Transcript for:
Thoracic Segmental Spinal Anesthesia Overview

system need to start my video again okay at thoracic level the spinal cord is positioned leaving a significant space between the posterior and the spinal cord and also at thoracic levels the now roots are very slight and thin also the CSF is comparatively very less making the block very effective with a very low dose of drugs used you can see here at Mid thoracic levels there is sufficient space between the posterior and the spinal cord it will be more clear in this slide you can see here also uh the impalonian GUI I did a study on the low incidence of neurological complications in thoracic epidurals after accidental dual puncture and they measured the exact distance at various levels and they found the distance to be around 5.19 millimeter at T2 levels 7.75 millimeters at T5 levels and 5.88 millimeters at T10 levels in the various positions like supine lateral and sitting positions and they found that the distance is more in all positions especially the sitting positions at Mid thoracic levels you can see here the distance is 5.95 millimeters at T6 levels spinal cord usually sits winter in the pics of the thoracic curve and more so when we ask the patient to flex the spine you can see here the distance between anterior and the spinal cordate on the left hand side and the distance between posterior and spinal cord and right hand side and also because of the angulation which is required to perform spinal at metallic levels the distance between the posterior and the spinal cord is further increased we need angulation of around 40 to 45 degrees to perform spinal atmosphorus levels and the distance gets further increase you can see in the next Slide the distance is almost 8 millimeters as compared to 4.5 millimeters at the lower thoracic levels oh thank you thank you that because the distance between the posterior Dura and the spinal cord is much more incorrect especially and also the roots always light and thin especially especially at Mid thoracic level as compared to lumbar so we need not be very worried about damaging the spinal cord when we are attempting to do a spinal anesthesia in the thoracic level am I right Dr naresh yeah yeah thank you uh we will move on to the next question um Dr suvarna do we need any specific type of needle for doing segmental spinal anesthesia do we always have to use only 27 or 29 gauge or we can use the needles that we are comfortable with in doing number spinals okay Madam can you say uh stay in my share slide is visible yes yes so coming to the needles The Cutting was the pencil Point needed there's always a debate the point is that with the pencil point needle the orifice starts at 0.8 millimeter from the tip and it ends only at 1.7 millimeter from the tip so what does that means you that means you need to introduce the pencil point needle further almost two millimeter inside to ensure that the hole is completely inside the spinal canal so the pencil point needle got a one millimeter blind tip beyond the hole so it has to be inserted further compared to chunky needle whereas our usual cutting needle got a terminal that means that upon Dural puncture the CSF will be appeared immediately so in such a way the cutting needle is safer because the CSF will appear immediately on Dural culture and in Metro Studies have shown that the pencil Point needles cause more damage the membrane than cutting needles neurological complications were compared between cutting and pencil Point needles the impolony at all as reported that there was no significant difference they could observe between the two type of natives so even the uh the pencil Point needles safety was questioned even in 1993 itself whereas when high incidence of paresthesia was observed in cesarean patients and the authorized rightly claimed that is there a price tag of potential neurotoma so I would go for a usual cutting needle than a pencil point needle and what about the size of the needle even systematic reviews and metallenses showed that pdph and the procedure failure rate is lowest with 26 Gates a dramatic needed with a smaller needle smaller cutting needle especially you may get a lower incidence of pdph but the risk of procedure failure will be higher so what I would recommend is whatever needle the you are confident with putting in a lumbar you should select that needle for the thoracic puncture so it whatever you are confident with the needle that you should take and between pencil point and putting it is always the cutting needle because there is a blind tip of about 0.8 millimeter for a pencil pointer so the possibility of neurological injury is more if it is the spinal cord so uh does anyone disagree with what Dr suvarna said that Dr naresh or Pat Sadi would you uh do you agree with what doctors wanna said or do you disagree no it's uh the incidence of parastatia is definitely more with the pencil Point needles as you have to enter a little bit more inside the interactive space because the tip is almost 1.7 millimeters away from its uh uh the hole is almost 1.7 millimeters away from the tip so you need to enter little more to get a free flow of CSF otherwise you can use uh any needle you are acquainted with and it is always better to use that combined spinal epidural kit which has a interlock Safety Lock to enter into the intractical space if you are combining it with the epidurals thank you Dr naresh uh Dr naresh had already mentioned a little bit about the angulation and all when he talked about the anatomy of the thoracic spine versus the lumbar spine uh Dr tarun what is the main difference in technique in attempting Dural puncture in thoracic space as compared to lumbar space because most of us would have done hundreds and thousands of lumber neural puncture about what uh what what is the difference when we want to do it in lower thoracic or mid thoracic uh it's fine please stop sharing please but yeah it looks like Dr tarun is having some technical challenge so uh Dr naresh uh understanding how the drug will spread is essential for a successful segment in spinal as Dr patsa the introduced in the beginning because you should know that you should know the anatomy well you should know what is the requirement for the surgery and that's how you are going to plan so is using a isobaric drug essential for segmental spinal or can be used even the Hyperbaric ones that we most of us are used to or Hyperbaric as some of the literature suggests yes a very good question actually using isobaric drugs is not a must but as a very drugs have some advantages as you can see that they are not positioned dependent you can use it in any position whatever position you use they are I mean you don't need to wait for some time they are not position dependent and they have a propensity of uh most of the time selective block that is referential sensory block and that's why the recovery is early the patient can be ambulated very early avoiding is very early and also the hemodynamic stability is there so isobaric drugs should be preferred actually for all laparoscopic superficial thoracic superficial abdominal surgeries or abdominal surgeries in morbidyl fail patients where relaxation is not issue so we will we will discuss a little more about the individual requirement for different surgeries sir thank you so much so people uh so the take home messages it's probably easier to plan and execute a segment isobaric drug right sir you can use Hyperbaric drugs especially in open surgeries when patient is a male muscular patient and you find that the relaxation is the issue or you you can use a combination of these any of the two drugs like you can combine isobaric with hyperbole you can combine isobaric with hypovari to have a desired caudal or capillary effect uh partha would you like to add something to that hello yeah one minute is it in there in the question what is the main difference in technique in attempting Dural puncture in thoracic versus lumbar space yeah in lumbar space we are usually accustomed and we have done thousands of cases but in thoracic spine whereas the angulation is more so it is a prefer to use paramedian approach and uh we have to make angle at 45 degree depending upon the which level we are inserting the needle see it is about t7 the thoracic vertebrates are more angulated so you have to make more angle so it is preferred for pyramidian approach if you try in midline approach you know the chances of failure are very high so we have to use paramedian approach in the thoracic segmental spinal thoracic spinal as compared to paramedial so angulation why can't we go in the midline and just angle it more why is it difficult most of the times the interlaminal space is very narrow at the midline uh especially from T4 to T9 where the Spanish process are very much angulated and most of the times going midline you uh if there is a actually some fibrosis or a interlaminal space is very narrow uh you cannot go in the midline you can either go paraspinous approach or a paramedic approach and especially from T4 to T9 otherwise below T9 it is as usual regulation is as usual as your Lumber So Below T10 usually it's not very difficult as you mentioned in your definition and then what one would normally use and you specifically mention there is an upper level and a lower level so can you explain to us how to plant volume of drug for segmental spinal partha I will I will make a small thing in that Dr naresh palwal statement he is very clear that the interlaminar space is also narrow is is not into spinous inside also it is narrow from T4 to t7 that is what we should understand that is why we are going from the lantern side got it so you can take your question now uh yes how do you decide on volume uh how much volume to give for any given uh surgery the basic tenant is using less structure one ml usually will spread three segments up and three segments down so that is the basis if you give one ml we think that everything is not actual means everything every case it should not be like this we plan that one number if you give will go up by three segments and go down by three segments for example if we give in t seven one ml it should be from T4 to Theta that is the plan that is what we should have in the mind before understanding the site of nose reception and understanding the site of puncture so we should understand where we are going and where is the NOC section one ml will go this side three segments and one ml will go through this side three segments is this true for all drugs hyper hypo ISO or yes is there any difference between uh the segmental spread depending on what uh kind of drug you're using up yes they have clearly proved that there are no major differences that there are no major differences sometimes it may be five or seven but with comparing Hyperbaric and isobaric there are no major differences in approximately six segments per one ml alone uh we'll go to the next slide one minute one minute that's our next slide is not coming you can just go ahead and say whatever you want yes this is the next ultimately we you ask for doses no breast surgery it's around T5 T6 this is important for people who are not using routingly that is why I put this slide colonic resection this is all approximately T45 t7 gas Factory t681 ml there's prostomy 1 ml lap pulley around T8 1.5 to 2 ml laparotomy 2 ml cesarean delivery around 1.5 ml nephrectomy 1.5 ml so breast surgery this is this is the level of incision and this is the probable volume and this is the probable sensory level um so there is a question in the chat box about the doors I'll give you a few seconds to take a screenshot of this slide uh go ahead meanwhile Dr naresh you wanted to add something yeah I have some objection about this slide actually I also objected when it was posted by British Enterprise this year the levels required for breast surgery they have mentioned is T1 to T12 actually it is C5 to t7 for mrm you need levels right from C5 to t7 this is not T1 to T12 this is for simple mastectomy you need just T1 to t7 only and also for some major abdominal surgeries like for gastrectomy this is not enough it's not enough you need some help and also about the isobaric drugs isobaric drugs are mostly site of injection and dose dependent first trade and also the depends from Patient to Patient there is variability because the CSF density and specific gravity uh and the temperature also causes some disturbances in the spread of these isobaric drugs so you may not always get the desired spread depending on the conditions isovarials are usually on the verge of being hyper very and if you give in the sitting position and keep the patient sitting for some time then you can have higher levels and also if you cool the truck at 24 degrees it can become Hyperbaric and also when you warm the truck at 37 degrees it can become hypovaric so you need to keep these things in mind for isobaric drugs and the Hyperbaric drugs are mostly gravity dependent for this trade at whatever level you inject they are not I mean will spread according to your listening they will be gravity dependent phosphate so there will be more rostral spread than Chevrolet spread when you use a hyperbaric is that what depends on in which position you have injected and in which position you are kept the patient afterwards yes just stop sharing your screen yes if you could just stop sharing a scene uh Dr Sachin most patients and surgeons in corporate hospitals prefer general anesthesia for most of their procedures except maybe hip and lower or maybe lower abdominal surgery so as a beginner how do you think we should choose a patient for segmental spinal so that things go smooth with patient surgeon and surgeon yes ma'am um incorporate cells most of the patients for abdominal and thoracic strategies they prefer GA so it is challenging for our newcomer on the acceptance issues are there so for the corporates one should begin with proper counseling uh of the patients as well as the surgeons explaining the benefits of this particular technique or what are the other techniques so the first few cases should be done under guidance of an expert and to start with the one should prefer doing segmental spinals in high-risk cardiac and uh respiratory patients after taking proper constraint from the patients and the relatives and once the surgeons in the OT team they become comfortable After experiencing the benefits it becomes easy to apply this technique to let's say asa1 and asa2 patients also so uh coming to the question how to uh how a beginner should choose the patient surgeon and procedure so the ideal patient for the beginner should be an ASA three or four cardiac respiratory compromised patient and surgeon should be an understanding competent surgeon who should be able to finish off the surgery early and the procedure should be a short procedure right so but isn't it a catch-22 situation I would like the other panelists also to come into this doing a technique in a high respiration with which you're not familiar or that that is that doesn't seem like the right thing to do especially one minute let me just complete the question please yeah so that is one side of it so if you are an experienced anesthetist experienced in handling high-risk patients and you have done hundreds and thousands of spinals and hundreds at least of thoracic epidurals and you start on the Journey of thoracic segment and spinal then what Dr Sachin says may be correct that you know you choose you may is choose to do it in a high risk patient where you are well washed and you have all the facilities for converting to GH required or whatever may be so when you are a beginner is it is it the right advice to say that you I know you added the I am just for the sake of argument I'm saying Sachin I know you specifically added the phrase do it under the supervision of a senior anesthetist that is the catch word however so but I just want a little bit of discussion on this because uh depend the number of case reports and they know anecdotal things that are coming now on WhatsApp and Facebook and all every day everybody so we uh and so finally at postgraduate and Anastasia should not get the idea that you know hey I've got this needle now so I can go anywhere and do any case and you know just poke a needle in the thoracic spine and do any kind so I will start uh with Dr naresh and then very briefly I want all of you to uh because this is the basic thing how do I start hello I always advise the people to start with cases where it is most indicated actually there you have a chance to I mean justify your giving thoracic segmental spinal especially the people from corporate setups they have started like this and uh if your spinal fails what uh will happen is you may not be able to do the second spinal anyway you are going to give generation for that patient and in case your second spinal is successful then you have a new pathway for doing it in ASA one two patients your surgeon will be happy he will be I mean convinced about the technique if you use it first time for a patient where it is most indicated thank you uh so what now would you like to say something I also think it is advisable to start with in some indicated patients the thoracic spinal should be done in the right patient by the right clinician only if you are confident with the thoracic epidural once you gain the perfect confidence then only you try the thoracic spinal and initially in the indicated cases then you can go for uh ASA 1 and 2 patients [Music] so at that time uh the chances of success are more uh then uh after uh accustomed with this techniques you can start with your routine cases or very short short cases clear cut cases like laparoscopic appendicectomy uh where the Clearfield cases or any open surgeries like open left or any uh very short time of surgery so you can more comfortable and you can show that now the patient is lifting the legs and all this thing the effect is very much easily aware of when person can void the urine erasing so Southern also get confidence and he will allow you to yes I will prefer the other ways and unfortunately I will try to give I will try to give really reasonably healthy patients where we can intubate easily where there is no difficult Airway anything a few cases and then convince and we are we know what is happening there then we switch on to two difficulties and this is my idea so two words for uh to me and partha feel that we should start with straightforward cases but that this is an ongoing debate I'm sure the audience will have their points we will come back to it again Dr raghavendra now that segmental spinal is an accepted technique there may be pressure on anesthesiologists working in resource constraint areas to take up more complex surgeries in sikha patients without proper equipment for monitoring or for providing safe general anesthesia so what do you think is the minimum anesthesia equipment which without which any anesthesia special and a specifically segmented Finance should not be given Dr raghavendra yes ma'am the thing is just because you are giving a segment of spinal doesn't mean that you're bypassing these standard stuff so segment notes even during the segmental spinal all day is the standard uh equipments are required so you are you are not bypassing the any equipments over there especially for Rural practitioners if if you're not a constraint at least see especially if you're giving a segmental spinal like to see whether the Ambu bag is there an essential machine is there what a working voted table is necessary effective hyperbolic solution or hyperbolic thread session uh and if does anyone want to add anything specific otherwise we go on to the next segment okay so now we'll come to a little bit some of it we have already discussed but nevertheless just though for those who join late and on talk to naresh what are the main advantages of segmental spinal over traditional spinal anesthesia many of the abdominal surgeries if we want we can do uh with a larger volume and you know and with the lumbar puncture and then do the abdominal surgery people have done it but obviously it comes with its baggage so what are the main advantages of segmental spinal over traditional numbers the structure is which were thought to be out of domain of spinal anesthesia like upper abdominal thoracic and superficial thoracic surgery is like breast surgeries are possible with segmental spinal and you need to use just half the dose then that is required at Lumber levels I have seen many people you are using 4 ml even 6 mL of the drug I have made few people who use 6 mL of the drug and still not getting the levels required I mean T3 T2 levels so with segmented spinal you can use just half the dose that is around 2 to 2.5 ML and get the levels required for the surgery like upper abdominal surgery and because of the low doses of drugs use there is less hemodynamic fluctuations early recovery or re-abulation chances of DVT are less and also there are cost of nausea vomiting chances are less patient Day Care procedures can be done avoiding is very early you don't need to put a catheter there are many advantages uh right so that there was some question uh I don't know whether we should take it now or later that if you cut off the afferent from the chest wall for patients who are because all of us seem to agree that for some of the cases that we could start with is respiratory because when there is a chest problem almost everyone from patient to surgeon to everybody is convinced that hey maybe we should not give general anesthesia if we incubate we may land upon a ventilator blah blah blah so uh how I mean what is the scientific explanation for not being worried about taking away the afferent from thoracic uh levels uh while in a respiratory patient can I answer yes please the main inspiratory muscle of respiration is diaphragm and because we are using very low doses of the isobaric drugs they have a preferential sensory blocks so most of the times the upper abdominal muscles and the intercostal muscles there is just a sensory block the post School expiration and being may get affected but usually there is no problem with inspiration and expiration uh thank you uh partha what are the advantages of segmental spinal overturning how it works better than the trying to give a large volume to get a high level for spinal lumbar spinal but uh what is the advantage over general anesthesia so we can use it in patients with morbid lung disease they have used two cases where the patient is actually posted planned for a lung transplant incidentally found got cholecystitis and they have done with segmental spine so this is one of the biggest advantage over general anesthesia a morbid lung disease like this the whole is lung is gone like this patient is on oxygen and that case of difficult Airway like this we can have better hemodynamics and especially after a pneumo peritoneum in GA especially a small head down we have to ventilate from down the patient the airway pressure will increase the BP will shoot up to 180 hundred and after that we start an ntg this will cause the richest PVP decrease and saturation will fall so these all these things have gone with segmental spinal there is no nausea you can have better recovery and this is ideal for day care surgeries yes we can do daycare surgeries we can discharge the patient also because even after the surgery the patient can walk post-op atelectasis and respiratory morbidity is extremely Less almost nil with this when compared to general anesthesia so these are all some of the advantages of segmental spinal over general anesthesia just like in intensive care now the trend is towards preserving patients spontaneous respiration because the patient's spontaneous respiration make you mismatch and everything everything else is you know much better than any best ventilation strategy that we can come up with so perhaps one of the reasons uh that the respiratory patients do so much better in under respire segmental spinal rather than or do badly and the general anesthesias because we are tampering with their natural respiratory drive and you know their Auto people or whatever it is that they do to maintain their saturation would that be a right assumption this so Dr tarun yes one of the common surgeries everybody's coating is you know mastectomy so uh why would you choose or people I'm sure people have done uh mastectomies under para vertical block or thoracic epidural uh and then uh what is the advantage of doing it as segmental spinal uh also some of the high risk patients for abdominal wall or some minimal surgeries when they are very sick I am sure all of us have done it before under uh local or uh you know tab block or erector sheet block or serratus and airplane block or whatever so what is the advantage of segmented spinal over all these assorted techniques that can be used in this reputations less hemodynamic fluctuation in any blocks if you have to give multiple blocks and that is also not uh 100 effective so this is Sure Shot very effective and 100 we will get the result see uh I have done around 1500 more than 15 minute cases but only one patient I have to repeat that segmental spinal no failure is there till there so in number I may get failure [Music] we can do everything in uh according to those we can adjust the rows and the duration of the surgery also it's extremely easy it's much more easier to convince the patient that I am going to do a single prick okay maybe two bricks one for local rather than telling that I'm going to okay at multiple levels and you know both sides and and then you have to wait for the onset and then you may feel something and then you may have to give some sedation all I your point is very well taken Dr karon thank you what are the contraindications for segmental spider everybody's been talking about the indications let's go to the other side contraindications are same as other spinal like patient refusal local and any local infection any increase pressure or uh uh more than that important is the surgery of long duration if it's a single shot uh thoracic spinal it is of short duration ordering so if you if it is a long durian surgery you have to combine with a cathedral technique either a continuous final or a combined spine lipidural and other relative contraindications are with the patients with a severe hypovolemia or uh left ventricular outflow tract obstruction and like a hypertrophic obstetric cardiomyopathy severe synoptic relations those are relative contraindications and any pre-existing neurological uh disease like uh like uh demyelinating diseases all those are relative contrary otherwise the absolute contraindications are same but it is of short duration only so you have to combine with any Cathedral technique if it is a surgery it's a long duration surgery hello hello yes Dr narration did someone want to add something how about thoracic scoliosis or something would you use uh segmented spinal in scoliosis um we don't we give the general anesthesia with uh intraopical opioids for uh scoliosis surgery not segmented spinal that is our institutional practice no no we're not talking about surgery for scoliosis we are talking about patient who has scoliosis coming for incidental other say abdominal surgery or say definitely try it's a relative contraindication where the spinal itself is difficult at thoracic level and if there is scoliosis and spread of the drug is very hard to predict the spread of can I add something yes sir actually it is the best technique and advice technique for patients with scoliosis there is restrictive lung disorder and if you find it difficult you can do a pre-procedure water so scan to find out the your interiminal spaces you can do it your ultrasound guided and even in cases where the previous spine is operated the chances of failure with segmental spinal are less than epidural you get chances of failure with thoracic or lumbar epidurals because of the adages and all this but with spinal it is very less you can try from the convex site if there is a glyphosis or scoliosis all convex side is always said to be more open for giving is fine you can take the help of ultrasound to find out the interlavinous space even use the the um thank you what should we specifically Monitor and look out for us normally when we give lumbar spinal we are quickly seeing whether the you know leg is getting paralyzed and whether the feet are moving abducted then or you know there is incontinent of the periods or whatever something like that so in in what should we Monitor and look for after giving segmental spinal and how long should we wait there is a question in the chat box about exactly how long should we be waiting to make sure the effect is there uh thoracic then you have to be a little careful and monitor the heart rate respiration and the blood pressure all three applications patient so uh thank you Dr um can I hear something yes sir yes uh isobaric drugs usually takes a little longer time for onset you cannot get panicked it may take around two to three minutes especially at the lower uh number levels the sacral rootsacral roots are thicker and they are not easily blocked with low volumes of the drugs it is actually universally proportional to your liposacral volume of CSF the blocket duration onset and the effect all is inversely proportional to your liposuction volume of CSF and you should wait for some time because you may not get the sacral rocket very early in isobaric drugs with Hyperbaric drugs it can be more quicker specifically to thoracic segmental spinal uh do you have any comments uh Dr naresh and as I have already been doing a thoracic segmental spider as I have already told you the thoracic now roots are very slight and thin also the CSF volume is very less as compared to Lumber so the onset different there is no difference in the onset time for Hyperbaric and isobaric drugs at thoracic levels does the onset vary with the addition of Narcotics no it actually has since the onset of uh you know this thing only thing is opioids which are on the side of being slightly Hyperbaric and the isobaric drugs which are already hyper Very Yes spread and onset is better with the addition of Fentanyl yes so um so the because the drug becomes Hyperbaric the onset is fast is that what you're saying there no no it's just from the worshiping Hyperbaric I mean it's not there are many factors dependent patients mention about that maybe we'll come back to it about how to uh do the segment of spinal while adding adjuvants a little later so Dr Sachin what are the complications of segmental spinal and what do you do if you think you have hit the cord or a root for what is the action you should think okay there are two parts to a question uh the number one is what are the complications of segmental spinal so uh the complications of segmentless Finance are almost uh same as the routine uh Subaru block Peak practice so uh the most common complication which you can encounter are uh post developmental headache uh transient bradycardia transient hypotension some neurological injury hematoma or cardiac arrest so coming on to the second part uh what to do if we hit the chord or the root so if there is accidental injury to the cord of the root the patient will suddenly experience the jerk and relating pain either unilaterally or bilaterally so immediately we have to withdraw the needle and we have to uh make sure that we don't inject anything otherwise then it will still damage will be permanent so uh after the case is done uh we have to look for uh muscle weakness or sensory loss in the patient after the effect of spinal or the segmental spinal pain so if we find that the patient is having some muscles weakness or sensory laws we might have to go for MRI for the confirmation and if on MRI we find that there is some evidence of neurological injury or edema then we might have to go for IV steroids that is methylprednisone one gram every day for about five days and then for about one to two weeks we have to give oral steroids also and for follow-up we might have to go for an MRI again after three months to look for any residual uh edema or uh personalities or something like that thank you Doctor searching for the detailed reply when it comes to uh when it comes to accepting segmental spinal the the naysayers their you know this is their nightmare right you go in a higher processing maybe T45 and do a spinal and you cause some injury and so in all the forums where segmental finally discussed there is this question about medical legally how uh how are you going to uh you know answer the in the court when the question comes as to why you use the doctor now would you like to add something to this when you think you have hit the card or rule should you actually proceed or should you just abandon the technique it does not come in the standard textbook so so you are answerable medical legally suppose here the patient does experience any paresthesia or uh pain on injecting those are the warning signs and you should immediately withdraw the needle and I would like to abandon the technique then because if you uh avoid such a warning signs that will land up in trouble so you like you can land up in a permanent neurological damage so only if you're confident with the technique only an experience and a seizure that should give or should attempt the segment of thoracic spinal and we should let her finish so uh so we are answerable medical Equity so we should never forget our primary principle that it is we should not do any harm so you should select the patient and you have only an experienced anesthesiologist should perform this technique it is not a technique for a novice anesthesiologist okay that is what I would like to add Dr tarun over to you yeah it's like in spine surgery the Orthopedics touch the nose root and they are doing the any some removal of the match on everything so unless you if you touch or any paresthesia is feeling there is no harm if you inject the drug then there is a problem so as soon as the patient feels paresthesia you have to withdraw the needle or if you are not considered abundant the procedure or select uh any one or two segment different segments but before injection you have to be 100 confirmed that that is not in the call if you inject then and then the core damage will be there that is the same yes if the patient feels paresthesia you just withdraw the millimeter and you just inject the drug there is nothing because if you inject in the court then and then only there will be damage to the point by touching the cord or feeling parasitia I will not damage there is cautious approach of uh thoracic spinal yes uh thank you Dr suvarna and Dr tarun for bringing up that point that was one of the things I thought we should discuss when we were saying what is the difference between the technique of thoracic spinal versus lumbar spinal so just to repeat you don't go with your needle continuously and then stop when you think you have punctured the dura and then remove the stilet to ccsf in thoracic final you go every time you you may have to multiple times remove the needle to keep checking because the click will not be as Dr naresh had explained the dura is quite thin so you mean and you use a much thinner if you use a thinner needle you may not feel the loss of resistance as typically as you feel so uh you must not try to do the entire thoracic epidural in one shot so just to repeat so moving on there are lots of questions about adjuvance in the chat box so Dr nourished what arguments can be safely used in segmental spinal and uh just before going to adjourns I would like to add on the previous question there can be midline gaps in the ligamental climate thoracic levels so while using a midline approach you may not find the click loss of resistance that's the reason you need to go bit by bit and uh coming to the endurance the attune should be such that it should not produce a new hemodynamic changes it should not produce undue respiratory depression or postok nausea and vomiting the adjuncts which I usually prefer is paternal dextromate clonidine or ketamine even midazolam I have used few times but other additives can also be used but I don't like the additives which will cause most of respiratory depression host of nausea vomiting because that will spoil the whole your profile of secondary spinal early recovery early wording and everything will be spoiled so attitude should be such that like drugstore wind it has a propensity to provide a duration in a dose dependent manner when you use around 2 micrograms two five micrograms it can provide a duration up to 3 hours with just two mL of the drugs with 10 micrograms even it can provide duration up to four to five us so it provides a duration in a dose dependent manner though potentiating the sensory block is known to shorten the motor block time it is actually theoretical but this is has to kept in mind and even you can use two attitudes together many people from Italy and all they are using multiple but those should be used only when you are acquainted with their behavior in traffic thank you Dr naresha partha is it safe to sedate a patient who would receive the segmental spinal and if you have to set it what is your preferred drug you can choose one example for abdominal and one example for uh chest I I the question is is it safe to sedate a patient after segmented smile so I prefer to administer sedative prior to segmental smile so metazolam two milligrams along with fentanyl 40 50 according to those one mics per kg FM tunnel and I also administer sometimes five milligrams of ketamine prior so we have to select cases and this is and then administer the drug you know your respiration you know the patient's condition and then administer I prefer to use prior to segmental style so does that mean that you do all your segmental spinals in lateral position yes okay so there are a lot of people who practice in sitting so uh what is about tarun or suvarna would you like to take this question after segmental spinal yes Madam if required patient is NCS apprehension and Sergeant cells also some loose talking surgeons are many surgeons are in the remote in OT atmosphere then we have to sedate it uh I usually use which additive I have used as a adjuvant that same drug I will use in a see suppose I'll use filter in 25 microgram in traffic so remaining General I will use an exactly 25 25 milligram of cat milk that will uh usually avoid every things and it will cover all the things and just 25 milligram cat milk and 50 my pentanyl is sufficient if I use Pentagon if I use Dex that's middle Terminix then I will use vexmate and with ketmin for 25 milligram not more than 25 milligram treatment is required foreign so oh so thank you very much for bringing up that uh sticky topic about how people behave inside the operation theater one of the reasons in my hospital I prefer to give Dental anesthesia many times rather than Regional is because of this problem uh you know people talk all kinds of things then there's somebody's trying to teach somebody else if it's a medical college the patient knows that they have come to a training institution they are there are going to be students but in private when that happens it can cause problems similarly when some equipment malfunctions you know people throw Tantrums this is not working the item is not working that is not working or you know so uh that is one of the barriers for using Regional anesthesia for abdominal and other surgeries so uh thank you for clarifying that you know you can go ahead and do a segmental spinal and then safely said it a patient and you can get over this uh hurdle uh continuing with you Dr tarun as mentioned by Dr naresh there are case reports of cocktails being used in segmental spinal including intrathecal sedation by our Italian and Indonesian colleagues my first problem with that is when you use for drug errors after all you've had case reports of tranexamic acid being injected into spinal thinking it is you know local anesthetic so when you use so many drugs is a you know it's pretty scary that even one with the wrong drug or a wrong dose can be catastrophic but they are having great success and they are you know sharing their data so what is your uh uh first often the infrastructure what we have intersector and that Italy and all this big corporate hospital is infrastructure is totally different so they are all educated peoples are there they can use the multiple drugs which is not advisable but they are using all sedative drugs they are using Techni in midazola and every many certificate combination of many drugs uh and there maybe their staff is in their technique is so I usually don't prefer this all cocktail therapies we usually stick to that isobaric drug and adjoint that is only my experience that foreign so then that minimizes error because you're not breaking one more ampoule or taking one more vial so that is a very good tip to take home so um what are the common situations where you would recommend segmental spinal Asia this is going to be a recap of all those things that we talked uh uh you know we refer to but just to formalize it what are the common situations where you would recommend segment is very less anesthesia okay the literature has reported the so many indications for uh segment and thoracic file anesthesia now there are reports mostly for breast surgery uh laparoscopic cholecystectomy upper abdominal surgery is like a gastrectomy even lower abdominal surgery is colon surgeries and uh even cesarean cystectomy uh nephrectomy so many Horizons are now coming up for uh segmental thoracic spinal anesthesia so many reports with a high success rate laparoscopic surgeries and breast surgeries and even gynec laparoscopic surgeries are very comfortable with the segmental spinal so the inhibition is depending upon the duration at present it is indicated mainly for the daycare surgeries of short duration that is its main advantage and if it is a longer duration you combine with other Cathedral technique uh thank you suvarna uh Sachin would you like to add anything to this what suvarna said uh actually ma'am what you said is regarding the all the common procedures which can be done under segmental finals so uh we can have some other procedures also which can be done under a segmentalist panel like uh a few cases have been reported also uh likely a metastanal surgery is a diaphragmatic hernia repairs uh vat surgeries other awake thoracic surgeries lung resections even the cardiac surgeries are also possible under uh segmental final and for long duration a drawback of segmental spinal which people talk about is the short duration without arguments so when we are using a continuous catheter technique with the segmental spinal so that particular drawback can also be uh taken care of so these are some Advanced indications which might be uh very common uh in usage in near future also is probably one of the uh things where we can extend it because it's usually for a lung condition and also normally don't take too long so uh your audio was a little Disturbed so I just wanted to repeat that one of the indications you suggested was for bats uh yes we have also done laminectomies disc with segmental spinals right hello yes Dr naresh that uh foreign at that time you cannot use this the procedures without capnotherex can vary well written I myself had on two three procedures of under secondary spinal then it's very good for new at surgeries yes a lot of we had a lot of discussion about which case to use segmented spinal and we had some difference in opinion so in what type of cases had segmental spinal been a game changer in your practice [Music] and uh [Music] saturation was there that was maintained without requiring oxygen also that was the first integral the second okay the second time or the thing is a patient every four years male patient came the diaphragm hernia the colonic Obsession okay the colonos rent so that case was a little over short neck and difficult and because she had a repeated uh vomiting she was drowsy also with the recollect imbalance taken up for the emerging surgery so that time when I given a segmental spinal in the thoracic level so even if the uh something was putting the hand into the uh inside the diaphragm to reduce the uh colonic Construction patient was absolutely comfortable and it shouldn't require any uh uh this one like uh respiratory Assistance or even in the postal protection very much comfortable only thing is I should have put a epidural on the same time but I had just given the spinal during the end of surgery a patient requires some amount of solution so these are the two for examples I'm getting but so many situations uh segmental can become a game changer yeah thank you we have uh almost we have we've had almost 400 people logging into today's thing and some people were late so we'll do a little bit of a recap Dr nourish how to identify correct intervertebral space for administering segmental spinal anesthesia just share my screen now you can identify the required little Spaces by either anatomical landmarks like C7 has a prominent spinous process if you move your neck and fight the first non-moving spinous process that is usually C7 most prominent one at times there is a prominence of C7 and T1 both but the first one non-moving segment is C7 from there you can calculate the required space Also the spine of the scapula corresponds root of the spine of the scapula corresponds to D3 and the inferior angle of the scapula corresponds to t7 the lower rib margin is around 10 centimeters away from your uh L1 and also the inter Crystal line which is which can be variable actually it's not a very good um but if you have ultrasound you can take the help of ultrasound for exactly calculating the required interest space you can do a preprocessor scan You Can Count upwards from alpha S1 in uh Dr partha will take over that question thank you so much to take a screenshot about landmarks to identify in a vertical Place space please do that we'll hold it for another 10 seconds I'll make it full screen no down sir okay like we already discussed identifying the correct space is Central to a successful segmental like you said one ml drug will move probably give three segments up and three segments down block so if we choose the wrong space our whole calculation can go wrong so do you think we should be using ultrasound or fluoroscopy routinely to confirm the space before we give a segment and spinal it is not needed as Dr naresh has already told clinical identification of T3 t7 is acceptable and it is always preferable to confirm both sides inferior angular scapula is coinciding with it the spine of the scapula is coinciding with the T3 both sides if you calculate it is mostly correct only but if you have USD and you are technical expertise exactly we can go down from alpha S1 go down to up up and find out your T10 T9 at all so fluoroscopy I am not much used but there are reports of a fluoroscopy in prone position they have used 1 ml of absolute alcohol with local anesthetic in few cases of esophageal and drastic malignancies as per palliation for painted so that is about the fluoroscopy experience to me and usually we can use ultrasound if there is some difficulty but clinical is more than enough so I I just because you mentioned that intratical in a prone position there was a question segmental spinal for spine surgery and the effect wore off in the spine surgery is continuing what would you do me yeah me I have done a few in this I have done a few techniques I was a surgeon to inject even he knows the Dural space just inject and put another 2.5 mL of Hyperbaric this is one technique this is not described or otherwise put the patient later sidely head and put a pro sealer level yeah is an option isn't it that I mean one thing uh during spine surgery when the patient is in prone position giving a hyperbaric drug is not advisable because it can have only a pure antivir block patient will have motor blockade only and the sensory block will not be there better use isobaric drugs in small alley chords actually just one ml can do can add some additives together yes so I hope the the person who raised the question got a so again again we are you know doing a recap and there was there are people who are doing it in different positions and all so Dr tarun uh partha said that he prefers lateral so what is your preferred position for administering segmented I usually preferenced sitting position I majored to do doing this plh that is a two drop technique so that question is taken by better this is the tlh in in tlh we are using two drug techniques so should I mention this ah no I just want to know mainly from you what is your preferred position for administering segment of spinal and what is the usual space you choose and consider the safest for beginners already Dr naresh is shown in the uh in the introduction but some people might have joined late so I thought what is the usual you choose protein abdominal and laparoscopic surgery yeah in all those surgery I usually prefer in sitting position the space is more open and usually para median or paraspinous approach and the level of drug in open surgery I prefer at least t11 to 12 levels the which is the good space I will prefer that instituting thank you uh Dr naresh is there a role for segmental spinal in pediatric practice yes definitely there is a role I'll just show you one slide where the anatomical uh these things are the same in pediatric patients also you can see here the durometer to spinal cord distance in pediatric patients actual distance and the distance corrected by angle which is required but one thing you have to keep in mind in pediatric patients you have to give spinal after sedating the babies so unless you are acquainted with a pediatric spinals you should not try this difference I have done many cases and Dr Rajesh Shah who is one of our colleagues who has a dedicated pediatric hospital he is really doing this second class finals in even neonates and fitted equations thank you Dr naresh now we'll come to this touchy topic do you recommend the use of segmental spinal in patients with anticipated difficult Airway I want Dr Sachin and Dr raghavendra to on both sides who would like to go first yes difficulty could be one of the indications of going for a segmental spinal so yes uh if segmental spinal can be uh administered for that particular surgery and there is no contraindication for segmental spinal or Regional I would uh recommend segment is finally to avoid the risks associated with GA or difficult spinal in that particular patients so uh regarding the second part of your questions what are the pros so if the patient is the highest cardiac patient uh this will give a less hemodynamic response so it will be better for that patient if the patient is uh at its respiratory patient the chances of desaturation will be less with segmental spinal and we can sometimes we can avoid some intervention like tracheostomy in emergency with segmental span if you are trying uh difficult Airway patients under GA and you might have to go for uh technology there is an obvious cost benefit also and uh it could be more comfortable for the patient because the struggle during uh awake intubations and all is too much for a patient s that you are justified in using segmental spinal in a patient with anticipated difficult area what about your doctor theoretically the difficult error should be the reason for giving a segmental spinal but as a clinician whenever I see a difficult uh incubation I fail to give a spinal and rather be any Regional technique if uh that's uh this one but theoretically as legally or [Music] that is quite acceptable all right yes there is just a warning from below about the using spinal in difficult Airway situations the giving Regional anesthesia to a patient with difficult Airway does not solve the problem of difficult Airway it is still there you need to get prepared for all intuition scenarios in such patients even if you give segmental or routine spinal for these patients it does not solve the problem or difficult Airway you can you may need to handle this Airway anytime because of failure of the block or any emergency situations so you need to be prepared for that foreign thank you um moving on uh Dr tarun would you use segmental spinal in a full stomach patient this is this is not a shortcut for any patients you do if there is a unfit patient or like that any criteria is not fulfilling yes this is a same indication as a lumbar spinal in lumbar spine also we are not doing in full stomach if it is an emergency then there is a totally different scenario we can insert the rice tube and spirit everything's and if there is a high risk patient then we can go at what this segmental spinal but not in full stomach or any uh any shortcut questions I just wanted to clarify the question it was not correct ornament is in an emergency for emergency surgery we do use lumbar spinal for uh you know as anesthetic technique even if patient has had a meal say uh because it's an emergency put those same rules apply for segmental spinal or do we need to have more care when we give uh segment with final in the patient with full stomach uh the routine care there is no difference in the segmental OR thorax spinal it is not like that it is a high volt high level upper level high level is the chances of vomiting service it is not like that right Dr suvarna uh do you think it is safe to administer segmental spinal in a patient with ongoing intra-abdominal bleeding because as a lot of people have shared their experiences with ruptured ectopic or you know whatever trauma and I think so what is your official take on it I request everyone to mute themselves please in a patient with the ongoing intraum abdominal bleeding the decision should depend upon the patient's clinical condition uh suppose you are not aware of what the underlying condition is they are confident that they can control the bleeding safely and easily you can go ahead otherwise in an unsure about the underlying pathology it would be safer to go for uh their anesthesia so let me be absolutely so tomorrow you have a ruptured a topic in your ER uh what would you do in our Institute of one of the largest limited descender the gynecologists are very expert and I would go for a thoracic spinal for a ruptured ectopic but not for an intra-abdominal bleeding in uh general surgery Institution all right uh muscular injury something like that I would not go for it okay so ruptured ectopic hemodynamically stable you would take or abstract ectopic even somebody who's who's all hypotensing even those patients you will take now stay with stable hemodynamics that is a relative on the severe hypovolemia in severe uh instabilities are relative contraindication otherwise it's stable ectopic I will go for if you think a routine spinal is contraindicated in a patient with unstable hemodynamics we are not going to plan this also so the patient has got a stable pulse volume is good everything we have correct topic there are six minor is okay no you can use it because the volume and those yes is very less no no I have a laparoscopic sulfing it to me because even normally the way after if I give a lumbar spinal I'm going to have some hypotension when I am getting a higher level so obviously the patient was already uh hypertensive uh you want I want to make a differentiation between lumbar spinal versus segmental spinal is that because of the lumbosaccharine sparing the and the preload is maintained the hemodynamics is better maintained with thoracic spinals right so one of the problems we face now is that almost everyone in our country seems to be on anti-platelet or some form of anticoagulant sometimes dual sometimes for dubious indications uh primary prophylaxis and all that so when it comes to hip fractures and all we have been progressively shortening the time of withholding anti-platelets or anticoagulants to go ahead with the lumbar spinal anesthesia is it safe to extend this practice to thoracic segmental spinal as well yes it is definitely yes because people are even quacks are using chlorophyllogrel people are rampantly using Clopidogrel and they even it is over the counter available for even the patients alone if it is a diabetic color yes I am going to prevent heart attack with this crepita Grill and they are taking it so lumbar spinal we are one or two days we have come down I think the same has to be there for segmented so if patient is on Dual anti-platelet how long would you wait before uh giving a segmental spinal aspirin is no problem is yeah yes depends upon the time what is the need of surgery if it is a real emergency semi emergency like that I prefer to wait for two days one right okay so swarna what are the common problems you've encountered by using uh segmental spinal for laparoscopic surgery and how do you manage and from the time you started have you done any modifications of your Technique to avoid these problems the patient can experience shoulder pain uh not every patient but depends the incidence is varying with between 25 to 30 percent so for shoulder pain one method I adopted is the slow initial initiation of the new peritoneum and the uh limiting the pressure of the new operon into less than 12 millimeters of mercury so you can answer your certain surgical colleagues to uh initiate the no peritone slowly and control the pressure and you can adopt methods like infiltrating the uh blockline aesthetic into the to the right dome of the diaphragm or we can give some sedative agents in indicated patients if the patient complains of pain or a discomfort I will give either a 0.5 milligram per kg keep them in or a small dose of and then One Max per kg fentanyl not for every patients but I give infiltration locality infiltration to advice tml routinely and if the patient experience any discomfort I give the sedation either ketamine or fentanyl small dose thank you suvarna Dr agavendra how to monitor entirely carbon dioxide yes so I I have a different technique for countering this shoulder pain I used to do an ultrasound of the neck see the flick now phrenic now and give 0.5 mL of 0.25 percent the people can eat it so right side only so right so this cuts off the shoulder pain almost there even the post-operative shoulder point is minimal and the the so called respiratory Excursion doesn't change with this minimal dilute solution of this this has been practiced by us for so many years and this study is under the review of Asian Journal of anesthesia right we'll wait for it to get published you will need as somebody who is sorry didn't get your question who's uh who asked the question okay so raghavendra how do we monitor entire carbon dioxide during laparoscopic surgery and the segmented spinal and what is the highest level you have encountered and at up to what level do you accept foreign [Music] uh increased or something like that your machines what is the upper level of uh entire carbon dioxide let us assume you are able to measure it properly with the proper device what is the upper level uh that you normally see and after what will you be getting worried let's assume that this patient is not COPD and is a otherwise a normal lung uh now the newer machines they are coming with a special prongs nasal prongs for monitoring etco to under spontaneous respiration and if you don't have that you can use either a nail cat tip or anything else and usually under a segmented spinal the there is not much of change in uh this atco2 only in cases whereas extraperitoneal hernia especially laparoscopy where there can be a subcutaneous and phyc one that time you need to keep a watch on the atco2 arising levels is alarm to see remove the trappings and see whether there is a separency of parasima which can extend up to the and patient can have problems so in case you find it suit is rising then just look for whether there is any subcutus and Phi Sigma if it is there just ask the surgeon to deflect the done wait for some time it's not correcting uh thank you or we have already discussed it but still it's a recurrent question in the chat box so I'm going to put it again Sachin does segmental spinal provide hemodynamic stability your experience is the chance of interrupt hypotension more or less with this technique uh yes one coming on to the first part of your question uh definitely yes uh segmental spinal provides excellent hemodynamic stability as compared to uh routine uh spinal anesthesia with minimal variations in heart rate and BP uh the reason being uh the T1 T4 fibers are generally spared and they're not blocked coming onto the second part regarding the experience of chances of intraoperative hypotension more or less with this technique so the chances of uh interop hypertension is less with this technique um mainly because uh the pulling of blood in the lower part of the body is less due to the less blockage of the lumbar and sacrifibers so the cardiac filling is more and the stretch receptors in right side of the heart are active so the cardiac output is maintained so due to these particular two reasons uh yes the hemodynamic stability is much much more in segmental spinal there may be a transient bradycardia and hypotension in initial five to seven minutes or let's say around eight to ten minutes but it generally reverts back to the normal within uh next uh say two to three minutes and there is minimal use of uh or minimal need of final drops with this segmented as compared to routine spanner which we are giving thank you I hope everyone who had these questions in the chat box has looked into that uh partha where do you think research on segmental spinal should focus now hello yes I think I think there are a lot of studies already gone in this but I will I would prefer this ultrasound gated segmental thoracic spinal should become the routine like that is one of the best ways to infuse motivation or whatever it is the belief in the anesthesiologist and the prayer of the so-called mental block of using this number two is respiratory mechanics and segmental spiral and animal study on the microscopic changes that is what I will feel this right so to wind up Dr naresh could you give us some tips and tricks uh for like the segmental spinal all the everyone in the audience is waiting for that and before you start I'd like to uh all our experts to type the organization in which they are working because there are a lot of questions asking where people can come and watch uh segmental spinal being done and perhaps even get chance to do so that they can go back and practice it in their place a request from all the panelists to put uh or even those in the audience who are practicing segmental spinal in a big way he's mentioned your organization or hospital or so that those who would like to come and be Observer or you know do a short Fellowship like thing they can do over to you Dr naresh we we only have two minutes left yeah I'll just quickly go through it uh patient safety tax precedence over the necessary risk to be taken for the success of the procedure so patient safety is always important and if you allow me two minutes I'll just share something about do's and don'ts in seconds final yes these are the dunes before proceeding no in detail about the various I mean about the technique various drugs which are available with you what are the different doses what are the different additives and sites of injection needed for that technique you should also know about your surgeon if you are not working with him you are working for the first time with him no how adaptable your surgeon is to the change conditions provided by the regional anesthesia especially in laparoscopic surgeries how flexible your surgeon is I mean how he's going to listen to your request about keep the minimum pressure minimal initial flow rate minimum and how efficient your surgeon is I mean how quickly you can do the procedure accordingly you can choose your mode of secondary spinal either you can do it in a single shot or you combine with epidurals or continuous final then you know in detail about the surgery Open Lab duration extend and also about the patient whether it is cooperative and willing for sole Regional or not what are the Commodities risk benefit ratio of segmental spinal then always use the position which you are accustomed to for giving spinal either sitting or lateral it hardly matters unless there is specific indication when you use drug techniques if facilities are available do a preprocedure scan individual spine cases if you have a CSC kit and you are using epidural cacute is the best option do always use multiple energies here with segmented spinals the multimodal analgia in the form of some interfacial plane blocks or the drugs like uh dexamethasone taclofenac or paracetamol which will not cause most of nausea vomiting and respiratory operations and as always do prepare and keep your backup plan ready about don'ts Don't force your surgeon to do it under Regional unless he is accustomed to it or unless there is a strong indication in favor of second spinals don't be rough interesting be gentle Advanced millimeter per millimeter don't proceed if there is slightest of paresthesia just withdraw the needle and change the direction don't use higher doses of La at Mid or high thoracic spaces I mean higher the space lower the dose that should be a victim then don't use unnecessarily add too many additives together because someone is using don't write it unless you are acquainted you already have mentioned don't use excessive sedation with higher loads of blocks what happens is it may change your respiratory patterns especially in laparoscopic surgeries unless you are planning to use some supragmatic devices don't use excessive traditions issues they are minimal and gradual and easily manageable don't hesitate to call for help or communicate in case of any doubts thank you thank you Dr naresh for that wonderful summing up I'd like to thank all the panelists for sparing their time and taking all the questions we try to address all the questions in the chat box as and when they came up I could ask another uh you know favor from the panelists if you could share your email ID or phone number also in the chat box uh thank you Dr bajwa for giving us this opportunity and I hope we did what you expected over to you sir your mom it was all a very absorbing discussion today because this stick this technique has developed over the last few years only and is successfully being practiced in many parts of our country there were many questions in the chat box about where we can see the videos how to upload the videos how can we go how can we learn the learning curve so many things were asked in the chat box the simple answer to that is ISA nhq the headquarter is committed to provide the academic platform to all such people we have a program of Isa skill centers at many places this technique is being practiced in a very good manner just like when we go to the post graduation courses where we learn the basics of spinal it's just like learning the basics of segmental spinal it's not that we have done hundreds of thousands of spinal anesthesia in the lumbar region and we are going to thoracic with the same technique yes it become easier for us but we have to be very careful and with very precise to use this technique and in doing so if we adopt skill centers in India I think many panelists and many of the practicing anesthesiologists in this webinar must have been doing it very precisely very meticulously in their centers they can always forward their names for the skill centers to be developed Isa nhq can recognize those skill centers we can have a training period and uh well all those people who want to attend to those skill centers they can get a seven days period something like that just like a small Fellowship they can go and learn especially in the difficult cases learning in the simple cases is okay but the difficult cases are always something which we should be learning it's a learning curve it cannot be done in a single day and Dr partha sasi also said this spinal in the number or in the thoracic the techniques the contraindications everything is same apart from that the dose is the doses definitely they have to be reduced as different meta-analysis and systematic reviews have seen that how uh minimal safe effective dose is done and moreover the safety of the patient is very important we cannot be adventurous learning a technique We cannot put our patient on risk for some mortality or morbidity the safety has to be ensured and Dr naresh paliwala has very rightly said the do's and don'ts those are very very necessary and very basic even at the uh you know you have passed out of your senior resident or you are a professor or at the head of the institution but for everyone learning curve is different but learning has to be there to practice this technique you cannot go on straight away so I I will be I put so many spinal so I will be putting in the first break the thoracic spinal you have to go away the basics these things are very important and Isa National is committed for all these type of things academics as well as provision of the training to the people who desire to get trained in segmental I request the people who are attending this webinar they can forward the request from their centers in a proper manner through proper Channel we can recognize those skill centers we can choose those skill centers for the training of segmental spinal anesthesia through all the budding or whosoever wants to learn the this technique this is a my humble submission from the headquarters I and by the this General is now open for discussion anybody wants to give suggestion they can raise their hands and can give further suggestion to this Dr Madhuri you want to speak something please unmute yourself yeah uh good evening and uh congrats congratulations for an excellent session so my question is that now since the uh strong wave of segmental spinal is spreading throughout our nation it is possible that a lot of research work is going to start on this topic it's going to gain impetus so now if I am a member of the Ethics Committee research Ethics Committee and if a study on segmental spinal comes uh what should I do like can we go ahead with it or what caution has to be exercised uh I would uh like the panelists to elaborate on this shall I answer this one yeah anybody no problem see the segmental spinal anesthesia is an established technique now although it is a difficult and not difficult rather a little bit more precision and skills are required for this technique already a lot of literature is there like being practiced in West also and I think in India we have done a landmark studies also here we have got published articles also those can be taken as a support when you put your proposal to the ethical committee it is up to the senior most anesthesiologist of the institution who forwards who put forward how to get the patient in a safe Zone while practicing this technique for the research purpose it's the responsibility of the person who's a senior most in the institution from there only you can take it forward the research can be carried out forward but the senior person has to come and he or she has to give the evidence easier as to thoroughly discuss the details the pros and cons of segmental spanning to the ethical committee the ethical committee is not well versed with this technique this I'm sure in India maybe if you understand this may be there in some ethical committees but still it is the responsibility of the senior most person who has the responsible to the department to go forward with the research this is my anybody refers or anybody there are at least 10 postgraduates in contact with me hello just wait that somebody is hello yeah there are at least 10 postgraduate students in contact with me who are doing a thesis topic on this subject and break out a approval from Ethics Committee so I don't think there should be a problem in thank you see uh before I congratulate the panels I answered two quick comments uh I agree with Dr bajwa ethical committee approvals won't be an issue in institutes if it is followed by the senior anesthesiologists because there is enough literature in Indian journals as well as International Indian International anesthesia journals to support it so if more and more research is done definitely the technique becomes more popular amongst the residents and the younger Consultants it is being nicely done in different centers across the country in private also and in institutes also and it it is a good technique and we can even we can even think of having multi-centric trials across the country under the banner of ISC secondly that is Food For Thought and ISS pill centers their approved centers and yes it will be very nice on the part of the clinicians who are doing this segmental anesthesia or who are doing anything different so that they can impart their knowledge and skill to the Future Generations that will be very nice so that these are the ISA and oversized certified centers of equivalence and skill center so I re-endors the appeal of Dr bajwa that you should please come forward and write to ISA headquarters for getting these accredited with the ISA National and personally I thank Dr paliwal Dr bagela Dr Sachin Dr suvarna Dr partha Sati and last but not the least Madam Mohan Ram you are done also and uh artist congratulations to all the panelists for such a nice deliberation and it was pleasure listening to all of you over to you Dr bajwa and madam you give for that patient for giving a segmental spinal or spine surgery especially yourself yeah hello yes yes I I usually what do you do I give the spinal in the structure in the structure I give this final of around T10 or T9 level 2 ml with 25 makes or 30 makes of Fentanyl and just put it down prone I I'll give this Final in the stretcher and just put it down Chrome that's all 2 ml or 2.5 ml in T10 level around that range which in terms you use this is foreign position also you can give spinal directly in the prone position in that case you can use either isobaric or even hypovaric drugs hypovaric results can produce a posterior spinal hemia anesthesia which is a new term and only the sensory Roots will get blocked I have a video of posterior spinal hemian anesthesia being produced spinal loss given in prone position for this uh minor surgery of spine that uh of the spine I don't do much of the spine surgeries but I have done two three cases where minimally inves you that this prolapse was there and it was given a hypovaric drug in prone position yeah I'm sorry I have that video yes if you can find the video meanwhile please find it and you can do it I have done eight to ten cases of spine fixation which dystectomy uh under a segmental spinal I usually take the patient on the OT table only and just giving in sitting position at around T10 or t11 depending upon the level of fixation higher choose higher level is chosen to decrease the discomfort chess discomfort between the wrong position and 2 to 2.5 ml with this middle terminal or cronial this drug is joint is added and immediately this isobaric drug is chosen and immediately we make the patient on the ground position and given bilateral electric spiny blocks product right does anyone else want to add anything excuse me ma'am yes go ahead yeah I would like to and ask a question uh how do you do a case of total uh laparoscopic hysterectomy yeah in this in almost plh usually two drug techniques that has been used as it is laparoscopic surgery the p910 level is chosen and uh just first uh we have to give this Hyperbaric point five percent uh Leo enabled or [Music] it is only 2.5 milligram or it is a 0.5 ml only after that uh injection of this 0.5 ml insert the stilet again then prepare the isobaric drug with adjuvant of your choice pendant or Dex meat or pronium whatever you want that ISO correct now remove the steel light and let the one drop of drug is goes out of this half of your needle then inject that isobaracteria make the patient Supine and give position of the lithotome this hyperbolic drug is required to cover the lumbar sacral Roots manipulation and vulnerable closure after the surgery yes I have that video can I share that yes uh do you think does that answer your question yes Madam yes ma'am but I'm just thank you meanwhile if anyone else has any questions please go ahead uh while the video gets ready and you can ask your question Madam here is one question go ahead oh there is whenever a combination of Hyperbaric whereas Hyperbaric uh we cannot uh justify the exact variety of the drug oh so is it advisable to combine the Hyperbaric and uh Hyperbaric drug at a time the second question is is there an advantage of a segmental spinal over thoracic epidural thank you yeah perhaps you joined late uh we discussed about the epidural that you know it's a technically more challenging and uh inadequate blockade or failure is higher with epidural than with spinal and uh so uh that Dr Tyrone had explained very well and as far as variety is concerned again Dr naresh explained that even when you use what you think is Hyperbaric depending on the temperature and adjuvant it may be almost ISO or even isobaric maybe hyper because of a change of temperature and mixing with adjuvant so actually none of this is very precise but uh Dr vagela has given this specific example where uh in in purely abdominal surgeries for laparoscopy you can use uh isobaric or whatever you want but without having as a lower lumbar and sacral blockade but the hysterectomy is one surgery which you cannot do so uh doctor might disagree with what doctor but obviously it works for him so he gives a small dose Hyperbaric weights for it to have onset and then after that he again reintroduces removes the skillet and let some CSF come out and then gives the drug which is meant for the laparoscopy so I hope you all enjoyed the video of Dr naresh any other questions thank you madam or two drug techniques actually uh I do it a little differently I don't wait for a drug to be here to fix so you are using just 0.5 mm of the truck I have a very drug and by the time you inject the two mL of the truck I use 27 gauge needle by the time you inject the 0.5 ml gets fixed to the lower sacral roots and it provides the adequate duration of analgesia in the labosacral groups this is just for providing a longer duration 40 English procedures or any Pele this colorectal surgeries or any velvetic manipulations going Beyond a specific time like uh your segmental spinal can provide initial number cycle blockade also with adequate dose but it is for limited duration it starts regressing problem loops and for providing adequate duration you need to use these two drug technique I mean even you can use Hyperbaric drugs in combination with isobaric drugs to provide a ah greater Keflex spread like in laparoscopic surgeries you can use a little hypovaric drizzle so you if you want to avoid that shoulder tip paint you can use little hypovaric drug along with your isobarics [Music] that she's interested in multi-centric study but where how we can conduct studies in perspectives and how we can get ethical committee clearance so because this was pertaining to the multicentric studies on the segmental spinal so answer is very simple nowadays there is DNB courses going on uh in majority of the Civil hospitals and there is an ethical committee there or even in the private corporate hospitals the DNB anesthesia has started so within a radius of 50 kilometers anybody in the hospital is located there and you are planning to conduct the courses you can easily get ethical committee clearances from there like in our haryana the charges are 25 000. so you that is for the experts which come but nothing like that that now you uh there is that issue is solved once forever you can get ethical committee clearances for conducting in private sector by applying to the ethical committee Boards of the where DNB and is going wrong right so uh over to you Dr bajwa um thank you Mom I think the majority of the discussion led to two segmental spinal today has been done beautifully one last question sir I'm really uh happy that you modded with the session so well it was quite as if you have been doing the segmental spinal moderation for a long long time now this is good because you know this is a huge topic it can require three to four hours for discussion which we have done in one and a half to two hours it's a good one and all the panelists they're they're wonderful I think they've prepared them wonderfully and even to the answers of the audience and uh that was a good thing and we have a eminent people from segmental finals in our this panel documentaries [Music] and all I think these type of webinars stimulate the research they stimulate the something of uniformity in our Isa our own anesthesiologist to come on a platform whether for the research purpose or whether for the skill acquiring the skill or whether there is opportunity to learn from the neural centers this webinar you know it creates a brainstorming in the minds of our you know the governing council member also how to go forward to make it more authentic more vibrant and more cohesive technique so that our it comes on the common platform of Isa I told already told before that the skill centers can be formed at various zones in various States also you have to forward the application that we can provide this training and Isa will be supporting the deserving candidates to go there otherwise they can go their own and just like the other examinations we have set for the uh skill when fellowships so we can have this Fellowship examination also for learning various techniques at these skill centers in the coming days so that is done but overall this panel discussion was very very absorbing I sat almost for uh you know right from the beginning of this discussion till now and I don't think so there was even a single weak point in the discussion what was lagging in one panelist was covered by the second panelist so we have thing we have given good answers to all the relevant questions regarding the safety efficacy doubts myths and Mysteries related to the segmental spinal to the moderator and to all the panelists and really I'm very thankful to all the audience who have participated like anything asking so many questions and you know brainstorming the minds of our panelists and the moderator it was wonderful wonderful I think webinar and the recording will be available on Isa nsq YouTube channel and you can watch and we will be uploading on the ISA website Facebook and WhatsApp media because the ISA nhq is a authentic site that YouTube channel as well as the ISA website where we can have to disseminate the authentic information not related to the social media so you can watch there also I think the YouTube will be available after this recording is ended here that from my side thank you yeah just re-endors that we have got educational scholarship of 25 000 rupees per member up to a maximum of 20 scholarships per year so these are for the deserving candidates for attending the conferences for attending such programs and they have to come through the respective City branch office bearers so educational scholarship twenty five thousand maximum and up to a 20 per year and it is a 50 50. 50 is paid by the mem Branch or by the member and 50 is sponsored by the ISA so the serving candidates can take advantage of this Isa educational scholarships also I didn't mention that because you know segmental spinal technique people will be coming forward so just telling them the amount to be spent on them so suddenly so many application can come without even getting the skill center first we should have a skill center then we can open this for them also that's uh that's definitely there anyone who is interested is always welcome at our Institute which is routinely done even by my or faculties in Dr Punjab Medical College amravati routine technique even our residents are doing it so anyone who wants to do it can come for observation you're always there you have handheld so many people I'm sure they will really enjoy coming and watching in in person yeah we have conducted at least four or five live workshops and recently we will be having one masterclass in avra on 2nd of June and also there are many in lined up in a queue in next four five months so anyone interested can do it I'm very much thankful to ISA for giving this opportunity actually there is more price for moderator than panelists in this checkbox so I am very much thankful to Madam for moderating the session so well don't worry it is because the modulator she took out everything from you she took out every answer from you that's what that's what I am saying the moderation was very good excellent excellencies I I'm really sorry I need to leave because I was supposed to be in another webinar at eight it's already Beyond Time thank you so much and thank you panelists [Music] thank you very much as long as