Prof. Mridul M. Panditrao adds another presentation to his collection. This is another Faculty lecture that was delivered at International conference on pain ... ISSPCON 2014, at Mumbai/Bombay, 7th Feb to 9th Feb 2014.
Patient control epidural analgesia Al Razi hospital KuwaitFarah Jafri
This is the Patient Controlled Epidural Analgesia protocol at Al Razi Hospital. This presentation was done before initiating the PCEA as a pain control modality in the hospital.
Anaesthetic management of ruptured ectopic pregnancy by Arowojolu BoluwajiArowojolu Samuel
anaesthetic management of a patient with ruptured ectopic pregnancy. helping anaesthetist to know what to do in emergency anaesthesia. this is an emergency case. salpingectomy. arowojolu boluwaji
Enumerates the effect of different anesthetic agents on the CNS and compares their relative efficacy and safety in providing good outcome in neuroanesthesia
A patient with pacemaker presents a complex challenge to the attending anaesthesiologist. The mode of management will be according to the type of pacemaker implanted. This presentation discusses in brief the peri-operative consideration in a patient with pacemaker.
Patient control epidural analgesia Al Razi hospital KuwaitFarah Jafri
This is the Patient Controlled Epidural Analgesia protocol at Al Razi Hospital. This presentation was done before initiating the PCEA as a pain control modality in the hospital.
Anaesthetic management of ruptured ectopic pregnancy by Arowojolu BoluwajiArowojolu Samuel
anaesthetic management of a patient with ruptured ectopic pregnancy. helping anaesthetist to know what to do in emergency anaesthesia. this is an emergency case. salpingectomy. arowojolu boluwaji
Enumerates the effect of different anesthetic agents on the CNS and compares their relative efficacy and safety in providing good outcome in neuroanesthesia
A patient with pacemaker presents a complex challenge to the attending anaesthesiologist. The mode of management will be according to the type of pacemaker implanted. This presentation discusses in brief the peri-operative consideration in a patient with pacemaker.
2012 Dialogue presentation by Chanel Tyler, MD – Assistant Professor, Department of Obstetrics and Gynecology at the UW School of Medicine and Public Health
Although back pain is a common problem, treatment options will vary depending on how long you had the pain and the severity of it. Dr. Rohit Oza explains the different types of injections you can use to help treat back pain.
Potts spine is the classical destruction of disc space and the adjacent bodies , destruction of other spinal elements,severe progressive kyphosis subsequently
Also know as spinal tuberculosis
Adult Orthopedic Imaging Series: Presentation #2 Native Hip DislocationsSean M. Fox
Drs. Carrie Bissell, Aaron Fox, and Kendrick Lim are Emergency Medicine Residents at Carolinas Medical Center and are interested in emergency medicine and medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine and Dr. Laurence Kempton, an Orthopedic Surgeon, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides that focus on Adult Orthopedic cases. This set will cover:
- Hip Dislocations
A dissertation is a practical exercise that educates students about basics of research methodology,
promotes scientific writing and encourages critical thinking. The National Medical Commission (India)
regulations make assessment of a dissertation by a minimum of three examiners mandatory. The
candidate can appear for the final examination only after acceptance of the dissertation. An important
role in a dissertation is that of the guide who has to guide his protégés through the process. This
manuscript aims to assist students and guides on the basics of conduct of a dissertation and writing
the dissertation. For students who will ultimately become researchers, a dissertation serves as an
early exercise. Even for people who may never do research after their degree, a dissertation will help
them discern the merits of new treatment options available in literature for the benefit of their patients
National Education Policy 2020 What is in it for a student, a parent, a teach...Prof. Mridul Panditrao
Ministry of Human Resource Development of Government of India has projected an elaborate and all-encompassing National Education Policy 2020 (NEP2020). Before independence, the education in India was under the complete control of the “Masters, the British Empire.” The education policies, like the one drawn by Macaulay, as would be obvious, were not for providing any quality education to the Indians, but to churn out the “Babus;” clerks and bureaucrats, to serve the masters, pure and simple. After independence, the society went through series of changes, policies were charted and certain reforms were brought in, but the impact was still not achieved. In 2015, the GOI adapted, “2030 Agenda for Sustainable Development (SD)” and since then the impetus has been initiated. The final culmination of a long drawn and all-inclusive process is NEP2020. NEP2020 has been a very elaborate planning document. The salient features of the issues, principles, aims, vision, challenges and solutions have been dealt with in this article. The main focus has been on the higher education and its implementation. Due importance also has been accorded to other issues such as vocational education, research and online and digital education to mention a few. Overall, it is a commendable and a very positive step forward on the part of the government. Only the time will judge, how much net effective output is actually garnered.
Notwithstanding the unprecedented advances the medical science has achieved, the fundamental value system of it’s practitioners has crumbled to a great extent. The principles and the foundations of the noble profession at present are very shaky and wobbly. The need and greed of lucre is the ‘principal principle’ which seems to be ruling this ‘materialistic’ world. Original guidelines of the Fathers of Medicine seem to be slowly fading away. Therefore it is the necessity in these testing times to introspect deeply and reinvent the vanishing science of ‘Medical Deontology.'
Updated Presentation has been uploaded replete with pertinent examples of the principles to make it more interesting and interactive training session!
Pantoea dispersa: Is it the Next Emerging “Monster” in our Intensive Care Uni...Prof. Mridul Panditrao
Prof. Mridul Panditrao, discusses, a case report; presentation, with unusual symptoms, unusual lab findings, unusual progression, but the same old ususal fatal outcome, in spite of trying everything. The main cause of thisultimately turned out to be Uncommon Genus Pantoea species dispersa. He adds the lextensive literatute Review too
Prof. Mridul Panditrao, dwells upon, the newer applications of Ketamine, good old friend of anaesthesiologists, a trusted weapon! Now is making a strong comeback for diverse indications like chronic/ neuropathic pain and major depressive disorders, in addition to its traditional applications of peri-operative analgesia.
Professor Mridul M. Panditrao, deals with this basic, complicated but very important topic for not only post- graduates but also for under-graduates. Various complicated issues have been discussed in detail, mainly from clinical point of view.
Prof. Mridul Panditrao wants to share his much acclaimed CME lecture in ISACON 2014, Madurai, India and many other places, on one of the very very important but often ununderstood and neglected essential topics in Anesthesia..... Vaporizers!!
Prof. Panditrao has added his original work on the subject of 'Medical Deontology'/Medical Ethics... a Powerpoint version and updated presentation of his editorial on the same topic. He expands his own ideas, priniples and moral values on this very very important but now and virtually neglected topic. The powerpoint presentation has been updated with specific and pertinent examples so that, while training the younger generation, it can become an interactive session
Prof. Mridul M. Panditrao has added another of his very important, useful and in vogue topic to his collection. This is his well acclaimed andwell received faculty lecture at recently concluded International conference on Pain... ISSPCON 2014, at Mumbai/ Bombay from 6th to 9th Feb. 2014.
Professor Panditrao expresses his views about the day to day challenge, faced in clinical practice. Considered to be a simple surgery, but the anesthetic management is very challenging because of the primary pathology, co-morbidities and repeated surgeries involved.
Strict Glycemic Control in Critically ill patients: The Demise of another ver...Prof. Mridul Panditrao
Prof. Mridul M. Panditrao tries to explain the pros and cons about the good strategy, whcih became controversial and almost obsolete. He also tries to tract the whole aspect of the phenomenon and reviews/ RCTs/
Strict (Tight) Glycemic control (SGC/TGC), as it is called, was and still is a good strategy. It can be defined as maintenance of the blood glucose level in the range of 80-110 mg /dl. with help of dose variable and intensive insulin therapy (IIT). Since its introduction, there have been conflicting reports of its efficacy and complications. This resulted in slow but steady neglect of this very good idea leading to its almost complete demise.
An effort has been made in this review, to impartially analyze all the available evidence and try to find the reasons for the negative publicity which led to the neglect or worse still, the wrong use of this protocol. Some suggestions for fair and proper implementation of the strategy are put forward.
etc/
The Anesthesiologist, especially young, faces a major challenge when faced with very ill/ severly moribund, elderly, cachwexic patients with history of fall and lower extremity fractures for elective or ortho surgical procedure. Prof. mridul m. panditrao, explains various problems faced especially with GA, and the best alternatives. Two different approaches of Combined spinal epidual are discussed, with use of adjuvants and also his own randomizede trial and experience.
My memorable case! AN UNANTICIPATED CARDIAC ARREST & UNUSUAL POST-RESUSCITATI...Prof. Mridul Panditrao
ABSTRACT
A case report of a primigravida, who was admitted with severe pregnancy induced hypertension
(BP 160/122 mmHg) and twin pregnancy, is presented here. Antihypertensive therapy was
initiated. Elective LSCS under general anaesthesia was planned. After the birth of both the babies,
intramyometrial injections of Carboprost and Pitocin were administered. Immediately, she suffered
cardiac arrest. Cardio pulmonary resucitation (CPR) was started and within 3 minutes, she was
successfully resuscitated. The patient initially showed peculiar psychological changes and with
passage of time, certain psycho-behavioural patterns emerged which could be attributed to near
death experiences, as described in this case report.
Ropivacane: A new break through in regional and neuraxial BlockadeProf. Mridul Panditrao
Prof. Mridul M. Panditrao, discusses the merits and demerits of all the three, local anaesthetics, viz; loidocaine, bupivacaine and the new comer, Ropivacaine, their pharmacology, structual differences, comarison, dosing guide and his own experince and a controlled comparative trial
Prof. Mridul M. Panditrao, from his University/ medical College days, gives tips on how to write your synopsis for your dissertation after you have registered and started your MD/ MS training programme. he also gives ideas/ steps to come up with a well constructed synopsis. Very useful for the first year MD/ MS PG students
Here prof. mridul M. panditrao, shares his personal views on the most controversial and problematic issues of dealing with the pharmaceutical industry and their representatives. The clinicians are constantly exposed to lure and lucre of these issues. He wants to guide the upcoming, young and promising clinicians about the ethical/ unethical aspects and hopw to maintain your own, clinician's morality when dealing with these set of personnel. he also dwells upon the vanishing science of medical deontology
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
2. Prof. Mridul M. Panditrao
Consultant
Department of Anesthesiology and Critical Care
Public Hospital Authority’s Rand Memorial Hospital
Freeport, Grand Bahama,
Commonwealth of The Bahamas
3. “Two conditions are, therefore,
absolutely necessary to produce
Spinal anesthesia:
Puncture of the Dura Mater and
sub-arachnoid injection of an
anesthetic agent!”
Gaston Labat,
1922
„Father‟ of modern regional anesthesia
5. INTRODUCTION
Neuraxial Blockade!
Historical:
• James Leonard Corning: 1885; first performed neuraxial blockade (epidural) in
healthy male volunteer
• August Bier: 1899; first clinical Spinal anesthesia
• Fidel Pagés (Spanish military surgeon): 1921; "single-shot" lumbar epidural
anesthesia
Spinal anesthesia has enjoyed a long history of success and
has already celebrated a centennial anniversary (1999)!
•Wulf HF: “The centennial of spinal anesthesia.” Anesthesiology 1998; 89:500–6
6. Neuraxial Blockade!
A well-planned, skill oriented and reasonably
successful modality of anesthesia.
• Anesthesiologists master spinal anesthesia early during training:
(90% technical success rate) after only 40–70 supervised
attempts!!!!
• However, once adequate proficiency has been achieved
• It is one of the easiest techniques to perform and get adequate
results.
•Kopacz DJ, Neal JM, Pollock JE: The regional anesthesia “learning curve”: What is the minimum number of epidural and spinal blocks to reach consistency? Reg Anesth
1996; 21:182–90
•Konrad C, Schupfer G, Wietlisbach M, Gerber H: “Learning manual skills in anesthesiology:” Is there a recommended number of cases for anesthetic procedures?
AnesthAnalg 1998; 86:635–9
7. Caution!
Even in expert hands, a well-executed „spinal block‟ may „fail‟!
• It is an unusual/awkward situation
• Especially, when the operator with adequate skill level encounters……..
1.
2.
3.
Difficulty in achieving the lumbar puncture
Inadequate/ complete lack of free flow of the CSF
Inadequate block: ???? Wrong : place/ drug/ dose/
concentration/volume
One has to analyze, the exact etiology of the failure!!
8. • Once the avoidable causes/technical reasons have been
eliminated or when it is impossible even to achieve the
„lumbar puncture‟ then it is termed as truly
“Difficult Spine!!’
Thus it is a interplay of various factors, which ultimately culminate in to
a „Unsuccessful/Difficult‟ or „Inadequate/Failed spinal‟
Fettes, PDW, Jansson J-R and Wildsmith JAW Failed spinal anaesthesia: mechanisms, management, and
prevention. BJA 2009;102 (6): 739–48
9. Definitions:
“Difficult Spine”:
• An anticipated or un-anticipated
• Failure of introduction of the needle
• Getting „wet tap‟ or free flow of CSF
• Multiple attempts at lumbar puncture
• Subsequent consequences/ problems
It can be one of the etiological factors of failed spinal!
10. Definitions:
“Failed/Inadequate spinal”:
• In spite of
• a successful lumbar puncture,
• satisfactory flow of CSF and
• injection of correct concentration/volume/ dose
• unanticipated, complete (failed) or
• incomplete/ patchy/ lower than required level of the
sub-arachnoid (or even epidural) block
11. Etiopathogenesis:
• Failed Spinal:
If one is circumspective, about the factors involved in this
process, four set of factors need to be considered:
• Operator
• Patient
• Equipment
• Miscellaneous
12. Etiopathogenesis
Operator factors!
•
Skill level/ experience & thorough knowledge of the anatomy
• more chances of failure in the hands of less experienced/ novices.
•
Proficiency/ practice of the Technique: how frequently on daily basis
the anesthesiologist, is performing the block?
• Even in the hands of so called „experts‟/ mature operators there can be
failure, if they have not been practicing the skill for some time in recent
past
• In fact this can be a major factor for these techniques falling in serious
disrepute and not being practiced, because of development of a „vicious
cycle‟.
13. Etiopathogenesis: Operator Factors
• The „approach‟ used:
• Conventionally the midline approach especially in
L3-L4 interspace - The intercristal line or Tuffier‟s line
• Lateral or para-median approaches, especially in heavily calcified
midline ligaments
• inherently more complex techniques
• need again excellent knowledge of anatomy,
• acquired skill and
• continued practice
•Lee JA, Atkinson RS. Sir Robert Macintosh’s Lumbar Puncture and Spinal Analgesia. Edinburgh: Churchill Livingstone, 1978
14. Etiopathogenesis: Operator Factors
• The angle of needle insertion used
• advisable to insert the needle, cephalad angle/bevel pointed upwards.
• even with adequate patient position; if
Incorrect angle
of insertion and
inadequate depth
of insertion
free flow of the
CSF is not
achieved
„failure‟ of the
block.
15. Etiopathogenesis
Patient factors!
• Un-informed, unwilling so logically uncooperative patients will
always be a hindrance in performing a successful block.
• Use of local infiltration : reluctance to use pre-block local anesthetic
infiltration, especially before sub-arachnoid block.
• The excuses which are given for this are,
• „Anyway it is just question of one prick, so how does it matter?‟
• „Infiltration will distort the local anatomy, mask the landmarks and make my
entry more difficult.‟
• „I am quite confident/ skilled enough to do the block in first attempt, why
should I bother about additional injections?‟
16. Etiopathogenesis: Patient Factors
No matter
• what proficiency level one may be able to boast about,
• that leaving aside all the ego rides/ excuses or any issues,
• one must use the local infiltration both intradermally as well
subcutaneously,
• making sure that the adequate volume/ concentration of Local
anesthetic is used
• so as not to mask the landmarks, but to provide the analgesia, for
the entire passage of the needle
http://www.frca.co.uk/article.aspx?articleid=100449
17. Etiopathogenesis
Equipment factor!
• The needles:
• smaller gauge of the needle is better
• A pencil-point should be used if possible.
• However, in some of the elderly patients, or strong muscular adult males it is
very difficult to introduce and smoothly pass the 27 G pencil-point needle.
• The drugs: multiple factors
• wrong drug, wrong concentration, wrong dose, wrong volume,
• even the wrong connection between the needle and syringe, thus loss/ leaking
of the drug
• Improperly stored, ineffective drug preparation
• Baricity of the drug also plays a significant role in final distribution/ spread of
the drug and level, density and uniformity of the block (Non-patchyness).
18. Etiopathogenesis: Equipment factor!
• The adjuvants:
• the physical (precipitation/ change of pH)
• chemical (Mixture of acidic and basic drugs producing an
ineffective salt)
• idiosyncratic ( The formation of a newer salt/ molecule leading to
unanticipated, rarely toxic actions).
19. Etiopathogenesis
Miscellaneous factors: „Resistance to Local Anesthetics!!!!!!‟
• Controversial area
• Unexplainable, recurring yet unproven factors
Various proposed hypotheses
• genetic predilection like redhead persons, especially females
• mutation in the receptor for the action of Local anesthetics, the Sodium channels
on the nerve fibers,
• pathological conditions like Ehlers Danlos syndrome
• even the history of previous scorpion bite.
•Panditrao MM, Panditrao MM, Khan MI, Yadav N. Does scorpion bite lead to development of resistance to the effect of local anaesthetics? Indian J Anaesth 2012; 56:575–8.
•Panditrao MM, Panditrao MM, Sunilkumar V, Panditrao AM. Can repeated scorpion bite lead to development of resistance to the effect of local anesthetics? Maybe it does! CRCM. 2013; 2, 179-82
•http://www.biomedcentral.com/1471-2253/4/1.
•Hoppe J, Popham P. Complete failure of spinal anaesthesia in obstetrics. Int J ObstetAnes 2007; 16:250-5.
•Panditrao MM, Panditrao MM, V. Sunilkumar, Panditrao AM. Effect of previous scorpion bite(s) on the action of intrathecal bupivacaine: A case control study. Indian J Anaesth 2013;57:236-40.
21. Concentrate upon the factors
• Patient factors
• Operator Factors
• Miscellaneous
22. Patient Factors
Demographic Profile:
(a) Age: The extremes of age
•
•
•
•
Age related changes - elderly patients: calcification/ossification
Consequences of osteoporosis
Degenerative disc disease
Decreased CSF volume
(b) Sex:
• Female spine - more challenges
Pronounced lordosis, More subcutaneous fat.
23. Patient Factors
(c) Weight:
• Both underweight as well as overweight
• Underweight patients - the skin &subcutaneous tissue: tougher/ loose,
due to absence of subcutaneous fat
• Practically very difficult to puncture them with „pencil point needles‟
• Entry point does not remain precise, in relation with the underlying
structures, especially in midline approach
• Overweight/ obese patients: Entire anatomy distorted, the skin
landmarks and the entry point are practically never well correlated
with deeper structures.
(d) Height:
Shorter patients - almost all the structures in the back are compressed
24. Patient Factors
Anatomical variations: Developmental anomalies
• Pathological processes of spine
• Kyphosis,
• Scoliosis
• epidural cysts called „Tarlov Cysts‟
Cause difficulty in lumbar puncture as well as failed blocks.
•Hoppe J, Popham P. Complete failure of spinal anaesthesia in obstetrics. Int J ObstetAnesth 2007; 16: 250–5
PophamPA.Anatomical causes of failed spinal anaesthesia may be commoner than thought. Br. J. Anaesth. 2009; 103: 459. doi:10.1093/bja/aep217
25. Patient Factors
Abnormalities of the spine: These truly are the causes of “Difficult Spine”
• Spinal stenosis
• Osteoporotic compression fractures
• Degenerative spondylolisthesis
• Adult scoliosis
• Degenerative disc disease
• Ankylosing Spondylitis
Although many other conditions exist, most of these disorders are in fact not
entirely separate entities but rather disease states along a continuum
Many of these conditions overlap in their presence and presentation in any
one individual.
26. Operator Factors
„Not so gentle handling of the patient‟:
• while positioning/keeping them still
• Anxious patient tends to be scared and un-co-operative
• sitting or lateral, the patient has to be exposed: very agitated, especially
females
• If the patient has already a painful condition, for which they are on
Operation table, like, lower limb fractures or intra-abdominal pathologies
27. Operator Factors
For adequate co-operation
• very gentle and careful handling of the patient
• maximum, physical, emotional as well as moral support
• patience on part of the anesthesiologist
• avoidance of transference
• A very humane, conscientious as well as caring attitude needs to be
developed.
• It would be very useful and imperative to give a combination of an
anxiolytic like midazolam along with an analgesic, especially in the
presence of pre-operative painful condition.
28. Operator Factors
Miscellaneous Factors:
• Assistance: while positioning, the role of the assistant in achieving and
maintaining the patient in the correct position cannot be
underestimated
• Positioning: Sitting or Lateral
29. Operator Factors
Positioning:
Conventionally, Sitting position has lesser degree of difficulty
• midline is properly maintained
• the landmarks are easier to locate
• patient less likely to be rotated or laterally flexed.
• Over-enthusiastic assistants - too much forward bending of the back
Space available for the needle tip‟s progress hampered
Correct position would be to keep the back straight
• Resultant sympathetic blockade – aggravated
Enhanced gravity-induced peripheral blood pooling - significant
hypotension.
•Fredman B, Zohar E, Rislick U, Sheffer O, Jedeikin R. Intrathecalanaesthesia for the elderly patient: the influence of the induction position on peri operative haemodynamic
stability and patientcomfort. Anaesth Intensive Care 2001; 29: 377-82.
30. Operator Factors: Positioning
Lateral position
• Elderly pre-medicated patients
• Compared to the sitting position, the lateral position may cause
less hypotension.
• The identification of anatomical landmark is difficult
• May be practically very difficult to assume it, with lower limb
painful pathologies like fractures/ Trauma
31. Prevention
• Pre-operative identification/confirmation
• Thorough history taking:
• Especially of any previous spine surgery,
• previous difficult/ failed spinal blocks
• any family history of similar instances.
• The pre-operative examination
• Examination of vertebral column, especially thoraco-lumbar spine, to
rule out abnormalities of spine, like kypho/scoliosis, any spinal
diseases/ degenerative conditions.
• If situation warrants then one may have to opt for imaging studies,
from radiological examination to CT, if required.
32. MANAGEMENT
“The true difficult spine is truly difficult to manage!”
• The „confirmed difficult spine may need mustering of all the skill,
experience and knowledge,
• even in terms of the team approach,
• advanced equipment,
• even assistance of radiological colleagues.
• Plan for suitable modification
• CT/ Ultra sound guided technique
• Not possible to use any one of the above techniques, then General
Anesthesia
The classical examples of difficult situation are as follows:
33. Previous spine surgery :
Spine surgery: a relative contraindication to neuraxial anesthesia.
*
Although it is generally accepted, as well as reported by some authors
• Post-operative spinal stenosis and other degenerative changes
• Presence of chronic pain making the patients reluctant to allow the needle insertion.
• The post-operative anatomical changes make the insertion of needle difficult, which has to
be inserted through the unfused areas.
• Evidence: it may be possible to do spinal in these patients more successfully, as compared to
epidural.
But there is an increased incidence of post spinal neurological deficit.
•*Harlocker TT, Wedel DJ Epidual and spinal anesthesia after a major spine surgery In Paul G. Barash, Bruce F. Cullen, Robert K. Stoelting, Michael Cahalan, M.
Christine Stock. Eds.Clinical Anesthesia 6thEdn. Lippincott WilliamsWolters Kluwer Health2009;1381
•Bajaj P. Regional Anaesthesia in the Patient with Pre-Existing Neurological Dysfunction. Indian J Anaesth. 2009 April; 53(2): 135–138. PMCID: PMC2900096
34. Pathological conditions causing severe structural changes:
Ankylosing Spondylitis (AS):Bamboo Spine, Bechterew's syndrome/
Marie-Strümpell disease
• Autoimmune seronegative, painful chronic inflammatory disease of the
axial skeleton
• with variable involvement of peripheral joints and nonarticular structures
• and intermittent exacerbations („flares‟) and quiescent periods.
• Spine and sacroiliac joints (spondyloarthropathy) - eventually fusion and
rigidity of the spine („bamboo spine‟)
• Cervical spine, especially atlanto-occpital joint, Temporo-mandibular
joint also affected, resulting in difficult airway management.
•http://en.wikipedia.org/wiki/Ankylosing_spondylitis,
35. Management: Ankylosing Spondylosis
• Difficult cases
• Insertion of needle via midline approach – impossible
(Calcified Ligamentum Flavum)
• Paramedian approach
• Modifications: Taylor‟s approach
• L5-S1 interspace
• Spinal needle inserted in a cephalo-medial direction through a skin
wheal raised 1 cm medial and 1 cm caudal to the lowermost
prominence of the posterior superior iliac spine.
•Jindal P, Chopra G, Chaudhary A, Rizvi AA, and Sharma JP. Taylor's approach in an ankylosing spondylitis patient posted for percutaneous nephrolithotomy: A challenge for
anesthesiologists Saudi J Anaesth. 2009 Jul-Dec; 3(2): 87–90. doi: 10.4103/1658-354X.57879. PMCID: PMC2876933
•Thota RS, Sathish R, Patel R, Dewoolkar L. Taylor's approach for combined spinal epidural anesthesia in post-spine surgery: A case report. Int J Anesthesiol. 2006;10:2.
36. Management: Pathological Conditions
Rheumatoid Arthritis (RA):
• Generalized arthropathy
• Mainly centered around the cervical spine
• Atlanto-axial as well as sub-axial joint
• General anesthesia is practically very difficult
• Recommended to try the regional techniques as the priority
• cases where the lumbar and thoracic spines are involved, in the
disease process, the spinal and epidural anesthesia may be technically
difficult or impossible*
•
*Fombon FN, Thompson JP. Anaesthesia for the adult patient with rheumatoid arthritis. Contin Educ Anaesth Crit Care Pain (2006) 6 (6): 235-239. doi: 10.1093/bjaceaccp/mkl049
37. Management: Pathological Conditions
Degenerative Disc Disease (DDD):
• Natural processes and conditions brought about by the general ageing &
wear/tear upon the spinal discs
• The secondary effects that this has upon associated spinal structures.
• Epidural injections of local anesthetics and steroids, under image guidance.
One may try the blind technique,
but the challenges, of positioning, pain, and
complete obliteration of landmarks can lead to difficulty!
http://www.spinal-foundation.org/Conditions/Disc-Degeneration. Degenerative Disc Disease or Disc Degeneration (Spondylosis).
38. Conclusion
• The spinal/epidural are well established, accepted and reliable/ trust
worthy techniques
• Especially in experienced and knowledgeable hands
• In spite of celebrating the centenary, there are, instances of „failure‟
• One has to differentiate between a „failure‟ which in actuality may be
due to an avoidable or technical causes from a „true difficult spine‟.
39. Conclusion
• Meticulous, planned and multidisciplinary handling.
• The challenge is when, we come across an „unanticipated difficult
spine‟.
• In these situations, the true skill, knowledge and experience and
• most importantly, the „team approach are the only available weapons
in the hands of anesthesiologists to overcome these challenges!!