Reader response
Myron Yaster MD
From Matt Careskey MD Peds Anesthesiologist- Kapiolani Medical Center for Women and Children, Honolulu Hawaii
My opinion is that some noise in the operating room, even during induction and emergence/extubation is acceptable, and can actually be beneficial to patient care. Particularly, I enjoy when music is playing at a reasonable volume during the "anesthesia times" of induction, airway + line placement and emergence. When the music is relaxing, agreeable and matches the vibe of the OR staff [here in Hawaii this is frequently reggae style island music], it tends to put people at ease, and reduces the overall stress level of the OR environment for everyone. We know that people work better and can think more clearly when they are not on edge.
For me personally, I actually prefer to have music playing especially when caring for sick children, cardiac kids and neonates. although of course there are instances when music has to be off and distracting noises minimized completely. But this is actually the point! You see, since preferring music and creating an affable and comfortable work environment on induction/emergence is my modus operandi, then whenever I ask for the music to be turned off or ask for people to quiet down, then everyone immediately knows I'm not crying wolf, and that things are critical. When I say "turn off the music", this is an automatic signal to prompt my OR teams to go into "help anesthesia mode." Whereas when the music is playing, they know the situation is under control and the patient is safe and sound! Furthermore, a well-chosen playlist can help establish a rhythm and flow to the anesthesia and surgical procedures, enhancing the overall workflow in the operating room.
With the appropriate DJ skills (ability to read the room and music preferences of the OR staff), clinical competence and attitude I think anesthesiologists should consider embracing OR music during these critical moments of anesthesia care.
From Bob Spear MD, retired
“Tastes great less filling” When performing a caudal with or without ultrasound guidance is it the volume or the concentration that matters in terms of block density, local anesthetic spread and block duration? In my practice, I found that using a lower concentration of local anesthetic and higher volumes made for a better and longer lasting block particularly in the youngest patients who had the least myelinated nerves.
From Dr. Hannah Lonsdale MBChB FRCA, Assistant Professor, Director of Pediatric Simulation, Division of Pediatric Anesthesiology, Vanderbilt University Medical Center
I wanted to add a warning about predatory conferences and meetings to today's excellent article on predatory publishing. Predatory conferences seem to have a similar MO to that described in today's article, inviting the "Esteemed Doctor" to present at an academic meeting with a contrived title in an exotic location, such as a big European or Asian city, but also with a virtual option. At least one person from my institution has unwittingly agreed to present at such an event. This adds legitimacy to the scam by allowing the marketeers to use a speaker from Vanderbilt University Medical Center as bait to attract other speakers and attendees.
The first time I received such an invitation I checked with a respected senior colleague as, at first glance, it appeared like an excellent opportunity for an international presentation and a fun trip overseas. I was quickly persuaded otherwise.
Like many academics, I rue this continuous barrage of time-wasting emails that arrive as a result of predatory groups scanning journal articles for corresponding author emails. I wish that there was a way to ban the exploitative and harassing behavior at source, as email spam filters seem only to partially reduce the influx.
From Raylene Dias DM, Dept of Pediatric Anesthesia, Seth GS Medical College & King Edward Memorial Hospital, Mumbai, India
We were delighted on reading “Look at that caudal go”. In our practice, caudals still are very much a part of our armamentarium. It is one of those blocks that has stood the test of time. Being a teaching Institute, it is one of the first blocks we teach residents and yes, we are now performing caudals solely using ultrasound.
We have found that we need to revisit the age old Armitage formula and while we still dose using this, we have been getting disappointingly lower spreads than expected. This discrepancy increases as the age increases with the achieved level much lower in older children. In our experience, 1 mL/kg routinely spreads up to T12-L1 level, rarely T11-T12 level, but never higher.
Needless to say, ultrasound has helped us in needle tracking and correct placement into the epidural space. We use it in difficult caudals where landmarks may not be very apparent, in cases with sacral dimples where the landmark technique may not be feasible. Especially in the neonatal and infant caudals, ultrasound has remarkably increased safety by avoiding ossification centres, low lying dural sacs and venous plexuses. It has made a caudal block possible even in the very formidable anatomies like ARMs with sacral anomalies coming for repeated abdominal surgeries like colostomy, ASARP, PSARP and colostomy closure.
To conclude, we are finally left with needle tracking using ultrasound for localizing and accessing difficult caudal spaces as well as dynamic flow tracking for ensuring adequate spread of local anesthetic up to the desired level.