Toxins

Who knew that toxins exist EVERYWHERE? I certainly wasn’t cognizant of my exposure to toxins. Teflon, PABAs, air, water, food, etc. But, I have learned so much and am constantly learning of the dangers of these toxins in our everyday lives. Most recently, all the soaps, lotions, and cleaning products have been updated in our house.

From Union-Bulletin.com

We use (all can be found on Amazon):

  • Puracy natural dish soap
  • Everyone Soap: hand soap and lotion
  • Nature Clean dishwasher detergent
  • Everyone 3 in 1 soap (adult and kids)
  • Everyone lotion
  • Attitude natural shampoo

EWG:

EWG: Skin DEEP:

  • ThinkSport spf 50+ sunscreen
  • Super Goop Play 50+ spf face sunscreen (currently a 3; would consider a better option)
  • Ilia, RMS Beauty, Lawless, Aether Beauty makeups

EWG: Food Scores:

  • Baby purees: Beech Nut, Earth’s Best Organic
From The Good Human

Profound Documentaries on Toxins/Food Industry:

Current Favorite Reads Regarding Health:

Continuous Regional Anesthesia Catheters

We’re setting up continuous regional anesthesia catheters in our hospital. It hasn’t been easy, but I’ve learned a lot along the way.

From Essentials of Pain Medicine (Fourth Edition)
2018, Pages 135-140.e2

Update on Continuous peripheral nerve block techniques


The Cleveland Clinic Experience with Supraclavicular and Popliteal Ambulatory Nerve Catheters. The Scientific World Journal
Volume 2014, Article ID 572507, 9 pages

  • Arrow, StimuCath continuous, nerve block procedural kit ASK 05060-cch 19 Ga, 60 cm catheter, insulated needle, 18 g 3.81 inch
  • The catheter was advanced 3–5 cm beyond the needle tip. During supraclavicular catheter insertion, the catheters were placed dorsolateral to the nerve plexus.
  • During popliteal catheter insertion, the catheters were placed next to the nerve with the needle coming from the lateral side of the thigh. The catheter was advanced 3–5 cm beyond the tip of the needle to end within the space between the semitendinosus and semimembranosus muscles medially and biceps femoris muscle laterally.
  • AmbIT pump (Summit Medical Production, Inc., Salt Lake city, UT, USA)
  • After catheter placement, an initial bolus dose of 20 mL ropivacaine 0.75% was administered. All patients were evaluated for sensory and motor block prior to surgery. Before discharge, the catheters were connected to AmbIT pumps infusing ropivacaine 0.2% with an 8 mL/hour basal rate and a 12 mL demand dose once per hour.
  • On the fifth day, patients were instructed to stop the infusion for 6 hours and then remove the catheter if their pain scores were less than 5 and well tolerated by the patients. If pain was more than or equal to 5 we asked patients to restart their infusions and we did the same every day until the catheter was removed.
  • The results of study demonstrate that the prolonged use of ambulatory catheters for a period up to 5 days did not lead to an increased incidence of complications as compared to other studies. Main complications were minor infections and pharmacological symptoms, which resolved with catheter removal and without the need for additional medical intervention.

Case Report: Continuous Erector Spinae Plane Catheter for Analgesia After Infant Thoracotomy. A&A Practice: November 1, 2018 – Volume 11 – Issue 9 – p 250–252


Erector Spinae Plane Block Catheter Insertion under Ultrasound Guidance for Thoracic Surgery: Case Series of Three Patients. Eurasian J Med. 2018 Oct; 50(3): 204–206.

  • epidural catheter (Perifix® Complete Set, B-Braun, Germany)
  • LA solution (a 1:1:1 mixture of 30 mL of 0.5% bupivacaine, 2% lidocaine, and 0.9% saline)
  • Block placed about 3 cm lateral to T spine
  • Rescue dose of LA mixture (15 mL of 0.5% bupivacaine and 15 mL of 0.9% saline) was injected through the catheter.
  • In addition, we used a 30 ml volume of LA, and we believe that plane blocks, such as ESP, need more volume, and that these blocks are volume dependent. 

Mitral Valve analysis

Review article: TEE of Mitral Valve. International Journal of Perioperative Ultrasound and Applied Technologies, September-December 2013;2(3):122-130.

New Concepts for Mitral Valve Imaging.  . 2013 Nov; 2(6): 787–795.

A Quantification Approach to Echocardiography of Mitral Valve for Repair. Anesthesia & Analgesia 12(1):34-58 · July 2015

4D-transesophageal echocardiography and emerging imaging modalities for guiding mitral valve repair.  Ann Cardiothorac Surg 2015;4(5):461-462.

Method—Comparison of Transthoracic and Transesophageal Echocardiography. Clin. Cardiol. 25, 517–524 (2002)

Virtual TEE: spectral Mitral valve

Echocardiographic atlas of the mitral regurgitation. J Saudi Heart Assoc. 2011 Jul; 23(3): 163–170.

Intraoperative transesophageal echocardiographic assessment of the mitral valve repair. Ann Card Anaesth 2010;13:79-85.

 
 
 

Computer-based comparison of different methods for selecting mitral annuloplasty ring size. Journal of Cardiothoracic Surgeryvolume 12, Article number: 8 (2017)

Prediction of the annuloplasty ring size in patients undergoing mitral valve repair using real-time three-dimensional transoesophageal echocardiography. . 2011 Jun; 12(6): 445–453.

 
 

The choice of mitral annuloplastic ring—beyond “surgeon’s preference”.  Ann Cardiothorac Surg 2015;4(3):261-265

Gold Standard to Measure MR – PPT 2016 U of Wash.

Paravertebral Block and Catheters

Review: Thoracic Paravertebral Block. Anesthesiology. Sept 2001.

Ultrasound-Guided Paravertebral Block Anaesthesia Tutorial of the Week. April 2018. Tutorial #376.

YouTube: PVB catheter technique

YouTube: LSORA U/S-guided PVB

YouTube: U/S-guided PVB by Block Jocks

YouTube: nerveblocks U/S-guided PVB

YouTube: thoracic PVB and anatomy

YouTube: Ottawa Hospital PVB

From SPPM Newsletter

Insertion of paravertebral block catheters intraoperatively to reduce incidence of block failure. Interact Cardiovasc Thorac Surg. 2012 May; 14(5): 648–649.

Continuous paravertebral block using a thoracoscopic catheter-insertion technique for postoperative pain after thoracotomy: a retrospective case-control study. Journal of Cardiothoracic Surgery volume 12, Article number: 5 (2017)

From The mid‐point transverse process to pleura (MTP) block: a new end‐point for thoracic paravertebral block. https://onlinelibrary.wiley.com/doi/abs/10.1111/anae.14004
Table 3. Drug and Dosage for Thoracic Paravertebral Block

A Systematic Review of Randomized Trials Evaluating Regional Techniques for Postthoracotomy Analgesia. Anesthesia & Analgesia:September 2008 – Volume 107 – Issue 3 – p 1026-1040

Evidence-Based Workouts

I’m currently on Week 8 of PWR at home by Kelsey Wells of BBG Sweat app. It’s a resistance/strength training program that’s 12 weeks long. I started it as soon as I got the thumbs up from the OB to workout again post-partum. I started with PWR at home beginner then moved my way to the PWR at Home 1.0. It’s a great workout to be able to do at home while the kids nap. The program is divided into chest/triceps, arms and abs, legs, back and shoulders. Basically, the goal is to do 5 resistance workouts/week with 3 LISS workouts and 1 HIIT. Well, in a busy world, it’s tough to fit in 5x/wk workouts.

So, it got me thinking and researching: What are the best evidence-based workouts out there?

Being a science-driven person (thank you med school!), I dug into the science looking for journal articles and browsing the thoughts of experts in the field. Here is what I found….


SAMPLE WORKOUTS

Home full body workout from Built With Science:

Workout A

Workout B



  • TransparentLabs.com: The Best Science-Based Workout Routine For Beginners
    • Workout Instructions:

      • Perform 12-15 reps 
      • Use weights that create fatigue, but not to create failure, (if you can’t complete 12-15 reps, reduce your weight).
      • Complete one set of each exercise, moving from the first to the second, to the third, etc.
      • Transition to the next exercise without a break
    • Dumbbell Front Squat
    • Dumbbell Shoulder Press
    • Barbell Bentover Rows
    • Dumbbell Split Squats (each side)
    • Dumbbell Chest Press on Swiss Ball
    • Wide-grip Pullups
    • Dumbbell Step-ups
    • Medicine Ball floor slams
    • Barbell Hip Thrusters
    • Decline Pushups
  • Built With Science Best Full Body Workout
    • Workout A
      • Barbell Bench Press: 3-4 sets of 6-10 reps
      • Barbell Back Squat: 3-4 sets of 6-10 reps
      • Pull-Ups: 3-4 sets of 6-10 reps
      • Lying Hamstring Dumbbell Curls: 3-4 sets of 10-15 reps
      • Standing Overhead Press: 3-4 sets of 6-10 reps
      • Face Pulls: 3-4 sets of 10-15 reps
      • Drag Curls: 3-4 sets of 8-10 reps
    • Workout B
      • Barbell Deadlift: 3-4 sets of 6-10 reps
      • Incline Dumbbell Press: 3-4 sets of 6-12 reps
      • Bulgarian Split Squat: 3-4 sets of 6-10 reps
      • Chest Supported Row OR Inverted Row: 3-4 sets of 6-12 reps
      • Dumbbell Lateral Raises: 3-4 sets of 10-15 reps
      • Incline Dumbbell Kickbacks: 3-4 sets of 10-15 reps
      • High to Low Chest Cable Flies: 3-4 sets of 10-15 reps
  • Stephanie Buttermore: Full Body Workouts
  • AthleanX: The PERFECT Total Body Workout (Sets and Reps Included)
    • Here is how to construct the perfect total body workout A:
      • 3D Lunge Warmup – 2-3 x 7 reps each direction
      • Barbell Squats – 3 x 5
      • Barbell Hip Thrusts – 3-4 x 10-12
      • Barbell Bench Press – 3 x 5
      • Weighted Chin Ups – 3 x 6-10 to failure
      • DB Farmer’s Carries – 3-4 x 50 steps with half bodyweight
      • Face Pulls – 2 x 12 (using 12 sets of 1 mentality)
    • Here is how to construct the perfect total body workout B:
      • 3D Lunge Warmup – 2-3 x 7 reps each direction
      • Deadlifts – 3 x 5
      • Barbell Squats or Barbell Reverse Lunges – 3-4 x 10
      • Barbell OHP – 3 x 5
      • Barbell Rows – 3 x 10-12
      • DB Overhead Farmer’s Carries – 3-4 x 50 steps with one quarter bodyweight
      • Face Pulls or other corrective – 2 x 12 (using 12 sets of 1 mentality)
  • AthleanX: The Perfect Abs Routine
    • Here is how to construct the perfect abs workout for beginners:
      • ISO Reverse Crunches x 30-60 seconds
      • Seated Ab Circles x 30-60 seconds (alternate cw and ccw directions) REST 30 SECONDS
      • Recliner Elbow to Knee Tucks x 30-60 seconds
      • Opposite Side Tuck Planks x 30-60 seconds REST 30 SECONDS
      • Oak Tree Stepouts x 30-60 seconds each side
      • Banded Pulldowns x 30-60 seconds
      • Plank Pushaways x 30-60 seconds
    • Here is how to construct the perfect abs workout for more advanced lifters:
      • Hanging ‘X’ Raises x 30-60 seconds
      • Hanging Leg Spirals x 30-60 seconds (alternate right and left twists) REST 20 SECONDS
      • Tornado Chops x 30-60 seconds (alternate right and left chops)
      • Opposite Scissor V Us x 30-60 seconds REST 20 SECONDS
      • Sledgehammer Swings x 30-60 seconds each side
      • Banded Pulldowns x 30-60 seconds
      • Plank Punchouts x 30-60 seconds
  • Stephanie Buttermore: Ab training everyday
    • Month 1-2: leg raises (3-4 sets of 20)
    • Month 3-4: ab crunch (3-4 sets of 20)
    • Month 4-5: crunch machine (3-4 sets of 20)
  • Jeff Nippard: 6 pack abs
    • 6 Pack Abs 55% type 1 vs 45% type 2 fibers
    • Weighted 6-12 reps | Unweight 15-30 reps
    • Training: 3-6 sessions per week | 2 exercises per session | 3-4 sets per exercise
    • Recommends: one crunch type movement | one leg raise type movement
    • Sample Exercises: hanging leg raises, lying leg raises v-ups, reverse crunches Cable wood chops, side bends long lever planks (elbows in front of eyes, posterior tilt =squeeze glutes)
  • Stephanie Buttermore: Glute and Hamstring focus
    • Warmup – 5-10 minutes
    • Dynamic stretching: leg swings, wall sit
    • Stiff-leg deadlift with barbell- 4 sets, 4 reps, 8 RPE
    • Machine hack squat- 3 sets, 8 reps, 8 RPE
    • Dumbbell frog pump- 2 sets, 30 reps, 8 RPE
    • Eccentric-accentuated lying leg hamstring curl- 3 sets, 6 reps, 8 RPE
    • Cable standing hip abduction- 2 sets, 20 reps/leg, RPE 8
    • Cable pull through- 11:25
    • Machine-standing calf raise- 3 sets, 8 reps, RPE 7
  • Jeff Nippard: The Most Scientific Way to Train Hamstrings
  • Jeff Nippard: Advanced Glute Training Science Explained
    • Day 1 – stretcher (squat), activator (hip thrust), pumper (banded side walks)
    • Day 2 – activator (hip thrust), pumper (machine hip abduction), pumper (side lying clams)
    • Day 3 – rest
    • Day 4 – rest
    • Day 5 – stretcher (romanian deadlift), activator (back extension), pumper (frog pumps)
    • Day 6 – activator (cable pullthroughs), pumper (elevated glute bridge), pumper (squat bouncer)
    • Day 7 – rest –> periodization –change up workouts every 1-3 months
  • Jeff Nippard: The Most Scientific Way to Train Glutes
    • Back Squat 2 sets | 5 reps (warm up) 3 sets | 4 reps (working)
    • Plate-Loaded Single Leg Hip Thrust 3 sets | 12-15 reps per leg
    • Walking Barbell Lunge 3 sets | 30 total strides
    • Lower Back (Hip) Extension 3 sets | 15-20 reps (load with a plate help to your chest)
    • Hip Abduction (machine, cable or plate) 3 sets | 15-20 reps
  • Chris Thompson: 30 minute full body
    • 2 sets, 8-15 reps, want to go to failure. Little rest as possible bt sets and exercises.
    • Bench Tuck
    • Calf Extension
    • Abductor Machine
    • Hyperextension
    • Hamstring Curl
    • Leg Extension
    • Squat Machine
    • Pull Up
    • Row
    • Dumbbell Lateral Raise
    • Dumbbell Curl
    • Barbell Bench Press
    • Dip

The more I started reading about strength training, the more I came across articles and blogs about CALISTHENICS. I’m still a bit confused as to what it is, but it seems like the gist of it is to use your own bodyweight and for full body exercises that can be done anywhere.

Given all this strength science, there must be data out there for workouts that have been around for centuries such as YOGA.


After reading about all this yoga information, I thought… What about PILATES?


My Plan


  • Kris Home Workout Full Body A (with abs and glutes)
    • Barbell Bench Press: 3-4 sets of 6-10 reps
    • Barbell Back Squat: 3-4 sets of 6-10 reps
    • ISO Reverse Crunches x 30-60 seconds
    • Seated Ab Circles x 30-60 seconds (alternate cw and ccw directions)
    • Pull-Ups: 3-4 sets of 6-10 reps
    • Lying Hamstring Dumbbell Curls/Swiss ball glute bridge leg slide: 3-4 sets of 10-15 reps
    • Recliner Elbow to Knee Tucks x 30-60 seconds
    • Opposite Side Tuck Planks x 30-60 seconds
    • Standing Overhead Press: 3-4 sets of 6-10 reps
    • Face Pulls: 3-4 sets of 10-15 reps
    • Oak Tree Stepouts x 30-60 seconds each side
    • Banded Pulldowns x 30-60 seconds
    • Plank Pushaways x 30-60 seconds
    • Farmer’s Dumbbells weighted walk – 50 steps
    • Dumbbell bench tricep skull crushers (go farther overhead, not straight above head)
    • Drag Curls: 3-4 sets of 8-10 reps
    • Back extensions: 3-4 sets of 10-15 reps
    • Cable standing hip abduction- 2 sets, 15 reps/leg, RPE 8
    • Single leg lateral lunge (for adduction) – 2 sets, 15 repts/leg

  • Kris Home Workout Full Body B (with abs and glutes)
    • Barbell Deadlift: 3-4 sets of 6-10 reps
    • Incline Dumbbell Press: 3-4 sets of 6-12 reps
    • Hanging ‘X’ Raises x 30-60 seconds/ISO Reverse Crunches x 30-60 seconds
    • Hanging Leg Spirals x 30-60 seconds (alternate right and left twists)/Seated Ab Circles x 30-60 seconds (alternate cw and ccw directions)
    • Bulgarian Split Squat (alternate upright vs leaned over like sprinter): 3-4 sets of 6-10 reps – if no weights, then jumping
    • Chest Supported Row OR Inverted Row: 3-4 sets of 6-12 reps
    • Eccentric-accentuated lying leg hamstring curl- 3 sets, 6 reps, 8 RPE
    • Tornado Chops x 30-60 seconds (alternate right and left chops)/Recliner Elbow to Knee Tucks x 30-60 seconds
    • Opposite Scissor V Us x 30-60 seconds/Opposite Side Tuck Planks x 30-60 seconds
    • Gliding leg curl (legs up on row seat): 3-4 sets of 10-15
    • Dumbbell Lateral Raises: 3-4 sets of 10-15 reps
    • Incline Dumbbell Kickbacks: 3-4 sets of 10-15 reps
    • Cable pull through- 11:25
    • High to Low Chest Cable Flies: 3-4 sets of 10-15 reps
    • Dumbbell frog pump- 2 sets, 30 reps, 8 RPE
    • Sledgehammer Swings x 30-60 seconds each side/Oak Tree Stepouts x 30-60 seconds each side
    • Banded Pulldowns x 30-60 seconds
    • Plank Punchouts x 30-60 seconds/Plank Pushaways x 30-60 seconds

  • Kris Home Workout Full Body C (with abs and glutes)
    • TransparentLabs.com: The Best Science-Based Workout Routine For Beginners Workout Instructions: Perform 12-15 reps 
      Use weights that create fatigue, but not to create failure, (if you can’t complete 12-15 reps, reduce your weight).
      Complete one set of each exercise, moving from the first to the second, to the third, etc. Transition to the next exercise without a break
    • Dumbell Reverse lunge
    • Farmer’s overhead dumbbell walks – 50 steps
    • Machine-standing calf raise- 3 sets, 8 reps, RPE 7
    • ISO Reverse Crunches x 30-60 seconds
      Seated Ab Circles x 30-60 seconds (alternate cw and ccw directions)
    • Barbell Bentover Rows or Seated Row
    • Dumbbell Split Squats (each side)/Walking lunges
    • Recliner Elbow to Knee Tucks x 30-60 seconds
    • Opposite Side Tuck Planks x 30-60 seconds
    • Dumbbell Chest Press on Swiss Ball
    • Lying single leg gliding leg curls on floor
    • Wide-grip Pullups
    • Dumbbell Step-ups
    • Oak Tree Stepouts x 30-60 seconds each side
    • Banded Pulldowns x 30-60 seconds
    • Plank Pushaways x 30-60 seconds
    • Medicine Ball floor slams
    • Face Pulls
    • Barbell Hip Thrusters
    • Face Down Arc (lay on belly – slow snow angel faced-down, not go above shoulders)
    • Decline Pushups
  • Kris Workout Full Body D (short on time or gym access)
    • Chris Thompson: 30 minute full body 2 sets, 8-15 reps, want to go to failure. Little rest as possible bt sets and exercises.
    • Bench Tuck
    • Calf Extension
    • Abductor Machine
    • Hyperextension
    • Hamstring Curl
    • Leg Extension
    • Squat Machine
    • Pull Up
    • Row
    • Dumbbell Lateral Raise
    • Dumbbell Curl
    • Barbell Bench Press
    • Dip/bench tricep pushes

Spinal drain for TEVAR

I had a patient come in for a 2 stage endovascular aortic repair. The patient had a 1st stage left carotid to subclavian bypass done about 3 days ago. We did a 2nd stage TEVAR for a descending aortic aneurysm. The patient did really well. Stayed in constant communication with the vascular surgeon as well as endovascular surgeon. A plan was in place. Patient was maximally beta blocked. I found dexmetetomidine to be a great drug for sedation pre-induction as well as blunting any responses to laryngoscopy during induction. Cordis for volume. Used the side port of the cordis for drips (nicardipine, phenylephrine). There were various times during the surgery where the surgeon wanted hypotension vs. hypertension. During deployment of the stent, SBP < 90. Once the stent was deployed, goal SBP 140 (MAP>90). Overall great case and great outcome for the patient.

What is a TEVAR (Thoracic EndoVascular Aortic Repair)?

Why place a spinal drain?

Management of spinal drain:

Potential complications


Key Points:

  • Pre-op planning: chat with the surgeon before hand regarding a plan. Make sure the OR team understands the plan.
  • Communication: before, during, after the case.
  • Be vigilant about tight BP control

Intermittent Fasting

A colleague of mine had suggested/introduced “The Obesity Code” to me and my reading list.  It’s a fabulous read and I highly encourage a read/listen.  Here are other books I have read and suggest.  After The Obesity Code, I chose The Complete Guide to Fasting… and since then, I’ve added Eat Stop Eat to my audiobook library as well.  I’m extremely intrigued about intermittent fasting.  I’ve followed a paleo diet for years, however, I’m curious to see if I could actually try intermittent fasting and not succumb to hunger bc I love snacking!

Here are some resources I’ve found to be useful:

From Brad Pilon, author of Eat Stop Eat:

To summarize: a rather normal dose of alcohol caused a decrease in fat burning, no change in carbohydrate burning, and a slight increase in overall calorie burning in men who were in the fasted state.

So the question remains. If metabolic rate increases, glucose oxidation stayed the same, and fat burning decreased… what the heck were they burning?

Turns out the answer is the alcohol… sort of.

In fact, blood acetate is such a priority that it’s mere presence can decrease lipolysis by ~50%, even when you are in the fasted state [Crouse JR, 1968]

And this is what happens when you drink during your fast. It’s not that you will gain more fat (unless you are drinking excessively), but you will stop releasing body fat, stop burning body fat, and burn acetate instead. This occurs without any change in insulin levels.

So sadly, it seems the answer is that you cannot drink during your fasts without diminishing your fat burning abilities.

 

I’ve decided to try the 16/8 IF schedule (16 hour fast, 8 hour eating window = 11a – 7p) when I go back to work.

 

Intermittent-Fasting-by-the-hour
From Libifit