LMA /IPPV - personal experience - 45 mins to 1 hour procedure.
Make sure pt has amodified mallampati class 1 airway so that you can emergently intubate if necessary. I leave out obese pts, GERD and other conditions prone for regurgitation.
Premed always includes H2 receptor antagonists and prokinetics
With classic LMA i limit the inflation pressure to 20. Still experimenting with proseal LMA
Always ensure that with LMA i mandatorily monitor the ETCO2, esp with spont we need to tinker around a bit to keep the values at acceptable levels

I think this is followed in most of the centres

We use 0.5% hyperbaric bupivacaine 10 to 12.5 mg +/_ Fentanyl 25 mcg. This is the standard recommended dose in most literature. If your patient is short statured you may reduce the dose to 8 to 10 mg or stay with the same dose but concentrate on proper positoning of patient after block to limit its cephalad spread and also tackle the ensuing hypotension rapidly and aggressively. Some consultants get away with leeser amount of bupivacaine. I much rather would have a slightly higher block than a block that wears off requiring some form of IV supplementation. Since these pateints are potentially full stomach, supplementation takes the safety of RA technique away
With regard to B/L knee replacement its not the height of block that matters but the duration for which the block lasts in the operated site. A block upto L1 wears off faster than a block that starts from say T6. Keeping this in mind I would give about 17.5 mg of bupivacaine with 50 mcg of fentanyl. This should cover operations on the knee for a duration of almost 3 to 4 hours. But the problems are uncomfortable position  for the patient, shivering due to hypothermia, pain in unblocked upper back etc. I would much rather do a continuous epidural supplemented by a light GA. That should provide good analgesia extending into post-op as well as keep the patient quiet and comfortable.

We occassionally encounter difficult airway patients for emergency surgery that cannot be accessed by central neuraxial blockade or is deemed not fully safe.
Some of these patients may have distorted anatomical landmarks in the neck due to thyromegaly or other masses thus precluding the performance of percutaneous airway blocks
Also the issue of performing airway blocks in a potential full stomcah patient is an issue.
any ideas on how to approach such a complex case coming for emergency surgery

Pain on injection occurs but is not too frequent.
I think propofol causes more problems with pain
I am not convinced that Rocuronium is cardiostable upto 5x ED 95 (product insert)
At 3 xED95 you definitely see tachycardia

Our experience with intubation with 0.6mg/kg of rocuronium for intubation offers only acceptable intubation conditions at 60 secs. This is surely inferior to intubating conditions offered by suxamethonium in the same time frame.
Roc 0.9mg/kg offers excellent intubation conditions, but undesirably prolongs the duration of action to more than 50 minutes making it an almost long acting relaxant
I am wondering if priming with 1/10th the intubating dose (0.05mg/kg) of roc given 2-3 mins before the intubating dose will improve intubating conditions at 60 secs.
Wonder if there is any literature or references available
Thanks for the help

Hi Folks
Trauma resuscitation (say B positive group) requiring blood can be given O negative blood for emergency. If Crossmatched B positive blood is sesequently available can we switch over immediately or are there any rules or restrictions to be adhered to.
What is the maximum volume of O negative blood that can be used in such circumstances.
Does it pose any problems during subsequent blood transfusions
Thanks

at our institute we do a lot of lumbar epidural for pain relief in patients with peripheral vascular disease waiting for surgery. These patients are usually on heparin, Clopidrogel and occassionally on low dose unfractionated heparin. Most of the anaesthesiologists out here seem not to worry about it and just do the epidurals and even get away with it. I recently quoted the ASRA recommendation and refused an epidural without stopping clopi for the recommended 7 days. Was met with usual disapproval of surgeons and nonchalance of collagues. Surgeons feel stopping clopi will risk the vascularity. They are willing to take risk.
What should we do in face of conflicting recommendation. Can the surgeons to take risk for potential parplegias that the anaesthetic technique may produce
regards
jafo.

Paediatric peri-op fluid therapy has been a topic of recent debate. All kinds of opinion and views.
In our place a lot of consultants use only Isolyte - P for practically any kind of surgery. This notion is based on the premise that paeds usually end up being hypoglycaemic. But anaesthesia itself produces hyperglycaemia. Also Iso-P is a hypotonic solution. I prefer to use RL exclusively intra-op. Just want to know what is the practice around the world and what does the current evidence support
regards
jafo