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

LMAs, Ventilators, and Pediatric Strabotomies

Icon at St. Sava - photo by JoAnn Sturman

Scott Sturman, M.D.

When the LMA was introduced into anesthesia practice, it allowed us to care for small children undergoing strabismus surgery without intubation.  The question remained how to best handle dead space and the accumulation of CO2.  Spontaneous ventilation allowed for a quick transfer at the conclusion of the case to PACU, but CO2 levels climbed much too high, and the depth of anesthesia proved unsatisfactory.

Assisted ventilation improved the situation, but it was not until the ventilator was used in the non paralyzed patient that physiologic levels of CO2 and reasonable depths of anesthesia could be attained.  Tidal volumes were adjusted to keep inspiratory pressures below 15 cm H2O.  Despite controlled ventilation, spontaneous ventilation usually returned within a few minutes when the ventilator was discontinued, and the patient transferred without delay to PACU.

Now with the advent of the PVS Pro ventilator mode, return to spontaneous ventilation is nearly instantaneous.  And there is nothing like meperidine 1mg/kg IM (up to 25 mg max) at this time to preemptively smooth the emergence phase in the recovery room.

Osijek, Croatia - photo by JoAnn Sturman

Shocking Elevation

Electrical Engineering Kathmandu Style - photo by JoAnn Sturman

Bill Etiz, D.O.

It’s common to note EKG artifacts during ESWL, however, they subside immediately after shock cessation.  The following case describes an instance when changes did not instantly terminate.   --  SS

A 67 year old male with a history of hypertension and a solitary left upper pole renal stone presented for lithotripsy.  Pre op EKG revealed NSR with non specific ST changes; a cardiac study six months prior demonstrated a normal Echo, EF = 69%, a negative stress test, and a normal myocardial perfusion scan.  The patient took his beta blocker on the morning of surgery.

The patient received general anesthesia, breathing 100% O2 spontaneously at 1 MAC of sevoflurane.  Standard shock protocol was used.  At 600 shocks at level 6 marked ST elevation was noted.  The heart rate was 70 and blood pressure 100/58.  I instructed the technician to stop shock therapy, and over the course of the next minute the ST segments returned to baseline. 

“How close is the shock wave from the heart?” I asked the technician.

“About 2 or 3 inches,” he replied.

Lithotripsy recommenced, but the ST elevation returned both in the gated and non gated mode.  The procedure was terminated after 1500 shocks, and again the segments returned to baseline in about a minute.  The patient awoke in PACU uneventfully, and an EKG showed no change from the pre op study.

Is it possible the ST elevation was due to vasospasm of the lower coronary vessels as a result of the close proximity of the shock wave?  When discussing the case with a cardiologist, he felt Prinzmetal’s angina the likely cause.

Pasan Ridge Trail - photo by JoAnn Sturman

There’s Nothing Like 6 Inches–Tuohy Needle, That Is

Torre Del Paine - photo by JoAnn Sturman

Scott Sturman M.D.

When placing a TAP block, the 6 inch, 17 gauge Tuohy epidural needle provides outstanding visibility and tactile sensation.  This is particularly the case in hefty patients where long distances to the block site are the norm.  The extra needle length allows one to employ less steep trajectories for better ultrasound images, while still have a enough length to hit the target.

6 inch needles work well with subcostal TAPs, where extension of the block to include the lower abdominal segments is required.  After the initial injection, the needle can be advanced inferior-laterally to follow the expansion of the transverse abdominis plane caused by the high volume, low concentration local anesthetic.

Prayer Wheels in Lhasa - photo by JoAnn Sturman

Tylenol Suppositories, VCRs, and Strabismus Surgery

Yosemite Falls - photo by JoAnn Sturman

Scott Sturman, M.D.

With unpredictable absorption and the availability of IV acetaminophen, tylenol suppositories are going the way of the VCR.  IV acetaminophen is suited perfectly for strabismus surgery, particularly pediatric patients, who tend to be feisty when awakening without local anesthetic in the wound in PACU.

IV acetaminophen is approved for children over the age of 2 and is dosed at 15mg/kg for ages 2-12 with a maximum daily dose of 3750 mg.  Above age 12 and 50 kg the 1 gram dose is appropriate with the same adult maximum daily dose of 4000mg.

In addition to IV acetaminophen one can consider the use of IM meperidine 1mg/kg to a maximum of 50mg for smooth emergence in PACU.

IV Buprenorphine for RX of Pruritis Due to Intrathecal Narcotics

Renovation St. Sava, Belgrade - photo by JoAnn Sturman

 
Scott Sturman, M.D.

Since nalbuphine (Nubain) is not available, there is no effective treatment for intractable itching due to intrathecal narcotics.  Benadryl has been used as a substitute, but it is ineffective and in some cases causes confusion and excessive sedation.  Beginning in August 2013 a limited cohort of patients experiencing severe itching from spinal narcotics has been treated with buprenorphine (Buprenex), an agonist-antagonist narcotic.  The dose is 150 ug given every six hours, but it is rare for a patient to require more than one dose.

Through Jan 15, 2014, a total of 99 patients have received the medication, and all but 9 experienced reduction of symptoms.  There have been no documented untoward side effects.  It is of interest to note that since Nov 2013 the rate of treatment has increased and the reported efficacy, as well. During this period 64 patients have been treated and only 2 have not benefited.  The lower rates of treatment and noted benefit from August - September may reflect the staff’s unfamiliarity with the drug.  In fact initial resistance from the nursing staff was common, and many were loathe to administer an unfamiliar medication, despite distraught patients with good pain control but miserable from persistent pruritis.  

Kalocsa, Hungary - photo by JoAnn Sturman

Arterial Line Placement with Ultrasound

 Kalemegdan in Belgrade - photo by JoAnn Sturman

Four observations follow regarding the placement of arterial lines with ultrasound guidance.  Dr. Ikemiya presents a thorough discussion of the subject, which is supported by comments from Drs. Van Putten, Radich, and Wiggins.

Kenneth Ikemiya, M.D.

I use the ultrasound on patients with 1) weak pulse 2) known severe PVD, or 3) one failed attempt using fingers and tactile sense.  In other words, I have a low threshold for asking for the Sonosite. After I prep the wrist and lower forearm, I do a quick scan of the radial artery as travels through the forearm.  It's remarkable how in just a few millimeters, there can be a significant change in the diameter of the vessel. I place the probe over the artery at the point I want to enter the vessel with the needle. I insert the needle out of plane about 1 cm distal from the probe at 45 degrees.  Be careful on how much pressure you use on the probe, so you don't compress the artery. Advance the needle till you see it enter the artery at its widest point. There will be a flash. I try to only enter the anterior wall, then thread the wire.  Finally I slide the entire ensemble in to the hub, then pull out the needle and wire. If you try and just advance the catheter, it can distort the tip of the catheter and leads to a dampened tracing. If the wire won't pass, then I go through the artery, pull out the needle, and withdraw the catheter till you get good flow. Then try and pass the wire.

The radial artery is designed to have redundancy at the wrist to allow for flexion and extension of the joint. Older patients may have soft, redundant tissue at the wrist as well.  I always hyper-extend the thumb AND put distal traction to make the skin at the wrist taught and straighten the artery. I go above the most proximal wrist crease as the artery tends to straighten more proximally.  Again, I enter the wrist 45 degrees in one plane and perpendicular to the skin in the other plane. This helps keep a calcified artery from dancing away from the needle.

Finally, I don't suture in the radial line. I feel in older patients especially, the suture can pull through their skin. It also serves as a hinge point where the catheter can slide in and out of the skin and/or artery. I use the IV Tegederm which securely fixes the catheter and provides visualization of the site.

Potala - photo by JoAnn Sturman

Cliff Van Putten, M.D.
 
Despite a seemingly proper orientation between catheter and artery, lack of blood return under ultrasound guidance is probably due to unrecognized penetration of the artery.  This misinterpretation can occur in the out of plane view, since the observer may not be visualizing the catheter tip, but rather, a baloney slice farther up the shaft of the needle.

Monk in Luang Prabang - photo by JoAnn Sturman

Ned Radich, M.D.
 
I typically do get a flashback with a-line placement.  I go out of plane about 1 cm from the entry point at the same angle one would with conventional a-line placement.  I think the problem is that one tends to focus on the screen and goes through the artery before realizing it; the radial artery is typically quite superficial. I adjust my technique to use ultrasound to locate artery, then watch the catheter as I'm advancing it past the skin (just as we've done in past). If I do not get flash, I use ultrasound to discern where my needle is and make necessary adjustment.

Great Wall - photo by JoAnn Sturman

Mike Wiggins, M.D.

Often one compresses the artery with the needle; especially if it's calcified. With ultrasound it appears the angle of entry to the artery is perpendicular, but it obviously is not.  One trick is to puncture it with a quick stab vs. a slow penetration. 

I view a cross section of the artery (typically more proximal than the usual non U/S spot, as the artery is slightly deeper and larger); the needle entry point is a few mm from the probe at about a 45 degree angle. I look at the needle tip as it pushes on the arterial wall and adjust as necessary to make it a straight shot. I do a quick jab to puncture the thick wall and perform the usual maneuvers. I always look at the screen just as I would with a peripheral nerve block.

Adductor Canal Block: Before or After the Case?

 

Danube at Kalocsa, Hungary - photo by JoAnn Sturman

Scott Sturman, M.D.

Our department’s preferred method for post op analgesia for ACLs and TKAs includes the placement of an adductor canal block.  At the conclusion of a TKA case last week, the surgeon asked, “Would you put in an ACB before the patient goes to the recovery room?”

“It’s already done.  I placed it before you started,” I responded.

The surgeon replied, “I was told the block doesn’t work well when it is put in before the tourniquet is inflated–something about the Esmark or tourniquet displacing the local anesthetic away from the nerve.”

“I’ve never heard that before.  How would that have any effect on the block?”

There may be a compelling reason for placing the ACB at the conclusion of the case when the tourniquet has been deflated, but it is difficult to support the argument from a fluid dynamic standpoint.  In the first place leg elevation and/or Esmark placement on the lower extremity only affects fluid in blood vessels.  Secondly, the ACB is placed well below the distal edge of the the tourniquet, so its compressive forces would have little influence on 20 or 30 ml of local anesthetic deposited around the superficial femoral artery at the level of the adductor canal.

On POD #1 it is not uncommon for the ACB to be working 24 hours after placement.  The most important considerations are an adequate volume of local anesthetic and making sure it is injected in the adductor canal on both sides of the superficial femoral artery.  

Danube at Budapest - photo by JoAnn Sturman

What's Going on Here?

 

Kalocsa, Hungary - photo by JoAnn Sturman

Scott Sturman, M.D.

Every once in a while the unexpected occurs. 

The patient, a healthy 18 kilogram six year old, presented for dental restoration and received midazolam 10mg orally by protocol.  The sedative left her calm but awake and provided near perfect conditions for masked induction.  She was intubated without muscle relaxants, received no narcotics, and placed on the ventilator with ETCO2 = 40.  MAC levels = 2.0.

When the surgeon advised it was about 20 minutes from completion, transition to spontaneous ventilation began.  Normally, under these conditions children begin to breath within a minute or two.  Thirty minutes later the surgeon finished, and the patient was not breathing despite high CO2 levels and MAC = 1.  15 minutes later with MAC = 0, the patient began to respond and was extubated.  Spontaneous ventilation abruptly ceased which required mask ventilation.  10 minutes later I asked the nurse to given the patient 1mg of flumazenil.  Within a minute the patient was breathing unassisted at a minute ventilation of 6 liters.

Nearly two hours elapsed between the administration of midazolam in preop and receiving the reversal agent in OR.  Of all the children I have anesthetized, this the first time I have seen a vigorous, non ill one respond to this particular preop with such significant respiratory depression...but there is always a first time. 

 Iron Gates on the Danube - photo by JoAnn Sturman

The Practically Perfect Anesthetic for TKA

Photo by JoAnn Sturman

J. Greenawalt, M.D.

Dr. Greenawalt graduated from Oklahoma University College of Med 1983 and OU Anesthesia 1986. Practiced in Oklahoma City as a solo practitioner until Feb 1989. Moved to Tulsa and practiced at St Francis Hospital for 24 years. Our group did about 6,000 ultrasound guided blocks annually. Moved to Spokane, WA in July 2013 to be nearer mountains, clean water and nice summers.....

The perfect anesthetic (oxymoron but work with me here) for a total joint is:

Adductor hiatus block with 30 ml of 0.5% Bupivacaine.

Popliteal fossa approach to the sciatic nerve block with 20 ml of 0.125% Ropivacaine. (No foot drop with that technique and very few need anything the PACU except ear plugs for chatty patients.)

Spinal with no spinal narcotics. The spinal should be 0.5% isobaric Bupivacaine which will give you 3 hours but causes less sympathetic block than the hyperbaric Bupivacaine.

Propofol infusion, if the patient is anxious or not much if he is a Korean or WWII vet and did something in the war that you can chat about during the case.

1 gm TXA before the incision.

Post op Gabapentin and oral narcotics.

 Abu Simbel - photo by JoAnn Sturman

Looking for the Perfect Anesthetic for TKA

Kathmandu - photo by JoAnn Sturman

Scott Sturman, M.D.

To improve anesthesia for TKA in the private practice setting, the combination of SAB with very low dose intrathecal narcotics and adductor canal block holds promise.  SAB with Duramorph 200 mcg and propofol infusion combined with multimodal therapy are the mainstays of the current TKA protocol, and although simple to perform, they yield highly reproducible results.

The nagging problems with this technique continue to be PONV and pruritis on the day of surgery.  It is worthwhile noting that these side effects dissipate by POD #1, and most patients at this time, unless narcotic dependent, have pain scores of 0-2.  Improvement is needed for treating pain on the day of surgery and avoiding the side effects of intrathecal narcotics.

Proposed Protocol:

SAB with either Duramorph 0.1mg or Dilaudid 0.1mg.  The comparative side effects at these doses remains to be seen, but if any conclusions can be drawn from our experience with epidurals, Dilaudid has fewer of them.

Single shot Adductor Canal Block with Bupivacaine 0.5% and 4 mg P.F. dexamethasone usually lasts 24 hours, and patient ambulation is unaffected on the day of surgery.

Surgeon protocols using multimodal RX: Pre op Celebrex and Oxycontin followed by p.o. narcotics with or without IV acetaminophen on the floor.

Continued investigation of buprenorphine 150 ug IV for RX of intractable pruritis following intrathecal narcotics.

Haute Route - photo by JoAnn Sturman

Stuck

  Boudhanath - photo by JoAnn Sturman

Scott Sturman, M.D.

You plan for spinal anesthesia with intrathecal Duramorph, but the patient claims an allergy to morphine.  The “allergy” stems from a past episode of nausea and vomiting, when the patient received intravenous morphine.  If you use Duramorph and the patient suffers from PONV, guess who will be blamed?  And in today’s legal climate one can never be too careful.

Intrathecal hydromorphone is an excellent substitute for Duramorph.  Anecdotally, is has fewer side effects than Duramorph, but it is not a panacea by any means.  The duration of action is about 2/3 of intrathecal morphine.  A dose of 0.15-0.2mg is adequate and well tolerated even in the geriatric population. 

A word of warning:  Hydromorphone is available in both 1 and 2 mg/ml preparations.  There have been incidents where this was not appreciated, which required a detour to the ICU with a naloxone drip. 

  Pa'san Ridge Trail - photo by JoAnn Sturman

Unilateral Subcostal TAP with Propofol for Lap CAPD

Haute Route - photo by JoAnn Sturman

Scott Sturman, M.D.

Bilateral subcostal TAP blocks with propofol infusion was previously described in Tricks of the Trade as a way to avoid general anesthesia for patients undergoing laparoscopic CAPD catheter insertion.  Recently one of my colleagues used this technique but employed only a left sided subcostal TAP, since the surgeon prefers to place probes in that side of the abdomen.  

I tried this technique using 30 cc of 1.5% Lidocaine and followed with a propofol infusion; it worked marvelously.  As long as the surgeon is able to work with inflation pressures less than 10 and there is no risk of aspiration, patients tolerate the procedure quite well. 

Haute Route - photo by JoAnn Sturman

I Wanna Go Home

 Egypt - photo by JoAnn Sturman

 

Scott Sturman, M.D.

It’s late in the afternoon, and you are the last anesthesiologist working at an out patient surgery center.  The surgeon tells you there is a 20 year old patient from out of town with a distal radius fracture that must be fixed tonight.  The PACU nurse in charge is so conservative that even the most robust patient must be able to solve a second order differential equation before being deemed discharge ready.  But you have dinner plans, and the patient, who is prone to motion sickness, would prefer to begin the long drive home as soon as possible following surgery.  What’s the best way to deal with these problems?

In this case an infraclavicular block with 30-40 cc’s of equal parts 2% Mepivacaine and 0.5% Bupivacaine with a propofol drip works just like a MAC with all the associated benefits.  The block is excellent even for forceful open reductions and tourniquet pain.  At the end of the case an awake, pain free and grateful patient will proceed to PACU, but there will be an even happier anesthesiologist, who doesn’t have to miss dinner because of a prolonged babysitting commitment.

 Lhasa - photo by JoAnn Sturman