Spinal Anesthestesia in patient with a septic knee: Better than general

[@henriquelaydner4080]

I really envy the fact that you have the structure to perform the anesthesia in a fully equipped induction room, without having to dispute space with surgical equipment and crew.

[@AdmirHadzic-gp8jf]

Yes. That is the KEY to the successful SERVICE of regional anesthesia: The structure and standardization.

[@la998-t2w]

Definitely not an HCA facility 😂

[@marcoantoniodiaz6612]

En mi experiencia profesional siempre que puedo uso la anestesia espinal, es increíble la estabilidad hemodinámica que proporciona cuando se toman las medidas para evitar la hipotensión y el ascenso del nivel anestesico, ademas de que la analgesia postoperatoria es muy superior, agradezco mucho sus videos

[@marciocarstens9674]

Awesome! I would like to add a fact that I observed in my clinical practice: liquoric drainage through the needle lumen is slower than in the sitting position. Thanks

[@AdmirHadzic-gp8jf]

Indeed. It requires understanding and experience so that you wait long enough for the CSF to appear as opposed to removing the successfully placed needle for another attempt due to the slower appearance of CSF.

[@warrencusick1140]

Additional observations: Paramedian attempts should be performed from the most dependent position (master of the obvious) and to increase the the hydrostatic pressure by placing the bed or gurney into Reverse Trendelenburg position may improve CSF flow.

[@ivarflores3299]

Amazing. Since I started following your videos, I personally adopted the paramedian approach. It has totally changed my practice for good 👍

[@nysoravideo]

Wonderful!

[@endlessrandomness1057]

Coincidentally did a case of a septic knee today with prosthetic removal + washout. 20mg of isobaric bupivacaine, over 4 hours of surgery, 5 hours since spinal anesthesia and patient still had motor block. At the end of the surgery he had an adductor canal block and off he went to PACU. Something interesting that I often see in spinals when there’s significant bleeding is the fact that heart rate does not increase, but MAPs drop very linearly. Todays case required two PRBCs due to ~ 1000mL of bleeding

[@zakalobi80]

We usually use tourniquet to decrease blood loss in these cases.

[@srinivasanmadusampathkumar6671]

Thank you very much for this beautiful clip. I always refer Nysora website and videos. I am a consultant from UK and work in the National Health Service. Have vast experience in regional techniques and promote spinal block in sick patients.. We would follow strict aseptic approach ( scrub , gown, sterile gloves , cap and mask) for all central neuraxis blocks and Catheter techniques .

[@AdmirHadzic-gp8jf]

Thank you for the comment. How's practicing regional anesthesia at the NHS?

[@kamilch2719]

Very comfortable position for patient, technique of SA with barbotage of CSF - I'm thinking why? Sepsis is still contraindication for SA. SA is not for very ill patients. Ps midazolam in premedication in very ill and old patients only for our precedure is also astonishing for me.

[@doctorbius]

Same thought as me

[@arisdelis1]

Agree 100% with Sepsis, low SVR...no way I'm doing a spinal..

[@theking258456]

I agree with nearly all your points, exactly what I was thinking... But what's your problem with barbotage? I think he aspirated a lot but still I usually aspirate at least little amounts in the middle and at the end of my injection to make sure my LA got where it should go...

[@sirted5330]

Thanks for the video but why are you talking about leaving her on her side for the spinal to fix when using isobaric mix? She was in left lateral but had a septic right knee. Thanks

[@nysoravideo]

Also great technique. What dosing do you use?

[@markgravenor1097]

Excellent video ! Thanks ! I would always do a spinal as well in these patients! Greetings from Cape Town ❤

[@nysoravideo]

Great to hear that skilled clinicians practice similarly everywhere! Greetings!

[@tomsim7003]

There is no risk of meningitis when you make a spinal anesthesia in septic patient ?

[@nysoravideo]

Meningits occurs due to the blood-born infection - septicime, NOT the spinal needle insertion into the CSF. Thank you for watching. Your thoughts?

[@KingLe0nidas07]

@@nysoravideo Couldnt the spinal needle go through an epidural vein and carry blood into the intrathecal space?

[@tomsim7003]

@@KingLe0nidas07 its exactly my question thank you 👍

[@joe9774]

Thanks for your tutorial! I prefer to give hemodynamically unstable patients a spinal with low-dose hyperbaric bupivacaine 0.5% in glucose (2-2.5 ml) or prilocaine. I place this spinal in a side position with the affected leg underneath. After injection, I leave the patient in this position for 10-15 minutes. This provides excellent anesthesia with little to no perioperative hemodynamic instability.

[@ruthmedina5]

I do the same but with isobaric with the affected leg above, it has better hemodynamic stability.

[@bartoszcetera1101]

Hang on…the left paramedian spinal with the left lateral position after for the right knee surgery? Am I missing something?

[@damalirobinson738]

Isobaric solution with 0.5% marcaine

[@ochelari01]

Does the left side is blocked , too? Or not. What is the min and maximum dose for one sided block? Thank you

[@victorlamberty8132]

Just today in a 96 y/o female with copd and for a ITT did the same: femoral block with ropicaine 12 cc and them a spinal with bupicaine and everything went well

[@Drcp77]

What concerns do you have for infection risk with sepsis?

[@nysoravideo]

None. The patient is already septic - and the threat of SCN infection is due to the blood-born infection, not the spinal needle, as erroneously taught in older anesthesia textbooks written by folks who do not understand regional. THoughts?

[@Drcp77]

Fantastic! Thank you for the clarification.

[@edenhein]

What about high Risk of Hypotonie and Meningitis in Sepsis. Sepsis is still contraindikation.

[@abdullatifalrabeei4819]

Very good job

[@VITOSAS-u2z]

Lo he hecho. Me ha resultado de mucho valor I have done. It has been very valuable to me

[@aymanelsafty7078]

What about the risk of VD effect and decrease of SVR by spinal in addition to the risk of epidural abscess

[@nysoravideo]

Theoretical. The biggest SVR decrease is with GA. Agree?

[@doctorbius]

Can i use hyperbaric marcain

[@aselaliyanage6298]

Thanks doctor

[@VITOSAS-u2z]

Quiero preguntar si añadir opioide a la anestesia espinal tiene algún valor adicional. En mi opinión. Si lo tiene. Quisiera saber el criterio de ustedes I want to ask if adding opioid to spinal anesthesia has any additional value. In my opinion. If you have it. I would like to know your opinion

[@timrance4254]

Quick question - I've been totally converted to the paramedian approach but find our 25g Pencil Point needles are a bit too flimsy when the space is very deep on high BMI patients - what type of needles are you using in the videos please ?

[@mirmahmud1438]

Excellent. Thanks for sharing

[@KingLe0nidas07]

I thought spinal or regional anesthesia is contraindicated in septic patients due to risk of seeding infection and causing meningitis or arachnoiditis?

[@nysoravideo]

Neah. THose books were written by folks who never did any regional. Check the responses above. Greetings and thank yo for watching!

[@AdmirHadzic-gp8jf]

Neah. That is old, conservative literature.

[@doctorbius]

@@nysoravideoevidence based?

[@maheshdesilva76]

I think some studies to show the safety of SA in septic patients would be helpful. If you can show there were no SA related complications(meningitis, epidural abcess, arachnoiditis, etc) in such up until about 2 weeks post op, then I can use that data to reassure my colleagues/surgeons/residents that it is safe 🙏🏽

[@mirak3317]

Why don' t you use hypobaric Marcaine along with fem. block?

[@tpraba15]

Agreed but all depends upon patient 's comorbidities especially their cardiac status, and how critically ill they are

[@AdmirHadzic-gp8jf]

Sure. But there is not much to think about. GA with multiple SRV lowering agents vs 2 ml of isobaric spinal - once done properly - it is baby sitting in the OR

[@tpraba15]

Thanks Sir​@@AdmirHadzic-gp8jf

[@Scottgas3]

How much unilaterally do you get with isobaric bupivacaine? Is tis the basic technique you use for primary total knee? How does it vary for total hip?

[@spiritstadium]

Hypobaric indicated for lateral

[@Scottgas3]

@@spiritstadium Yes, that is one way, however taking time with patients in lateral position will intensify the block on the dependent side. Of course, this effect is more pronounced with hyperbaric solutions (especially the motor block). My question was concerning the degree of uilaterality with this isobaric technique.

[@nysoravideo]

None. It is a billateral block. Greetings!

[@Scottgas3]

@@nysoravideo Then , in regard other question here, it doesn't matter which side the patient is lying on.

[@zooxalju]

Why not choose femoral + sciatic nerve blocks?

[@AdmirHadzic-gp8jf]

Also possible. However, 1) every nerve block carries about 5% of risk of incomplete SURGICAL anesthesia - with femoral + sciatic - that is a >10% chance of a need for conversion to GA or heavy sedation intraoperatively - which is avoided with spinal. 2) Femoral + sciatic requires 20-25 ml of LA, spinal is 2ml. So dose issue in sick patients. But, yes it can be done with nerve blocks/have done it many times. Just think - KSS principle

[@ОстапПетрів-ш7ь]

Do you use fentanyl or morphine intratecally?

[@vitalygurtskaya2661]

Why to keep patient on the side if isobaric anaesthetic is injected?

[@Fischbola]

So what are your contraindications for Spinal?

[@ramashka14]

good job

[@nysoravideo]

thank you for watching. You do the same?

[@ranica5720]

Mulțumim!

[@osamahaddad2589]

By the way usually uae lidocaine as main dose with adding analgesia dose of ropivacaine what do you use?

[@nysoravideo]

Do not MIX local anesthetics for analgesia. Just use bupivaicne 0.25%-0.5%. Mixing lidocaine shortens the duration of the long-acting LA. Greetings

[@osamahaddad2589]

@@nysoravideo amide alone need up to 20 min and sometimes no time for that, so maybe will use lidocaine at beginning and ropivacaine at the end

[@siemdecleyn3198]

Lucky patient!

[@nysoravideo]

Most definitively! Thank you for watching?

[@kamakshiguna298]

Paramedian approach to L5-S1 interspace is Taylors approach

[@nysoravideo]

Yes, indeed. Although - the technique of Taylor is described as a bit more lateral approach. But - AGREE> You do the same?

[@AdmirHadzic-gp8jf]

Indeed. It shows age! ;) Most youngsters do not know what Taylor is. And after Neuman's papers - soon - the students of anesthesiology may not even know what spinal anesthesia is to begin with!

[@maimadkour9946]

Can you correct the video title 😢?

[@aneebnizamani4039]

Perfectly managed

[@roelofjansevanvuuren1029]

Crime against humanity is quite harsh

[@osamahaddad2589]

Without taking surgeon consideration and his skills wasting time and convert to GA with more bad result and sometimes only resident who is the main surgeon and some surgeon himself effect choosing of spinal otherwise absolutely agree and doing it routinely

[@nysoravideo]

Great. Your comment shows skill and maturity as a clinician! Greetings

[@medic13601]

Would spinal and regional block reduce the risk of malignant hyperthermia.

[@nysoravideo]

Yes!

[@AdmirHadzic-gp8jf]

YES, no risk of malignant hypothermia with regional anesthesia.