For patients with difficult spine and scoliosis, particularly the elderly, there is a paramedian approach called “taylor technique “, wich is described in old Bonica’s obstetrics anaesthesia book. It uses sacral landmarks to direct you to the big L5 S1 space and it is usefull in patient’s with extensively ossified spines… worth a video…
Msha allah awesome I like this paramedian skills mostly I used in djibouti hospitals iam nurse anesthetist in djibouti but I learn anesthetist for Somalia
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I swear that you are the best doctor in anesthesia i have ever seen Your explination is very very nice thank you doctor i wish you talk about anesthesia drugs or methods according to patients diseases
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I routinely use the paramedian approach with 27 g pencil point needle … in addition I would 1. insert the needle on the site to be operated on and 2. direct the bevel as well to the side that will be operated and I find very often that the anesthesia will last much longer on the chosen site …
HI Meinhard Kritzinger! Thank you for sharing. Indeed, we all do things differently; in the end - it is what works for you. Thank you for watching and do subscribe to the channel - we have a lot more coming up soon; let's share the experience, learn from each other, and all get better at what we do. Cool that we have this medium now to collaborate without barriers. Greetings from NYSORA!
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I love the paramedian approach but it does take some getting used to. Especially with epidurals, the LOR feeling isn't the same and it's a lot easier to get an unintended dural puncture. Would love to hear Dr Hadzic's comments on this.
Thanks for your lessons that I really enjoy but I am surprised that you don’t use the ultrasound to assist in neuraxial blocks. In our unit no one attempts spinal or epidural without using ultrasound with nearly 99.99 % success rate. It helps a lot and it is quite easy. Regards
ultrasound for every spinal is a huge waste of time. I do 4 total joints a day with spinals and I never use ultrasound. I also have a 99.99% success rate
My only problem with the technique shown here is that he advances the needle without the mandrel at the end. You should always advance the needle with the mandrel in place to avoid clogging the needle and/or inserting material into the subarachnoidal spance
Hi baconmann! You are definitively correct. However, here the stylette (mandel) was actually used. Having said that - there are times when the needle needs to be advanced a few mm more, as it falls short of entering the intrathecal space - and taking the styllete out does not result in CSF drip. In these situations, I personally do not re-insert the stylette (mandrel) back for those few mm. I have not noticed this to be a problem in clinical practice, but it saves some time. Best regards and thank you for commenting!
Definitely my thoughts as well sir. My consultant yell at me because of doing this in a difficult spinal situation. And then he show me how it's clogged when that type of needle contact in non fluidal space.
So do u also knock the pt out? Or is this all u use? 🤔 interesting to see this approach I would think easier once your comfortable doing it. I love your videos!
You can do a total hip with spinal anaesthesia alone. A GA here would be redundant and excessive. Classically you do one or the other with the evidence suggesting neither is superior to long term outcomes.
What is the center of "two centimeters lateral and two centimeters caudal" in your opinion? For me, the center is the inferior border of spinous process. However, sometimes I find it so caudal that the needle ends up in a sharp angle to reach subarachnoid space.
Hi Bennet! Thank you for the great suggestion. We will definitely put this on our list. Greetings to you and all your colleagues and make sure you subscribe to our channel so you don't miss these upcoming videos. Best Regards from NYSORA!!
I love this technique and demonstration. Question: has anyone used this technique with the introducer? Is it less necessary because we are avoiding the interspinous ligament? Will this technique work with a "naked" 25G pencil point needle? Thanks!
Hi There! If you would like to learn more about this Technique, visit here:- nysoralms.com/courses/nysora-compendium-of-regional-anesthesia/ and subscribe to learn in detail about Spinal Tap and you will join thousands of your colleagues discussing management of anesthetic cases, always updated protocols AND visual guidance to all procedure sin regional anesthesia."
It's not clear in the video if it's from the tip of the spinous process or the interspace between two spinous processes. But observing the video carefully, I think his left thumb is palpating the tip, yes. Also, that's how I do the paramedian approach
@@baconmannn Hi there. OK - the main principle is that the needle is 1) inserted about 2 cm lateral to the midline. Everything else is secondary - as the needle is progressively "walked off the lamina" proximally to pass through the interlaminar space into the subarachnoidal space. 2) If one can with certainty palpate the interspace - then inserting a needle 2 cm lateral AND 2 cm caudad with a slight medial and cephalad orientation is a good start. The goal is not necessarily to have a 1-time pass to success but to have a strategy to walk off the lamina to success. Hope this helps and will develop a more detailed animation video to help with this. Best
Is the 2cm lateral and 2 cm distal relative to the midpoint of the tip of the spinous process? The angle is 30-45 degrees laterally, but what is the caudal angle?
Sir your camera angle was like patient looks at anesthesiologist during pre oxygenation in GA. Secondly you haven't completed elaborated how much we should move lateral upward medial lateral !
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It's not a spinal tap. A spinal tap uses a larger needle to drain CSF for diagnosis. The prep is not done right. Start from the center and work outwards. Don't bring in contamination from the outer edges to the central area where you will be introducing the needle.
Hey Satyashila! Noted! Thank you for sharing. We all get better this way. Make sure you subscribe to this channel; a lot more is coming soon! Greetings!
Why do u prep before spinal in this fashion....? I thought it is moving in circular and outward direction from the point of puncture.... just like the surgeons do!
Prepping in circles may be better. But we do this a couple of times with a lot of products, so it probably does not matter. Best regards and thank you for your comment.
@@DRBLUESNYCwhen you prep in circles, the disinfectant going above the central point may ooze downwards into the area of insertion, that’s why I wash in vertical lines spreading out from the midline 3-4 times.
@@DRBLUESNYC but if he hit the spinal cord by mistake advancing needle little more and the patient would be in a wheelchair for rest of his life couple centimeters more
By T12-L1, the spinal cord becomes the cauda equina. It exists "like strands similar to a horse's tail"n and not a solid giant nerve. Not easy to pierce with a needle.
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For patients with difficult spine and scoliosis, particularly the elderly, there is a paramedian approach called “taylor technique “, wich is described in old Bonica’s obstetrics anaesthesia book. It uses sacral landmarks to direct you to the big L5 S1 space and it is usefull in patient’s with extensively ossified spines… worth a video…
I didn’t understand at all the para median technique, but with you video i did ! Thank you so much
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Msha allah awesome I like this paramedian skills mostly I used in djibouti hospitals iam nurse anesthetist in djibouti but I learn anesthetist for Somalia
Hi Khadir abdi lahi! Glad you like the video. Thank you for watching. Do subscribe to this channel and share with your colleagues; a lot more videos are coming up - let's share our clinical experience! Cheers!
Mr Hadzic explain very well ... thank you....!
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I use it frequently. Thanks
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I swear that you are the best doctor in anesthesia i have ever seen
Your explination is very very nice thank you doctor i wish you talk about anesthesia drugs or methods according to patients diseases
He does! See the library where the different solutions are discussed, bupi, ligno, etc
Hey Hana Gasme! Thank you for a good suggestion. We will definitely put this on our list. Make sure you subscribe to this channel; a lot more is coming soon! Greetings!
@@nysoravideo i will do it do not worry and oli will tell anybody i know about your fantastic vedios
amazing video, can't wait to try
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I routinely use the paramedian approach with 27 g pencil point needle … in addition I would 1. insert the needle on the site to be operated on and 2. direct the bevel as well to the side that will be operated and I find very often that the anesthesia will last much longer on the chosen site …
HI Meinhard Kritzinger! Thank you for sharing. Indeed, we all do things differently; in the end - it is what works for you. Thank you for watching and do subscribe to the channel - we have a lot more coming up soon; let's share the experience, learn from each other, and all get better at what we do. Cool that we have this medium now to collaborate without barriers. Greetings from NYSORA!
Great Technique 👍
Hi Ashish! Thank you! Cheers!
Great Technique! Thank you for sharing!
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Very well explained 👍
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Thank you for sharing this video. Very Helpful!
Hey Training Admin! Glad it was helpful! Stay Connected!
Great video and explanation. I would recommend all of my colleauges paramedian technique. It is definitely a lifesaver for difficult spinal.
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Veri informative and elaborative. You are a great teacher
Wow, thank you!
Great technique i like paramediam
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@@nysoravideo .
I love the paramedian approach but it does take some getting used to. Especially with epidurals, the LOR feeling isn't the same and it's a lot easier to get an unintended dural puncture. Would love to hear Dr Hadzic's comments on this.
Same, especially thoracic
Yes!
Thanks for your lessons that I really enjoy but I am surprised that you don’t use the ultrasound to assist in neuraxial blocks. In our unit no one attempts spinal or epidural without using ultrasound with nearly 99.99 % success rate.
It helps a lot and it is quite easy.
Regards
where is that
ultrasound for every spinal is a huge waste of time. I do 4 total joints a day with spinals and I never use ultrasound. I also have a 99.99% success rate
My only problem with the technique shown here is that he advances the needle without the mandrel at the end. You should always advance the needle with the mandrel in place to avoid clogging the needle and/or inserting material into the subarachnoidal spance
it's likely a cutting tip quincke needle, as it's an older patient, so less risk of PDPH
Hi baconmann! You are definitively correct. However, here the stylette (mandel) was actually used. Having said that - there are times when the needle needs to be advanced a few mm more, as it falls short of entering the intrathecal space - and taking the styllete out does not result in CSF drip. In these situations, I personally do not re-insert the stylette (mandrel) back for those few mm. I have not noticed this to be a problem in clinical practice, but it saves some time. Best regards and thank you for commenting!
Definitely my thoughts as well sir. My consultant yell at me because of doing this in a difficult spinal situation. And then he show me how it's clogged when that type of needle contact in non fluidal space.
Excellent job 👌
Hi Muras! Thank you! Cheers!
Explained very well 👍
Hey KD! Glad it was helpful! Stay Connected!
I use paramedian technic for all of my patients 🙂🙂
So do u also knock the pt out? Or is this all u use? 🤔 interesting to see this approach I would think easier once your comfortable doing it. I love your videos!
You can do a total hip with spinal anaesthesia alone. A GA here would be redundant and excessive. Classically you do one or the other with the evidence suggesting neither is superior to long term outcomes.
well explained, thank you.
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@@nysoravideo done.
Thanks
Great 👍👍👍👍
Thank you! Cheers!
What is the center of "two centimeters lateral and two centimeters caudal" in your opinion?
For me, the center is the inferior border of spinous process.
However, sometimes I find it so caudal that the needle ends up in a sharp angle to reach subarachnoid space.
Very well explained sir🎉
Sweet! Thanks a million.
You're welcome!
Thanks very much ❤
You're welcome 😊
Good explanation, please make a video about paramedian epidural
Hi Bennet! Thank you for the great suggestion. We will definitely put this on our list. Greetings to you and all your colleagues and make sure you subscribe to our channel so you don't miss these upcoming videos. Best Regards from NYSORA!!
ممتاز
I love this technique and demonstration. Question: has anyone used this technique with the introducer? Is it less necessary because we are avoiding the interspinous ligament? Will this technique work with a "naked" 25G pencil point needle? Thanks!
Hi There! If you would like to learn more about this Technique, visit here:- nysoralms.com/courses/nysora-compendium-of-regional-anesthesia/ and subscribe to learn in detail about Spinal Tap and you will join thousands of your colleagues discussing management of anesthetic cases, always updated protocols AND visual guidance to all procedure sin regional anesthesia."
Yes, why no introducer? I find a 25g spinal needle needs the support
Just to clarify: it’s 2cm lateral and 2cm caudal from the tip of the *spinous process*?
It's not clear in the video if it's from the tip of the spinous process or the interspace between two spinous processes. But observing the video carefully, I think his left thumb is palpating the tip, yes. Also, that's how I do the paramedian approach
@@baconmannn Hi there. OK - the main principle is that the needle is 1) inserted about 2 cm lateral to the midline. Everything else is secondary - as the needle is progressively "walked off the lamina" proximally to pass through the interlaminar space into the subarachnoidal space. 2) If one can with certainty palpate the interspace - then inserting a needle 2 cm lateral AND 2 cm caudad with a slight medial and cephalad orientation is a good start. The goal is not necessarily to have a 1-time pass to success but to have a strategy to walk off the lamina to success. Hope this helps and will develop a more detailed animation video to help with this. Best
@@DRBLUESNYC Thank you!
Dear doctor Hadzic, why not a smaller gauge needle, i see this one is 22G, quite big for today's standards, don't you think?
Is the 2cm lateral and 2 cm distal relative to the midpoint of the tip of the spinous process? The angle is 30-45 degrees laterally, but what is the caudal angle?
gracias profesor
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Wounderful
Anamazing
Stay Blessed
Thank you! Cheers!
Sir your camera angle was like patient looks at anesthesiologist during pre oxygenation in GA. Secondly you haven't completed elaborated how much we should move lateral upward medial lateral !
Perfekt
Hey Mohamed Elhabil! Indeed. Thank you for your comment! Make sure you subscribe to the channel so that you do not miss some super educational upcoming videos!
@nysoravideo what is the gauge on ur spinal needles, which manufacturer. In our case we could not use our spinal needles without an introducer (braun)
It's not a spinal tap. A spinal tap uses a larger needle to drain CSF for diagnosis.
The prep is not done right. Start from the center and work outwards. Don't bring in contamination from the outer edges to the central area where you will be introducing the needle.
No use of introducer needle?
Why would you advance the needle without the stellate?!
Too much movements with camera.. . Thanks for sharing knowledge
Hey Satyashila! Noted! Thank you for sharing. We all get better this way. Make sure you subscribe to this channel; a lot more is coming soon! Greetings!
@@nysoravideo yes sir.. Thanks for fantastic video.. It's helping me a lot in my private practice.... I am freelancer anaesthetist
Why do u prep before spinal in this fashion....? I thought it is moving in circular and outward direction from the point of puncture.... just like the surgeons do!
Prepping in circles may be better. But we do this a couple of times with a lot of products, so it probably does not matter. Best regards and thank you for your comment.
@@DRBLUESNYC thx alot sir... really appreciate that u took the time to address my query. Keep teaching us with da same enthusiasm
@@DRBLUESNYCwhen you prep in circles, the disinfectant going above the central point may ooze downwards into the area of insertion, that’s why I wash in vertical lines spreading out from the midline 3-4 times.
Doesn’t tht paralyze the patient
Neah. This is the purest/most natural anesthetic for the lower body that goes away just the same in 2-4 hours. Cheers and thanks for watching Koko.
@@DRBLUESNYC but if he hit the spinal cord by mistake advancing needle little more and the patient would be in a wheelchair for rest of his life couple centimeters more
By T12-L1, the spinal cord becomes the cauda equina. It exists "like strands similar to a horse's tail"n and not a solid giant nerve. Not easy to pierce with a needle.
لا نريد إعجاب او متابعة شاركونا الأجر و فقط😉🌹🔥🔥🔥.....