a saline drip set with a NS bottle, the height where it is hanged from remains same, and the gravitational force will remain same throughout the whole procedure. This is how it works by exerting a steady pressure due to gravity. The moment you are in epidural space the NS drip starts running at a steady and good speed.
Note: I have manaed to  puncture dura once even by this method. I was sure that I am in space , but there was no flow from drip, so I pushed further and there was dura puncture. But the raitio of success is very good.
Try it a couple of times with a 100 ml NS bottle and see.

Right as you are, even I wonder if it is right to use Dopamin as a routine. And so far as fluids are concerned, many Anaesthesiologists now a days believe that since Hypotension is created by Vasodilation, one should use a vaso constrictor and there is no role of fluids.
But our observation is that if good amount is fluids is not given, the urine output is not good, this makes an obstretrician very much concerned.
I feel a combination of Ephedrin along with fluids is best. One can keep Phenylephrin and  Dopamin to use as a second line.

I have been associated with a psychatrist in my private practice. Off late though ECT is not so much practiced, at least in my practice. He used to complain that his patients of Depression worsened after ECT, they even became suicidal. Propofol was newly launched in Indian market in those days. And I had switched on to Propofol.
Later while surfing around on net and also discussing with other colleagues, I found out that it increases Depression in a patient of Depression. It also helps in patients suffering from Schizophrenia. In fect we had made a dictum to use Propofol in Schizophrenia and Thiopenton in Depression.

Hi,Madhav,
If you attend any of the CMEs organised by the teaching institutions, you will see what I see. There are Resident doctors who are regestered for MD, DA, DA-CPS, and DNB.
This is a big number of residents. The institutions , to solve their problems of working doctors keep creating more and more Anaesthesiologists. They need this docrtors in OT, Recovery wards, Trauma ICCU, and ICU. Every other hospital is now advertising for posts of DNB.
These doctors will soon come in private practice.
The demand supply ratio in this town has already tripped. It will grossly trip when more come in this market. A time will come when the it will be impossible to compete in this, what you call rat race. We are hitting a hammer on our own feet. We are in for deeper trouble.
To compete there will be economising, in drugs, materials and quality.
In short , to survive, maintain the quality and you will be respected the best.
This can be a very long discussion. And I do not think that it will be discussed in any conference.

Hi,
Amit,
        First a reply to your asking about using Procele LMA for Lap Tubal Ligation. The law of the land says that Endotracheal Intubation is must. It has got nothing against LMA. It is decided by Health and Family planning department that intubation is mandatory. They go by statistics only. Since it is a national programme, where by the Govt comapnsates a patient in event of mishap, thay have drawn fixed guidelines. Their statistics show that mortality is much higher when tube is not introduced. Hence the law. Do not get tempted.
         All the same this does not apply to other lap surgeries. You can conduct ( I have been doing) diagnostic lap procedures and even a lap appendix or other lap surgeries, preferably with Procele for obvious reason.
        There are centers in Mumbai which have presented a large series of LAVH done only under LMA classic.
But, when we feel that time taken will be grossly long, we prefer intubation.

Hi,
That is a good trap you have laid. Trying to give a central neuraxial block will be almost beyond thinking, with all unsheethed nerve bundles.
Have you given a thought to intrathecal Pentazocine, Fentanyl( acts much shorter about 20 mins only) or even Ketamine intrathecally?
I have tried all these combinations for some thing or other, they were good enough. But for MS, I do not know.
I wonder if these narcotics may be safe? I am sure some will read this and get back to us.

Hi Jafo ,
Yes, I did try out a thing which I used to read in places. I thought  that may be the Oozing in the patient will be a bit lesser and we may enjoy the surgery a bit better. Any case the surgery out lasted the effect of 1.5 ml of Bupivacain 0.5%. Any case there was no difference in oozing . It lasted for 5 hours.
You are right , one should not try out such unnessary stunts.
Sorry about the late reply. The net was down for a long time.

Hi Amit,
Glad to see your note.
     Though I have not seen a simillar picture, one of my Anaesthetist group member was admitted to ICCU post MTP, for ARDS. The anaesthetist and the ICU ppl were thinking that it was due to Propofol used for MTP. She recovered very fast, and was off the venti in 2 days, may be due to her young age.
     Atleast, let ppl know that they should not get tempted into using  left over Propofol for next patient, specially the ones available in Ampuole form. I have seen even very senior anaesthesiologists do that.

Hi,
I tried spinal anaesthesia in prone position after giving GA and then given a prone position. I just want to know whether CSF flows on its own or you have to aspirate to check. I had to aspirate. It worked well too.

Is there a site or other study material where by common public may see the technique of giving an Epidural Labour Analgesia? Is there a site where an animation film is available? It would be then quite easy for us too if we can simply show it to patients.

WE have been using 20 mcg of Inj. Fentanyl( Other molecules are not available in India) Sufentanyl is there but very difficult to acquire.
WE give 20 mcg Fentanyl IV and keep the rest of 80 mg diluted in a syringe. We keep giving it IV as 2 or 3 mcg demand dose. I have never connected a syringe pump on a patient in labour, that too a late stage. So we keep giving demand dose only.
It has worked well, though  not sufficient experience to present it.
In no case there was foetal dystress. Though we keep Nalox available.
Can any one present their experience.
Gases like Entonox are only heard of over here.
I did read about Sevo for labour. Will try it out.

There are times when we are trapped due to non action of epidural or very late call for an epidural, or technical difficulty in giving one.
Can one recommend a good alternative that can be given  I V?

        I am a consultant in private practice in Mumbai with a group of 5  qualified anaesthesiologists and 3 trained technicians. ( You requested us to give our status)
         A hospital where we practice, the surgeon says that Vomiting is the lousiest sensation in the world. See that my patients do not vomit.
We routeinly give all possible drugs that are known to reduce PONV.
We give Metoclopromid, Ranitidine, Ondensetron and even Dexona, but the PONV rate was still high specially in Obstatric cases, mainly when Prostodin was given.
After changing over to Granisetron instead of Ondensetron, our PONV rate is almost nil.

There are times when we have felt that it will be tough to locate the epidural space. Specially in very old patient where u get same feel all over. And your saline also goes smoothly even when you are no where near space.
We have used C -arm with dye to confirm our position before injecting our drugs. This makes it fullproof, specially when you think that Epidural is the only option, and GA is not right for the patient.

You asked for drugs used intrathecally for labour analgesia.
We here in India use it when we know that patient will deliver in a very short while. Specially when called at 7-8 cm dilatation and patient suddenly becomes roudy. At this time it is not easy or needed to give an epidural.
We inject 0.2 ml of Buivacain Heavy and 25 microgram of Fentanyl.