Integrating ultrasound with the combined spinal-epidural kit as a rescue technique during difficult spinal anaesthesia

Conducting spinal anaesthesia in patients with elevated body mass index is commonly difficult, yet there are no guidelines to direct best practice. Landmark techniques are sometimes insufficient, leading to increased failure rates and suboptimal patient outcomes. Although ultrasound-guided techniques are now considered standard care for central venous access and regional anaesthesia, there has been relatively sparse uptake of this widely available resource for central neuraxial block, despite evidence of its efficacy.This article outlines a successful case of ultrasound-assisted spinal anaesthesia, after landmark techniques failed, in conjunction with a combined spinal-epidural kit. This unique combination of techniques has not been published as an amalgamated rescue strategy for difficult spinal anaesthesia. This article adds to current evidence by highlighting the potential benefits of combining these techniques into a novel approach either when difficulties are expected or as a rescue technique after failed landmark-based attempts.

Inverse centripetal dissection: A rescue technique for mis-dissected lenticule during SMILE

Management of mis-dissected lenticule during Small-incision lenticule extraction (SMILE) is technically challenging and might be experienced more by novice surgeons especially in eyes with low refractive errors and thin lenticules. Presently, we describe a rescue method of inverse centripetal dissection (ICD) to manage mis-dissected lenticules. In this technique, after inadvertent dissection of posterior plane prior to anterior plane, the double-ended SMILE dissector is rotated along its shaft axis clockwise from the left upper margin of the mis-dissected lenticule to form an inversely folded lenticule which is then subsequently dissected centripetally till midline. This is then extracted by performing lenticulorrhexis with a pair of microforceps. We performed this technique in 10 eyes of 10 patients and the lenticule extraction was accomplished successfully in all eyes. At six months follow-up, the uncorrected visual acuity was 20/20 with a clear interface in all eyes. The ICD approach might serve as a useful rescue technique for managing mis-dissected lenticules.

Permanent External Biliary Catheter: A Difficult Problem Managed by Rescue Technique of Hepaticocholecystogastrostomy

Percutaneous biliary drainage is commonly performed procedure after failure of ERCP in patients with biliary obstruction. Failure to internalization can lead to permanent external catheter. In the present case, problem of external biliary catheter was solved with hepaticocholecystogastrostomy. Guidewire from the external drain site could not be passed across the stricture, instead it was entering in the gall bladder. This was used as an opportunity to internalize the catheter. First EUS guided cholecystogastrostomy was performed, followed by placement of stent between right biliary system and the stomach, through the cholecystogastrostomy stent. This led to drainage of right biliary system into the stomach, and the external catheter could be removed.