Dr J C John

@DrRobbieErskine Nicely done Robbie

Monday morning revision total knee arthroplasty..gotta love a Paramedian thoracic Spinal (hanging drop for refinement😉)

@mick_kerr @BlockIt_Hot_Pod Top quality video , well done and thank you

And here's part 2 - looking at all the other things we can inadvertently damage or inject into. youtu.be/HcF0Imiyfs0 @BlockIt_Hot_Pod

@DrRobbieErskine If it’s for a hip, often find you might need to add water to your spinal drug to make it hypobaric and get it up to T 10 @KiJinnChin courtesy

Robbie’s spinal tip this week: if a spinal anaesthetic in an obese patient is a struggle in a sitting position then turn them to lat decubitus position and try L5S1 Paramedian (possibly with Ultrasound if you need)👍

@chandra_ri64999 @PeterMerjavy @HouthoffKavita @NavBahal @Steve_Coppens @AlexanderLJones @jon_bailey_anes @EMARIANOMD @KalagaraHari @dr_rajgupta @bobfunn @DrTimJen @PeterRoseAnesth @garrettsbarry @jeffgadsden @Ropivacaine does dexmed in the spinal last as long as morphine does. I find morphine 0.2 mg lasts about 24 hrs

@PeterMerjavy @HouthoffKavita @NavBahal @Steve_Coppens @AlexanderLJones @jon_bailey_anes @EMARIANOMD @KalagaraHari @dr_rajgupta @bobfunn @DrTimJen @PeterRoseAnesth @garrettsbarry @jeffgadsden @Ropivacaine Time has come to become opioid free ..n alpha blockers are doing their job very good

It’s been my view for years that the side effects outweigh the benefits. Opioids can just go in IVs. @EMARIANOMD @KalagaraHari @dr_rajgupta @bobfunn @DrTimJen @NavBahal @PeterMerjavy @PeterRoseAnesth @Steve_Coppens @HouthoffKavita @garrettsbarry @jeffgadsden @Ropivacaine

@KartikBSonawane @RAPMOnline good post, Karthik. I have two queries. If ESP block does not affect ant rami, how does a thoracic eco work for rib fractures ? Is it possible that the spread of dye in a cadaver would be different to a live patient

For me, involvement of the ventral rami in ESPB is a complication or unwanted side effect. We administer ESPB for spine surgeries where only dorsal rami involvement is required. Using ESPB for anterior surgery is not my preference. Therefore, although controversial, the results of this study are in my favor.

🚨 🚨 MUST READ ALERT 🚨 🚨 🔬 This new anatomical study shows that the ESP block may not be a paravertebral "by proxy". 😱 No ventral rami were affected by this block, which is contrary to prior assumptions. 🔗 Read it all here: bit.ly/3XKrGO0

@SMunigangaiah Can't wait to catch up on your story when you get back Hope you said hello to @KartikBSonawane

Having great time visiting Ganga hospital, Coimbatore in South India 🇮🇳 they perform staggering 3000 spinal surgeries every year! I was astonished by their theatre work flow , most efficient use of theatre space, rapid turnover of patients! Team led by visionary leader Prof Rajasekaran! Around 10 % of UK 🇬🇧 population on some waiting list @NHSuk @NHSEngland need to adopt strategies and models around the globe to tackle this issue!

@ashwani_doc @BlockIt_Hot_Pod @DrRobbieErskine @jeffgadsden @RCoANews @doctimcook @RegionalAnaesUK Mighty useful for sensory nerves too, lateral female cut, lateral forearm cut n, sup peroneal, sural

@DrRobbieErskine @BlockIt_Hot_Pod @jeffgadsden I do use the friendly nerve stimulator for all the motor nerves…for reassurance and safety. I sincerely hope this could be considered for #NAP8 @RCoANews @doctimcook @RegionalAnaesUK

@BlockIt_Hot_Pod thanks @jeffgadsden for pointing out use of nerve stimulation in axillary block. I am a huge fan too of the nerve stimulation. It's very fascinating and reassuring particularly for trainees when you can demonstrate the twitching of little finger for UN & so on 🙏

@DrRobbieErskine @AlwinChuan Difficult sometimes when they have had a spinal and a GA or heavy TIVA for a hip or a knee to convince them that the GA bit is unnecessary risk I often get the surgeon to suggest it They have had a chance to develop better rapport

@AlwinChuan This is the usual experience in my practice. I’m sure we need to “encourage” RA to give patients the opportunity to then make a rational choice in future between the two.

Yes, told in surgeon rooms that RA is 1st choice; if they’re still undecided I have a chat to them. Can’t remember the last time a patient declined after explaining rationale, risks of RA AND of GA. They are all happy they chose RA in stage 2 recovery w their coffee and biscuit

@syahrul1988 @glauncel @chandra_ri64999 @mjoldman @KartikBSonawane @DrTuhinM @AoraIndia @ESRA_Society @mokaeleni @SGSocAnaes @ASRA_Society @KalagaraHari This is the real question ? What is the risk of cord damage in thoracic spinals 1 in 23000 is quoted in lumbar spinals @chandra_ri64999 did 5 in a day , I was was there . So 5days a week = about 1000 a year , Similarly other practitioners doing similar no's

@glauncel @chandra_ri64999 @mjoldman @KartikBSonawane @DrTuhinM @AoraIndia @ESRA_Society @mokaeleni @SGSocAnaes @ASRA_Society @KalagaraHari @JohnJohnC1 Thoracic spinal itself inflict great enough risk tho

Laparoscopic dermoid cyst removal under thoracic spinal anaesthesia..mild sedation n tolerated by the patient very well

@garrettsbarry @KartikBSonawane @glauncel @chandra_ri64999 @DrTuhinM @AoraIndia @ESRA_Society @mokaeleni @SGSocAnaes @ASRA_Society @KalagaraHari It's not deep sedation I was there !!!

@KartikBSonawane @glauncel @chandra_ri64999 @DrTuhinM @AoraIndia @ESRA_Society @mokaeleni @SGSocAnaes @ASRA_Society @KalagaraHari @JohnJohnC1 I don’t understand why use thoracic spinal for laparoscopic surgery. Sorry. Why not do a safe / controlled GA w/ ETT. I’m with @glauncel re: eye tape. I would think most mildly sedated patients would find eyes taped shut to be distressing. This looks like deep sedation.

@glauncel @chandra_ri64999 @mjoldman @KartikBSonawane @DrTuhinM @AoraIndia @ESRA_Society @mokaeleni @SGSocAnaes @ASRA_Society @KalagaraHari These patients have less sedation that I see often in awake procedures done in the UK Drugs used are ketamine under 40 mg, or dexmed under 20 to 50 mcg and buprenorphine These drugs are ideal due to their lack of resp depression

@chandra_ri64999 @mjoldman @KartikBSonawane @DrTuhinM @AoraIndia @ESRA_Society @mokaeleni @SGSocAnaes @ASRA_Society @KalagaraHari @JohnJohnC1 You’re adding the risk of a deep sedation/ GA to the risk of thoracic spinal (subarachnoid) anaesthesia.

@mjoldman @glauncel @chandra_ri64999 @KartikBSonawane @DrTuhinM @AoraIndia @ESRA_Society @mokaeleni @SGSocAnaes @ASRA_Society @KalagaraHari 4. I watched 2 lap chole, 3 spinal fusions , 1 pcnl, 1 hysterectomy under thoracic spinal 1 Spine had a fracture at T11, so Richa did spinal at T6 and L3 All patients mild sedation No GA If I had done a GA, I would have needed tons more drugs,kit I am convinced this is better

@glauncel @chandra_ri64999 @KartikBSonawane @DrTuhinM @AoraIndia @ESRA_Society @mokaeleni @SGSocAnaes @ASRA_Society @KalagaraHari @JohnJohnC1 I agree - it's a bit odd. Patients who are "lightly sedated" do not require their eyes taping. What is the rationale if they are not anasesthetised? GAWA?

@glauncel @chandra_ri64999 @KartikBSonawane @DrTuhinM @AoraIndia @ESRA_Society @mokaeleni @SGSocAnaes @ASRA_Society @KalagaraHari 3, One should also bear in mind , different cultures will respond differently to surgical situations . Eye taping to reduce stress in theatre is common practice in India Absolutely doesn't mean they were deeply sedated. Purpose of my visit was to see for myself how it's done

@chandra_ri64999 @KartikBSonawane @DrTuhinM @AoraIndia @ESRA_Society @mokaeleni @SGSocAnaes @ASRA_Society @KalagaraHari @JohnJohnC1 The video in this post … the patient’s eyes are taped.

@glauncel @chandra_ri64999 @KartikBSonawane @DrTuhinM @AoraIndia @ESRA_Society @mokaeleni @SGSocAnaes @ASRA_Society @KalagaraHari 2. Eye taping was a bit strange only because it's so diff to what I do in my European practice But sedation was very mild, 1 mg buprenorphine, or 20 to 30 mg ketanine or 20 MCG deemed All patients were responsive to oral commands , Spinal makes them sleepy too

@mjoldman @glauncel @chandra_ri64999 @KartikBSonawane @DrTuhinM @AoraIndia @ESRA_Society @mokaeleni @SGSocAnaes @ASRA_Society @KalagaraHari 1. I spent 2 days last week shadowing @chandra_ri64999 and observed 9 cases of thoracic spinal and was blown away by the potential for it Avoiding GA alone is reason enough to consider this in most patients Risk of cord damage frightens me, but Richa has done over 2500

@KartikBSonawane @chandra_ri64999 @shiv_cybersurg @Prasannasimha @DrTuhinM @ASRA_Society @KalagaraHari @ESRA_Society @DrDiveshArora @anesthesiadocmd @pritanand @BucksUSGRA @drmohansai Interested to know how he got hold of CSF !!

@JohnJohnC1 @chandra_ri64999 @shiv_cybersurg @Prasannasimha @DrTuhinM @ASRA_Society @KalagaraHari @ESRA_Society @DrDiveshArora @anesthesiadocmd @pritanand @BucksUSGRA @drmohansai It's CSF only. To check baricity it has to be CSF. Baricity of any solution is specific gravity of that solution with respect to CSF.

Right hemicolectomy in a severe COPD patient under segmental spinal anaesthesia ..T 8..9 SS ..with epidural catheter same space ..surgery finished in 100 minutes..epidural catheter used for postoperative pain management

@KartikBSonawane @chandra_ri64999 @shiv_cybersurg @Prasannasimha @DrTuhinM @ASRA_Society @KalagaraHari @ESRA_Society @DrDiveshArora @anesthesiadocmd @pritanand @BucksUSGRA @drmohansai Like it , what solution is in the vertical tubes mimicking CSF ?

@shiv_cybersurg @chandra_ri64999 @Prasannasimha @DrTuhinM @ASRA_Society @KalagaraHari @ESRA_Society @DrDiveshArora Kindly go through this video by Dr. Tarun, who described spread pattern of LA into the CSF as per the baricity.

@chandra_ri64999 @SinghDralok1305 Amazing

Happy to share..my husband a busy orthopaedic surgeon was called by IVRI ..Indian veterinary research institute for hip replacement in a dog ..he designed prosthesis n done for the first time in INDIA

@chandra_ri64999 Massive case series , nicely done You were measuring time to achieve block height of T4 and also the bromage scoring lower limb power, but you haven't mentioned it in the results Interested for spine surgery

cureus.com/articles/13968… …study published recently in pubmed indexed journal..study done in a large group under segmental spinal Anesthesia with out any side effects

@hjas18anes @chandra_ri64999 @KartikBSonawane @DrTuhinM @ASRA_Society @ESRA_Society @mokaeleni @KalagaraHari @AoraIndia Hi Richard It would be helpful to most of us who have never contemplated a spinal above L2 to know exact dosing for a lap chole So what drug, % , volume, level , baricity Thanks

@chandra_ri64999 @KartikBSonawane @DrTuhinM @ASRA_Society @ESRA_Society @mokaeleni @KalagaraHari @AoraIndia Very well done! I'm seeing some of my colleagues attempt this. Questions : 1. What level do you do your puncture? 2. Hyperbaric or isobaric? Dose? 3. Any problems with CO2 monitoring? 4. How has the patient response been?

Lap chole conducted 1 year back under Thoracic spinal anaesthesia..now coming for adenocarcinoma skin at epigastric port ..again TSA ..showing follow up of no neurological injury after 1 year..trying to remove myths of giving SAB beyond the traditional site