Tag: ultrasound

Prosthetic Heart Valves

ASE Guidelines: Recommendations For Evaluation of Prosthetic Valves with Two-Dimensional and Doppler Echocardiography.

Recommendations for Evaluation of Prosthetic Valves With Echocardiography and Doppler Ultrasound. A Report From the American Society of Echocardiography’s Guidelines and Standards Committee and the Task Force on Prosthetic Valves, Developed in Conjunction With the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, Endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography. JASE Guidelines and Standards| Volume 22, ISSUE 9, P975-1014, September 01, 2009.

Recommendations for the imaging assessment of prosthetic heart valves: a report from the European Association of Cardiovascular Imaging endorsed by the Chinese Society of Echocardiography, the Inter-American Society of Echocardiography, and the Brazilian Department of Cardiovascular Imaging. European Heart Journal – Cardiovascular Imaging, Volume 17, Issue 6, June 2016, Pages 589–590, https://doi.org/10.1093/ehjci/jew025

Echocardiographic Assessment of Heart Valve Prostheses. J Cardiovasc Echogr. 2014 Oct-Dec; 24(4): 103–113.

From Echocardiographic Assessment of Heart Valve Prostheses. J Cardiovasc Echogr. 2014 Oct-Dec; 24(4): 103–113.
From Echocardiographic Assessment of Heart Valve Prostheses. J Cardiovasc Echogr. 2014 Oct-Dec; 24(4): 103–113.
From Echocardiographic Assessment of Heart Valve Prostheses. J Cardiovasc Echogr. 2014 Oct-Dec; 24(4): 103–113.
From Echocardiographic Assessment of Heart Valve Prostheses. J Cardiovasc Echogr. 2014 Oct-Dec; 24(4): 103–113.
From Echocardiographic Assessment of Heart Valve Prostheses. J Cardiovasc Echogr. 2014 Oct-Dec; 24(4): 103–113.
From Echocardiographic Assessment of Heart Valve Prostheses. J Cardiovasc Echogr. 2014 Oct-Dec; 24(4): 103–113.
From Echocardiographic Assessment of Heart Valve Prostheses. J Cardiovasc Echogr. 2014 Oct-Dec; 24(4): 103–113.

Evaluation of Aortic Prosthetic Valves. JASE 2018. PPT.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143:e72–e227.

Prosthetic Heart Valves: Selection of the Optimal Prosthesis and Long-Term Management. Circulation. 2009;119:1034–1048.

Prosthetic Heart Valves
From Circulation. 2009;119:1034–1048
From Circulation. 2009;119:1034–1048
From Circulation. 2009;119:1034–1048
From Circulation. 2009;119:1034–1048

On-X heart valve echo. Slideshare, Jan 2016.

Transversus Abdominis Plane (TAP) block

Indications and Technique

Figure 1. Biomed Res Int. 2017; 2017: 8284363.
Figure 1. Anesthesiol Res Pract. 2012; 2012: 731645.
Figure 5. Anesthesiol Res Pract. 2012; 2012: 731645.
Figure 6. Biomed Res Int. 2017; 2017: 8284363.

Pros & Cons

The Effect of Transversus Abdominis Plane Blocks on Postoperative Pain in Laparoscopic Colorectal Surgery: A Prospective, Randomized, Double-Blind Trial. Diseases of the Colon & Rectum: November 2014 – Volume 57 – Issue 11 – p 1290-1297

How to perform a TAP block?

YouTube: U/S guided TAP block

YouTube: RAUKvideos U/S guided TAP block Fast forward to 0:39

YouTube: 3D How-To U/S Guided TAP block Fast forward to 1:00

YouTube: 2012 ISURA TAP block lecture Fast forward to 16:55 for summary.

YouTube: ASRA Society Fast forward to 0:55. Sound off.

YouTube: Pajunk TAP block

Current mix:

  • July 2020
    • 0.25% bupi + epi + 1 mcg/kg dexmedetomidine (roughly 30 ml per side)

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

Update:

Nov 2021:

https://www.sciencedirect.com/science/article/pii/S1053077020300987?via%3Dihub

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

Suprascapular blocks

Trends are evolving in decreasing intraoperative and postoperative opioid use.  Therefore, anesthesiologists are constantly learning new regional techniques to help with postoperative pain.  For shoulder surgeries, I’ve moved away from interscalene blocks toward supraclavicular blocks.  I think the interscalene block provides a better block of a total shoulder surgery, however, certain patient comorbidities often make the supraclavicular block a better choice.

Nice paper from Anesthesiology, Dec 2017: Suprascapular and Interscalene Nerve Block for Shoulder Surgery: A Systematic Review and Meta-analysis. Anesthesiology 12 2017, Vol.127, 998-1013.

Nowadays, it seems that suprascapular blocks are gaining in popularity (I’d probably use it to supplement the supraclavicular block.

Supplies and Technique (from USRA):

Suprascapular Nerve

ssn1

How to position the ultrasound probe:

ssn5
From USRA

05_1_a_shoulder-suprascapular-artery-and-nerve_dsc_5085_copy

Ultrasound Image

ssn4
From USRA.  SSM = supraspinatus muscle
SSA = suprascapular artery
SSN = suprascapular nerve
TZM = trapezius muscle
STSL = superior transverse scapular ligament

05_1_c_shoulder-suprascapular-artery-and-nerve_labels

Useful Links

Pregnancy

The first day of my last period was April 25, 2017.  According to my Glow app, my average period length is 6 days and it looks like there’s roughly 37 days between periods.  That’s about 10 days longer than the average Jane.  That last period occurred on our honey moon! We came back home on May 9.  Then, I had a weeks worth of diarrhea from May 20-27 and ended up taking ciprofloxacin at that time.  As June approached, I was just fatigued for a bit and so was Bear.  We thought we had caught a bug or had some kind of weird travel lag from the trip.  I was still surfing regularly with Ross — maybe a couple times a week.  Around the summer solstice June 20, I had some light cramping. Breasts had been tender for a while, but that wasn’t anything out of the ordinary as my period approaches.  In early June, we went to  the Toast the Coast Wine Festival at the Del Mar Fair (June 10) and then the evening of June 20, we had burgers and beers at Encinitas Alehouse.  I had a funny feeling to pee on a pregnancy stick that evening, so I did.  Lo and behold it was POSITIVE!  I quickly called out to Bear to make sure he got an eye on the reading to make sure I was reading it correctly.  The next day, we went to the drug store and got one of those digital ones so there couldn’t be any reading errors.  It said PREGNANT.

IMG_0002

Once we found the info out, I immediately called to setup an appointment with my chosen OB/GYN.  I feel lucky to have a job in anesthesia because I get to directly see the work of our surgeons and care providers so it gives me an idea of who to seek for my own care if needed.  I setup an appointment with Kim Washkowiak for July 5 (1st ultrasound) and then an initial consultation on July 11.  I also started researching best books to read during this time and finally chose the Mayo Clinic Guide to a Healthy Pregnancy.

According to the Mayo Clinic Guide to a Healthy Pregnancy: From Doctors Who Are Parents, Too! that we’re reading, the chart states the following….

  • Week 1 If the first day of your last menstrual period was: Apr 25
  • Week 3 Conception likely occurred around: May 9
  • Weeks 5-10 Period of greatest risk of birth defects
    • Beginning of organ formation: May 30
    • Major organs have formed: Jul 4
  • Week 12 Risk of miscarriage decreases: Jul 18
  • Week 23 Some preemies can now survive: Oct 4
  • Week 40 (full term) Estimated due date: Jan 30

Mayo Clinic Guide to a Healthy Pregnancy: From Doctors Who Are Parents, Too! (Bestsellers) (Kindle Locations 2230-2237). RosettaBooks. Kindle Edition.

IMG_0004
10 weeks, 1 day

But according to our OB and U/S reports, we’re due February 20, 2018.

July 5, 2017

I’ve had about 2 weeks of low grade nausea.  I keep wanting to eat small meals to stave off the “morning sickness” that rears its ugly head throughout the day.  I’ve got some ginger candies to help.  I’m also eating more plant-based meals (Veestro and Splendid Spoon) and craving grapefruit and fruits!  I haven’t worked out much bc of the nausea.  I’m trying to get 3x 16oz waters down in a day.  Initially, I was having to pee a lot…. not just during the day but it would also wake me up in the night.

Week 18 – Sept 19-25, 2017

Recap:  The nausea was the worst for me from weeks 7-13.  It slowly got better.  Things I did to calm the nausea: ginger chews, ginger hot water/tea, bananas, toast, crackers, pasta, hydration, rest.  I found it worst during the day.  During that time, I also shunned Veestro and Splendid Spoon.  In fact, I could hardly tolerate any of my paleo foods that I typically eat.  Crackers and carbs were my savior.

Fast forward to week 18… life is good!  We just got back from a 2 week vacation to the Azores. I’m back at work and now I have Mondays off.  We’ve been doing research on state disability, maternity and paternity leave, vacation days for 2018, infant day cares, pediatricians, etc.  I still don’t see much of a baby bump yet, but my usual clothes are starting to feel tighter. Got my flu shot!  Pregnant ladies, it’s IMPERATIVE you get your flu vaccine (not the nasal one though) — read the CDC guidelines here.

So far, we’ve found the following books helpful:

Week 21: Oct 10 – 16, 2017

I’m still feeling pretty energetic and able to maintain my pilates workouts.  Typically, I aim for 3-4 one hour sessions/week.  The ladies at Club Pilates in Del Mar are fantastic and are always offering me alternatives for new moves as I advance in my pregnancy.  I’m hoping to keep this up until delivery and beyond!  We’e completed two prenatal classes so far.  Scripps offers a lot of classes and resources and we’re taking advantage of the learning opportunities!  So far, we’ve done Getting Ready for Baby part 1 and 2.  It was a great overview for absolute essentials we may need for our newborn as well as how to change a diaper, swaddle, when/how to bathe, etc.  It also included an excellent session given by a pediatrician on normal/abnormal poops, diaper changes, breastfeeding, circumcision, vaccines/shots, etc.

I’ve been in a rabbit hole of baby registry items/reviews and we’re slowly building our list.  I’m pretty meticulous about researching anything prior to pulling a trigger on anything big (house, car, insurance, stocks, appliances, electronics, etc.).  I consider a newborn to be a really BIG thing!

OB Anesthesia entries from my blog:

Week 22: Oct 17 – 23

This week, it was recommended that I only stick to the pilates 1.0 or 1.5 classes.  😦  Pilates has been great, but they’re totally right.  My cardiovascular capacity needs to really stay in check.  The mini is the size of a papaya this week.

Week 23: Oct 24 – 30

We just got back from our last flight to Boston.  Overall, I felt like I traveled fine… but I could see it being tougher as the pregnancy progresses.  Lately, I’ve been booking infant care tours for our little one when they turn 3 months.  I have two girlfriends with 2 kids who are terrific moms…each offer the advice of getting a nanny (instead of daycare).  I think a nanny or our moms would be great, but my biggest push for the daycare is to engage early development and socialization.  I think the nanny and our moms are great to help on certain days, but Bear and I work and that would be a 5 day a week commitment.  That’s a lot to ask for from our moms who live out of town.  Plus, I do not want a complete stranger (i.e. the nanny) around our baby just yet.  Consider it the mamma bear in me.  But, I want accreditation, vetting, background checks, early childhood education, experience…. and from what I am finding in my searches… it’s really hit or miss with the nanny.  I really am taking to the Montessori method for independent learning and self-soothing and the way it encourages infants/toddlers to participate in their environments.  Plus, one of the Montessori schools we’re looking at does language immersion.  Many educators have said that the most absorbent stage of learning is from 0-6 years.  Great link that compares infant care and nanny care.

YouTube video of LePort Montessori Infant School

Plus, I don’t really believe in decorating a nursery and such — we’re in the midst of creating/designing/constructing a companion unit and will then at a later date do a large remodel of the house.  So, simplicity and minimalism are my jam.  I read this article on the Montessori way of setting up your home for infant and I love it and would like to replicate it!

Comparing Montessori and Reggio learning styles (2 infant care philosophies we are looking at):

I’m ecstatic to learn about MontiKids ($30 off with referral code: REFW6UGPGEGO5) – a toy delivery service that bases it’s philosophies on Montessori.  Every 3 months, the company will send you age/development appropriate toys to you.  I am so thankful for minimizing screen time and maximizing play/learn time with my future kiddo.

My YouTube Kid Playlist

We had our first breastfeeding class last night. It was actually really really informative.  We’re always the smallest “bump” in the class as I think most of the moms in there are due November…. and we’re not due until February.  But, I love having the info ahead of time so I can plan….and I only know my schedule one month in advance 2 weeks prior to the new month.  We’re definitely on board for 6 months of exclusive breast feeding and then starting organic, non-GMO, hormone-free foods around that time with supplemental breastfeeding.  I’d love to breastfeed for at least 1 year if it’s possible.  We’ll see!  I know it’s not an easy task.

All things Montessori:

We had our 24 week growth scan ultrasound on Oct 30. Everything looked great!

Week 24: Oct 31 – Nov 7

This week, the mini is the size of a large zucchini.  At this stage, we have a viable fetus.  Things are still going well.  I’m feeling little kicks.  Mini’s insertion of the umbilical cord is just slightly off center on the placenta.  The last growth scan showed no vasa previa and the baby was already positioned head down.  Funny thing, at every ultrasound… the Mini is super chill.  The ultrasound tech will push the probe into my belly to shake/wiggle the baby to move and change positions…. but to no avail.  Hopefully, they’ll be this chill when they’re born!

I’m looking at various cord blood companies to see whether it’s worthwhile to bank stem cells from the umbilical cord when the baby is born.  Basically, it’s kind of like having a backup source of undifferentiated cells that could turn into anything (bone marrow, red cells, white cells, tissue, etc.) if we ever need to use them down the line.  My biggest question is: what’s the viability/longevity of these cells to be effective if we need them?  It’s a pretty large upfront cost.  And nothing is guaranteed.  So… I asked my OB what she did with her kids and she said the first one it was free, and then she paid for the 2nd and the 3rd.  I’m going to continue my polling today to figure out if it’s worth it or not.  What I’d really like to know is if anyone has had to use these stem cells….. was it worth it?  Did it change the course of disease or alter treatments?

table-1

Cord Blood Info:

So after reading through every one of these links…. I’m leaning more towards NOT banking.  If something isn’t going to be useful 10-20 years down the road…. why bother?  Plus, in 10-20 years, research and medicine will have advanced that there may be better treatment options available – i.e. creating stem cells that are a match to a recipient.  There are public stem cell and tissue registries.  I suppose the key thing is would we have a match for our multi-racial family from a public bank/registry?   We both have ZERO genetic history of diseases or cancers.  It’s a big upfront cost — and I’m not sure the technology is quite there for advanced treatments.  But, if I were to choose a private cord bank company right now, I’d probably choose CBR.

Update Jan 15, 2018, 34 weeks, 6 days: We ultimately re-discussed the cord blood/tissue banking and decided on CBR.  After chatting with several moms who did it…. a lot of them have regrets for not doing it…. and the ones who did it have peace of mind.  Bear and I further researched the topic and decided we would do it and chose CBR.

IMG_0077
24 weeks, 3 days

Had my 24-26wk Glucola testing on Nov 6.  This was after an unseemingly busy call day and night.  In fact, I got called back to the hospital at 2am and was starving — so had half a bagel at 2am (and therefore breaking the 12 hour fast rules).  I went in for the Glucola test at 7:30am.  The Glucola drink is 50g of sugar that tastes like a really flat Sunkist soda.  I thought for sure my test would be positive given my cortisol surge with the busy and stressful call day…… and fueled by my half bagel at 2am.  But, low and behold, my result was 126 (range less than 139) and negative for gestational diabetes.  Woohoo!!  Here’s some interesting reading material on gestational diabetes and diagnosing it: part 1, part 2.

Week 25: Nov 7-13

Definitely seeing and feeling changes during this week.  There’s no mistaking that I’m pregnant.  Before I just felt “fat” and heavy in the belly — so funny that some of my colleagues asked if I put on weight.  That stuff doesn’t bother me, but it cracks me up how guys can be so frank.  I’m still trying to do at least 3 classes a week of pilates.  I’m really enjoying Club Pilates that’s a studio all around the country.  Currently I’ve dropped down to just the 1.0 and the 1.5 classes — but they’re still kicking my booty!  I was consistently doing the 1.5 and 2.0 classes up until 23 weeks.  My fam has an ongoing bet whether the Mini is a boy or a girl.  I love it!  I even want to get in on it — but I can’t be the biased house.  So far…..here’s the tally…
Stud Hubs = girl
Mimi = girl
Aunt Chawn = boy
Uncle Larry = girl
Mom’s friends (Raymond and Nashat) = girl
My thoughts = I have no idea! How do people predict this stuff? Girl names keep popping in my head though.
At work (Lisa, Rick, Suzette, Thuy, Katy) = boy
At work (Juliette, Christina, Annetta) = girl
Baby shower majority = boy
Massagers at ThaiSport = girl
I can’t wait to see the bets roll in!
Week 26: Nov 14 – 20
Even at 26 weeks, I’m up daily at 6:22am… perks of the job.  There’s usually one or two pee awakenings in the middle of the night usually anywhere from 1-4am.  I think this sleep deprivation thing will be just like a call night.  I’ve been doing those for years (yes, at least a decade).  Night call on OB is roughly an every 2 hour wakeup call for an epidural or a bolus or a C/S… or it’s a trauma rolling in through the OR.  I think I’ll handle the transition well — but maybe that’s wishful thinking.  I want to do it all — have an amazing career, raise the Mini and be an awesome mom, and be everything my husband has ever dreamed.  Is it possible?  Will I be tired? Time will tell.  In the meantime, I’ve had a fabulous time jammin’ out on my uke.  In fact, I got an early Christmas present for myself — a new uke!
I’ve been doing more research and reading and listening to Audible books every spare chance I get.  This is of course at the same time when November and December are the busiest times at work (a lot of people try to fit their doctor visits in before their deductibles run out at the end of the year)…. and we’re starting a small (phase 1) remodel.  But, there’s never a good time to get stuff done despite being busy, so we just go for it!
Here are the books that I’m currently listening to or reading or are on my future reading list:
Week 27: Nov 21-27
 Happy Thanksgiving week!!!
  • Nov 23: Took the Amtrak train up to Camarillo to hang with Ross’ fam for Thanksgiving.  The train is the way to go!  Lots of space, bathrooms (important when a prego gal is going to the bathroom every 2 hours!), wifi, charging outlets, cafe cart, etc.  Ever since living in Boston, I have been a huge fan of public transportation!  It’s the way to go!  Thanksgiving was great.  Lots of great food, company, conversation, and mingling!
  • Nov 24: I’m on call today and just got called into work — that’s the life of a doc — we signed up for this so don’t feel sorry for us.  We know being on call and away is part of the gig.  No sympathy needed.  Saturday, we’ll go to my mom’s house and have another yummy feast!  For some reason, this year…I’m really loving and craving leftovers!  I know my mom will hook it up as I told her to prep a lot so I could eat it for at least a week.  Been playing the uke a lot lately (especially since getting my new tenor uke!).  Starting to form calluses on the fingers (used to have these when playing the violin)… such a good thing!  This lil kiddo is def gonna love music and the uke!  Now, to play more classical music and read to them!
  • Nov 25: Thanksgiving at my mom’s was great.  Lots of great food and leftovers and of course football — that’s our Thanksgiving tradition!
  • Nov 27: Everything looked great at my 28 week appointment. Got my dTaP vaccine.  Baby’s HR in 140s and baby is growing nicely.  My BP was good 119/64.  155lb on the scale (whoa!).  That’s about 20lb over my norm!  It’s definitely an adjustment to seeing the changes in my body…what it can and can’t do.  I’m getting more short of breath these days and that’s with hardly ANY activity.  Taking a flight of stairs – yeah… short of breath.
  • Things I miss most: hiking, wine, rock climbing, feeling in shape, being at peace (vs thinking about a million things constantly), date nights (usually too tired by the end of the week)
  • Things I won’t miss: being thirsty and drinking water all the time, peeing a couple of times in the middle of the night, not being able to sleep through the night while also being tired in the day (currently thinking about a lot of things right now), the low pressure/cramping, being short of breath, reflux, asking myself whether something is too hard or too heavy to lift or push, the hormonal push to growl at everyone
Some great link finds:
 Week 28: Nov 28 – Dec 4
 Today, the Mini is the size of a large eggplant.  Kick counts have started.  I have to get 10 kicks in an hour from now until the due date.  So far, the Mini has been meeting the 60 minutes on the 10 kicks.  Today was a long day at work — 11.5 hours all while being czar as well.  I feel like the month of December has been full of 10-12 hour days.  So, I decided to keep a log of my hours from now until my due date.  This Mini is gonna be resilient and adaptable.
I started having sacroiliac pain will doing bridge in pilates last Wednesdays.  It was a new feeling for me.  It felt kinda like something pulling my hip bones apart.  The pain was sharp and constant (but nothing I couldn’t handle) and stayed right in that sacroiliac joint.  It has resolved since then after a couple of other pilates classes.

1200px-sacroiliac_joint
From Wikipedia

The Mini is doing well and making all their kick counts (10 in an hour).  Yesterday, we saw Todd and Lauren’s baby Skyler and she was absolutely adorable!  Almost 2 months old and such a gem to hold.  Todd and Lauren will be great parents!  One of the other girls there, Jenny who has had 4 kids, was such a wonderful wealth of information!  I felt like we talked most of the night!  Great food and company and baby welcoming!
My stress meter has been high this week.  The lack of sleep, the million things I’m reading and thinking about for a work-related issue/project, and the planning/decision-making for our phase 1 renovation of our home.  The great thing is that Bear is a great shoulder to lean on and I think he can tell that I’m feeling stressed (rarely do I show it).  I think it’s adorable how he looks after me and makes sure I’m ok.  D-Day was Dec 4.
Week 28 work hours: 51.5 hours
Week 29: Dec 5 – 11
Our mini is the size of a cauliflower this week!  There’s no mistaking that I’m preggo now — the belly can’t be sucked in.  It’s been interesting going through the changes with my body.  It’s such a surreal experience: the bump, the reflux, the constant peeing, the oops pee, the constipation/gas/bloating, the smaller stomach size (I get full on half my meals!), the sleeping positions to get comfy,… and it’s only going to get more interesting as the weeks go on.
 Week 29 work hours: 44.5 hours

Week 30: Dec 12 – 18
 The OB shift was a gnarly one on Tuesday.  Worked solid from 7a to midnight.  There were a lot of colds on the OB floor.  It’s only a matter of time before I come down with something.  As luck would have it, I got assigned two TAVRs on Wednesday and worked from 8a-3:30p…. and that’s post-OB at #21.  Well, I did come down with a cold.  Mainly sore throat and slight sinus congestion.  Bear was sweet and brought some tom yum soup home for me as well as picked up a whole pharmacy of goodness.  I hit the Chloraseptic, lozenges, and Emergen-C.  Called the OB to find out if these meds were safe to take.  Theraflu is NOT safe for pregnant gals to take.  Tylenol and Robitussin are safe (neither of which I’ve needed).  Fortuitously had Thursday off bc I was unassigned that day (oftentimes we get work at a surgery center or something).  Spent the day on the couch in my jammies.  Bear brought home some pho for lunch and just took really good care of me.  He’s a solid support system!  Back at work today (Friday) for a full day and working both days this weekend.  The Mini is making their kick counts and growing!
We had another OB appointment today and growth ultrasound.  Everything is looking great!!  My BP is 110/60.  Fetal heart rate was in the 140s.  I weighed in at a whopping 156 lb.  For our ultrasound, the Mini measured at 3lb 15oz and is 60% on the growth curve!  They’re in the middle range for amniotic fluid, which is just right.  So far, everything is just going great for our lil Mini — who isn’t so mini anymore!  I’m feeling more of the symptoms of heartburn, stomach fullness, bloating/constipation/gas/etc…. and the bladder is taking a beating!  Nowadays I’m getting up 3-4 times a night (roughly every 2 hours).  The gals at work eagerly remind me that this is just prepping me for motherhood — funny but too realistic of a joke!
Week 30 work hours: 48.25

Week 31: December 19 – 25
 This week was a rather joyful week as we were in the Christmas spirit!  The work week was a busy one as people try to fit in their surgeries before their insurance deductibles reset at the beginning of the 2018 year.  This year, my fam came down from Temecula and I whipped up a cabernet beef short rib, mascarpone polenta, and banana bread pudding.  My mom and aunt brought fermented cabbage, salad, and brownies.  We picked up some sides like beet salad and broccoli salad.  Overall, this was the first time I was making the recipes, but I was ecstatic that it came out as yummy as it did!  I did make some tweaks to the original recipes as I added some things more to my taste.
On Christmas Eve, Ross and I headed up to LA to spend time with Ross’ fam.  His brother made reservations at Fogo de Chao, a brazilian meat restaurant.  The meat cuts were tasty and the buffet bar was loaded with veggies and yummy fruit (I went back for thirds on the winter citrus fruit!).  For dessert, we had a delicious fruit ice cream.  After a big lunch (I didn’t even eat dinner that night bc I was still so full!), we headed back to Ross’ fam’s place and played Bingo, LCR, and pictionary.  Everyone was having a great time!
Christmas day, Ross and I had a nice peaceful morning opening presents and listening to Christmas music with the fireplace going.  It’s bittersweet to think that this will be our last Christmas alone together before the Mini comes!  It’s exciting to think how the Mini will change our lives in incredible ways!  Today, we pulled the trigger on MontiKids bc it’s such an amazing company that creates toys that are age appropriate with a focus on development and the Montessori way.  Here’s one gal’s review on MontiKids.
Hours worked: 35 hours
Week 32: Dec 26 – Jan 1
 My last full night call was Dec 26.  It ended up being a really nice, decent call night…. but I couldn’t get comfy sleeping in the call room.  I find that I absolutely NEED my Snoogle pillow.  So, not much sleep Tues night.  Came home and crashed Wed from 8a-11a.  Did a pilates class and felt good.
  • Thurs, Dec 28th: I don’t think I drank much water that day and ended up feeling pretty dehydrated.  Went to pilates and as I was doing bridge pose started feeling light headed like I was going to pass out.  I stopped and rolled onto my left side and put my legs up on the reformer foot bar (venous return is key!).  I stayed in this position until I felt back to myself (roughly 10 minutes) and then I finished off the class.  BUT,… when I went home that evening, the Mini did NOT make their kick counts.  They would maybe do 1 kick in an hour (instead of the 10 they’re supposed to get).  I fell asleep before I remembered to call the OB office.
  • So, Friday, I went to work and did a double heart day and then walked up to Labor and Delivery to get on the monitor to check out fetal heart tones.  Everything seemed to be ok — and that was a huge relief for me!
  • Saturday, Dec 30: Ross got a new car!  We needed to seriously upgrade his ride to something more child friendly and safe for our lil Mini!  The new year will be welcomed in 2018 with a lot of new changes!
Pilates this week has been a real kick in the pants.  I felt faint twice and realized that the wedge padding I use is not high enough for me bc I still feel light headed and get reduced venous return with any increase in heart rate.  Bridge pose is out for me as are most exercises on my back.  I’m super bummed about that.  For January, I dropped from the unlimited pilates plan (go as much as I want) to just the 4 class pass.
NYE was a busy day!  I worked from 7a-5:30p and then went out to a nice 7p dinner with my Bear at our first date spot Cucina Enoteca.  We got home around 9ish and tried to stay up, but we passed out on the couch from then until midnight!  Thank goodness for DVR bc we could rewind the NY ball drop and watch it and celebrate!  We opted for a new year tradition: planting one tree/plant (indoor or outdoor) each year!  This year we planted three indoor palms (chamaedorea costaricana, howea forsteriana, chambeyronia macro) and one outdoor palm (from our wedding: the blue green palm — butia capitata blue).
 Hours worked: 37.5 hours
Week 33; Jan 2 – Jan 8, 2018
 Our Mini is the size of a pineapple!  Nowadays, sleep is escaping me (from the multiple wakeups to pee to just not being able to sleep despite being exhausted) — my most comfortable position is propped up with pillows and oftentimes I find my best sleep upright on the couch.  Bear is starting to nest — it’s so cute to see.  I easily go through a liter of La Croix in a day, but I found out that the BPA in the aluminum cans clearly aren’t good.  So Bear went to Jimbo’s and bought three different soda water beverages in glass containers.  He is soooooooo thoughtful!  At work, I’m heading to the bathroom every 2 hours.

Hours worked: 26 hours

Week 34: January 9 – 15, 2018

Even though this week was a bit lighter for me (I had originally taken this week off as a staycation, but opted to just take Friday off), I couldn’t get comfy sleeping.  I took an OB call on Wednesday and was essentially done around midnight (I have a midnight rule at work: if I’m still at work at midnight, I just sleep in the call room).  While sleeping in the call room, I was only sleeping 1.5 hours at a time.  The insatiable thirst and constant and consistent potty breaks are starting to become unbearable.  I’m tired all the time and it’s from getting up every 1.5 hours all through the night.  It’s not even something I feel like I could fix unless I had a urinary foley catheter in place.  The belly feels like it’s getting bigger: getting up and out of bed is becoming more difficult (I have to roll to one side and then get up vs just getting straight up from a bend at the waist); the SI joint pain has returned with more frequency but it’s not unbearable; the Braxton-Hicks contractions are more common and coming higher up on my belly — before I would have maybe 1 every couple of days — this week I’m having several a day.  The Mini is still making their kick counts.  The gals on OB think I’m having a boy — they base this on: my “glow”, lack of acne on my face, the way I’m carrying the baby, my lack of all over weight gain…. although I’m not sure any of these old wives tales are accurate in any way.  I’d be ecstatic with a healthy baby, regardless of sex.

I’ve finished several books:

  • Brain Rules for Baby (Updated and Expanded): How to Raise a Smart and Happy Child from Zero to Five – listened to this on Audible (during 2nd trimester) and it’s outstanding.  Highly recommend for first-time parents and just setting a solid groundwork/foundation to build when baby comes.  This book was such a gem as it related a bit of science to baby development.
  • Unconditional Parenting: Moving from Rewards and Punishments to Love and Reason – started this on Audible (3rd trimester).  This book was a nice eye opener that not all praise and punishment is the right kind.  I learned a lot about fostering positivity with effort and not just for anything that is done.  I agree that punishment is not a good system for motivation, but this book really uncovers that reward is NOT the best system for motivation either.  I plan to implement these techniques for our Mini.  This was my 3rd favorite book in the bunch I’ve been reading.
  • Montessori from the Start: The Child at Home, from Birth to Age Three – listened to this on Audible (3rd trimester).  Also gifted to both moms. This was a close second to Brain Rules for Baby (for me).  It tackles the principles of Montessori and the whys and hows to implement this method of development.  It promotes independence of the child, but also places importance on how to promote brain development with the simple things (simple toys: no bright lights or sounds, no screens, the power of imaginative play, etc.).  I highly recommend this book as a 2nd read after Brain rules for Baby.

Starting these:

Our baby shower went off without a hitch!  It was great catching up with people and seeing the outpouring of love for our lil one on the way!  We could’ve easily fed 50 people — it’s always hard to know how much food to factor in.  We had Cardiff crack (tri-tip), burgers, pulled chicken sliders, coleslaw, veggies, dips and chips, cakes, cookies, potato salad.  It was an incredible feast!!  I only wish I could eat more!  I was only able to get a bite of beef tri-tip, one burger slider, and one chicken slider down before I was super stuffed!  Dessert came later around 7p for me.

The Braxton-Hicks contractions are more frequent now — having at least one daily — but anywhere up to 5 in a day.  Still waking up every 1.5-2hours nightly for a pee.  Drinking adequate amounts of water (I probably go through 4x 32oz of water daily and also 1x 32 oz water nightly.

We ultimately re-discussed the cord blood/tissue banking and decided on CBR.  After chatting with several moms who did it…. a lot of them have regrets for not doing it…. and the ones who did it have peace of mind.  Bear and I further researched the topic and decided we would do it and chose CBR.

Hours worked: 19.5

Week 35: January 16 – 22, 2018

This week has been insanely busy.  Not sure if that’s how the schedule just worked out this week or people are back to signing up for surgeries.  Additionally, this week Bear and I felt that the Mini was significantly bigger.  I feel more fatigued, larger, more difficulty moving around, more thirst and urinating, etc.  Lately, my craving has been winter citrus — oranges and mandarins.  Really, I’m craving anything with liquid… I can’t get enough.  Another great treat we’ve enjoyed is root beer — what is going on with these cravings?  Bear has been nesting hard!  He’s organized the house, setup the bassinet, installed the car seat, packed his hospital bag and the baby’s bag.  It’s so cute to see him so excited and nesting!  He’s been such a great husband, supporter, massager, and I know he’s gonna be an amazing father!  I can’t believe how fast the days are moving now!  We got our Cord Blood Registry kit and filled out everything for it so it will be ready to go with our hospital bags.

Things I’ve been looking at today:

Hours worked: 54.5

Week 36: Jan 23 – 29, 2018

We had our 36 week AFI and NST. I’ll be doing these twice a week now as I’m deemed “high risk” because I’m AMA (advanced maternal age: > 35 years old). My BP was great at 108/76. Fundal height was right on track at 36. AFI was normal at 9 (but the range I was told was 5-25). I want that number to be higher. Dr. W asked if I could drink more water. I’d happily do that — currently I’m drinking 6 x 32oz of water in a 24 hour period. My urine was free of protein and glucose. All good things. I’m 160lb. Whoa! Mini is head down right now. So far, everything is good!  Had the 2nd AFI and NST after a 14 hour workday.  AFI was 9.5 and NST was perfect – nice and reactive.  Dr. W said I could stop working at anytime, but I really want to save up all that time for when the baby comes.  Good to know that I can pull that card when I just can’t take it!  I was really dragging after working 37.5 hours in 3 days.  My legs are swelling, despite my best efforts of wearing calf compression socks and trying to put my legs up.  There’s a dull ache by the end of the work day.  Luckily, my Bear is always down to give my legs and feet a good rub down at the end of the day.

And I had to look at the odds of going into labor…

Hours worked: 45.5

Week 37: Jan 30 – Feb 5, 2018

Our 1 year wedding anniversary on Feb 4!!  I can’t believe how quickly the year flew by and everything that has come our way!  It’s been an incredible year! Nevermind that it’s SuperBowl Sunday (go Eagles!)…  we spent a wonderful relaxing spa day at Rancho Valencia.  The Duet 90 minute massage was incredible (we had Sara and Noelle — both were fantastic!).  A chill day lounging by the pool — I couldn’t have asked for a better way to celebrate our 1st year wedding anniversary!  In fact, Bear and I decided we will have a full spa day every wedding anniversary.

My cravings lately have been all things citrus and A&W root beer!  I’m trying to cut back on the sodas – I’ve never had such a craving for them (not even before pregnancy!).  This led me to look into the issues of artificial sweeteners.  Basically, I’m gonna stick to organic oranges, mandarins, OJ and La Croix Naturally Essenced Sparkling Water Variety Pack, 12 ounce Can (Pack of 24) bubbly waters.

Feb 5 was our weekly appointment for NST/AFI/Dr. W for week 38 (which is tomorrow!).  I’ve lost a couple of pounds and was 158.8lb for today’s visit.  Who knows what that is from as I haven’t changed anything in my diet or activity level (although this past week was pretty taxing). 117/73, hr 70.  FHR 140s.  Good NST read with adequate accelerations and contractions.  I’m contracting several times throughout the day, but not regularly.  AFI was 10.5 today!  On the cervical exam, Dr. W said I was at best finger tip (which is more than what it was last week – softened closed cervix).  There’s some spotting after the exam this go around.

Things on my mind lately:

I’m already thinking of getting out and about with the newborn.  We have a retirement party coming up for some of our colleagues and I want to go…but I also want to bring the Mini.  I think my strategy is a carrier and keeping it a short visit.

Getting a newborn out in a restaurant:

Hours worked: 47.5 hours (in 4 days)

Week 38: Feb 6 – 12, 2018

Had a bit of light spotting on Wednesday (38 weeks, 2 days).  Still contracting away. The tiredness is evident – the lack of sleep for the last month has been tough.  Maybe next week I’ll get the doctor’s note. NST was reassuring and the AFI was 10.1 on Thursday.  Everything is still going great!

February 10, 2018 — There’s been a change in my contractions.  Instead of just being abdominal contractions, they’ve turned into more back and abdominal contractions.  Right now, they’re about 8-10 minutes apart, lasting 40sec – 1 min.  Looks like we’re getting close.  With the contractions is the urge to poo.  I’ve started spotting again.  I’ve been up since 4:30 bc of the new back contractions — they’re pretty uncomfortable.  The abdominal contractions just feel like a strong menstrual cramp.  I’m on call this weekend (I traded down to #3 today bc I was #1 in the main OR).   Let’s see how this day plays out!

For the Chinese zodiac…

  • If baby is born before the Chinese New Year (before Friday, Feb 16, 2018), they are the year of the ROOSTER
  • If baby is born after the Chinese New Year (on or after Friday, Feb 16, 2018), they are the year of the DOG

Saturday, Feb 10, 2018

I woke up this morning around 4:30a feeling a lot of low back pressure and new buttock/tailbone pressure.  It woke me up from sleep.  It lasted for about an hour and then subsided.  Luckily, the day before, I traded with Milbern down to #3 for my #1 weekend call.  The new back pressure was off and on throughout the day — timing the contractions were about 11-13 minutes apart.  They definitely felt different from my other contractions which were mainly front and abdominal.  By the time the evening rolled around, my contractions were 5 minutes apart and still painful!  We went in to Labor & Delivery to get checked out since they said come to the hospital if you’re 5-1-1 (5 minutes apart on the contractions, 1 minute in length, and for 1 hour total).   Once we got to the hospital around 6pm, I got checked out and was only 1 cm dilated.  We found that the baby’s position was OP/OT.  One of the midwives suggested some positions to try at home to see if we could turn the baby — trust me, I was all ears to help get this baby into a more deliverable position!  We left the hospital to try these techniques.  There was a website she recommended called SpinningBabies.com that was super helpful for a bunch of these techniques.  We tried me being on all 4s with a bit of inversion.  We tried a hot bath with ice packs on my back.  I tried a couple of the techniques from the Spinning Babies website.   We tried these different techniques all the way until Sunday, Feb 11 at 2am.

Sunday, Feb 11, 2018

2am we came back into the hospital bc our contractions were now about 3.5 minutes apart.  The pain was still pretty intense despite our best efforts to get the baby to turn.  When we came back in, they opted to either give me some Tylenol and Ambien or Nubain and Phenergan.  I opted for the Nubain/phenergan combo as the pain was intense and the midwife stated I needed to relax to allow my cervix to dilate.  I was able to sleep for 3 hours and then after waking up, they decided to admit me as I was 3 cm dilated and 80% effaced AND could get an epidural.  That’s exactly what I did next.  Shiyin did an awesome job with the placement.  After that, I was able to get comfortable and get some rest.  I was started on Pitocin a couple of hours after the epidural.  By around 3pm, I had progressed to 6-7cm dilated.  Then I had SROM’d and enjoyed a celebratory pickle.  By around 7pm, I was 7.5-8cm dilated, but baby was still OP.  There was a forebag of amniotic fluid that was ruptured by the midwife.  We again tried a bunch of the different positions to help move the baby out of OP, but to no avail.  Around 8:30p, I was 10cm dilated and started pushing.  I was doing 10 seconds of pushing x3 per every contraction.  My OB (Kim Washkowiak) who wasn’t even on call came to deliver her.  This went on for an hour until our little girl was born at 22:09pm.  She looked perfect!  We were able to get skin-to-skin immediately and our cord blood and tissue was sent.  She got checked out by the baby nurse and everything looked great!  She was 7lb 3oz, 21 inches long.  She came out with a cute conehead!  An hour after delivery, she was latching and had a strong suck and we were able to breastfeed immediately.  This has been such an adventure and we’re so excited to see what each day brings!

Hours worked: so far… 42 hours (in 4 days)

Screen Shot 2018-02-10 at 6.20.40 AM

BRAINSTORMING

http://www.babybargains.com

https://www.babygearlab.com
https://www.momtricks.com/

Setting up a baby registry
Help and favors registry
https://www.babylist.com/hello-baby/pregnant-chickens-kick-ass-registry

Strollers

Baby Carriers/Backpacks:

https://www.consumerreports.org/cro/backpack-carriers/buying-guide.htm

Car Seats:

Breast Pumps:

Beds:

High chairs:
Graco Blossom 4 in 1 system

Great Day Cares:
https://www.babylist.com/hello-baby/8-important-signs-of-a-great-daycare

Local Day Cares to check out:

PEC 1 & 2 Blocks, Serratus Anterior Block

I’ve been hearing more and more about PEC 2 block for mastectomy.  What’s wonderful about this block is that it seems that the risk of pneumothorax is lower than for a paravertebral block.

Egyptian Journal of Anaesthesia; April 2014. Thoracic Paravertebral Block vs. Pectoral Nerve Block for Analgesia after Breast Surgery

SlideShare powerpoint: PEC 1 & 2 and Serratus Anterior Blocks

pec-i-and-pecs-ii-serratus-anterior-block-11-638

Current Anesthesiol Rep, 2015. Regional Anesthesia for Breast Surgery: Techniques and Benefits.

Rev Esp Anesthesia Reanim; 2012: Ultrasound Description of PECS 2 (modified PECS 1): A Novel Approach to Breast Surgery

Poster Summary of PECS 2

unnamedl

TAP, PEC 1, & PEC 2 Blocks PPT

Anaesthesia, 2013. Serratus Plane Block: A Novel Ultrasound-Guided Thoracic Wall Nerve Block.

NYSORA 2014: Update on truncal blocks

Summary:

  • U/S guidance: probe position similar to infraclavicular block. Find 3rd, 4th rib.
  • Pt position: Head away from side of block. Ipsilateral arm abducted.
  • PEC 2: Inject 20 ml 0.25% bupi between pec minor and serratus.
  • PEC 1: Inject 10 ml 0.25% bupi between pec major and pec minor.
  • Serratus: 5th rib, mid-axillary line. Inject 30 ml 0.125% bupi along top (superficial) and bottom (deep) of serratus muscle (which is just deep to the latissmus dorsi).

YouTube: PECS 1&2 Block

YouTube: Serratus plane block

Update: Oct 24, 2018

PECs blocks in Cardiac Surgery

http://www.annals.in/article.asp?issn=0971-9784;year=2018;volume=21;issue=3;spage=333;epage=338;aulast=Kumar

http://www.apicareonline.com/ultrasoundguidedblocksforsurgeries-proceduresinvolvingchestwall-pecs-12andserratusplaneblock/

https://www.ncbi.nlm.nih.gov/m/pubmed/29016551/

 

Paravertebral Block: basics and cancer recurrence

 

From J Anaesthesiol Clin Pharmacol. 2011 Jan-Mar; 27(1): 5–11.

Why do paravertebral blocks?
Paravertebral blocks and decreased cancer recurrence
Paravertebral block techniques

From NYSORA

But wait… what about the potential side effects/adverse events from a paravertebral block?

Why not do a TIVA with propofol and dexmetetomedine and local anesthesia via surgeon?  Where’s that study to compare?

** Update **  July 20, 2016 –> What about the PEC 1&2 Blocks as well as Serratus block?

Prolonging blockade with adjuvants:

Paravertebral block basics and cancer recurrence #paravetebral #block #regional #ultrasound #anesthesia #cancer

From J Anaesthesiol Clin Pharmacol. 2011 Jan-Mar; 27(1): 5–11.
Why do paravertebral blocks?
Paravertebral blocks and decreased cancer recurrence
Paravertebral block techniques
From NYSORA

But wait… what about the potential side effects/adverse events from a paravertebral block?

Why not do a TIVA with propofol and dexmetetomedine and local anesthesia via surgeon?  Where’s that study to compare?

** Update **  July 20, 2016 –> What about the PEC 1&2 Blocks as well as Serratus block?

Prolonging blockade with adjuvants:

TAVR Team: conscious sedation vs. general anesthesia

Today, we had a guest speaker Christian Spies from Queen’s Hospital in Hawaii who spoke on his experience with his TAVR team and conscious sedation vs. general anesthesia for these patients.  More specifically, we are speaking of the transfemoral route.

Keypoints:

  • Patient selection is key (consider for COPD; bad for OSA)
  • Short surgical time for monitored anesthesia care (MAC)
  • Decrease invasive monitoring (no PA catheter,+/-CVP)
  • No difference in hospital LOS or 1 year mortality rate
  • Move from TEE to TTE if MAC
  • Be prepared to convert MAC to GA (can be difficult in already tenuous patient in a crowded space under the drapes)
  • MAC agents: dexmetetomidine, propofol, ofirimev
  • Decrease pressor use
  • Develop an algorithm for MAC vs. GA and patient selection

From goinggentleintothatgoodnight.com

For my own lit search:

***Update May 1, 2018***

We at Scripps Memorial Hospital in La Jolla do most of our transfemoral TAVRs via conscious sedation assuming appropriate patient selection.  These patients still tend to be the inoperable patients not cleared for open heart AVR (aortic valve replacement).  My techniques and choices for setup have changed over time as I’ve had a chance to fine-tune my plan based on prior experiences with TAVR.  Patients typically come to the hybrid room with a 20g PIV placed by the pre-op RN.

My Setup:

  • 4 channel Alaris pump:
    • dexmedetomidine @ 0.7 mcg/kg/hr until incision –> 0.4 mcg/kg/hr until valve deployment –> off
    • norepinephrine @ 2 mcg/min (titrating on/off, up/down as vitals suggest)
    • Isolyte (IV carrier fluid) @ 200ml/hr until valve deployment –> 50ml/hr
  • Cordis neck line
    • Initially, I would have the interventional cardiologist setup a femoral venous line since they’re getting access to the groin.  However, the cardiologist would use that femoral line for emergent ECMO cannulation and I would lose my venous access and have to depend on a measly 20g PIV.  Nowadays, I try for a short 14g or 16g PIV.  If I can’t get one, the patient gets an awake right IJ cordis for large venous access.
  • Hot line fluid warmer with blood-Y tubing: this is for hookup to a large PIV or cordis line
  • Right radial arterial line
    • I started only placing right radial arterial lines because there was a case of a dissection and I immediately lost my left radial arterial line and couldn’t do pressure monitoring.  I insist on only using the RIGHT radial for my arterial monitoring.  Do not let the cardiologist only give you arterial monitoring based on their femoral arterial access.  It will only give you intermittent monitoring and there are critical points leading up to the deployment where you need CONTINUOUS arterial monitoring.  Therefore, I’ve found the right RADIAL arterial line best for continuous monitoring.
  • Facemask for continuous oxygen at 10L/mim with ETCO2 monitoring
  • For trans-subclavian/axillary approach vs. transfemoral approach TAVR, I’ll put in a supraclavicular block right after Cordis/large-bore PIV venous access for patient comfort while still utilizing conscious sedation/MAC.

My Technique:

  • When the patient gets to the room, transfer patient to OR table.  Start IV fluids @ 200ml/hr.  Cases that go well are about 2 hours from start to end.
  • Facemask O2 at 10L/min.
  • Start sedation: precedex/dexmedetomidine @ 0.7 mcg/kg/hr.  Some patients may receive 1-2mg midazolam x 1 and 25-50mcg fentanyl for radial art line placement.
  • Place right radial art line with lidocaine for skin numbing.  Place PIV with lidocaine.  If unable to get access for PIV, prep neck –> sterile gown/glove/drapes for U/S guided Cordis placement with lidocaine.
  • OR staff preps patient.  Antibiotics prior to incision.
  • At incision –> precedex to 0.4 mcg/kg/hr.  25-50mcg fentanyl PRN discomfort. 10-20mg propofol push for discomfort if needed while large sheath placed for valve deployment.
  • Crossing valve –> BP changes.  Manage with volume or levophed.
  • Valvuloplasty
  • Don’t treat over-drive pacing too aggressively when the valve is deployed.  Typically, once the new valve is in, a little volume will help normalize the BP.
  • Once valve is deployed, turn precedex off.  No other sedation or BP meds needed.  Change IVF rate to 50ml/hr.
  • Patient heads to PACU awake, interactive, and comfortable.

What techniques do you like to do?  Any suggestions on a different approach?