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Post by Kristen Horsman on Mar 1, 2019 8:49:52 GMT -5
This month’s journal club is presented by Jen Hannon. She is hoping that with the imminent opening of the Johns Hopkins Nurse Anesthesia program that CRNAs at JHH will regain some opportunities with regional techniques.
Please refer to the attachment that was sent via email. If you have a subscription to Current Reviews, this month's journal article is Lesson 7 Volume 41 titled "Neurologic Complications Associated with Regional Anesthesia". Nonetheless, this is a good refresher on complications of regional as we still care for patients before and after regional is administered.
The questions to encompass within your response:
1) Many of our patients at JHH have preexisting neurological disease. What do you find in your practice regarding regional anesthesia in these patients and what would to prepare to do?
2) Will recent research findings regarding the termination of the conus medullaris change your practice technique for spinals?
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Post by Moishe Mayer on Mar 6, 2019 11:24:05 GMT -5
1- At Hopkins, we are fortunate to have a Regional Team do it all....It depends on what procedure and technique are needed; if it is really necessary then I'd document preexisting conditions and symptoms, and consent pt for possibility of exacerbation.
2- First I am hearing of the this. I need to do more research to see if it actually extends until L4??
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Post by mcesaire on Mar 12, 2019 10:22:21 GMT -5
1. I've noted that the moment a patient reports having any history of neurological disease or symptoms the team deems regional anesthetic risk/benefit to be too high or a risk and any and all options for regional anesthesia is eliminated. I think our rather litigious society and medical field increase the conservative nature of Practitioners when they are making a decision on how to proceed. However, this is where I think education and reviewing literature is valuable. I did not know that up to 20% of patients are identified to have severe spinal stenosis. That number is staggeringly higher that I would have guessed. Therefore these patients have an increased risk of spinal abcess and hematomas. What's of note is that it is not typically the technique of the Provider that increases the risk of harm patients but rather as Moishe mentioned a careful and thorough assessment. I also appreciated how the article then states that this is not reason to decrease the practice for patients but to instead note that this risk exists and to adjust accordingly (ex. decreasing the amount of local that is given). I think while we have guidelines and protocols to follow, its valuable to know that you have to be flexible and knowledgeable as a Provider to know who is at high risk, what modifications can be given to care and technique when giving regional anesthesia, and accurately assessing and documenting any neurological symptoms. 2. The termination of the conus medullaris will undoubtedly change practice because you would be aware of the risk of injury. It was common knowledge during training and education that the spinal cord ended around L1 and yes with some variability but that was something taken in consideration when performing neuraxial anesthesia. The problem once again is not allowing for variability in our population and as we see now, there is enough evidence and information to show that more people then previously thought have a spinal cord that extends to L4, furthermore our assessment and baseline judgements for landmarks and location of the various regions can also be very far from fact. In my opinion this just requires a stronger need to assess patients in a critical and detailed manner in order to understand and document any preexisting deficits, assessment during needle placement is very crucial, and 24 hour and 48 hour monitoring after perioperative care is even more crucial since most problems can be avoided with rapid assessment, acknowledgement of symptoms, and interventions. This was a highly informative article. Thanks!
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Post by Ben Waldbaum on Mar 14, 2019 13:03:45 GMT -5
1.) A friend of mine who is an anesthesiologist and does a lot of expert witness testimony told me that he has "more business than he can handle with peripheral nerve injuries secondary to peripheral nerve blocks." These complications are devastating and I think under reported. As such, if a patient comes in with questionable neurologic status, I would be even more hesitant to recommend a regional anesthestic technique. To me, the benefit does not outweigh the risk.
2) No. Be careful and always assume the spinal cord is in your pathway.
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nanci
Junior Member
Posts: 57
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Post by nanci on Mar 22, 2019 10:11:41 GMT -5
1)We do have a significant amount of patients with neurological disease present for surgery and I have found that it has been well documented in their preops- especially when the patients have gone to the PEC Center for their preop evaluation. I also find that the regional team here at Hopkins is very cautious and if the risk is high they elect to not do regional. They are very conservative- but of note, they have increased their peripheral nerve blocks. That may be d/t the increased amount of robotic/laparoscopic cases so that blocks more efficacious than epidurals in some instances.
2) Termination of the conus medullaris- all patients are different so you go into the procedure expecting there will be some variability and just be cautious and cognizant of the possibility of it being below L1.
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Post by c velarde on Mar 22, 2019 13:46:58 GMT -5
I think pre-existing neurological deficits should be well documented. The regional anesthetic can cause more harm but surgery may also contribute to neurological damage. I would not do a regional technique with known neurological deficits present. 2. Always be cautious and try to stay below L1. Always document level and motor movement post procedure.
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Post by Mary Clothier on Mar 26, 2019 6:42:04 GMT -5
1.Great article, as stated in the article, preforming reginal anesthesia on patients with pre-exciting neurologic disease is controversial. The scarcity of data on the subject forces the practitioner to carefully consider the risk-to-benefit ratio of regional anesthesia in this patient population, I would not take the risk!
2.Classically taught that the Conus Medullaris terminates @ L1, however its termination may be as low as L4, potential trauma from a needle exits. Practitioners may not be very accurate in assessing the vertebral level by palpation! Again consideration of the risk-to-benefit ratio in this patient population, and variability with level location and identification, do no harm, I would not take the risk!
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Kristen Praesel Lang
Guest
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Post by Kristen Praesel Lang on Mar 26, 2019 8:21:36 GMT -5
1) Many of our patients at JHH have preexisting neurological disease. What do you find in your practice regarding regional anesthesia in these patients and what would to prepare to do?
There are a lot of patients with pre-existing neurological disease. It needs to be well documented and often is when patients visit the pre-evaluation center prior to surgery. In my current practice, the block team places all blocks in our surgical patient population. I would say that they are generally conservative in their approach when patients have a history of neurological disease.
2) Will recent research findings regarding the termination of the conus medullaris change your practice technique for spinals?
Although it is known that the spinal cord ends around L1, is important to remember that patients can vary anatomically. All blocks should be placed cautiously. Additionally, proper documentation of identified landmarks, level of placement, and level of block should be assessed and documented with each patient.
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Post by Jackie Howell on Mar 27, 2019 11:11:43 GMT -5
1. Many patients come to surgery with pre-existing neurological disease. As mentioned in previous posts, a thorough assessment, documentation, and risk stratification should all influence the proper anesthetic plan for the patient.
2. I'm not sure this research would change the approach to neuraxial techniques as most practitioners are cautious in anatomic assessment, placement, and the feedback we receive from patients upon placing of spinal/epidural needles.
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Post by Sarah Rollison on Mar 27, 2019 16:19:52 GMT -5
1) I think the first step for management is to obtain a thorough history and assessment of the neurological disease if possible, as others have mentioned. The literature is very inconclusive on this topic, but rather as the article states, the choice of regional should be made on a risk/benefit basis for each patient. Personally, I am terrified of the legal consequences that could arise from performing regional anesthesia on this subset of patients. There is little way to know if the regional anesthetic has impacted the disease process, created a new injury, or exacerbated the symptoms. From a patient safety aspect and from a legal standpoint, I think it would be best to avoid regional anesthesia. Of course there are other health problems that may make general anesthesia the worst possible option, wherein regional is the best approach. I think in these circumstances its best to have a discussion with the patient, surgical team, and rest of the anesthesia team about the surgical and anesthetic approach so that everyone is aware of the risks, benefits, and possible outcomes.
2) It's scary to know that the conus medullaris can extend to L4 when classic teaching is to place a spinal at the L2-3 interspace, or even occasionally higher. I think this will make me more cautious when placing spinals, and perhaps may lead me to select a lower interspace if easily identified. I think the best practice is to avoid spinal in situations with abnormal spinal anatomy or spinal trauma/surgery, as this may impact the level of the conus medullaris, as well as make placement challenging. Slow, controlled placement of the spinal with frequent patient assessment should be the standard of care for patients receiving a spinal.
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Post by Kim Hall on Mar 28, 2019 14:59:57 GMT -5
1. I agree that a thorough assessment as well as risk/benefit discussion are key when there is pre-existing neurological disease. I too would be concerned with the legal repercussions.
2. I think I would be more cautious when performing a spinal after learning the conus medullaris can extend to L4. I will continue to explain to the patient that their feedback is essential and frequently assess while placing the needle.
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Post by emedina1 on Mar 28, 2019 19:33:36 GMT -5
I will be very carefull with patients who present with any kind of neurological symptoms. A thorough assessment is imperative that being said I will always think of the benefit versus the risk.
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Post by jessica switzman on Apr 1, 2019 12:02:23 GMT -5
Thank you for a good review and article. I too hope we will have the opportunity to do more Regional Anesthesia. MANA is having a one day regional workshop 4/13 and there might still be space available.
It is very important that pre-existing nerve injury be documented prior to the block and the pt fully accessed to make sure they are a good candidate. Risk/benefits should be thought about.
I have been doing Spinal and Epidural blocks for many years and am I consistently access the patient for pain, numbness, area fleet, etc. Feedback and careful technique are essential with all Spinal, Epidurals and nerve blocks. The patient should not be so sedated that they cannot give feedback
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