Epidural blood patch

I was asked to consult on a 30-something year old patient who had a recent subdural hemorrhage. It was a spontaneous event without trauma. After a week of stabilization of the SDH, the patient started developing positional headaches. CT scan showed a CSF leak from C4-T5 ventrally and another one from T6-T10 dorsally.

CT head: Small evolving right greater than left bilateral subdural hematomas, not significantly changed compared to prior. No evidence of new hemorrhage. Trace right to left midline shift is unchanged.

Cspine/T-spine/L-spine with contrast: Extensive CSF leak. The dominant component of this process is a ventral epidural contrast collection extending from C6-T4 levels, but there is also abnormal dorsal epidural contrast extending from T5-T10. The contrast is densest in the cervicothoracic ventral epidural space, also suggesting that this is the primary leakage site.

MRA neck without acute abnormalities. MRI cervical/thoracic/lumbar spine which incidentally revealed multifocal demyelinating lesions in the cervical cord with a focal lesion at T7 and MRI brain showed multiple foci of T2 flair hyperintensity in the supratentorial white matter of the brain, suspicious for undiagnosed demyelinating disease.

What is a CSF leak?

What is an epidural blood patch?

Recent update on epidural blood patch: Review. Anesth Pain Med 2022;17:12-23.

Typically, anesthesia gets consulted for lumbar epidural blood patches after lumbar CSF leaks. However, in this case, the CSF leak occurs quite high in the cervicothoracic spine. Oftentimes, it’s very difficult to inject a greater volume of blood in the lumbar epidural space due to back pain to reach the higher cervical and thoracic areas.

From Post Dural Puncture Headache – We Can Prevent It. July 2014.

Why not do a lumbar epidural blood patch to reach the cervical or thoracic space?

One question that is often asked is whether CEBPs are necessary, or would lumbar EBPs suffice, even for dural leaks at the cervical levels. There are several reports indicating that lumbar EBP can permanently alleviate the headache regardless of whether or not the site of leakage is identified . However, other reports demonstrate that lumbar EBP does not always result in permanent relief [36–38]. A study by Diaz suggests that the site of leakage should be identified by radioisotope cisternography and treated with EBP targeted to CSF leak site levels . Cousins et al suggested that placement of the EBP close to the site of CSF leakage is important . Studies have shown that blood injected at the lumbar level does reach the cervical levels. Ferrante et al., for instance, performed epidural blood patch at L3-4 and placed in the patient in trendelenburg for 22 hours . He was able to show presence of blood in the epidural space at the cervical levels on postprocedure MRIs. The mean spread of the blood patch in the epidural space has been found to be 4.6 ± 0.9 vertebral levels . Most of the blood spread in the cephalad direction . However, the amount of blood that reaches the higher cervical levels in comparison to the amount of blood needed to form a stable clot is unclear. Despite spread of blood to cervical levels, Beards did note that after an epidural blood patch, the majority of the clot and mass effect appears to be concentrated in the area around the injection site .
Cervical epidural blood patch—A literature review. Pain Medicine, Volume 16, Issue 10, October 2015, Pages 1897–1904.

Efficacy of epidural blood patches for spontaneous low-pressure headaches: a case series. J R Coll Physicians Edinb 2016; 46: 234–7.

Sagittal postmyelogram CT of the cervical and upper thoracic spine showing a ventral epidural contrast collection. VES indicates ventral epidural space; VSS, ventral subarachnoid space; C, cord. From Feasibility of Placement of an Anterior Cervical Epidural Blood Patch for Spontaneous Intracranial Hypotension. American Journal of Neuroradiology August 2013, 34 (8) E84-E86

How does one reach a cervical or thoracic epidural space?

Cervical epidural blood patch—A literature review. Pain Medicine, Volume 16, Issue 10, October 2015, Pages 1897–1904.

Epidural Blood Patch at C2: Diagnosis and Treatment of Spontaneous Intracranial Hypotension. American Journal of Neuroradiology November 2005, 26 (10) 2663-2666.

Thoracic epidural blood patch with high volume blood for cerebrospinal fluid leakage of cervical spine (C2–3) complicated with spontaneous intracranial hypotension. Acta Anaesthesiologica Taiwanica. Volume 53, Issue 3, September 2015, Pages 112-113.

Thoracic Epidural Blood Patches in the Treatment of Spontaneous Intracranial Hypotension: A Retrospective Case Series. Pain Physician 2015; 18:343-348.

A, Postmyelogram CT at the level of the T7–8 disc interspace demonstrates a ventral CSF leak (*white arrow*) containing contrast with an attenuation slightly less than that of intrathecal contrast. A small spiculated osteophyte (*white arrowhead*) is the presumed cause for the leak. B, Lateral projection dynamic myelogram of the midthoracic spine confirms the origin of the CSF leak at T7–8. Note the split of the contrast column at this level consistent with a ventral CSF leak (*white arrow*). From CT Fluoroscopy–Guided Blood Patching of Ventral CSF Leaks by Direct Needle Placement in the Ventral Epidural Space Using a Transforaminal Approach. American Journal of Neuroradiology October 2016, 37 (10) 1951-1956.

Utilizing this information, I thought this patient would be better suited for a CT-guided targeted (cervicothoracic) ventral epidural blood patch performed by the IR team. Additionally, I recommended conservative therapy: hydration, caffeine, Fioricet, lying flat, and an abdominal binder.

CT Fluoroscopy–Guided Blood Patching of Ventral CSF Leaks by Direct Needle Placement in the Ventral Epidural Space Using a Transforaminal Approach. American Journal of Neuroradiology October 2016, 37 (10) 1951-1956.

Feasibility of Placement of an Anterior Cervical Epidural Blood Patch for Spontaneous Intracranial Hypotension. American Journal of Neuroradiology August 2013, 34 (8) E84-E86.

Abdominal Compartment Syndrome

A Clinician’s Guide to Management of Intra-abdominal Hypertension and Abdominal Compartment Syndrome in Critically Ill Patients. Crit Care 24, 97 (2020). https://doi.org/10.1186/s13054-020-2782-1

Abdominal compartment syndrome among surgical patients. World J Gastrointest Surg. 2021 Apr 27; 13(4): 330–339.

Patients with ACS will usually be critically ill and unable to provide history and symptoms. On physical exam, patients present with a distended abdomen. However, palpation and abdominal circumference are not reliable for the diagnosis of ACS[25].

A prospective study in postoperative ICU patients showed physicians have less than a 50% chance to identify IAH by clinical examination[25]. The clinical abdominal exam as IAP assessment has an estimated sensitivity of 56%-60% and specificity of 80%-87%[25,26].

Signs of ACS will present as the end-organ effect from the physiologic changes (Table (Table2).2). The most notorious signs are usually abdominal distention, oliguria, high ventilatory pressures, diminished cardiac output, and metabolic acidosis[26].

Abdominal Compartment Syndrome. StatPearls, Nov 2021.

The more commonly used method is an indirect measurement such as intravesicular catheter pressures (e.g., Foley catheter), which has become the gold standard due to its widespread availability and limited invasiveness. The trans-bladder technique involves using aseptic clamping the drainage tubing of the Foley then connecting the Foley to a three-way stop tap adjusted to the level of the mid-axillary line at the iliac crest to zero transducers follow by injecting 25 cc of sterile saline into the bladder. Measurements should be taken at end-expiration and complete supine position and expressed in mmHg. Bladder pressures below 5 mm Hg are expected in healthy patients. Pressures between 10 to 15 mm Hg can be expected following abdominal surgery and in obese patients. Bladder pressures over 25 mm Hg are highly suspicious of abdominal compartment syndrome and should be correlated clinically. It is recommended that pressure measurements be trended to show and recognize the worsening of intra-abdominal hypertension.

Contraindications to using bladder pressures include bladder trauma, neurogenic bladder, BPH, and pelvic hematoma. Bladder pressures may be inaccurate if the patient is not sedated or lying flat.[9][10]

How to Measure Intrabdominal Pressure

The primary treatment for ACS is surgical decompression. However, the early use of non-surgical interventions may prevent the progression of IAH to ACS. Early recognition involves supportive care to include keeping patients comfortable with pain well-controlled. Decompressive procedures such as NG tube placement for gastric decompression, rectal tube placement for colonic decompression, and percutaneous drainage of abscesses, ascites, or fluid from the abdominal compartment. The neuromuscular blockade has been described to be used as a brief trial in an attempt to relax the abdominal musculature, leading to a significant decrease in abdominal compartment pressures in the ventilated ICU patient. If conservative and medical management does not resolve the IAH and further organ damage is noted, surgical decompression using emergent laparotomy may be considered. [11][2]

After surgical laparotomy for compartment syndrome, the abdominal fascia may be closed using temporary closure devices such as (vacs, meshes, and zippers). The fascia can be appropriately closed after 5 to 7 days after the compartment pressures and swelling have decreased.

Responsibility for your own health

I was shocked to see that the NHS could ban surgery for the obese and smokers. That’s socialized medicine. You take a conglomerate group of people (the UK) on a limited budget for healthcare… and basically find the cheapest most cost-effective way to deliver healthcare. But in a way, it’s empowering patients to take responsibility for their own health. Smoking, for sure — I agree 100% that surgery should be banned for this population. Obesity is a bit trickier — there’s genetics and environmental factors at play in this one. I don’t think anyone chooses to be obese. But, people do have the power to change their eating and exercise habits. Despite these efforts, there are some people who are still obese…. and these people should not be faulted.

Why single out the obese and smokers?

obesity-and-cv-disease-1ppt-44-728 — From SlideShare

obesity-and-cv-disease-1ppt-43-728 — From SlideShare

tobacco-health-statistics — From TobaccoFreeLife.org

Smokers and the obese have elevated surgical risk and mortality, which means more cost to treat and hospitalize and provide ongoing care.

I think the NHS is on to something here. They’re opening doors to moving the liability and responsibility away from physicians and towards patients. This is a plus. Outsiders may see it as separatism and elitist to only provide care for people who are healthy. But look at the facts and the data…. obesity has a lot of co-morbidities associated. Smoking has a lot of co-morbidities associated as well. Why should physicians be penalized for re-admissions, poor wound healing, longer hospitalizations when the underlying conditions themselves are already challenging enough? In fact, I would urge insurance companies to provide incentives to patients/the insured with discounted rates for good and maintained health and wellness. With all the technologies, medications, and information out there, it’s time patients take responsibility for their own health. I take responsibility for mine — watching my diet, exercising, working on getting enough rest, maintaining activities to keep my mind and body engaged, meditating for rest and relaxation. It’s not easy, but my health is 100% my responsibility. I refuse to pass the buck to my husband, my family, my physician, etc. I do what I can to optimize my health and future — and if that doesn’t work… I call for backup.

Patients need to change their mindset re: health. It is not your spouse’s responsibility to track your meds. It is your responsibility to know your medical conditions and surgical history. The single most important (and thoughtful) thing a patient can do is keep an up-to-date list of medications, past/current medical history, surgical history, and allergies to bring to every doctor’s appointment and surgery. This helps streamline and bring to the forefront your conditions and how these will interplay with your medical and surgical plan and postoperative care. Please do not forget recreational drugs, smoking habit, and drinking habit in this list. It is very important to know all of these things. Also, your emotional history is very important. Depression, anxiety, failure to cope, etc. This all helps tie in your current living situation with stressors and your medical history.

Links for educating yourself in taking responsibility for your health:

Emergency Checklists

It seems like in today’s day and age, emergencies are occurring everywhere. From hurricanes to shooters to earthquakes and fires… I think it’s always important to know what to do. Here are some fabulous checklists I’ve found for getting through those emergencies. These are not substitutions for knowledge and training. Clinical judgement warranted.

Emergency Manual from Stanford — Printable PDF

Ariadne Labs OR Crisis Checklist

Ariadne Labs Safe Surgery Checklist Template

Ariadne Labs Ambulatory Safe Surgery Checklist Template

Project Check

Newton-Wellesley’s L&D Checklists

WHO Safe Childbirth Checklist

Checklist for Trauma Anesthesia

ASRA checklist for Local Anesthetic Systemic Toxicity

WHO Surgical Safety Checklist

WHO H1N1 Checklist

Johns Hopkins Central Line Checklist

STS Adult Cardiac Surgery Checklist

Ariadne Labs Cardiac Surgery Checklist

STS General Thoracic Surgery Checklist

STS Congenital Heart Surgery Checklist

University of Kansas Daily ICU Quality Checklist

Sleep Deprivation Significantly Affects Mood Status of Anesthesiologists

Sleep Deprivation Significantly Affects Mood Status of Anesthesiologistshttp://goo.gl/uKRPem

Everything was significantly affected: tension, anger, fatigue, irritability. And from a cognitive standpoint, reaction time, in particular, increased in all subjects.

OB Anesthesia

Today, I’m on call covering OB.

MGH: OB anesthesia Q&A for patients

BWH: OB anesthesia Q&A for patients

IARS 2010: OB anesthesia in the 21st century

IARS 2011: OB anesthesia update

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

Indian J Anesthesia 2006: Acute Pain – Labour Analgesia

Presentation on mobile epidural

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

June 2011: Update on rural OB anesthesia

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

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

My Reddit Comment

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

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

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

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

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

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

ASA Nov 2001: PCEA during labor

Br J Anaesth 2010:Labour analgesia and obstetric outcomes.

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

Neuraxial anesthesia in the non-pregnant patient

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

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

From my blog:

The 10 most stressful situations in anesthesiology from an anesthesiologist’s perspective

These aren’t my own thought, however, I can easily agree with the list below. One of the things that was left off this list was pediatric hearts. I had the chance to do a one month pediatric cardiac anesthesia rotation at a very busy Children’s hospital and it was definitely an eye opening experience. Teeny tiny babies. Itty bity tubes and IVs. The heart plumbing/circuitry was anything but normal. I have the utmost respect for pediatric cardiac anesthesiologists — and that’s coming from an adult cardiac anesthesiologist.

Taken and shared from The Anesthesia Consultant Blog:

TOP 10 MOST STRESSFUL SITUATIONS IN AN ANESTHESIOLOGIST’S JOB

Emergency general anesthesia in a morbidly obese patient. Picture a 350-pound man with a bellyful of beer and pizza, who needs an emergency general anesthetic. When a patient with a Body Mass Index (BMI) > 40 needs to be put to sleep urgently, it’s dangerous. Oxygen reserves are low in a morbidly obese patient, and if the anesthesiologist is unable to place an endotracheal tube safely, there’s a genuine risk of hypoxic brain damage or cardiac arrest within minutes.

Liver transplantation. Picture a patient ill with cirrhosis and end-stage-liver-failure who needs a complex 10 to 20-hour-long abdominal surgery, a surgery whichfrequently demands massive transfusion equal to one blood volume (5 liters) or more. These cases are maximally stressful in both intensity and duration.

An emergency Cesarean section under general anesthesia in the wee hours of the morning. Picture a 3 a.m. emergency general anesthetic on a pregnant woman whose fetus is having cardiac decelerations (a risky slow heart rate pattern). The anesthesiologist needs to get the woman to sleep within minutes so the baby can be delivered by the obstetrician. Pregnant women have full stomachs and can have difficult airway because of weight changes and body habitus changes of term pregnancy. If the anesthesiologist mismanages the airway during emergency induction of anesthesia, both the mother and the child’s life are in danger from lack of oxygen within minutes.

Acute epiglottitis in a child. Picture an 11-month-old boy crowing for every strained breath because the infection of acute epiglottis has caused swelling of his upper airway passage. These children arrive at the Emergency Room lethargic, gasping for breath, and turning blue. Safe anesthetic management requires urgently anesthetizing the child with inhaled sevoflurane, inserting an intravenous line, and placing a tracheal breathing tube before the child’s airway shuts down. A head and neck surgeon must be present to perform an emergency tracheostomy should the airway management by the anesthesiologist fails.

Any emergency surgery on a newborn baby. Picture a one-pound newborn premature infant with a congenital defect that is a threat to his or her life. This defect may be a diaphragmatic hernia (the child’s intestines are herniated into the chest), an omphalocele (the child’s intestines are protruding from the anterior abdominal wall, spina bifida (a sac connected to the child’s spinal cord canal is open the air through a defect in the back), or a severe congenital heart disorder such as a transposition of the great vessels (the major blood vessels: the aorta, the vena cavas and the pulmonary artery, are attached to the heart in the wrong locations). Anesthetizing a patient this small for surgeries this big requires the utmost in skill and nerve.

Acute anaphylaxis. Picture a patient’s blood pressure suddenly dropping to near zero and their airway passages constricting in a severe acute asthmatic attack. Immediate diagnosis is paramount, because intravenous epinephrine therapy will reverse most anaphylactic insults, and no other treatment is likely to be effective.

Malignant Hyperthermia. Picture an emergency where an anesthetized patient’s temperature unexpectedly rises to over 104 degrees Fahrenheit due to hypermetabolic acidotic chemical changes in the patient’s skeletal muscles. The disease requires rapid diagnosis and treatment with the antidote dantrolene, as well as acute medical measures to decrease temperature, acidosis, and high blood potassium levels which can otherwise be fatal.

An intraoperative myocardial infarction (heart attack). Picture an anesthetized 60-year-old patient who develops a sudden drop in their blood pressure due to failed pumping of their heart. This can occur because of an occluded coronary artery or a severe abnormal rhythm of their heart. Otherwise known as cardiogenic shock, this syndrome can lead to cardiac arrest unless the heart is supported with the precise correct amount of medications to increase the pumping function or improve the arrhythmia.

Any massive trauma patient with injuries both to their airway and to their major vessels. Picture a motorcycle accident victim with a bloodied, smashed-in face and a blood pressure of near zero due to hemorrhage. The placement of an airway tube can be extremely difficult because of the altered anatomy of the head and neck, and the management of the circulation is urgent because of the empty heart and great vessels secondary to acute bleeding.

The syndrome of “can’t intubate, can’t ventilate.” You’re the anesthesiologist. Picture any patient to whom you’ve just induced anesthesia, and your attempt to insert the tracheal breathing tube is impossible due to the patient’s anatomy. Next you attempt to ventilate oxygen into the patient’s lungs via a mask and bag, and you discover that you are unable to ventilate any adequate amount of oxygen. The beep-beep-beep of the oxygen saturation monitor is registering progressively lower notes, and the oximeter alarms as the patient’s oxygen saturation drops below 90%. If repeated attempts at intubation and ventilation fail and the patient’s oxygen saturation drops below 85-90% and remains low, the patient will incur hypoxic brain damage within 3 – 5 minutes. This situation is the worst-case scenario that every anesthesia professional must avoid if possible. If it does occur, the anesthesia professional or a surgical colleague must be ready and prepared to insert a surgical airway (cricothyroidotomy or tracheostomy) into the neck before enough time passes to cause irreversible brain damage.

The Operating Room

Welcome to the medical world. It’s not for sissies. You’ve done a great job outlining your experience. Keep up the great work! There is a light at the end of the tunnel…and it is every bit as rewarding as you could imagine!

Life at Hogwarts College of Medicine

Originally written in mid-January

I was about to sit down for a warm pre-dinner snack of daal, rice, and tilapia when my phone buzzed insistently from the tabletop. I stood there for a moment, staring at the screen, until I processed the words, “meet me in 30 min.” I wolfed down my dinner, stuffed my ID badge and white coat into my laptop bag, and dashed out the door into the freezing evening weather.

When I arrived at the hospital, I was sweating profusely into my jacket. I met my research advisor in her office, and she led me into a new world – one of windowless hallways, where there were no lost visitors or rambunctious first-year medical students to penetrate the silence. There were only faceless doctors and nurses, solemn and solitary as they headed toward their mission.

In the operating room, I watched as the anesthesiologists placed their monitors…

View original post 524 more words

24 hours with an anesthesiologist

A piece I’d like to submit for: CNN Money 24 hours With….an anesthesiologist

About Kris:

I grew up in a small west Texas town called Abilene, TX. My mom was a standard tiger mom in that she encouraged me to pursue multiple activities while nudging me to do my best. After drama lessons, tennis lessons, basketball, volleyball, piano, violin, band, taekwondo, pageants, and just life, I left Abilene and pursued a biomedical science degree at Texas A&M University. My earliest memory of wanting to be a doctor started when I was in the third grade. I hadn’t been feeling well and was diagnosed with pneumonia — I had been reading a book called This is the Child. My family practice physician Dr. Lawson was about to prescribe me prednisone and I immediately got worried because that was the same medication used to help with the child’s leukemia. Dr. Lawson picked up on my early curiosity and invited me to hang out with him in his medical office observing patients. After college, med school proved to be a great experience at University of Texas Medical Branch in Galveston and felt like learning on steroids (as compared to college). My clinical rotations led me to the path of choosing anesthesiology as a career. Anesthesia is the perfect combination of anatomy, physiology, pharmacology, psychology, and sociology. I matched into a terrific internship in Austin, TX and continued my anesthesia training at the prestigious Massachussetts General Hospital. Following 4 grueling years of training, late nights, memorable cases, and lifelong friendships, I chose to pursue a cardiac anesthesia fellowship at University of California San Diego — a world renowned institution for the treatment of right heart failure following pulmonary thrombosis. 14 years after graduating high school, I have the job of my dreams. Here’s a sample of my day…

My Day:
Today I’m #2 in our call lineup, which means it will be a pretty busy day. Typically, we have 15 call spots in our main operating room (OR) numbered #1 to #15. #1 position gets the first pick of cases. #2 gets the next pick and so on.

5:45a Early heart day wake up. Today, I will be providing anesthesia to a 70-something year old lady who needs a new heart valve. On heart days, I wake up at 5:45a to be at work by 6:30. And on regular main OR days, I wake up at 6:15a to be at work by 7:00. Ahhhh… To have more beauty sleep!

6:17a Breakfast in the car – it’s either green juice, Shakeology, or banana on the go!

6:31a I meet the patient and her family in the pre-operative area. We go over a detailed plan for her anesthesia as well as answer any questions. One of the best parts of my job is meeting all different types of people. It’s an amazing feeling to meet people at one of their most vulnerable moments in their lives and win over their trust and respect. It is my job to safely manage their physiologic processes. Oftentimes, patients tell me it is the anesthesiologist who is the most important part of a surgery — they understand how easy it is to bring them close to the brink of death and then revive them back to a wakeful state. It’s incredible the amount of trust patients place in your hands in such a short time after meeting them.

7:15am The patient is under anesthesia and all invasive monitoring lines (arterial, central venous pressure, cordis, pulmonary artery lines) have been placed. The transesophageal echocardiogram is performed and results are relayed to the cardiac surgeon.

7:45am Cardiac surgeon makes incision. The patient is monitored throughout the case. Multiple screens show all the physiologic monitoring results.

10:00a Bathroom break! Partners/colleagues break each other out so there is always an anesthesiologist monitoring the patient. It’s also a good time to grab a snack!

My work bag with some life saving snacks to avoid hangriness!

11:32a Drop first patient off in Cardiac Care Unit and grab some lunch. The doctor’s lounge keeps us fed with soup and salad. Today, I’m feeling the vegetable soup. Grab a quick bathroom break and then to interview the next patient.

11:45a Electrophysiology study for atrial fibrillation ablation. The view from this OR is such a delight!

The view from my little nook.

14:00 I get a call from our anesthesia czar, one of my partners who runs the schedule. He was wondering if I would make my 15:00 hip replacement. After a quick conversation, we decide that I would call him in 30 minutes for an update.

14:33 We are finishing up with the current case and I call the czar back to find out about my next case. I learned that there is an emergent heart that will be started by another colleague and that I will continue the lineup in EP (so my day went from a 16:30 finish on paper to roughly a 19:00 finish). Anytime I am in the top 5 call positions, I know not to make defined plans because you never know if there will be addons or changes to the schedule. This makes my social life a bit frustrating as my non-medical friends have a tough time understanding and adapting to this “you don’t get out of work at 5p?” concept.

15:20p Drop patient off in the Post Anesthesia Care Unit (PACU). Grab a quick snack and head back to EP for the next patient.

15:25p Speak to the next patient who has arrived for an afib ablation as well. Induce and get started with the case.

19:22 Drop last patient off in the PACU. As #2 on the call list, I look at my watch and realize that I am #2 at night. This means I will be the 2nd person they call tonight if extra rooms in the OR get booked (traumas, heart call, etc.). As much as I’d love to head home and grab a glass of wine and unwind, I meet up a friend for dinner to catch up and relax.

21:42 Head home. Shower. Brush my teeth and get into bed. There’s always a risk of being called into work. Tomorrow will be a shorter day. After the hectic day, I am still thankful for my wonderful job and colleagues. Looking back at my journey to get here, I smile because I couldn’t be happier.

When the bark is louder than the bite

In residency, you learn to deal with many different personalities. This ranges from super sweet and helpful to utterly cruel and egotistical. At MGH, our CA-3 year was spent running the call schedule on night call (the first-call experience). It’s a terrific experience in prioritizing as well as organizing your team to prepare for what rolls through the OR doors. Fast forward 4 years and now I’m in private practice.

While running the schedule on call, I get a call from the trauma surgeon saying a patient with an epidural hematoma needs to come to the OR emergently and couldn’t wait for another anesthesiologist to be called in from home (home call gives an anesthesiologist 30 minutes to come into the hospital for an emergency). So, I made the executive decision to pull the anesthesiologist from the elective suboccipital craniotomy case to do the emergency. It was a crani to crani and neuro to neuro switch… meaning the neuro team and crani trays were already open and ready to go. It made the most sense in my mind. Of course, without missing a beat, the “elective” neurosurgeon showed complete disdain of my decision. To add fuel to the fire, he proceeded to berate the OR nurses, myself, and staff to make sure his displeasure was known. I stood by my decision because it was the best decision for the emergency craniotomy patient who could have potentially died. Secondly, I chose not to call in my final anesthesiologist for an elective case as we would have gone on “trauma bypass”. This means that no traumas or emergencies could come to our hospital. The “elective” neurosurgeon became more livid by the minute. 2.5 hours after he was supposed to start his case, I finished my first case and was able to get his case started.

Now, who does an elective suboccipital craniotomy for tumor case on a Saturday? Secondly, he decides to do this in a sitting position — this has it’s own sets of risks. He needed a precordial doppler, which our hospital did not have, so we called for it from our neighboring sister hospital. In the meantime, I had another plan…that was to put down a TEE probe to monitor for venous air embolism (VAE). After speaking to the patient and family, I proceeded to explain the risks/benefits of arterial line, central venous line, transesophageal echo, mechanical ventilation, blood transfusion, and intensive care unit stay. It’s always a lot for the family to comprehend, especially while meeting them for the first time. However, it is our job as anesthesiologists to make them comfortable and calm their fears.

**This picture taken from a google search for “precordial doppler”. It is not my own.**

We get to the room and proceed with vital signs monitoring. Uneventful induction and intubation. A right internal jugular vein central venous line is placed (mainly to use as a Bunegin-Albin catheter). TEE probe placed to look for air in RV and possibly air lock and RV failure –> VAE. Radial arterial line placed and transduced at the level of the head. Pt was placed in Mayfield pins and positioned in steep sitting position with reverse Trendelenberg and flexing the legs up. Neuromonitoring commenced looking for changes in sensory and motor signaling.

All throughout the case, the TEE showed various amounts of air coming through the right side of the heart:

With greater amounts of air, there would be a detectable decrease in blood pressure as well as end-tidal CO2. While the right ventricle was still capable of pushing blood forward, I simply increased the blood pressure pharmacologically and increased the patient’s volume with normal saline from the IV. Rarely does one get to see this TEE view as most of these cases are monitored non-invasively via pre-cordial doppler or ETCO2 and BP.

Lastly, this patient had a great outcome. A 2cm x 2 cm hemangioma was resected with minimal disruption or trauma to surrounding tissue. 2 hours after a lengthy 4 hour surgery, the patient was sitting with their family… communicating and interacting with them. All motor and sensory intact.

Pearls from this case:

1) Always do what is best for the patient. When a life-and-death situation presents itself, it gets priority. Period. It doesn’t matter what pressure or temper tantrums you get from outside parties. Make the best clinical decision. Organize a plan. Stick with it.

2) Find out the surgeon’s plan. This case was not booked in sitting position. Some of these cases are done in prone position, which makes the likelihood of VAE significantly lower than in sitting position. Knowing the surgeon’s plan of attack is critical to an anesthetic plan.

3) Read. Read. And read more. Although I’ve been out of residency and fellowship for 4 years, cases will always test your knowledge as well as make you learn new skills/techniques to better your plan. Take the time to do your best. Always review. Medicine is a lifelong learning career.

4) Don’t sweat the small stuff. The “elective” neurosurgeon who raised such hell at the beginning of the case was thanking me for my help and expertise by the end of the case. Learn as much as you can from your residency. Take the knowledge gained and let your clinical acumen do the talking. There is no room for ego when taking care of a patient. Your ability to be well-read, well-trained, and well-respected will dictate the tone. No fluff is needed when you bring 100% to the table. Don’t be intimidated by the loud bark.