For abdominal e.g laparotomy or thoracic dermatomes e.g. thoracotomy, rib fractures
Alternative to epidural
Patient awake – sitting or prone
Identify midline (in transverse plane)
Block at level of:
- T7 level for abdominal cover, even rooftop
- T5 for thoracic cover (T2 – T9)
Scan laterally so transverse process (TP) in in middle of screen.
Rotate probe vertically to para-sagital plane
Identify layers of subcutaneous tissue, trapezius, (+/- rhomboid), erector spinae (ES)- with articulates with transverse processes
Local anaesthetic at superior entry point. Deep infiltration to level of muscle.
Use Tuohy needle or regional catheter pack needle, in plane approach
Access ESP below ES muscle, adjacent to TP. Can hit it (original description) but more painful. Create space with saline.
Then threat catheter. Leave at least 10cm in the space. Load with 20ml of 0.375% l-bupivicaine to each side.
Then run infusion 0.25% l-bupivicaine at 10ml per hour (split between both sides).
– NG @ LGH
Perspective from The New England Journal of Medicine — What Is Value in Health Care?
Source: What Is Value in Health Care? — NEJM
Keep dry – almost no fluid prior to resection
Then catch up
A-line, CVC, +/- swan sheath
Consider iVC compression by surgeons if hypotensive
Muscle relaxant (consider infusion)
Analgesia: spinal diamorphine, wound infusion catheter (2.5mg/ml levo-bupivicaine @ 10ml/hr). If using morphine PCA – caution (with liver impairment)
Maintain muscle paralysis while robot is docked – consider infusion of relaxant
Meticulous positioning with pressure point protection
Difficult to access patient intra-op
Have enough slack on lines
If steep trendelunburg e.g. prostatectomy caution with fluids, raised ICP and IOP, airway oedema.
Recipe for radical prostatectomy:
GA, ETT, 2x IVI, a-line
O2/air/desflurane. MAC 0.8-1.0
Remifentanil (0.1-0.2mcg/kg/min) and atracurium infusion
<500ml prior to anastomosis, max 2000ml in total (if no significant blood loss).
Excellent editorial in the journal Anaesthesia casting comparison between high pressure high stakes environment of NASA and healthcare delivery.
A very interesting article and comments, arguing that although Consultant numbers have increased, Consultant productivity has decreased due many systemic factors including workforce planning (including lack in increase in nurses), social and community care capacity limiting patient flow, and capital e.g. lack of ICU beds, IT infrastructure.
Many questions are raised though, such as how can ‘productivity’ be a accurately and meaningfully measured in a useful and comparable way in such a complex system. Also, how does one account and value ofter features such as quality and safety? It’s complex!
Useful online educational resource for ICU covering, amongst other things, ECMO and echo.
Take home messages:
- Make a TO BE list rather than a TO DO list
- how would the best version of oneself go in to work? – energetic, creative, resilient, positive, confident, upbeat, happy
- Zig Ziggler
- Vipassana Vendatta
- Can choose to be positive vs be a mood hoover
- Do not moan. ‘get over it’ choose to be positive, be grateful
- If you did know the answer what would it be? If we were the best team, how would we act?
- ratio of good/praise to bad/negativity:
- 1:1 high risk
- 2:1 at risk
- 3:1 – minimum for good relationship
- 6:1 – high performing team
- 8:1 – children
- 1st FOUR MINUTES = be the best self.
- Reframing positively e.g. ‘was it good, great or amazing?’
- Appreciative enquiry – meeting and discussing what went WELL
The Art of Being Brilliant – mentoring update