hi,
   its really difficult situation.it all depends what sort of anaesthesia you are giving.more common in regional blocks compared to spinal,epidural anaesthesia & gas anaesthesia which is associated with least tourniquet pain manifested by hpertension ,tachycardia etc.it also depends on intensity & level of regional anaesthetic block.choice of local anaesthesist & spplementation of block with opioids also matters a lot.if deepening of anaesthesia & substantial analgesia also doesn't relieve the pain then last resort is deflation of cuff which will immediately relieve the pain & hypertension.

hi,
   was it a narrow complex tachycardia or broad complex?rhythm was regular or irregular?it may be SVT OR VT.was preop ECG normal?if it was SVT it will be terminated by vagal maneuver or inj.adenosine 6 mg iv,if it doesn't respond to 6 mg,give 12 mg bolus.if it still doesn't respond think of other things like VT etc.use amiadarone iv or synchronised  cardioversion will be treatment of choice.if it is polymorhic VT give high energy unsynchronised cardioversion.if it was irregular narrow complex tachycardia,think of atrial fibrillation or  if regular narrow comlex it can be atrial flutter or MAT,use diltiazem or beta blockers if not contraindicated.always treat underlying cause like hypovolemia,hypoxia,hypo & hyperkalemia,hypoglycemia,hypothermia ,hydrogen ion acidosis etc

i am sorry for my intervention.regarding pulmonary complications  i want to talk just exclude pneumothorax in a case of paravertebral block as its totally iatrogenic.thank you all.

hi,
  i want to know from all of you regarding utility of thoracic paravertebral block.i have given few paravertebral blocks all in case of mastectomies.when i compared it with thoracic epidural block,i found paravertebral thoracic block superior to thoracic epidural block.i found wonderful painfree period after giving paravertebral block.rescue analgesics after 12 hours.if you put catheter then there is no question of rescue analgesics.no pulmonary complications in each cases.i think it can be used where thoracic epidural block is contraindicated like hypovolemia etc
                                                                        DR.SIMANT

dear gasman,
           you are absolutely right.atleast by doing this you avoid a major catastrophe.we in ranchi ,india also practice this.

hi, carmanucor,
                  you are very right.you are performing femoral block before giving spinal block.it means lesser doses of bupivacaine needed,so less hypotension obviously.if you perform only spinal block without tilting the patient then there will be profound hypotension.here discussion is going on regading spinal block without the help of other nerve blocks.thank you

hi,
   you are very right.actually it was done under lumbar epidural only.it has been wrongly written by mistake.space chosen was L4-L5 not T4-T5. i am very sorry for this.i have posted this topic  as patient was 108 yr old with cardiac function compromised.

hi, 
i am dr.simant wring from ranchi,india.i have given  a lot of unilateral spinal anaesthesia in orthopedic cases ,cholecystectomy,appendicectomy.advantage is minimal sympatholysis,minimal use of vasopressors like ephedrine,lesser amount of iv fluid to be used.it has got a definite advantage in case of elderly people,IHD cases where you have to use ephedrine in minimal doses.you will avoid unnecessary hypotension to be managed.so,it has got clearcut advantage.

hi,
  what we do in our setup in ranchi,india if a child is not allowing an iv line assess ,we just give IM KETAMINE to sedate patient according to bodyweight then place iv line then ,we go for securing airway.

hi,
i am dr simant from ranchi,jharkhand,india.i am experienced in giving epidural both in lumbar & thoracic region.in my view sitting position is comfortable one.if patient can't sit then go for left lateral position.if you are going for lumbar epidural then go via median route,if you fail choose paramedian route.in case of thoracic epidural always go through paramedian route.its technically more easy.in the case of adult use air for loss of resistance.in case of child use saline for loss of resistance

DEAR AFFERTUS,
           THANKS FOR YOUR SUGGESTION.PERSONALLY I TOO COULD HAVE OPTED FOR GA.BUT WE DON'T HAVE VERY GOOD SETUP.PATIENT WAS NOT HAVING ECHO REPORT,I TOOK HELP OF PHYSICIAN ON DUTY.I THOUGHT IT WAS A CASE OF MITRAL STENOSIS.PERHAPS WITH HEART FAILURE.BUT PHYSICIAN THOUGHT IT WAS NOT A HEART DISEASE.I GOT CONFUSED.I OPTED FOR SPINAL WITH MINIMAL DOSE OF BUPIVACAINE THINKING OF MINIMAL SYMPATHOLYSIS.MORNING TIME WHEN ECG WAS DONE.IT WAS SHOWING RT AXIS DEVIATION.ECHO WAS LIKELY TO BE DONE.BUT BY THAT TIME PATIENT DIDN'T SURVIVE.I COULDN'T DO MUCH.

dear affertus,
         thanks for your reply.just i am talking about some pulmonary diseases like COPD,EMPHYSEMA,INTERSTITIAL LUNG DISEASE,YOU JUST GIVE LOWER THORACIC EPIDURAL RESULTS ARE FAR BETTER COMPARED TO GA.AS SUCH THORACIC EPIDURAL IN T7-T10 REGION DON'T UPSET HEMODYNAMICS THAT MUCH,ITS BETTER COMPARED TO SPINAL REGADING HEMODYNAMICS & EQUIVALENT TO LUMBAR EPIDURAL.IT WILL GIVE YOU HIGHER SENSORY COVERAGE NEEDED IN CASE OF LAPAROTOMIES,IF YOU ARE OPERATING ON STOMACH OR ABOVE.I HAVE GOT A VERY GOOD EXPERIENCE OF GASTROJEJUNOSTOMY UNDER THORACIC EPIDURAL.ONLY 100 MG OF KETAMINE IV I USED.EXCELLENT RESULT.THORACIC EPIDURAL ITSELF IS A STRESS INHIBITOR.VERY LOW CHANCES OF POST OP PULMONARY COMPLICATION.I AM TALKING ABOUT ATELECTASIS.VERY GOOD ANALGESIA it provides.so i think it can be a good alternative when you are dealing with the patients having lung disease
                                                                 DR.SIMANT

can you tell me dear isaac why this procedure can't be applied ehen gas anaesthesia is totally contraindicated & hemodynamics are stable

SIR,
    I,DR.SIMANT KUMAR JHA, GAVE SPINAL ANAESTHESIA IN A CASE OF LSCS.LADY WAS 35 YR OLD.IT WAS HER THIRD ISSUE.IT WAS A CASE OF IUD WITH PLACENTA PREVIA.I EXAMINED THE PATIENT.MY CVS FINDING WAS MITRAL AREA-1st HEART SOUND LOUD,TACHYCARDIA,PULMONARY AREA-P2 LOUD/I WAS NOT ABLE TO DETECT ANY MURMUR/CHEST AUSCULTATED-RT AXILLARY AREA-COARSE CREPITATIONS/AS PATIENT GAVE A HISTORY OF CHRONIC COUGH WITH DYSPNOEA ON EXERTION/ON TABLE PATIENT WAS BREATHLESS WITH SPO2-75%/ I THOUGHT IT WAS A CASE OF MITRAL STENOSIS WITH NO ECHO AVAILABLE/CHEST XRAY FINDING-CARDIOMEGALY,PROMINENT AORTIC KNUCKLE,VASCULAR MARKING PROMINENT IN RT HILAR REGION.
I IMMEDIATELY SOUGHT A PHYSICIAN' OPINION/HE SAID IT WAS NOT A CASE OF VOLVULAR HEART DISEASE/AS IT WAS A CASE OF PLACENTA PREVIA TOO & PATIENT WAS NOT IN A POSITION TO SIT WITH CHANCES OF PROFUSE BLEEDING,I GAVE SPINAL ANAESTHESIA IN LEFT LATERAL POSITION IN L3-L4 SPACE WITH 25 GUAGE NEEDLE..5% BUPIVACAINE ONLY 2.5 ML GIVEN/PRE OP BP WAS 130/80 MM OF HG WITH 200 ML OF URINE OUTPUT/AS INCISION WAS GIVEN & DEAD BABY WAS TAKEN OUT.IT TOOK 20 MINUTES FOR THE SURGEON/IN THE MEANTIME I GAVE O2 THROUGH MASK CONTINUOUSLY/TWO IV LINES WERE SECURED/THROUGH 1 LINE FRESH BLOOD WAS BEING GIVEN & THROUGH ANOTHER LINE RL WAS GIVEN,PATIENT SUFFERED CARDIAC ARREST/IMMEDIATELY PATIENT WAS INTUBATED & CPR GIVEN/RT INTERNAL JUGULAR WAS CANNULATED/12 MG OF IV EPHEDRINE GIVEN/DOPAMINE IN 5% DEXTROSE STARTED/IV ATROPINE 5 AMPOULES AT REGULAR INTERVAL GIVEN WITH 2 AMPOULES OF DILUTED ADRENALINE USED/CARDIAC MASSAGE CONTINUED IN A RATIO OF 100 PER MINUTE WITH 10 VENTILATION PER MINUTE/AFTER 1/2 AN HOUR  OF CPR HEART STARTED BEATING ,BUT STILL NO SPONTANEOUS RESPIRATION/IT TOOK ANOTHER 1 HOUR FOR SPONTANEOUS RESPIRATION TO RETURN/IN THE MEANTIME IPPV GIVEN THROGH BAG/SPO2 FINALLY WAS 85%/PATIENT STILL HYPERVENTILATING WITH SLIGHT EXTENSOR RESPONSE/BOTH PUPIL WERE DILATED & SLUGGISHLY REACTING TO LIGHT/I SHIFTED THE PATIENT TO ICU/PUT ON VENTILATOR ON SIMV MODE/STARTED NORADRENALINE & DOBUTAMINE/WITH BP NONRECORDABLE/PATIENT REMAINED ON VENTILATOR FOR 5 HOURS/PATIENT WAS TO BE TAKEN TO AHIGHER CENTRE/WAS TAKEN OFF FROM VENTILATOR ,SUFFERED CARDIAC ARREST/COULDN'T BE REVIVED/I WANT TO KNOW where i went wrong?
   DR.SIMANT KUMAR JHA,RIMS,RANCHI,JHARKHAND,INDIA

sir,
   
I,DR,SIMANT KUMAR JHA,RIMS,RANCHI,JHARKHAND HAVE GIVEN AROUND 20 THORACIC EPIDURALS IN ALL SORTS OF LAPAROTOMIES INCLUDING EMERGENCY PROCEDURES ,CHOLECYSTECTOMY ETC/MOST OF THE CSES THE  SPACE CHOSEN WAS EITHER T7-T8 OR T8-T9/EVEN I HAVE GIVEN THORACCIC EPIDURAL IN 10 CASES OF CS/SPACE CHOSEN WAS T9-T10/IN ALL CASES THROGH PARAMEDIAN ROUTE/IN FEW CASES GA WAS CONTRAINDICATED/I
ITS BENEFIT -GOOD ANALGESIA,LESSER DVT COMPLICATIONS,LESSER PULMONARY COMPLICATIONS,POST OP ANALGESIA THROGH CATHETER,LESS MOTOR BLOCKADE/I WANT TO KNOW HOW YOU PEOPLE RATE THIS PROCEDURE
                                                                     DR.SIMANT KUMAR JHA,RANCHI,JHARKHAND,INDIA