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thank you very much,i am appreciated.and well ,back to everybody and this like home and i have been San Francisco since my collage day as my two sister live here and like all of you coming back to San Francisco is fun thing.epecically i am thankful of many of you are back here for this particular meeting and it is great to see many of you and see friends and new friend here and other people as well.
the topic of present of us is gonna to be an epidural and equinox .and certainly want to talk about --analysis(----分析）that how to use in growing and perhaps useful in this condition time and time when a woman can not recieve a ---technic as we recognized that majority of the time can use ---technic and can make sure that is up to part and , does nothing and rare in role
in terms of looking at epidural technic, ithink about it ,reason for why i call this equinox has a coupl of reasons:first ,if you look at the dictionary definition of the equinox ,we could note when sun crosses the ---equator(赤道），make a time a day equivelent to day and night ,as you know here we are in the centric , we have to no deviation through day and night and we have to able to do our technic at any appointed time and other reason i name it for song written by joln coltrance and what i like about Coltrane is he is a prominent musician in jazz at the time of his soaring (此处先生说的是：searing 我以为是口误，所以改下哈)popularity that is in 1960s to 1970s.reason he was promptly popular is that he had a real attention on his craft ,he is known to take a rift note which is a collection of forty notes ,sometimes he practiced himselft after four or five hours at a time ,moreover,he played the different type of instruments to get the more varity of different approach ,bacause of that his attention is the way that we should look at our own technic and should be question based our own and we are gonna to ask yourself :if some of this innovation of things are what we have been incorporated with ? some were capable with and some perhaps were we have to change our incorporation into our practice,but once we decide to do that ,we need to practice,practice and practice
now ,you maybe familar with -- musical with--in 1959s.my favorite things are the --- tune that comes out of this and was one of growing and surpopular tune comes out of that .it was the jone Coltranes favorite songs as well .in fact,he was known to take this one song and take forty-five measures to reflect the voice and he played and played and take about forty minutes and he was known to take this one song and sometimes he only played this one song for entire concert.he was also recorded eigteen different albums and is able to be sort of profession statement and similarly,i think we have our favorite ways in doing things and sometimes thing need to be challenged ,reexamined and incorporated .one of them is certain patient positioning and by showing hands, so i could see how many people by large set patients up while doing the placement .ok,wide majority there.now ,there are maybe some advantages to setting the patient uprightly, but there could be advantage to lateral position as well and has a part in patient movement .there are a number of studys that look at connectic motion of woman in pregnancy,even fully pregnancy at forty weeks gestation.limitation in mvement by back and forward ;side to side,even rotational is only two to three precent and we have witnessed to install that position while we try to do placement and i know that .when you once is in the lateral position ,you actually have secured by bed and you can not move back and forward because fixtion calls fitness bad and you can not move side to side because the bed is in the way .and overall thay can take a more relaxant posture and that posture non movement is certainlly helpful to us ,but there are some other reasons expecially an optional bilateral position is not avaliable and that he has a cord prolaps or if they have a fetal part presenting. these are individuals you can not setting up. as i said your labour analgesia would actually move onto another type of analgesia,you are gonna to inform not for the delivery or you will commit the patient to the general anesthesia.so if you can not do your technic in lateral position and if you get confronted with that technic and now there would be something that adds your amendment terms ,and there are other advantages in lateral position as well.Bahar illustrate this rank to mark nine hundred patient to either exited a lateral or a lateral ten degree trendonburgar position and what he found in the lateral trendonnurgar position but the just lateral position,the blood in the needle was less and blood in the catheter was less and you may think this is only for normal size individual and he also rank to mark four hundred and fifty patients behind the mark to the same three position and found that this advantage was trendonburgar position or just lateral position in the term of blood in the catheter here and overall correlated with he takes both studys together is less overall attempts because of less need of catheter replacement while performing in lateral space .but how does it makes sense ? Igarashi provides some answers to that ,and what Igarashi did is taking a fiberoscope(光导纤维镜）and thread it into an epidural needle(硬膜外穿刺针），he take first the individual in non pregnant state and examine her epidual space and found that the vein collateral system was diminished ,small and natural and nothing prevents the intrusion of catheter or needle;but take this individual at twelve weeks of pregnancy and you will find they will be further engorgement of vein system and you find when she gets to full term and it will have engorgement and further crudement of the vein collateral system in the epidural space.the epidural system is valveless and does not present any sort of barrier to change hydrodynamac pressure.so if we send them a collum of fluid up ,it will translocate to the bottom of element and that is the channel and that would be the lumbar section (腰椎部）where operating your catheter and needle。so consideration for the lateral approach.how about the epidural needl placement ?we think about this just bevel of needle makes a difference ,turning the face of cephalad of the epidural right,perhaps caught that is one beter than other .and this is the question that addressed by huffnagle sj.basically what he did is that randomizing(随机分配） a hundred and sixty patients into forty age groups to either have the beleve faced cephalad(头向）left or right caudad(尾向）and what he found was that cephalad orientation has less number of one side of block , less number of inadequate block and also greatest number of puncture with comfort ,so this cephalad orientation is benefitful and now what is interesting is gonna to beaming in a couple of what orthepedics（骨科）papers have derived some information from this .that is saying if you are coming in for left knee replacement that some individual are actually turning the bevel of needl of epidural technic to the left side and this orthepedic papers also suggest you will have better block coverage on affected or surgical side and what the patient would not want that
i am after coming in for unilateral（单侧）surgery,you want to block on unilateral side,however we we know a paracentesis(穿刺术） is a bilateral（双侧） procedure。we want both side ,sometimes we get one side ,but both sides is definitively what we want,so cephalad orientation is good.
how about the epidural space identification ?everyone of us has a favorite of doing things and show hand some of us have lost in the resistance of saline（生理盐水） ,ok , of course,a number and some of us have lost in resistance of the air and all right ,just some people of our generation divide，but that is certain i was trained with losing the resistance the air and for longest time losing the resistance of the air is my technic ,howerve as i started doing the study i made the conversion. nothing of honour, other have the advantage and we will talk about it and we will consider whether not one has the value over the other and we will take this to subjected to different types of studys in clinic meta analysis you will find that,in terms of differences,looking specificly at unlock segments ,incomplete analgesia or episode of post puncture of headache,surprisely ,there is no differences.SC the next speaker is gonna to come up he did a nice meta analysis that demonstrated that there is no statistical(统计学）differences between two technic and that probably indicates that what we do our best was very familar with that technic and then very successful with that technic ,it was said there are a couple of place where probably were not lost in resistance of air technic .one would be the woman that had a post puncture headache ,it can do a blood test .she has some of air that may communicated over and other woman may have A-V tunnel connection,so that usher some of air into the circulation and may go up into brain and do nothing any good there and but looking at complication(并发症） specifically we know the air has a number of complications both subcutaneous tissue and inter something ahead and we had a case and this is represented by graphic here,and that was the picture of woman that had not lost in the resistance of air and she had some air in the entrence of the angle of spine space（看不懂CT,疼呀，望有懂CT的同道看一看这个CT) ,she has a such significant pain such distortion of her vision and diminishing hearing ,the day after birth,we sent her to hyperbar chamber to decompress and this is certainly enough that can not happen and sometimes to evade some of air however saline has some of complications as well.as we do our placement,this never happen to you?you get that drop of fluid coming back out of it? he is certainly pondering :uh ,is it a CSF(cerebra spine fluid)?or this is just nearly the saline that ever used and i know my some of practiced collegue ,good friends of mine ,do get lost in the resistance of local anesthetic .i do not acquaint with that should be technic of choice,but he certainly do his job successfully.but what happened when you get the fluid that coming back and how do you distinguish whether or not it is a CSF or if it is local anesthetic or if it is a saline more commonly .alhs(人名）addressed this question by looking at a couple of factors.what he did is look at the warmth and temperture of the fluid.you can do this on the gloved hand and you can actually do this throwing a glove ,then can distiguish some of tempeture difference and if warmed ,it told you that it mostly is a CSF ,PH difference ,that is a greater way to say it is a CSF.and present glucose and protein as well .but what ALHS have demonstatrated however was you need all four factors in order to definitively tell one from the other and the most difficult to discriminate the two is PH |
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发表于 2013-4-15 07:27:10
