Category Archives: general surgery

Thoracic epidural tips for lateral / GA

– POSITION WELL

– count up from L2/3 and also down from C7 spinous process (major prominence in neck) to identify level

– if under GA try 3 different spaces before resorting to para-median approach as patient is not awake to be a marker of danger

– maintain thumb of non-needling hand on spinous process above space

– feed epidural to that natural curve tends to take it cephelad

– tunnel catheter (less movement, earlier marker of infection):

  • nick in skin prior to needling
  • feed 16G gelco sub-dermally in lateral direction approx 5cm
  • cut off end obliquely
  • pass through catheter without touching skin
  • CAREFUL NOT TO CUT EPIDURAL CATHETER

 

– PM @ LGH

 

Laparoscopic hypercarbia

Increase MV 12-18L/min (preemptively):

High RR (compared to Vt)

High I:E. Adv: reduced peak airway pressure for a given Vt, permits higher MV. (Improved oxygenation due to increased mean airway pressure.) Dis: reduced CO due to increased mean airway pressure, in obstructive airways can lead to gas trapping.
If oxygenation not a problem then reduce PEEP to increase MV for same peak airway pressure
Consider largest possible ETT.
Ask surgeons to deflate if necessary