Hi,
Dr. Dimple, You mentioned 2 % Xylocain spray. Have you ever tried 10 % Xylocain spray available in market? It is most convinient to use and good action.
And that will only prevent cord irritation. Trachea is still sore. LMA is also painful. At times there is avulstion of palate mucosa, which gives severe pain and dysphagia.

Hi,
Everyone always speaks of aspiration, when ever LMA is discussed. I do not deny the possibility, but it is an over cautious feel. We have been, off late using LMA supreme, which has a gastric channel. Over my very frequent use of LMA in Gynaec  lap surgeries, once I have seen gastric juice coming out of Gastric channel. I put in a catheter in the channel and sucked it out.
Another thing, aspiration in prone position? Mother gravity helps it coming out of the mouth and not in the trachea.
Lot of hypothetic worry, but once you get used to it you will prefer LMA over a tube.And does a tube prevent Aspiration??????

Hi,
Dr. Neelam, I think you are on the dot for the diagnosis. Anyone would like to involve or blame the anaesthesiologist. But an overzealous position given by OT staff for a vag Hyst, is the cause of this. The nerves get stretched and typical symptom is quadriceps plasy, the leg gives in or buckles up at an attempt to get up from the bed. It is a very frightening feel for the patient. Be patient and things will get ok. Ofcourse you will have to rule out a few other conditions like nerve injury or an epidural hematoma etc. If you do not investibgate, this may amount to negligence.
Management wise, nothing like a shot of Methyle pred 250 at the earliest, it may help.
It takes time to settle down, over a week or so.
Glad, you did not get disheartened by the surgeon calling you up.

A hematoma under the tongue after the surgery is over. But then why was the nose packed? You should have packed some thing else, if at all.
You have mentioned INR as 21.1. I wonder if you evwen get this picture( Must be writing error, I hope) It will be criminal to operate at this level, if right.
Ecospirine??? every one wants to blame this tiny tablet for any thing that bleeds. It was stopped for over 15 days and all reports are normal, then why even think of it?
Latest is, not to stop ecospirine or clopido etc even on the day of surgery.
I think that the bleeding took place form some lingual vessal during surgery.
Do not hurt our cardio friends on ecospirine issue.
Regards, I love to read all your cases, they are full of life.

Yes, that is a funny and a blind thing to happen.
We have had another funny experience.
A full term patient was taken for em section. She was given a spinal block. For no reason she got a total spinal block with 5 % Lignocaon Heavy. ( Bupivacain was not still marketed). We managed the patient well and all was OK.
Incidentally the same patient came for her elective section in another hospital after 3 years. She informed about her past experience. It so turned out that the same anaesthesiologist was there and he recollected the event( A very remote thing to have same patient again in private practice in town like Mumbai)
This time she was informed that same thing may not happen again, it is incidental.
To our amazement she got a total spinal again.
Must be some anatomical defect in the spine.

Hi,
Anybody tried insertion of LMA in prone position?
Read an article in Indian Journal of Anst Dec 2008??
Was impressed with the study. Read and read over and over again. They had used LMA Classic in the study of 200 cases with only two cases where they had to reinsert, in variety of cases inclusive Spine and in obese patients.
We made up our mind to try once. We use LMA Supreme. This is much better shaped device. We do Liposuction in obese patients in prone position first and later in supine position.
We tried it in a case. Made the patient sleep in prone position and then induced her. It was easy to ventilate ( as the tongue does not fall back, it rises in prone)and very easy to insert the LMA. We connected the patient to venti.
The patient was in prone for an hour and half, and all was ok.
We made her supine and completed the surgery of front in next 2 hours.
It was most easy.
We tried it in about a dozen cases after that and are happy.
The idea is to try it once, so that one is not afraid, if ever a tube gets dislodged in prone, you can always insert an LMA and manage the case.
Sounded like a creazy idea to start with, but the article was presented nicely and we were tempted in trying it.
Please let me know if any one has tried, and if any difficulties.
Regs.

HI,
Nothing against Dopamine but still one standard protocol is to be followed. Vasodilatation is created and the bucket has become bigger. Either make the bucket smaller by vasoconstrictors or fill it to keep the volume. Vasoconstrictors start from age old Mephenermine ( Still available and of choice to many) but almost never used due to its renal effects. Next in line will be Ephedrin, though weak, but works good enough. Penylephrin is a better drug, to be kept in reserve if ephidrin does not help and then comes Dopamine and Norad.
Let us keep them in that order as per the need. No need to use a battle tank for a small correction.
Same thing applies to Colloid and cryst.
A combination of Vasoconstrictors and fluids is still the best option.
Right you are, Dr. Jafo.
Regards.

Hi,
Thanks to the site, giving us a forum for a good and healthy discussion.
Dr. Kalpesh wrote quite a few letters. I am glad that he recd a lot of replies.
I hope that Dr. Jafo, with his to- the -point approach, does not become an examiner. He is a class apart. My complements to you sir.

Hi again,
Another comment, to make on use of Lignocain in spinal anaesthesia.
Quite a few ppl have stopped using this drug in spinal, specially when a much longer acting drug is available. We put some additives to make it work still longer( alangesia), like Buprigesic - 24 hrs, Clonidine - 8 / 10 hrs, Many even put Butorphenol, Tramadol, Fentanyl and so on.
If we can make the patient painless for a longer time , why use a short acting drug for surgery. Specially ortho cases, where time fundas are ????? Enough time is taken for cleaning and then plastering etc.
This was just a comment and not a suggestion.

Hi,
That was bad to lose a patient, a young and a fit man.
To me this looks like an embolism, may be fat, may be a clot, leading to hypotension, and then PH leading to failure and death.
The movements of shifting are also responsible for a clot shifting and giving pulm embolism.
Is there something that you can do to  prevent an embolism?????
We have a habit fo taking the blame on our head by feeling that this was a spinal hypotension.
Let us come out of it.

Just to inform you what all can happen in our set ups.
We gave a continuous brachial plexus block for a case of a bad crush injury of hand. The block was given with a BD Intima needle( a Venflon with an injecting tail like a scalp vein). We wanted the block to work for a very long time, and post op pain relief along with vasodilatation.
Third morning we rec a call that the staff is not able to inject Pantaprazole through that.
We asked them why they are using that port( Labled clearly" Do Not Inect")for injections.
The reply was that, since there were no lines on one side and dressing was  done on the other side, they gave all injections including RL and NS on the previous day in that port.
God only knows how the brachial plexus bared all the insult.
Despite all of us, the patient improved and went home Ok.
Carefullllllll.
This can also happen.

Thanks a lot on behalf of the whole team that was present there.
I like your replies, as they are always sounding logical and scintific.
A small point to correct, the venti and IPPV was on right through the surgery after induction. He was never on spontanious respiration. It all started suddenly after about 2 hours.
Unfortunately a spine surgery patient is in Prone position and so very well covered and with a curtain, that nothing was seen before the monitors started alarming.

Read This:
21 yr male, Fall from height, fracture L-1 spine with paraplegia.
All investigations normal. Posted for instrumentation under GA in Prone.
Standard induction with Propofol, Fentanyl, Medaz, Roc intubation, Venti with Gas Oxygen and Iso as needed. Well controlled BP.
Goes on nicely for 100 mins. At this the surgeons drill and put a screw at T 11. The ventilation became difficult, taken over hand ventillation, but desaturates. The surgical team complains about air bubbles in the field of surgery. BP started dropping and the ECG showed patterns. Leading to a flat line.
Pt was made supine and CPR started. Recovered after a DC shock.
On observation, there was a great surgical emphysema all over the body from Eyes to Knee and elbows. few needle punctures were made all over, the patient, gradually sattled. Surgery was finished in lateral position and he needed Dopamine support for a while , patient was reversed and  was allowed to go to ICCU with a T- Piece and oxygen.
Portable X ray did not show any tension pneumo after he improved. (now atleast). There was surgical emphe all over in the X ray.
Patient regained full consciousness in next 36 hrs and was extubated.
Our impression on the spot was that either there was some rent in the trachea or some trauma in the lungs during the surgery.
There was no sign of trauma to trachea, no blood in ET tube or throat pack,. No gas in the mediastinum on X ray . Can it be from surgical field???
I am at loss on ideas now. Make geusses.

As per your question, part one, we had injected 2.5 ml (12.5mg) of Bupivacain Heavy, and had acted too.
It shows that the drug was in right plane and not in epidural vessals, which is still low to cause toxic dose at 12.5 mg IV Stat. The drug acted very well till the surgery was over and the pt was shifted to the room.
The whole thing started 3 hours after the surgery, and by now the action of spinal must be over. That is why we felt that it has nothing to do with Spinal, but opioid.
We injected 0.1 % Bupivacain with Buprenorphin 60 mcg at the end of the surgery and was never repeated, as the cath was removed when the convusions started.
Regards

I have been reading all ur points in this chapter.
Do make comments on Anaesthesia for Tightening of Internal Os.
This is a fairly routine surgery and performed around 20 weeks of gestation. Any special precaution you like to mention?