Enhanced Recovery After Surgery (ERAS)

srv160008f1

Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J. 2011 Oct; 5(5): 342–348.

Dario Bugada, Valentina Bellini, Andrea Fanelli, et al., “Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach,” Surgery Research and Practice, vol. 2016, Article ID 3561249, 6 pages, 2016. doi:10.1155/2016/3561249

Enhanced Recovery After Surgery: If You Are Not Implementing it, Why Not? PRACTICAL GASTROENTEROLOGY • APRIL 2016.

A Systematic Review of Enhanced Recovery After Surgery Pathways: How Are We Measuring ‘Recovery?’  Session: Poster Presentation. Program Number: P613

46210

Sturm L and Cameron AL. Fast-track surgery and enhanced recovery after surgery (ERAS) programs. ASERNIP-S Report No. 74. Adelaide, South Australia: ASERNIP-S, March 2009.

Summary of Enhanced Recovery after Surgery Guideline Recommendations. Canada.

Patients Benefit From Enhanced Recovery Programs: Are Better Prepared for Surgery, Have Less Pain, Studies Show. Oct 2016. American Society of Anesthesiologists.

Enhanced Recovery after Surgery Guideline: Perioperative Pain Management in Patients Having Elective Colorectal Surgery: A Quality Initiative of the Best Practice in General Surgery Part of CAHO’s ARTIC program. April 2013.

Preserved Analgesia With Reduction in Opioids Through the Use of an Acute Pain Protocol in Enhanced Recovery After Surgery for Open Hepatectomy. Regional Anesthesia & Pain Medicine: July/August 2017 – Volume 42 – Issue 4 – p 451–457.

Regional Anesthesia for surgery and other comparative studies. Sweden.

ERAS: Role of Anesthesiologist. UTSW.

Stanford Anesthesia ERAS pathway website

13012_2017_597_fig6_html

Enhanced Recovery after Surgery Versus Perioperative Surgical Home: Is It All in the Name? Anesthesia & Analgesia: May 2014 – Volume 118 – Issue 5 – p 901–902

The Role of Regional Anesthesia in ERAS pathways. Sept 2015. UCSF.

ERAS Pathway Improves Analgesia, Opioid Use and PONV Following Total Mastectomy. Anesthesiology News. May 2016.

Anesthesia Practice and ERAS. Cooper University Hospital. 2017.

ERAS: Anesthesia Tutorial of the Week. Number 204. Nov 2010.

ERAS and Anesthesia. Anesthesia Business Consultants. May 2015.

All about ERAS: Why anesthesiologists need to understand this concept. Becker’s ASC Review. June 2015.

hqdefault

I’d love to incorporate my findings and use of lidocaine infusions and ketamine infusions on intraoperative and postoperative pain as a multimodal pain management pathway.

Ketamine for intraoperative and postoperative analgesia

I’m always looking for ways to improve myself. Lately, I’m looking at various clinical elements of my practice and select certain endpoints that will better my practice of medicine.

This time, I’ve focused on cutting back on opioids intraoperatively for pain. I’m looking specifically at ketamine, an old drug with multiple benefits (and some downsides). Not only does ketamine help with intraoperative pain, but it also helps with postoperative pain. I’d like to incorporate some type of ERAS model for all of my patients and surgeries.

ketamine_hydrochloride_050

Ketamine: (different doses I’ve seen in the literature below)

• Induction: 0.2-0.5 mg/kg

• Infusion: 0.1mg/kg/hr before incision

◦ 2mcg/kg/hr x 24hr (spine)

◦ 0.1-0.15mg/kg/hr x 24-72hrs (UW)

◦ 2mcg/kg/min

◦ 2-8mcg/kg/min


What I’m using nowadays:

  • Oct 2017:
    • Cardiac open hearts: induction bolus=0.5mg/kg + infusion=0.1mg/kg/hr and stopping when last stitch placed. Patients seem to require less postoperative narcotics. Looking at time to extubation to see if this is improved.  Time to extubation seems the same as my prior non-ketamine patients because RT and RNs follow a weaning protocol.  Patients are more comfortable and require less pain medication.
  • Dec 2018:
    • Cardiac open hearts: induction bolus = 0.5 mg/kg + another 0.5 mg/kg bolus when re-warming; infusion 0.2 mg/kg/hr stopping when last dressing placed.
  • July 2019:
    • Cardiac open hearts: induction bolus = 1 mg/kg + 0.5mg/kg bolus pre-CPB.  No infusion.  This formula is roughly in between the bolus (0.5mg/kg) + infusion (0.1mg/kg/hr and 0.2mg/kg/hr) for <5hr case.  For hearts >5hr, add 0.25-0.5mg/kg bolus when re-warming (0.5mg/kg dosing roughly approximates a 7hr case).
  • Sept 2019:
    • Cardiac open hearts: No induction bolus.  1mg/kg bolus prior to incision.  0.5mg/kg bolus pre-CPB.  0.25-0.5mg/kg bolus rewarming on CPB based on length of case (see July 2019 notes).

fg01_e6952
Is intravenous ketamine effective for postoperative pain management in adults? Medwave2017;17(Suppl2):e6952 doi: 10.5867/medwave.2017.6952

Ketamine: Current applications in anesthesia, pain, and critical care. Anesth Essays Res. 2014 Sep-Dec; 8(3): 283–290.

Effect of intraoperative infusion of low-dose ketamine on management of postoperative analgesia. J Nat Sci Biol Med. 2015 Jul-Dec; 6(2): 378–382.

Ketamine for Perioperative Pain Management. Anesthesiology 2005; 102:211–20.

CLINICAL GUIDELINE FOR USE OF KETAMINE AS AN ADJUVANT ANALGESIC FOR USE BY ANAESTHETISTS ONLY. NHS Royal Cornwall Guidelines June 2015.

Ketamine as an Adjunct to Postoperative Pain Management in Opioid Tolerant Patients After Spinal Fusions: A Prospective Randomized Trial. HSS Journal: Volume 4, Number 1.

The Use of Intravenous Infusion or Single Dose of Low-Dose Ketamine for Postoperative Analgesia: A Review of the Current Literature. Pain Medicine Volume 16, Issue 2, pages 383–403, February 2015.

Role of Ketamine in Acute Postoperative Pain Management: A Narrative Review. BioMed Research International. Volume 2015; Article ID 749837, 10 pages.

 

Ketamine in Pain Management. CNS Neuroscience & Therapeutics 19 (2013) 396–402.

Ketamine for the Management of Acute Pain and Agitation in the ICU: Future, Fiction or Just another Drug-Induced Hallucination? Ann Pharmacol Pharm. 2017; 2(11): 1059.

Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial. Lancet 2017; 390: 267–75.

A comparison between intravenous lidocaine and ketamine on acute and chronic pain after open nephrectomy: A prospective, double-blind, randomized, placebo-controlled study. Saudi J Anaesth 2017;11:177-84.

00213
Acute and Chronic Post-Thoracotomy Pain, modes of treatment

Another project I’m working on is the effect of lidocaine infusions on intraoperative and postoperative pain.


***UPDATE July 8, 2018 ***

AnesthesiologyNews: July 2018: New Consensus Guidelines Issued for Use of IV Ketamine for Acute Pain.

  • Question 1: Which patients and acute pain conditions should be considered for ketamine treatment?
    Conclusion: For patients undergoing painful surgery, subanesthetic ketamine infusions should be considered. Ketamine also may be warranted for opioid-dependent or opioid-tolerant patients undergoing surgery, or with acute or chronic sickle cell pain. For patients with sleep apnea, ketamine may be appropriate as an adjunct to limit opioid use.
  • Question 2: What dose range is considered subanesthetic, and does the evidence support dosing in this range for acute pain?
    Conclusion: Ketamine bolus doses should not exceed 0.35 mg/kg, whereas infusions for acute pain generally should not exceed 1 mg/kg per hour in settings lacking intensive monitoring. However, dosing outside this range may be indicated because of an individual patient’s pharmacokinetic and pharmacodynamic factors and other considerations, such as prior ketamine exposure. However, ketamine’s adverse effects prevent some patients from tolerating higher doses for acute pain; therefore, unlike for chronic pain management, lower doses in the range of 0.1 to 0.5 mg/kg per hour may be necessary to achieve an acceptable balance between analgesia and adverse events.
  • Question 3: What is the evidence to support ketamine infusions as an adjunct to opioids and other analgesic therapies for perioperative analgesia?
    Conclusion: There is moderate evidence to support using subanesthetic IV ketamine bolus doses up to 0.35 mg/kg and infusions up to 1 mg/kg per hour as adjuncts to opioids for perioperative analgesia.
  • Question 4: What are the contraindications to ketamine infusions in the setting of acute pain management, and do they differ from chronic pain settings?
    Conclusion: Patients with poorly controlled cardiovascular disease or who are pregnant or have active psychosis should avoid ketamine. Similarly, for hepatic dysfunction, patients with severe disease, such as cirrhosis, should not take the medicine; however, ketamine can be given with caution for moderate disease by monitoring liver function tests before infusion and during infusions in surveillance of elevations. On the other hand, ketamine should not be given to patients with elevated intracranial pressure or elevated intraocular pressure.
  • Question 5: What is the evidence to support nonparenteral ketamine for acute pain management?
    Conclusion: Intranasal ketamine is beneficial for acute pain management by achieving effective analgesia and amnesia/procedural sedation. Patients for whom IV access is difficult and in children undergoing procedures are likely candidates. But for oral ketamine, the evidence is less convincing, although anecdotal reports suggest this route may provide short-term advantages in some patients with acute pain.
  • Question 6: Does any evidence support IV ketamine patient-controlled analgesia (PCA) for acute pain?
    Conclusion: The evidence is limited to support IV ketamine PCA as the sole analgesic for acute or periprocedural pain. There is moderate evidence, however, to support the addition of ketamine to an opioid-based IV PCA regimen for acute and perioperative pain therapy.

New guidelines for the use of IV ketamine infusions for acute pain management have been published as a special article in Regional Anesthesia and Pain Medicine (2018;43[5]:456-466).

The guidelines were jointly developed by the American Society of Regional Anesthesia and Pain Medicine (ASRA), the American Academy of Pain Medicine and the American Society of Anesthesiologists.


Update Nov, 30, 2018

Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Regional Anesthesia and Pain Medicine: July 2018 – Volume 43 – Issue 5 – p 456–466

Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists.  Regional Anesthesia and Pain Medicine: July 2018 – Volume 43 – Issue 5 – p 521–546


Updated Sept 2019

Postoperative pain management in patients with chronic kidney disease. . 2015 Jan-Mar; 31(1): 6–13

Ketamine and CKD

Ketamine is an N-methyl-d-aspartate receptor antagonist that is commonly used as an adjunct for the treatment of acute postoperative or posttraumatic pain to improve pain scores and reduce opioid consumption by approximately 30-50%.[] Certain patients seem to benefit more from the addition of ketamine, including those with chronic neuropathic pain, opioid dependence or tolerance and acute hyperalgesia.[] 8% of administered ketamine is metabolized by the liver forming norketamine, which possess only 20-30% of the potency of ketamine. Norketamine is then hydroxylated into a water-soluble metabolite excreted by the kidney.[] Most clinicians believe that dose modification for ketamine is not required for patients with decreased renal function.[,

 

 

Pregnancy, epidurals, and birth plans

A little background info… I’m an anesthesiologist for a fairly busy practice. That means we get called when you need an epidural or c-section. I am currently in my first pregnancy (so I haven’t experienced my own birth process), however I’ve seen and managed thousands of epidurals for delivery.

One of the most important things moms can do for their pregnancies… Eat right (clean, get plenty of veggies and fruits) and exercise. This is the best prep work you can do! Secondly, have an open mind when selecting your birth plan. You are not in control of what will happen. What happens with your baby is what will dictate what you will need and what will be best for your baby. Many mothers have opted for a “natural” delivery and have been successful. Some mothers have been in a fully equipped medical center and have had bad outcomes unrelated to interventions for their baby.

Your goal as a mom is to guide and give direction to your delivery team of your wishes — but this is a process that changes throughout your labor so flexibility is key.

Epidurals are NOT harmful for your baby. There are multiple studies that’re well backed with huge sample sizes that prove this. Epidurals can slow certain stages of labor, but it’s NOT harmful to you or your baby. There are a lot of misconceptions about epidurals. Whether it’s patient experience, epidural effectiveness (and this can be patient controlled), or fear of the unknown… epidurals have been given a bad reputation and sometimes these traumatic experiences are passed down without rhyme or reason (similar to the anti-vaccine movement which is dangerous!).

So, pick a birth plan… be flexible with it. Do what you can to optimize your health (and birthing experience) via diet and exercise. Lastly, no one loses when they’re comfortable. Comfort leads to a good experience and overall a happy mom, baby, and family.

Here’s my plan (which isn’t for everyone):

1) more plant-based diet w some fish

2) exercise via walks, hikes, and pilates/yoga/barre

3) birth plan: vaginal delivery with minimal pain (epidural immediately: I don’t want to feel a thing)… but anything to get the baby out safely.

4) breastfeed like crazy if possible

5) go back to work after 3 months

6) breast milk for at least 6 months (but will try for a year)

My plan isn’t for everyone… it’s for me. Good luck!!

Walking labor epidurals

What is an epidural?

What is a “walking” epidural?

Anesthesiology 2 2000, Vol.92, 387. Walking with Labor Epidural Analgesia: The Impact of Bupivacaine Concentration and a Lidocaine–Epinephrine Test Dose.

MJAFI, Vol. 63, No. 1, 2007. Walking Epidural : An Effective Method of Labour Pain Relief. 

Int J Women’s Health, 2009, 1: 139-154. Advances in labor analgesia.

R. Can J Anesth/J Can Anesth (2010) 57: 103. Walking epidurals for labour analgesia: do they benefit anyone?

MOBILIZATION IN LABOUR AFTER REGIONAL ANALGESIA. Euroanesthesia May 2005. Royal Free Hospital. London, UK.

Impact of first-stage ambulation on mode of delivery among women with epidural analgesia. Australian and New Zealand Journal of Obstetrics and Gynaecology 2004; 44: 489–494

h9991523_001
From WebMD

Walking Epidural with Low Dose Bupivacaine Plus Tramadol on Normal Labour in Primipara. Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (5): 295-298.

Clinical Guidelines: Labour Analgesia. Jan 2017. King Edward Memorial Hospital, Australia.

BJOG, Feb 2015. Neuraxial analgesia effects on labor progression: facts, fallacies, uncertainties and the future.

Position in the second stage of labour for women with epidural anaesthesia. Cochrane Database of Systematic Reviews. Feb 2017.

Ambulatory Epidural Analgesia in Obstetrics: Clinical Effectiveness, Safety, and Guidelines. Canadian Agency for Drugs and Technologies in Health. Rapid Response Reports. Nov 2010.

Contin Educ Anaesth Crit Care Pain (2004) 4 (4): 114-117. Epidural analgesia in labor.

CSE for Labour Analgesia. 

cseanatomy

From the ASA 2017 (October in Boston):

  • CSE: 1 cc 0.25% bupi + 15mcg fentanyl (good for primip)
  • 25g Dural Puncture without dosing sometimes (primips)

MitraClip and TEE for MR

IMG_0056

European Heart Journal – Cardiovascular Imaging (2013) 14, 935–949.  Peri-interventional echo assessment for the MitraClip procedure. 

Everest Clinical Trial results PPT

Open Heart 2014;1:e000056. Two-year outcomes after percutaneous mitral valve repair with the MitraClip system: durability of the procedure and predictors of outcome.

ASE Echo 2016: Percutaneous approaches to MR. UofMichigan PPT.

2015: The role of 3D TEE in the MitraClip procedure – UofColorado PPT

Abbott TTE checklist for MitraClip

EuroValve Congress 2015: MR in the MitraClip Era

2012: Echo in mitral valve intervention. 

IMG_0057

Abbott MitraClip device and delivery system package insert

Neth Heart J (2017) 25:125–130. MitraClip step by step; how to simplify the procedure.

IMG_0059

IMG_0060

Transseptal Puncture technique with TEE

JACC Cardiovascular Imaging: July 2012. Role of echo in percutaneous mitral valve interventions. 

MitraClip Cases with TEE: Mayo Clinic.

Lidocaine infusions for pain

From Anesthesiology 2017

ASRA.com: Clinical Implications of IV Lidocaine Infusion in Preoperative/ Acute Pain Settings. May 2017.

BJA Educ, April 2016. Intravenous lidocaine for acute pain: an evidence-based clinical update

Lidocaine Infusion for Perioperative Pain Management – Vanderbilt

Cocharane Library, July 2015. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery.

Perioperative Use of Intravenous Lidocaine. Anesthesiology 4 2017, Vol.126, 729-737.

30tt01

Open Access Journals, Jan 2017. Lidocaine Infusion: A Promising Therapeutic Approach for Chronic Pain.

Anesthesiology, April 2017. Perioperative use of IV lidocaine.

From ASRA May 2017: Clinical Implications of IV Lidocaine Infusion in Preoperative/ Acute Pain Settings

ClinicalTrials.gov: Effect of IV Lidocaine Infusions on Pain

Here’s what I’m currently using:

  • October 2017
    • Lidocaine bolus: 1.5mg/kg on induction
    • Infusion: 2-3mg/kg/hr after induction to end surgery
    • If cardiac on CPB: bolus 1.5mg/kg on induction; Infusion: 4 mg/min x 48 hrs or discharge from ICU; On CPB bolus 4 mg/kg.
  • July 2019
    • I am currently not using lidocaine infusions as my open heart patients are getting great relief with ketamine.  I also came across some literature that said lidocaine infusions do not help postoperative cognitive decline.  However, I may reassess this at a later time and reinstitute.  We do not currently have an acute pain service.  Look at the ASRA, May 2017 issue, I do like the dosing regimen used at UVA. See below.
    • In our institution, an infusion rate of 40 mcg/kg/min after 1–1.5 mg/kg bolus is used perioperatively as part of our ERAS protocols. The infusion rate is decreased to 5–10 mcg/kg/min at the end of the surgery and continues at the same rate until POD 2. Our acute pain management lidocaine infusion protocol uses a 0.5 mg/min starting dose with a maximum of 1 mg/min for adults, and doses between 15 to 25 mcg/kg/min for pediatric patients <40m kg.

I’m also currently working on ERAS protocols for my practice as well as the use of ketamine infusions for intraoperative and postoperative pain and recovery.

From Jama Surgery 2017

Reflections

Today, I’m #20 on the call schedule after being #2 last night.  It wasn’t bad… I left work around 7:30p and never got called back to the hospital.  That’s a great #2 night!  A couple of days ago, I awoke with a pinched nerve along the left side of my neck and it’s incredibly uncomfortable turning my head and just doing regular tasks (i.e. making the bed).  Right now, I wreak of Bengay and I’m partially comforted with some Aleve.  Hot compress, you are next!  Sometimes, it’s really nice to enjoy a lazy morning with zero agenda other than to catch up on life and maybe even do some self reflection.

A buddy of mine sent me this article and asked me my thoughts….

How Many Children Should You Have?

I gave it a once over and thought, this is interested.  A small sample size of various parents from various geographical regions all commenting on their children.  Their is italicized because it seems like commenting on what the perfect number of children to have is so personal and completely unique to their experience.

It’s a heavy duty article with a lot of good perspective. I kind of agree with them all. I liked the one with 3 kids best… and the one with no kids the least. Since when did the purpose of procreation become about supporting the older generation? I had a tough one with that. I don’t think people have kids to look after them in old age.

What do u think?


This article came at a perfect time for me.  Bear and I just got married; we’re older… and we’re looking to start a family.  I just went on an Amazon spending spree for knowledge:

Even as an M.D., I am thirsty for knowledge in an area that I know pretty little about.  Sure, I’ve rotated on OB/GYN as a med student — but that was back in 2005.  Plus, doing two months of a rotation doesn’t equal a full understanding of mom’s body and baby’s development.  It taught me how to safely deliver a baby, but I need to know and understand the building blocks leading up to that.  Secondly, I’m an anesthesiologist who places labor epidurals for our pregnant ladies getting ready to welcome their little bundles of joy into the world.  I typically meet the moms when they are having contractions and wanting pain control and follow-up with them at delivery.  So you can see, there’s a 9 month knowledge gap that I need to fill in.

If you’re a future mom and are interested in an epidural, educate yourself on the pros and cons as well as what you expect to feel and when to ask for an epidural.

My blog post regarding OB Anesthesia

Remember, it is dependent on YOU as you are in control of your pain.  A pain scale will vary from person to person (i.e. everyone has different pain tolerances).  There’s no magical dilation number that tells you when to ask for an epidural.  Keep in mind that you will need to hold extremely still when you do ask for an epidural.  So please make it easy on your anesthesiologist (and yourself) and ask for an epidural when you are able to be as motionless as a statue — otherwise, it may be too risky to request an epidural if you are in too much pain to stay still.

 

PEC 1 & 2 Blocks, Serratus Anterior Block

I’ve been hearing more and more about PEC 2 block for mastectomy.  What’s wonderful about this block is that it seems that the risk of pneumothorax is lower than for a paravertebral block.

Egyptian Journal of Anaesthesia; April 2014. Thoracic Paravertebral Block vs. Pectoral Nerve Block for Analgesia after Breast Surgery

SlideShare powerpoint: PEC 1 & 2 and Serratus Anterior Blocks

pec-i-and-pecs-ii-serratus-anterior-block-11-638

Current Anesthesiol Rep, 2015. Regional Anesthesia for Breast Surgery: Techniques and Benefits.

Rev Esp Anesthesia Reanim; 2012: Ultrasound Description of PECS 2 (modified PECS 1): A Novel Approach to Breast Surgery

Poster Summary of PECS 2

unnamedl

TAP, PEC 1, & PEC 2 Blocks PPT

Anaesthesia, 2013. Serratus Plane Block: A Novel Ultrasound-Guided Thoracic Wall Nerve Block.

NYSORA 2014: Update on truncal blocks

Summary:

  • U/S guidance: probe position similar to infraclavicular block. Find 3rd, 4th rib.
  • Pt position: Head away from side of block. Ipsilateral arm abducted.
  • PEC 2: Inject 20 ml 0.25% bupi between pec minor and serratus.
  • PEC 1: Inject 10 ml 0.25% bupi between pec major and pec minor.
  • Serratus: 5th rib, mid-axillary line. Inject 30 ml 0.125% bupi along top (superficial) and bottom (deep) of serratus muscle (which is just deep to the latissmus dorsi).

YouTube: PECS 1&2 Block

YouTube: Serratus plane block


Update: Oct 24, 2018

PECs blocks in Cardiac Surgery

http://www.annals.in/article.asp?issn=0971-9784;year=2018;volume=21;issue=3;spage=333;epage=338;aulast=Kumar

http://www.apicareonline.com/ultrasoundguidedblocksforsurgeries-proceduresinvolvingchestwall-pecs-12andserratusplaneblock/

https://www.ncbi.nlm.nih.gov/m/pubmed/29016551/

 

The Price You Pay

“Now you can’t walk away from the price you pay” Bruce Springsteen, The Price You Pay…..I was called in at 2:30 a.m. recently for an aortic dissection. Seems like no one ever dissects in the middle of the day. When Dr. Newsome walked into the room he looked at me and said, ” it seems like we’ve done a few of these over the years.” Indeed we have…these cases are generally long and difficult. There is a feeling you get at the beginning of the case, usually around the time when you first see the patient, when you realize that you are more than likely going to be there anywhere from 8 to 12 hours or longer. It’s kind of a sinking feeling, especially if you had something planned that you were hoping to do, but the feeling recedes and you go about your business doing what must be done. It is a wonderful thing to be part of doing something that prolongs someone’s life. We are also financially compensated for what we do. But it comes with a price. It is a very surrealistic feeling to be driving home on a sunny Sunday evening at 6:00 p.m. after being at the hospital since 3 a.m. People are out enjoying life, surfing, riding bikes, going out to eat, whatever else they might enjoy, and all you want to do is make it home and fall into your bed. Basically, you have given up a day of your life. Which, at this stage, is not an infinite supply. It takes a toll on your body also. You feel like you’ve been run over by a truck. Everything hurts, and it’s usually a couple of days before you start to feel like yourself again. That being said, I can’t really complain as the scrub tech for the case was the amazing Ann McCullough who seems to have twice the endurance and stamina of someone half her age. Plus I got to spend the day with Drs Stahl, Wang and Newsome as well as Danny and Chad….priceless…oh yeah, at the end of the day when everyone was leaving Danny congratulated Chad on doing such a great job and said he would take call with him anytime. Seems like a small thing but the smile on Chads face told me it meant a lot to him. Things like that are why Danny is such a great person to work with…..

OB Anesthesia

Today, I’m on call covering OB.

MGH: OB anesthesia Q&A for patients

BWH: OB anesthesia Q&A for patients

IARS 2010: OB anesthesia in the 21st century

IARS 2011: OB anesthesia update

A&A 2013: A Randomized Controlled Comparison of Epidural Analgesia and Combined Spinal-Epidural Analgesia in a Private Practice Setting: Pain Scores During First and Second Stages of Labor and at Delivery

Indian J Anesthesia 2006: Acute Pain – Labour Analgesia

Presentation on mobile epidural

2014: CONTINUOUS VERSUS PATIENT-CONTROLLED EPIDURAL ANALGESIA FOR LABOUR ANALGESIA AND THEIR EFFECTS ON MATERNAL MOTOR FUNCTION AND AMBULATION

June 2011: Update on rural OB anesthesia

Oct 2013: Presentation on Labor analgesia. Epidural vs CSE, bolus v infusions

To epidural or not to epidural. That is the question.

My Reddit Comment

A great YouTube video on what an epidural is and what it will feel like.

YouTube vid of a real epidural placement ** Needles are involved in this one**

Lately, I’ve been changing my regimen for pain control with PCEA.  It seems most of my partners use a 10ml/hr basal rate, 5ml bolus dose, 10 minute lockout, and 30 ml/hr max.

My current strategy for PCEA (0.0625% bupi + 2mcg/ml fentanyl):

  • 5ml/hr basal rate
  • 10ml bolus
  • 20 minute lockout
  • 35 ml/hr max

Anesth Analges 2007: A Comparison of a Basal Infusion with Automated Mandatory Boluses in Parturient-Controlled Epidural Analgesia During Labor.

ASA Nov 2001: PCEA during labor

Br J Anaesth 2010:Labour analgesia and obstetric outcomes.

Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation: A Prospective, Randomized, Blinded Clinical Trial

Neuraxial anesthesia in the non-pregnant patient

Anesthesiology Research and Practice 2012: Recent advances in epidural analgesia.

Br J Anaesth 2012: Failed epidural: causes and management.

From my blog: