The TriVantage NIM: A Kinky Tube

Haute Route, Switzerland - photo by JoAnn Sturman

Scott Sturman, M.D.

A word of caution about the updated Medtronics NIM TriVantage endotrachial tube:  At room temperatures it is stiff enough to intubate without a stylet but when exposed to temperatures in the oropharynx, it kinks quite easily and can cause significant problems with ventilation.  It has a tendency to bend acutely at the teeth, and access to correct the problem is limited during thyroid surgery.  

Big Sur - photo by JoAnn Sturman

Tranexamic Acid for TURP

Elephant Seal Peninsula Valdes - photo by JoAnn Sturman

Scott Sturman, M.D.

Last week I administered transexamic acid, 1 gm pre op followed by 1 gram in PACU, to a patient undergoing routine TURP.  Blood loss was demonstrably lessened intraoperatively.  Following surgery, bladder irrigation was nearly clear by the time the patient left the room, and blood loss was imperceptible in PACU.

Granted, this is only case #1 of one, but tranexamic acid should be considered for TURP.  

Moulay Idris, Morocco - photo by JoAnn Sturman

Modified TAP Block for Lower Abdominal Procedures

Luang Prabang, Laos - photo by JoAnn Sturman

Scott Sturman, M.D.

Conventional TAP blocks performed on obese patients can be tricky, owning to the depth of penetration and the steep needle trajectory.  The subcostal TAP on the other hand has the advantage of excellent needle visibility and well defined tissue planes.

Extend a parasagittal line downward from the nipple to the costal margin.  Use this intersection as the entry point for the modified TAP.  The needle is directed laterally and inferiorly until the TAP plane is identified.  Advance the needle as 30 cc of .25% bupivacaine is injected.  The local should form a prolated, football-like form as it separates the internal oblique and transverse abdominis. 

Nile at Cairo - photo by JoAnn Sturman

I’m in the Wrong Business

The Good Old Times - photo by JoAnn Sturman

 Scott Sturman, M.D.

I thought stories like this only happen in Chicago.

Out patient surgery centers are mandated by accreditation agencies to prevent deep venous thrombosis (DVT) in surgical patients.  All patients are assessed on admission to determine their respective risks, but the criterion is so broad that nearly everyone is eligible and merits prophylaxis.  The mainstay of treatment are sequential compression devices which squeeze the patient’s lower legs during surgery and in the recovery room.

The surgery center’s cost for the compression device is $24 for two squeezers (one for each leg), but out patient surgery centers cannot recoup these outlays since insurance companies pay a one value, global fee for each surgery.  To protect themselves legally, even though the chances of a DVT are remote in many of these patients, compression devices are used on nearly every patient.  In the process the center loses $24 per patient.

Enter the compression device vendor -- An offer is made whereby the seller of the product will provide the supplies and equipment free of charge to the surgery center provided the individual patient can be billed directly by the vendor.  If the patient’s insurance company denies payment, there is still no charge to the surgery center.

Recently, a former surgical patient brought a check from a major health insurance company to the operating room director at an out patient center.

“I must have received this check by mistake,” she said.

“Here, let me take a look at it,” replied the nurse director.

The check from the insurance company for $890 made out to the compression device vendor was sent erroneously to the patient.  The original invoice from the vendor stipulated a $445 charge for each leg, thus the $890 aggregate charge.  Even with a conservative 100% mark up by the vendor to the surgery center, the vendor’s cost is $12 per pair.  The 7500% mark up for a $12 item was more than the combined fee of the surgeon and the anesthesiologist for the case.

Instances like these, where a vendor can bypass the patient and bill the insurance company directly, are the tip of iceberg, and one of the reasons healthy people pay $1500/month and more for a high deductible health plan. 

Roadside Stand China - photo by JoAnn Sturman

Ultrasound Guided Axillary Nerve Block

  Big Sur - photo by JoAnn Sturman

By Andrew Wall, M.D.

It is great to have an extra arrow in your quiver when it comes to regional anesthesia of the upper extremity.  There are instances where a supra or infraclavicular block may be impossible or difficult.  Infection, dressing, implanted device or catheter at site of injection may be prohibitive.  These blocks may be technically difficult due to patient habitus, patient cooperation, or inability for optimal positioning.  The supraclavicular block is a very reliable, relatively easy block to perform.  However, in certain populations there is concern with phrenic nerve palsy (although less with ultrasound and low volume local anesthetics).  Patients occasionally complain about the extent of numbness and paralysis of the arm and shoulder, especially after hand surgery.   The infraclavicular block may remedy some of these concerns but is technically more challenging.  The needle is more difficult to visualize because of the steep angle to the probe.  There is also a higher risk of pneumothorax. 

One option to consider is an ultrasound guided axillary nerve block.  Advantages include no risk of pneumothorax or phrenic nerve palsy and the site is easily compressible if bleeding occurs.  Since this block is at the level of the terminal branches, it may be useful as a “rescue block” where a specific branch would be targeted.  It is also a very superficial block at this location allowing superb visualization of structures and your needle.  There is, however, more anatomic variation at this level making it less reliable than supra and infraclavicular block - especially for surgical anesthesia.

The optimal position is a supine patient with operative limb abducted to 90 degrees and externally rotated.   An arm table is useful for this position.  Standard monitors, supplemental oxygen and sedation of choice are provided.   Sitting at the head of the bed, the operator should place a linear transducer perpendicular to the axillary artery.  The needle will enter in a cephalocaudad direction, through the biceps and toward the triceps.  At this level the main terminal branches (Radial, Median and Ulnar) should be visible surrounding the artery.  On the way to the axillary sheath, the musculocutaneous nerve can be targeted.  It is surprisingly easy to see between the biceps and coracobrachialis muscles.  It is sometime embedded within the coracobrachialis muscle.  After 5-7cc of local is injected here, continue to the axillary sheath.  While all branches should be within the sheath it is prudent to inject aliquots in four quadrants surrounding the artery.  Although more time consuming, these branches have motor innervation so a nerve stimulator can be used for identification. 

This technique is only indicated for surgeries below the elbow.  It will not reliably cover tourniquet pain.  For cutaneous coverage of the upper arm, one would need to supplement the intercostobrachial and medial brachial cutaneous nerves. 

There are great tutorials and pictures available on-line at WWW.NYSORA.COM  

 Big Sur - photo by JoAnn Sturman

It Seemed Like a Good Idea

Anchorage to Denali - photo by JoAnn Sturman

Scott Sturman, M.D.

Once upon a time an obstetrician returned from a conference with a new idea and began injecting large volumes of intraperitoneal bupivacaine for post op pain relief at the conclusion of caesarean sections.  This may have had some benefit in the era before spinal anesthesia with intrathecal narcotics became the standard of practice, but times have changed.

Owing to the large surface area and generous blood supply, local anesthetic is rapidly absorbed from the peritoneal cavity.  Blood levels can be unacceptably high, especially in the case when intraperitoneal bupivacaine is combined with TAP blocks after general anesthesia.  From a pure pharmacokinetic standpoint, the duration of pain relief from intraperitoneal medications is much shorter than that of intrathecal morphine.  The benefit is exceedingly small. The practice is antiquated and should be abandoned. 

Hard Rock, Bucharest - photo by JoAnn Sturman

Anti Fibrinolytic RX for Jehovah Witness and Hip Fracture Patients

Morning Mist Bulgaria - photo by JoAnn Sturman

Scott Sturman, M.D.

Most TKA and THA patients now receive prophylactic tranexamic acid to minimize perioperative bleeding.  Anecdotally, the department has seen fewer transfusions and the need for fluid boluses to maintain blood pressure and urine output after surgery.   Anti fibrinolytic therapy is also used for other cases where significant blood loss is anticipated.

At a recent M&M conference a literature search demonstrated anti fibrinolytic RX as one of the few strategies where blood loss is actually reduced during surgery and trauma.

There are two additional sets of patients who should be considered for receiving tranexamic acid to reduce perioperative blood loss -- Jehovah Witness and hip fracture patients.  The former group should benefit especially from this treatment option due to the lack of therapeutic options in cases involving massive blood loss.

Hip fracture patients tend to be frail and elderly and at risk for fluid management problems.   By preemptively treating these patients with anti fibrinolyics, blood transfusions and crystalloid requirements should diminish, thereby reducing the chances of fluid overload in patients prone to heart failure.  Standardizing the use of tranexamic acid in this patient population should be considered.

Kalemedgan in Belgrade - photo by JoAnn Sturman