Walking labor epidurals

What is an epidural?

What is a “walking” epidural?

Anesthesiology 2 2000, Vol.92, 387. Walking with Labor Epidural Analgesia: The Impact of Bupivacaine Concentration and a Lidocaine–Epinephrine Test Dose.

MJAFI, Vol. 63, No. 1, 2007. Walking Epidural : An Effective Method of Labour Pain Relief. 

Int J Women’s Health, 2009, 1: 139-154. Advances in labor analgesia.

R. Can J Anesth/J Can Anesth (2010) 57: 103. Walking epidurals for labour analgesia: do they benefit anyone?

MOBILIZATION IN LABOUR AFTER REGIONAL ANALGESIA. Euroanesthesia May 2005. Royal Free Hospital. London, UK.

Impact of first-stage ambulation on mode of delivery among women with epidural analgesia. Australian and New Zealand Journal of Obstetrics and Gynaecology 2004; 44: 489–494

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From WebMD

Walking Epidural with Low Dose Bupivacaine Plus Tramadol on Normal Labour in Primipara. Journal of the College of Physicians and Surgeons Pakistan 2010, Vol. 20 (5): 295-298.

Clinical Guidelines: Labour Analgesia. Jan 2017. King Edward Memorial Hospital, Australia.

BJOG, Feb 2015. Neuraxial analgesia effects on labor progression: facts, fallacies, uncertainties and the future.

Position in the second stage of labour for women with epidural anaesthesia. Cochrane Database of Systematic Reviews. Feb 2017.

Ambulatory Epidural Analgesia in Obstetrics: Clinical Effectiveness, Safety, and Guidelines. Canadian Agency for Drugs and Technologies in Health. Rapid Response Reports. Nov 2010.

Contin Educ Anaesth Crit Care Pain (2004) 4 (4): 114-117. Epidural analgesia in labor.

CSE for Labour Analgesia. 

cseanatomy

From the ASA 2017 (October in Boston):

  • CSE: 1 cc 0.25% bupi + 15mcg fentanyl (good for primip)
  • 25g Dural Puncture without dosing sometimes (primips)

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My other OB blog links:

OB Anesthesia

Birth plans

Reflections

Fun on the job

Mitraclip and TEE for MR

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European Heart Journal – Cardiovascular Imaging (2013) 14, 935–949.  Peri-interventional echo assessment for the MitraClip procedure. 

Everest Clinical Trial results PPT

Open Heart 2014;1:e000056. Two-year outcomes after percutaneous mitral valve repair with the MitraClip system: durability of the procedure and predictors of outcome.

ASE Echo 2016: Percutaneous approaches to MR. UofMichigan PPT.

2015: The role of 3D TEE in the MitraClip procedure – UofColorado PPT

Abbott TTE checklist for MitraClip

EuroValve Congress 2015: MR in the MitraClip Era

2012: Echo in mitral valve intervention. 

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Abbott MitraClip device and delivery system package insert

Neth Heart J (2017) 25:125–130. MitraClip step by step; how to simplify the procedure.

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Transseptal Puncture technique with TEE

JACC Cardiovascular Imaging: July 2012. Role of echo in percutaneous mitral valve interventions. 

MitraClip Cases with TEE: Mayo Clinic.

 

Lidocaine infusions for pain

From Anesthesiology 2017

BJA Educ, April 2016. Intravenous lidocaine for acute pain: an evidence-based clinical update

Lidocaine Infusion for Perioperative Pain Management – Vanderbilt

Cocharane Library, July 2015. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery.

Perioperative Use of Intravenous Lidocaine. Anesthesiology 4 2017, Vol.126, 729-737.

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Open Access Journals, Jan 2017. Lidocaine Infusion: A Promising Therapeutic Approach for Chronic Pain.

Anesthesiology, April 2017. Perioperative use of IV lidocaine.

From Jama Surgery 2017

 

Here’s what I’m currently using:

  • October 2017
    • Lidocaine bolus: 1.5mg/kg on induction
    • Infusion: 2-3mg/kg/hr after induction to end surgery
    • If cardiac on CPB: bolus 1.5mg/kg on induction; Infusion: 4 mg/min x 48 hrs or discharge from ICU; On CPB bolus 4 mg/kg.

I’m also currently working on ERAS protocols for my practice as well as the use of ketamine infusions for intraoperative and postoperative pain and recovery.

Deep Hypothermic Circulatory Arrest

Case

 

 

OpenAnesthesia.org: Cerebral ischemia: deep hypothermia

SCA 2013 PBLD: Anesthetic Management for Deep Hypothermic Circulatory Arrest

BJA: Deep hypothermic circulatory arrest. July 2010

JCVA: Perioperative management of deep hypothermic circulatory arrest. Aug 2010.

Anaesthesia, Pain, and Intensive Care: Deep hypothermic circulatory arrest – anesthetic considerations. Aug 2016.

Annals of Thoracic and Cardiovascular Surgery:  REVIEW: The methodologies of hypothermic circulatory arrest and of antegrade and retrograde cerebral perfusion for aortic arch surgery. 2008.

Cardiac Surgery in a Jehovah’s Witness Patient

AVR

Brief case summary

Habler_Fig1 v2_1
From Nata Online

Literature Search

Habler_Fig2 v2
From Nata Online

Antifibrinolytic Debate

The healthcare debate

Here it is.  I didn’t want to opine, but it’s here and I can’t get away from the topic.  I see it at work.  I watch it at home.  It comes up in discussions…  so in order to make it stop, I’m going to give you an idea of what I see and what I think about Obamacare and whatever else is out there.

April 2015

Public Integrity: Insurers backed Obamacare, then undermined it.  Now they’re profiting from it.

February 2016

Talking Points Memo: The real reason insurance companies are complaining about Obamacare

August 2016

CNN: Will Obamacare survive as insurers pull out?

October 2016

Salon: Making a killing under Obamacare: The ACA get blamed for rising premiums, while insurance companies are reaping massive profits

November 2016

Portland Press Herald: Maine Voices — The problem isn’t Obamacare; it’s the insurance companies

December 2016

NYT: Health insurers list demands if affordable care act is killed

The Huffington Post: The Obamacare paradox — The real reason health insurance companies don’t like the ACA

January 2017

Market Watch: I’m a former health insurance CEO and this is what Obamacare repeal will do.

Great Z’s: Liberals are out of touch

March 2017

LA Times: Here’s the secret payoff to health insurance CEOs buried in the GOP Obamacare repeal bill

Common Dreams: Why big insurance adores the American Healthcare Act

What I see:

When Obamacare was initiated, I recall seeing a patient who had broken her foot while hiking locally.  She had a surgeon who was covered under Obamacare, as well as an anesthesiologist.  However, the hospital chose not to accept Obamacare and she had to pay out of pocket for her overnight stay.

It seems that we’re seeing more and more insurance companies pulling out of the system because it doesn’t seem to be profitable for them.  Insurance companies are a business; they’re not looking after the wellbeing of the patient.  Physicians, nurses, caretakers, the care team look after the wellbeing of the patient.

How many people do you know are satisfied with their insurance coverage?

I’m covered by Anthem on a PPO plan with about 240 physicians.  My insurance rate is lousy for the coverage I receive — a high deductible plan.  I’m young and healthy and take responsibility for my health — why am I paying $620/mo for barely there medical coverage as a physician?  Well, the answer is that our company makeup is a majority of older partners who skew the coverage toward a higher premium — basically a mini-Obamacare environment.  I’m subsidizing their health coverage… and someday, hopefully I will still be healthy bc I’m responsible for my health (keypoint right there folks) and doing everything I can now to give my body the best fighting chance to survive into “old” age.

My question: 

Anyone think to make insurance companies accountable with transparency re: ACA?  Start there.  Does anyone else think it’s odd that the people who are helping shape the bill don’t actually participate in the care/exchanges like the public?  All the while, government and insurance companies dictate coverage and force physicians into tougher situations to deliver care.  Is this what you (the public) want?  When was the last time you saw the fine print of the bills being passed?  Don’t just follow the masses, look for the details and truth for yourself.

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What government officials have for insurance: