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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
becaue PH comes back in some approinted two or some approinted four or appronted six and you did not have all of four factors to distinguish the two ,you could not tell the difference ,as i said you ,most of you commonlly just do provocative task ,we threading the catheter ,we dosing very judicially
and what we set the reaction is,and what we based on the reaction and we determine whether or not it is a spinal or epidural catheter,so let us think about the way we test the catheter,perhaps we want to engage the idea whether or not it is a spinal catheter or if it is epidural catheter or if it is the location that dose not want ,such as intravenously .that question posed here is :do you use the test dose? i was admited many people do it .perhaps one that most to be used is lidocain three mililiters one and half percent withe some epinephrine(肾上腺素） in it ,question that you have to ask is :is this test sensitive? and if you look at the component of epinephrine and you look specific pregnant woman and you look at heart rate changes and sometimes heart rate change will occur,because it increase by the distribution that occur during the pregnancy ,but it also can be messed by the contraction that occur at similar or near similar time ,since you rely on the lidocain and you will say this forty-five milligram of lidocain if it enters intrvascular and will tell me it is a intravascular and response is no.i have done a number of study in the UK(united kingdom),those crazey brains ,i can say that because my wife is a british,but it takes reliably about a hundred of milligram of lidocain in order to distinguish wether or not intrvenous with lidocain and so let us talk about intrathecal (鞘内注射）component,yes, absolutely lidocain in the spinal space will give you a nice spinal anesthetic,but do you really want an spinal anesthetic for labour analgesia ?and i was admited you do not.the other question to concern ourself is whether or not it is harmful .there are a coupl of case of reports even that a small amount of epinephrine admittedly into the woman have proclaimed here at gestation hypertension or hypertension had a catastrophic increas in renal blood pressure and there are also associated with decrease in the renal blood flow .perhaps we are doing harm to this .finally if some place allows ambulation ,just add small amount, even properly placed at the epidural space will impare the ambulation and if it do not allow ambulation and it will at least impare the motor mobility and there are none of parturient that like having a dead numb leg while in the bed enjoying the analgesia admittedly,but they want to move from side to side .so what is the guide we get ?avoid the epinephrine if the epinephrine is concerned if they want to continue in it ,change your threshold from in stead of fifteen beats per minute that many people used to ten beats per minute change,monitor the maternal heart rate .there is nothing a pose like a song ,there is nothing you can not jump and there is nothing to hold the pose,and someone just watches the lound bell right here ,can pose back and forth and if you are claiming nothing ,monitor it and also avoid during a uterine(子宫） contraction and finally with everthing ,every dose we give through a catheter ,we should witness what happen and do a careful clinical assessment and how about the saline prior to a catheter ?is there something benefit or is there something disobey to this ?you know ,ok ,see a positive hands ,yes, many of us ,under the belief,perhaps the saline push away the something at the epidural space and so expand the epidural space and so if we do the losting resitance to saline technic ,we incorporate saline into epidural space before we thread the catheter.
question is whether or not this makes thing different. Gadalla did a nice study which randomised the individual to either have zero milliliter saline ,he did a losting the resistance to the air technic ,or ten milliliter of saline ,basically,what he found is that in saline group ,two percent chanceand in dry group ,twenty percent incidence,and so it did make a difference,so this is one reason why we like the losting resistance to saline technic.Tsen ,before we have performed meta analysis,look at different studies,it does seem to be value in placing some amount of saline before threading the catheter ,andso we cut the incidence of blood in the catheter by thirteen percent to six percent,so that halves.what is interesting is however most of study what we have done before flexible tip catheters will be in play.i mean i used the-----catheter that have a flexible tip,in fact, some of this studies what we have done ,nylex was used and nylex is very stiff .i remember when i was first started--- the reaction to nylex catheter,it has a stylet in them ,i mean you can put that thing through breakwall,i mean it is very impressive ,but in look into the fact of this flexible tip catheter,we also recognise that this has an advantage in terms of not geting into this trip,so there are maybe some benefit looking into the selection of catheter when you do your epidural placement. and how much secure the catheter ? you have got through the travel ,locating the epidural space and you have threaded the catheter and functioned and it was threaded beautifully ,where are you gonna to secure the catheter and when do you exactly tape the catheter ? and to evaluate this and we have this question this posed
and that is :does patient movement actually correspond to catheter movement? have you ,sort of, witnessed some of you sometimes have the patient move or maybe even examine the analgesia that maybe it is one side or something go back in there and it seems a lubricant has moved your catheter around,i mean many of us have witnessed the catheter does seem to move.W did a nice study which is a fellow in STF and basically what he did was to take 255 parturients in the placement by same orient to place ,but before they taped catheter in,they had the patient sitting up and then take a lateral position and they examine whethwr or not catheter move and it did appear to move in majority and wide majority of patient.now i have drew a couple of cartoon for you here ,basicallywhat they were saying is that when you were hunched over,you have the skin,soft tissue and everything compressed aganist on processed soft tissue used,and how about have the patient sitting up? those tissue relaxe away from epidural space ,they wraped away and left a way for this process,as i said ,if you tape the catheter in,it is gonne to be moved ,but if you do not tape until you lay them down,you actually allow the pass of movement of soft tiuss around that catheter.
and such that preserved the location in epidural space. and now on contrast that as i mention to the episode where you know --------------and you put the patient sit up because you do not want that catheter move and it just moved on you and it moved just because of the natural force of soft tissue under the skin relaxe their way from the epidural space and how much does it move ?here is Hamiltons result.basically they indicate that from flex to up position,there are some movement ,there are more movement from lateral to up position and overall you can see great movement, sometimes ,four centimeter catheter movement in some individuals and so if someone is only placed the catheter three centimeter and that catheter is out .moreover when you think about we will not worry about this ,just threading more catheter like leaving a nub on,and you connect the tub on and rid of skin,and probable doing that is you will get more one-side block.there are a number of studies ,nice work by JKJ three to seven centimeter ,and show that seven centimeter placment into the epidural space led to more one side block.and once you have placed the catheter ,you want to make an impression of it.how do you dose it ?does dose actually matter ?question here is whether or not if we use various dilutive solution will better off than if we use concentrative solution and Christiean did a very nice study in this in Switzerland
basically what they demonstrated was is you use bupivacaine and you use twenty milligrams ,but in some of concentrative form that bupivacaine of four millimeter and the other use very delusive concentration of twenty millimeter,but it is same milligrams amount,and you will have more pain relief with more delusive solution,admittedly it is in greater motor block,that is because of diffusion to the different level that is for the motor ,sort of pathway and overall the duration increase as well.this and many other studies and some that we conducted is the reason why we shifted the way from ten to twelve millimeters of a quarter percent of bupivacaine to twenty millimeter of zero point five percent of bupivacaine.we found greater advantage of doing so.how about dosing the catheter ?and specifically the situationwe all face,well ,at least i face ,i mean you still have not got one side block,bit i certainly do it .what will you do in that situation?do you dose the catheter ?doyou pull back the catheter and dose it?and this was question that was addressed by Belin and basicaly they take the individuals ,and then thread the catheter five centimeters into the epidural space and they found the woman had one side block and randomised those half of those women to either just receive five millimeter of local anesthetic or other half pull back one centimeter ,then dose the catheter.you wonder : oh, is this make a difference? should i be going through the snags via pulling down ,take a term ,take back the catheter and retape the thing s and then dose it .and what they found was this : that if you compare the people only received the local ,vice versa ,you pull back the catheter, then did the local .there is no difference between two.
how about dosing the catheter ? specifically,that situation we all face,at least i faced,i mean you still have got one-side block,we certainly do it .what would you do in that situation? do you dose the catheter ?do you pull back the catheter and dose it ?thiswas the questions addressed by belin.basically he takes the individuals and threads the catheter five centimeters into the space and he found the women one-side in block and he randomised half of those women just either recieved five milliliter local anesthetic or other half pull back the catheter one centimeter and then dose the catheter .and you wonder ,uh,is this make a difference?should i go through ----of pulling down ,take a term,pull back the catheter and retaping things and dose it?and what he found was this: that is if you compare the people just received the local with those pulled back the catheter and the did the local ,there is no difference between two.both become comfortable,relatively three quarter of the time,interestingly because if initial therapy did not work,what J did the study is :then he did an option,so in the group that he only gave the local anesthetic ,if still uncomfortable,then he pull back the catheter and gave more local anesthetic;and the group that pulled back initially gave the local anesthetic ,and he just gave more local anesthetic,and what he found is that get a hundreds of percent of people comfortable.and now challenge for J is a coup of reasons ,once i see J,you and i both have been doing ---analgesia for a while,we both do studies,ther is often times that one-side patients i can not get comfortable and quite surprisedly,you have got a hundreds of percent of women comfortable and you know that is what find in the study .i know J ,and i find him an effortful guy ,dose a good research and good clinic initiation .so i have taken the theme of value,but the other question i asked him was that if you believe that local only works ,why not just give another bolus only
but other question i asked him was if you believe that local only works ,why not just give another bolus of local only?because that way you own truely tell whether just volume make a difference from one-sided block and then he said ,that is a good idea ,i should have done it ,but we did not ,therefor this is what we will have ,but other people can do the study ,we are engaging that study right now ,hopefully, there are some results next year too,to see if all we need to do is just bolus whether or not that is more successfully than doing any manipulation of the catheter
how about using neuraxial opioids ?do they actually make a difference ? expecially when you are trying a general analgesia.Y did much of the work here. apart of this, he did a fellowship with staff ,basically what he demonstated was the difference between bolus of dose of fentany vice versa infusion of dose ,what they finds that infusion was that it was very similar to the subdermic analgesia ,it was dosed so slowly ,just got it absorbed and you could distiguish two and really find that if give same amounts and slow dose of IV format,however you can find if you bolus that dose at single appointed time ,you will get segmental effect ,you get the opioids within the neural segment as well as central effect |
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发表于 2013-5-20 17:12:11
