Friday, September 12, 2008
Ortho list and R&D
I had a fancy anaesthesia technique day during my Orthopaedics list today. It could have been one those boring lists but of course , one has to have their own imagination and creativity to make it interesting !
I have always wanted to do a CSA ( Continuous Spinal Anaesthesia ) since reading about it ; however I've not had a chance in my two years in UM so far. I don't know whether it is just ignorance or unfamiliarity in the faculty ; but since I'm in the third year now we have to take our own initiative. I am blogging this out today because it was my 2nd successful attempt of this technique ! ( in record i have attempted 4 ; 2 had to be abandoned )
CSA offers the attractive possibility of extending the block during surgery when needed. It provides an easy technique to reach an adequate level and duration of anaesthesia with small intermittent doses of local anaesthetic, which also minimizes the risk of possible cardiovascular and respiratory disturbances. Evidence found that it gives a lot of advantage in the elderly population.
The technique is fairly similar to the CSE technique , but this time around you WANT to thread the catheter in the subarachnoid space when doing epidural , it is totally the opposite.
I had an 86 year old Malaysian lady who was senile and fragile coming for Interlocking nail after suffered a femur fracture. Having multiple diseases with a fairly weak heart ; GA will not be the first choice. Giving a "simple" spinal can be dentrimental as the risk of unstable haemodynamics may happen. Epidural anaesthesia was possible but hey.. CSA was more fancy ! It was not easy to mobilize her and giving the initial Fascia Iliaca block certainly help to ease the pain for positioning.
I proceeded to do the CSA in the induction room ; it was easy enough to identify the epidural space. Then comes the difficult part in negotiating the thin catheter into the intrathecal space. I was using the spinocath set which has a slightly different technique from PAJUNK catheters. Honestly , i learnt the technique more through the company video then from anybody else. Alhamdulillah , it was in and worked well .. too well that the Auntie was worried that we were about to chop of her legs !! hahahaha...
I wish I had inserted the CSA in my first 77 year old lady patient with hip fracture ; initially the orthopods were looking into inserting a BIPOLAR but after 2 hours.. then they told me they need to do the WHOLE TOTAL HIP REPLACEMENT ! She was only on spinal anaesthesia and gulpp... I dunno whether we should GA her. The surgeons did suggest that but after explaining that i have to put the patient back in supine from her lateral position , they went like OOHHH... Hmmm.. talk about expecting the unexpected and i guess the reason why most anaesthetist don't trust surgeons so much !!
I told them to proceed and see how it goes. Meanwhile , I was ready to GA her at any time ; by inserting LMA SUPREME for her in lateral position ! It would have been cool... We were ready man !! Alhamdulillah , my spinal anaesthesia duration was prolonged maybe with the help of the fascia iliaca block that I've given earlier before positioning her. Guess how long it lasted with only 2.6ml of local anaesthetic in the subarachnoid space ?
4.5 HOURS !!!! Lama tu... hahahaha.. we didn't need to convert but it was wearing off when they were closing the skin. Auntie still managed to smile while thanking me at the ned of Op..
We then had a 26 year old gentleman with irreducible recurrent shoulder dislocation. They tried to reduce him the night before but it was futile as he was fairly awake despite tonnes of sedative given. He has this history of drug dependence making the whole thing more complicated.
We decided to give the brachial plexus Interscalene block for a change as we didn't want the patient requesting for opioids post op to satisfy his needs rather than as a pain relief. The block was simple enough to do but at the same time the complication was obvious as well ! He developed Horner's syndrome and he looked like he was winking at everybody he looked at !This would happen in 10 - 25% of people. He is young therefore I guess his phrenic nerve paralysis was not obvious . He was pain free on his shoulder site but he was trembling in all other organs despite saying not ! I gave my own SPECIAL COCKTAIL ( hehehehe.. apa rahsianya ? ) and just held my mask over his face when the orthopods reduced the dislocation !
MORAL OF TODAYS EVENT : A Boring list can be the most interesting day in your practice !