Dr. Eric Freeman writes from China
Pictures from China by Dr. Eric Freeman
5/14/08 11pm
Kidney transplant under combined spinal-epidural anesthesia
The mood around the OR this morning was a rather somber one as expected. The mass destruction of the earthquake that hit Central China 2 days ago was affecting every one is someway. A few of the anesthesiologists in the department left last night to lend their services. I gave 300 RMB to a donation fund at the restaurant I eat most of my dinners at. That is the least I could do; the quake could have easily affected Nanjing but someone was watching over me.
Today highlight was a combined spinal-epidural for a kidney transplant. Yes, you reading this correctly. A neuraxial block for kidney transplant, unless the patient refuses. They perform about 60-80 transplants a year here. The patient was a 45 year old male with his sister being the donor. She opted for general anesthesia and another resident was involved with that case. About 2 hours later, as they were finishing up in the adjacent room I got the patient into fetal position. Palpating my landmarks, I threw on my tight 7.5 sterile gloves. I felt a nice “pop” with the glass syringe in hand and then pushed the spinal needle through the epidural needle. I have yet to get an answer from anyone about the size of the spinal needle, but I am assuming it is a 26 gauge. Between this needle size and the onset time of ropivicaine, it is almost like being trapped in a c-section with certain OB attendings…..painfully slow. I have noticed the remarkable difference in the intrathecal anesthetic effect of bupivicaine and ropivicaine. Ropi’s sensory block takes a good few minutes and the motor up to 8 minutes. Got a T8 level with 2cc of .75% ropi and 1cc 10% dextrose and repositioned the patient. Radial A-line in smoothly and I was set to place a central line. However, my attending did not feel one was necessary so we went with the 18 gauge. The attending pushed 2.5mg of droperidol for sedation. I had never used that much droperidol so I thought I should be vigilant and watch the QT interval during the case. The anesthesiologists do not like to pump the patients with about 4 to 5 liters of crystalloid like we do. We gave about 2L crystalloid and 250cc of 5% albumin. The surgeons worked diligently and about 2 hours later the BP started to rise. Aspirated back on our untested catheter then pushed 5cc of our standard 1% lido and .375% ropi combo. This is sufficient to cause both a motor and sensory block. The case finished in 2 hours 45 min. Quick. You would think it made sense to keep the catheter in for post-op analgesia, yet we pulled it. This was for two reasons; not enough anesthesia staff to follow up with pain management care, and also the cost to the patient. We started the patient on IV PCA.
All of the residents carry around the MGH Handbook of Anesthesiology. I have made an effort and point out to them that Dr. Philip Lebowitz of our department was one of the founders of this famous book. About half of them understood me…
Early in the afternoon, one of the attendings named Dr. Zhu asked me if I wanted to go play ping pong afterwork. For a minute I thought he said “beer pong”, or at least I was hoping he did. I began to reminisce about the good old college days. Not to brag but I was quite good at it. In brief, 2 people on each side of the net. A cup full of beer in each corner. The team would get a point only when the cup was hit. First one to 21 wins. Each time the cup is hit, the other team has to drink 1/4 of it. My proficiency at beer pong might have explained the grades I received in O-chem.
A quick taxi ride and we arrived. This was definitely a sight to remember. A very large gymnasium with about 30 ping pong tables. People in different uniforms. I think there was some tournament doing on. Besides drinking tea and eating rice, ping pong is one of the Chinese favorite activities. I learned that it is their national pastime, like baseball is ours, yet I don’t think steroids is an issue in this sport. I remember flipping through the channels years ago on ESPN and seeing some professional players go at it. They hit the ball so damn fast you could barely see it. Dr. Zhu went over to speak to some of his friends, yet I was ready to play. I have played ice hockey for 15 years and consider it a physically demanding sport. I was a bit confused seeing people doing all sorts of warm-up and stretching. Just a little ball to hit around in a small confined area. Boy as was I wrong. I went over to one table and hit around with this one guy. He tossed the ball so high up on his serve I could barely follow it. This was followed by was some crazy spin action. I was able to return the ball, just not on the table. I think this guy got fed up with me as he beckoned a girl over. I hit around with her and didn’t fare any better. I was rather disgusted with my performance and was doing a lot of cursing. Loudly. I don’t think anyone seemed to mind since no one understood me. All caught on video. I then played three games against Dr. Zhu and of course, lost them all. I did get some points. Afterwards, Dr. Zhu escorted me to a corner where for 45 minutes had a private lesson with a coach. Forehand, backhand, forehand, backhand. I easily whacked around 500 ping pong balls before I got dizzy and my arm began to hurt. I worked up quite a sweat and I had enough. I was tired was ready to relax with a nice cold beer. The only problem was that I could not hold one up….