Dr. Eric Freeman writes from China
Pictures from China by Dr. Eric Freeman
5/12/08 4:30pm
Spinal Anesthesia in an 11 year old.
The two scoliosis cases that I was supposed to do today were cancelled and I am not sure of the reason why. My first case was an 11 year-old boy for tumor resection of his tibia. After speaking to Dr. Xieke, he said the anesthetic plan was for a combined spinal-epidural. Huh? In an eleven-year-old? I was explained that in China, the patient’s anesthetic is often dictated on what they can afford to pay. Apparently IV PCA and general anesthesia and much more expensive than spinal or epidural anesthesia. This patient’s parents wanted regional anesthesia. What about increased spinal headache risk? An uncooperative patient? At least the parents were not in the OR. 1 mg midazolam and ahead I proceeded. They like to do all of their neuraxial blocks in the lateral position. Dr. Cui said the interspace is much greater than the supine position. I have done a handful of spinals in the lateral position, rarely an epidural, but the majority are supine. They have combined spinal-epidural kits in this hospital, that’s it. No separate spinal or epidural kits. Too expensive. Gertie Marx, Sprotte, Quicke, Whittacre are nowhere to be found. Glancing to my right was the kit. I knew I was in for a surprise when I opened it. 3 sponges, an 18g Tuohy needle, multiple needles, a 20cc syringe, 5 cc syringe, a 5cc glass “loss of resistance” syringe, 20g catheter, and a spinal needle. I am a size 7.0 glove. The Chinese 7.0 in the kit was too small. After prepping the patient, I was set to go. No 25g finder needle as I am used to for local anesthesia placement. An 18g needle with 2% lidocaine had to suffice. Feeling for landmarks, I grabbed the epidural needle and plunged away. Bone. Redirected. Bone. Redirected. Ah, finally between spinous processes. My next challenge was the glass syringe. This was a first for me. I can’t really describe the feeling but I was not liking it. This was beginning to feel like day one of my OB rotation as a second year. As anesthesiologists we must be adaptable, yet it is hard after you have done hundreds of epidurals with a plastic syringe. I did not have good tactile sense with this syringe plus the sterile gloves were rather thick. Yes, I know. Excuses, Excuses. After poking around for a few minutes I gave up. Even though my gloves were not very smooth, warm CSF was not the answer. Dr. Cui stepped up and repositioned the patient, got the loss of resistance, but no CSF flow after the spinal needle was placed. He ended up just threading the catheter, aspirating and then gave a test dose. This test dose was just plain 2% lidocaine, 5 cc. No epinephrine. After repositioning the patient, we loaded with 5cc 1% lidocaine plus 5cc 0.375% ropivicaine. Interesting combination. I know that the lidocaine dose is only analgesia. I later looked up and found that you can get a moderate to dense block with just 0.375% of ropi.. The case proceeded uneventfully and when it was over, we took out the catheter and brought the patient straight to the ortho floor, no PACU visit. Dissapointed in my performance, Dr. Cui told me not to worry. I wanted to sit the patient up. Another excuse for my failure. He said I will be much better by the end of the month, and that all will be done in the lateral position. I made a note to myself to add saline into the glass syringe to decrease any friction. When I return to the states I have a few weeks of pediatric anesthesia. The next time I work with Dr. Broderick I will suggest to perform a combined spinal/epidural in a peds patient. I wonder what her response will be…..
I was curious how much an anesthesiologist made in China. On average, depending on their year, the annual salary is 6,000 RMB. One RMB= 1USD. Do the math. Pretty low compared to our standards, yet the cost of living is much lower as well. This figure is before taxes, which is about 20%. Attendings make about 8-10,000 RMB per month.
Our second case was an L4-L5 laminectomy on an otherwise healthly 35 year old man. I wanted to get some more experience with remifentanyl so I induced with 2mg midazolam, 100ug remi, 200mg of propofol, and 10mg vecuronium. I did another asleep fiberoptic. I showed the resident some of the tracheal anatomy and orientation. Afterwards, I told him a few techniques to become more facile with the scope. Flipping the patient over, I made sure all pressure points were protected. I asked the nurse for some extra bed sheets to place under both elbows so they would not lie against the wooden arm-board for hours unprotected. We ran our standard propofol and vec infusion. I added 0.15ug.kg.min of remi to the mix. Sevo on 0.5 MAC. The case was uneventful, with half hour to go the vec was stopped and ten minutes later I bolused 200ug of fentanyl. Off to the PACU the patient went, intubated of course. I’m getting more proficient with my Chinese extubation phrases. The nurses must enjoy hearing it as the room erupts with laughter. One hour and ten minutes after the vecuronium was discontinued, I extubated the patient. Again, no reversal agents given.
Between cases I sometimes take a stroll into other operating rooms to see what is going on. I am not quite sure what the incidence of corneal abrasions here in China is, but I’d say about have the time patient’s eyes are covered with tape. I asked one of the residents about this. I told him that we would get slapped by our attendings if we forgot to tape a patient’s eyes. He agreed that this should be done, yet explained that the shape of the Chinese eyes facilitates eyelid closure and that if tape is not placed, it is not so harmful.