Take home messages:
In the elderly, hypotension is BAD. Keep MAP>55 and systolic no more than 10% less than baseline systolic. Consider running pressor infusion c.f. obstetric spinals
Always consider regional, BIS, no/less opioids (though not at expense of adequate analgesia)
Consider heavy prilocaine for hips & knee – if surgeon is experienced/quick
Oxycodone > morphine
Predict and treat delirium. HELP principles. Might be context specific therefore do better in own home. Involve geriatricians.
New anticoagulants – ideally need 73 hours but is balance of risk (given that mortality with #NOF increases per day)
Prehabilitation (exercise!). Not just walking. Remember strength training (stand from siting) and balance (stand on one leg with eyes closed)
EPOCH take home themes: data = power, engage and involve everybody, have a systems thinking approach, develop leadership & project management skills
Use frailty scoring systems e.g. Edmonton Frail Score
Looks cool but it is useful? Difficult to aspirate imagine.
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
1 part jelly
1 part lignocaine spray (10%)
= 5% lignocaine
Apply to inflated cuff, then deflate
extubate fully awake but ETT tolerant without coughing on ETT
intra-op can be less deep, epecially with good going regional e.g. caudal
EdM @ LRI
Identify surface landmark
enter approx 45 degrees
upon entry anlge needle more parallel
advance needle slightly
then keeping needle stable, advance the cannula. Does not need to be to hilt.
Watch/aspirate for CSF or blood
inject LA (+1-2mcg/kg clonidine) as per Armitage regime, visualising the skin/subcut tissue
The feel of entering cuadal space is similar to the gentle LOR when piercing rubber bung on antibiotic bottle.
If after inserting needle through sacrococcygeal membrane and resistance is encountered on advancing cannula or needle or injection of LA (likely the dorsal aspect of the ventral plate of the sacrum) then withdraw cannula/needle and redirect cranially, walking off the bone if necessary. Better to enter at caudal aspect of sacral hiatus.
More reliable and consistent than nerve blocks.
Use up to approx 20kg weight/7yr
Single-breath vital capacity inhalation induction with high concentration sevoflurane (SBVC – HC)
Does exactly what it says on the tin.
Prime the circuit with 8% Sevo with >= 6 L /min O2 (+/- N2O).
Hold face mask against surface to build up Sevo.
Practice vital capacity breathing with patient.
Following forced expiration apply face mask and instruct to take vital capacity breath.
Induction complete in 50-60 sec.
– PB @ LRI