Catheter pack or Epidural pack
20ml of 0.25% l-bupivicaine for each side
Using US identify rectus muscle. Above umbilicus. Transverse plane if necessary.
Then view in longitudinal/sagittal plane
Enter as close to midline as possible, but alow enough clearance for dressing and wound.
Identify plane. Hydrodissect using saline and create space
Thread catheter as far as it goes
Then attach filter etc and inject remaining LA to see spread
Dressing pack – catheter to be exiting caudally. May use glue.
Attach infusion devise.
18G (‘green’) needle & syringe
After insertion of epidural, withdrawn Thouhy by 1-2 cm so that it remains in patient but outside of epidural space
Small nick in skin adjacent to epidural needle, on side of which epidural catheter is to be tunnelled
Local anaesthetic using green needle in subcut plane laterally
Apply a slight curve in abbocath needle
Then local anaesthetic using abbocath
Exit at exit site of epidural catheter. Use plastic tube to apply tension to skin to help this. Do not exit too far away otherwise will struggle with dressing.
Cut off proximal wide part of abbocath
Pass epidural catheter through abbocath
Then remove abbocath
Pull back epidural to correct position
Then pull through tunnel
Glue the two skin incisions
– slowly over 1min. caution if slow resting HR. May need pre-med with glycopyrrolate
Intubating conditions when apnoea, low HR, in approx 15-60 sec
– FA @ LCH
In a situation where the view is good but difficulty is encountered passed ETT between the cords consider the following:
Manoeuvring Airtraq (+/- head/airway) e.g. ‘drop’ it into pharynx to align angles better
Positioning of the glottis ‘target’ towards bottom right of screen
Use of bougie or wide bore NG tube (with ETT railroaded)
Alternative ETT e.g. standard instead of RAE
0.5mg/kg (preservative free) ketamine.
Prolongs action of caudal. Up to 12-16 hours.
Good for paediatric orthopaedics
Always loose lots of fluid and they tend to be relatively under-resuscitated by end of op.
Have same set up for lines, monitors, etc, every time so that when things change this is constant, and when you need to respond quickly you know where things are, because there are always there.
On one port of CVC line attach a 20cm or 50cm extension so that it is way away from neck so you can easily access it without needing to rummage under drapes.
If C-spine injury is suspected then Plan A use a technique of McCoy blade + bougie with the aim of just seeing the arytenoids to guide the bougie i.e. do not aim for a ‘grade 1’ view. This approach reduces unecessary cervical spine traction and movement.
– JH, QMC
Lignocaine 1-1.5mg/kg IV or topical
Pre-med with benzo/midaz (for LMA)
Anticholinergics (reduce secretions)