Episode 64: Navigating 3 Types of Anesthesia in the Acute Care Setting

The goal is to learn , inspire and bring Cardiopulm to the forefront of conversation . Thanks for joining me today and let's get after it . Hello , hello and welcome to another episode of Talking All Things C ardiopulm . I am your host , D dr . Rachele Burriesci . So today is Tuesday . c I'm trying to do the impossible again this week .

I'm heading out of town to New York , New new Jersey , on Thursday with Nicki Nikki to visit the family . This is probably the first Father's't know if I've been home for Father's Day since 2013 . It just never hits on the right time for coming into town , so I figured I'd give dad some love .

I've come in on Mother's Day a few times because it also coincides with my mom's birthday . So a few times because it also coincides with my mom's birthday . So coming in just to have a weekend with the fam , which is wonderful . I'm excited , hoping to maybe get to the Jersey Shore and actually get some beach time .

If you're new to me , the ocean , the beach , is literally my zen and I think besides family , obviously , is the number one thing that I miss about living on the East Coast . Went to the beach , often , go to the shore quite a bit , and there's just like a level . There's just a different energy that the beach brings .

For me , it's the strangest combination of positive energy and calm and it's probably one of the only places where I can relax and like let go of the other stuff . If I'm home , I'm always piddling around the garden doing something work-wise . My brain really never shuts down On the beach .

It's like the one place where I get full permission to just be , enjoy the surroundings , read a book , whatever it might be . But there's just something about putting my feet in the sand , my feet in the water , right at the ocean break , that just like . It's almost as if someone plugs me in and charges my battery . So I'm super excited .

I'm hoping we get to hang out at the beach for a bit . Um , cause I'm I'm needing some of that energy Nicki But with travel comes getting things done and we just recently came back from travel . So I don't know , I feel like I'm on repeat , but time is just flying . We're the second week in June already and I'm kind of like what is happening with time .

So please don't rush summer for me . I know we're about to hit hot temps and I already know I'm going to hear people complaining about the heat and humidity . I'm going to hear people complaining about the heat and humidity . I'm all for it . I love the summer , I live for it .

I will sit out there and do work and it can be a hundred degrees and like a hundred percent humidity . It's just part of me and I do not like to rush this time of year because what's going to happen is all of a sudden we're cruising into December and we're going to be complaining about it being too cold . So enjoy the time that you're in .

If you're a season person , enjoy the season for what it is . I very much appreciate the seasons . The summer is my favorite season and I'm going to do my best to take it in . So I'm just trying to do the impossible . Today MOSCs my garden is still not finished MOSC Just trying to MOSC do the impossible . Today , my garden is still not finished .

Nikki and I redid some pavers along the garden . I convinced her that it would be a quick , one-day project . In theory it should have been , but I think I mentioned this last time we kind of do the most all the time , and we added a drain pipe and re-leveling and all the stuff .

So we still have one section to go and we still have to like solidify the pavers . So I'm hoping we can get that done tomorrow . So when we leave it's done , NPTE but I don't know if that's going to happen . Because of that , my garden is not complete , so I have to get my garden box back in , get my basil in .

I have plants that I have seeded that still haven't gone into pots and so , just like the little things that I typically enjoy , I just haven't had the time to like dedicate to it , and now I have to try to get it done before we leave , because they just can't make it on their own for another week .

So put good time energy NPTE my next two days , just because that's what I need . And if you're in the same boat where like time is flying and you're trying to get things done , just take it one task at a time , and that's really how I've been trying to cruise by this , because that's all you can do . I officially got two of my three mosques submitted .

I have my last mosque , the Cardiopulm Mosque . The only thing I have left is the case study and I plan on writing that up on the plane . I find that a plane ride is like my most productive work time , if I need to get something done .

When I was in academia I could get a whole PowerPoint done on flight there and then one back and it was just like I was cruising . The only issue with the flights is the Wi-Fi , and if the Wi-Fi isn't good you kind of have to have a backup task where you don't need Wi-Fi to get your stuff done .

So I've had some like not so good Wi-Fi situations in the last few plane rides . So I'm hoping for some good Wi-Fi and just kind of take away at these tasks . I'm still not done with the MPTE prep course . I'm officially up and running and then I have all the videos uploaded . I'm just working on some of

OG

PT the back end stuff . 100% took way more time than I thought it was going to , but you know it is what it is . So I'm hoping to potentially put that out in the next week or so .

But if I don't get out in the next week , we may just be skipping this round of NPT and I'll just do the crash course a month out just to make sure I at least hit those NPT preppers ahead of time . So be on the lookout . I'm really pushing , I'm trying to maximize every time to get this done and it's just taking a little bit longer , all right .

So today I wanted to talk about anesthesia . I had to double check the podcast library to see if I've talked about this before , and I am seeing that I have not . So if I'm repeating myself , apologies . I even looked to see if I wrote a blog on it .

I know I have a document , because I started like piecing out this talk months ago and I just never did it , but I can't find my notes . I don't know what platform I was going to post it on . So we're just gonna we're just gonna go for it today .

So the reason why I want to talk about anesthesia is because it really can play a huge role in your post-op evaluation . And so if you're an OGPT , this might not be new to you . If you're a new grad , like all hands on deck , listen up , because this is going to be very useful .

And if you're still in school , this is a good one to kind of put in your back pocket , because it's going to come around later for you if you're especially going into the acute care setting . So , number one , if you're dealing with patients post-operatively , like immediate acute , post-op day zero , post-op day one , this podcast is for you .

So the three primary types of anesthesia that you're going to see , primary types of anesthesia that you're going to see , I'll put a fourth on . There is general anesthesia , spinal anesthesia , epidural , and sometimes you'll have a peripheral nerve block , but that's never on its own . That's why I'm going to throw it in as a fourth .

And this kind of plays a very big role in your evaluation because , depending on when you're seeing your patients , this can very much affect what your patient's capable of doing and also what you should expect in the process . Right Like , especially if you're working with total joint patients , you're seeing patients post-op day zero .

So when I started my career in New York , I ran a post-op day zero program . We called it rapid rehab . It was one of the first in the country . There is an article on this , I will post it in the show notes and we were one of the first .

So we were kind of figuring things out as we went and it didn't take very long to see that there are very specific trends with anesthesia . So general anesthesia is probably not the most common type in the post-op joint population but is often used .

I had a physician tell me once that if a patient has more comorbidities they might utilize general anesthesia because they can titrate a little bit more easily , kind of on the gas , off the gas , and adjust if needed . Once you give a spinal , you've given the spinal right Like you can't really adjust from there .

You're going to have to use external factors to assist with , like blood pressure , heart rate , if something was to change , and epidural does have some tweaking based on my understanding of this . But you might see general anesthesia General anesthesia from a post-op day zero perspective and even maybe post-op day one .

The primary things that you're going to see are lethargic behavior . Right , it's going to take them a little time to come out . There might be some confusion . You just kind of have to wait for that to wear off .

Hypothermia or just really coming back to their homeostatic temperature take some time and these patients might have like chills and chattery and they'll be with a bear hugger and they might be with a bear hugger longer than someone else . That has a different type of anesthesia .

And the number one thing that you should be aware of as a PT in the PACU or seeing patients post-op day zero with general anesthesia is nausea , vomiting , your generals puke . So if you're seeing patients very early on , make sure you have a basin .

Where I'm at now has like the green bags , which is nice because it can really cover , you know , the mouth and give you some room . The kidney bean basins really useless . Don't even make the attempt to because if you put that in front of someone post general anesthesia that's going to barely cover the situation .

So back in the day I would grab a bathing basin like the deep buckets and it just kind of gives you a little room to play if you have to adjust . But the green bags are nice too because they can go right over the mouth . So really nausea , vomiting is going to be your primary problem with these patients .

Typically once they lay back down it resolves , not always , but typically you do want to definitely monitor vitals . You might get some hypotension , you might have risk of change in heart rate , but not that . Concerning with the general anesthesias . If you see these patients post-op day zero , they're the most common patient that you will see .

Have a whole conversation with , learn about their whole family , all of the things , and the next day you are brand new human to them , so that anesthesia takes a little bit of time to wear off and you know you just have to reintroduce yourself and you're going to be like really you don't remember me and they'll be like absolutely not , I've never met you before

. And then you start revealing information that they gave you yesterday and then you can kind of see like , oh , maybe I , maybe I did meet you . And then , from a longer term perspective , with general anesthesia you have risk of atelectasis . We have decreased surfactant production .

So , regardless of what type of surgery the patient has , we should be doing breathing exercises with them , at minimum incentive spirometer . But you definitely want to be encouraging deep breathing as well as airway clearance and coughing if they have any junk in the lungs . Next on the list is spinal anesthesia .

Spinal anesthesia again very common in our post-op joint patients and these really just need time so they come out of surgery . They're in the PACU . I want to say four to six hours is like typical time that this patient might be ready for you , but they're going to have bilateral large extremity weakness , numbness , heaviness .

Their legs are going to be like jello . I think Nikki likes to say she uses pasta as a reference . Nikki likes to say she uses pasta as a reference . Right , I've really changed this woman , being married to an Italian . Do they feel al dente or are they very noodley ? So when these patients are not ready , their legs will buckle .

And so in the PACU , the quick and dirty check right , because you'll get called to see these patients . They're ready for you , they're out of surgery , they're ready for you . And so you'd come downstairs and like they can't feel their legs and so you've kind of wasted this travel trip .

So an easy way to just ensure that the patient might be ready is to have the patient straight leg raise their non-operative leg , so like if they came in for a left total knee or left total hip . You have the nurse ask the patient to straight leg raise the right side . If they can't clear the right leg , that patient is not ready .

So just a quick and dirty check , the straight leg raise . It's just one thing to do that can really save you a ton of time .

Post-op , especially post-op day , zero spinals can have some hypotension .

So you definitely want to be monitoring vitals , you definitely want to make sure that if they are hypotensive , that you know they're being supported with fluids , and sometimes they just need a little bit more time before you see this patient , because if you , you know , go supine to sit , they might get orthostatic and then might not get past sitting , and so

patients are leaving much earlier than they used to . So when I was treating total joints , our average length of stay was three to five days , with the like three being the goal , and we were getting closer to that three after our post-op day zero initiative . But now patients are leaving on post-op day zero .

So if you have to ensure that the patient is safe for discharge to home , you need to accomplish more than just sitting edge of bed . They need to be able to ambulate at least a short distance and if they have stairs , can they navigate and negotiate steps to get into their home while and I want to be clear about this being hemodynamically stable , right .

So you know just things that you can educate on to make your experience as a PT treating on post-op day zero a little bit more efficient . There are always issues with this because typically depending on your schedule .

So back in the day we did 11 to 7 shift and we actually shifted our schedule to adjust for post-op surgeries the problem is you still can only get to so many of those patients because , let's say , your last case comes out at three , four o'clock . They're not going to be ready for you and if they are ready for you , it's as you're walking out the door .

So there is some time things that you have to consider and how much time it's also going to take to evaluate these patients , because they're not just going supine to sit , sit to stand , maybe emulating 10 feet , like you have to clear them for home in the PACU or if they're to the floors or whatever .

So something to consider if you're kind of in this situation . You know , unfortunately there's a lot of different things , a lot of different factors that can play into this and interdisciplinary communication is probably the most important . But everyone has their priorities and so that can make it difficult to achieve like the end goal for everyone .

So just kind of throwing that little piece out . But your spinals very commonly they're going to buckle on you . They're going to have noodle leg . Really assess lower extremity strength , mmt before sit to stand and then definitely make sure that you're monitoring blood pressure , monitoring blood pressure . And next up is our epidurals .

Oh man , so in New York epidurals were like hot . It's kind of funny to watch different trends happen as we've moved across the country and also things are like in style or they go out of fashion or I don't know .

Maybe everyone took the same CEU course because you start seeing different trends and maybe anesthesia or pain medication or what have you , but epidurals were very common when we were treating in New York . And boy were they . They were spicy right . So epidurals have probably the most post-op concerns . Number one they also can have lower extremity weakness .

The thing about epidurals is depends on placement of that actual epidural to know if the patient's going to have good pain control . So a lot of times in the PACU we would have an issue where , let's say , there again a left total knee or a left total hip , the patient's in an extraordinary pain but their right leg is like numb and heavy and all the things .

So the epidural is just basically shooting to the right versus to the left and that patient is has like all the wrong effects . The pain is , the pain medication is going towards that right leg . That right leg is not strong . Left leg that had the surgery is not being covered . So typically they'll do some adjustments and hopefully help with that .

But they can also have bilateral lower extremity weakness .

So if you're treating someone with an epidural and now typically epidurals last more than post-op day zero , so you might have a day or two days or even three days to kind of pay attention to the overall epidural effects Always assess MMT , even if you're working with patients with , like , liver kidney transplant so that's where I see my epidurals most now is a

liver kidney transplant unit . Almost almost all of them have epidurals . So every now and again you'll get one or two that just can't . You know they have heaviness in their legs or just kind of a little unsure . You're doing bed thorax or like another like piece .

As to why I typically do bed thorax before getting someone up is because you get a lot of information out of that lower extremity movement . So , like they're having a really hard time doing heel slides , you start asking more questions Does this feel more difficult than before surgery ? Like , yeah , it's really heavy , my legs just feel like 200 pounds Red flag .

Right Now you're reassessing make sure you're reassessing MMT in the sitting position and see if they can longer quad and actually hold against resistance , because if they can't , you're done . So lower extremity weakness can still occur in either leg post-epidural . Number two they can also have nausea , vomiting .

So epidurals are interesting because sometimes I have all of them , which is really not fun for the patient . But sometimes it's just like one specific thing and if you go from supine to sit and the patient starts to feel nauseous and it starts progressively getting worse , when you lay them down they get better .

So usually I just kind of see if we can wait it out and if it's not getting worse , just lay them down and it pretty much goes away . But they can also , you know , have vomiting . It just kind of depends . Dizziness very common . But the big , huge issue with epidurals is that they can be hypotensive and they can bottom out .

Is that they can be hypotensive and they can bottom out ? So they're like the number one patient population that has orthostatic hypotension without a history of orthostatic hypotension .

So essentially what I tell my students or new grads or anyone that I'm mentoring who is maybe new to the acute care world or epidurals , is assume that they're going to bottom out on you , assume that their blood pressure is going to drop until proven otherwise .

So this patient , the epidural , post-surgery , whatever surgery it is , you are assessing vitals , you do not pass go , you do not try to take a shortcut Hashtag . Vitals are vital . I know I talk about taking vitals . You do not pass go , you do not try to take a shortcut Hashtag . Vitals are vital .

I know I talk about taking vitals probably more than most people , but in this patient population you do not pass go without having a baseline set of vitals because , most importantly in this patient , if you don't have a baseline blood pressure and you have the patient sit up and it's 120 over 70 , you have no idea what that number means .

They could have been 150 over 70 moments ago . You have to have to have to have baseline vital sign measurements . It is the only way you're going to know and be able to predict what's going to happen next . And even if they don't bottom out on you , do not trust it . I am not kidding . Be overcautious with the epidural .

They tend to bottom out and this is the patient population that you're looking for . The other signs Do they all of a sudden get a flash of heat ? Are they cold , clammy ? They got diaphoresis ? They just get less chatty . Pay attention , do not push . This is the patient that , on post-op day one , I usually say and this is probably the only time I say this .

If we get to the chair , you hit all the milestones , but if we lay back down , that's very common as well . You have to give some of that . It is so uncommon to ambulate a good distance with someone who has a brand new epidural post-op day one . Does it happen ? Yes , do I trust it ? No , absolutely not .

If I can have a chair follow underneath that person , you better believe I have someone pushing a chair right behind them . It is very , very rare that you have a patient that sits up . Blood pressure stays good , they feel good , they have good pain control . Everything is like going in the right direction . It's rare . Does it happen Totally ? So ?

I'm not here to like scare you , but I will tell you these patients will syncope , so proceed with caution . I want to say an epidural just has a yellow flag all around , right ? I'm not saying don't try to ambulate . I'm not saying don't get to the chair .

I am saying you're going to have to use your clinical judgment throughout that episode of care because it can change like that . That's it and you have to expect it Like . Expect it until they prove you wrong is a really good motto for an epidural Period and if they end up ambulating , awesome , amazing . Does it happen ? Yeah , totally . Is it common ?

No , it is way more common to stand up , they feel awful , nauseous , diaphoretic , blood pressure drop by greater than 20 , and they go pale . That is a much more common scenario than the patient ambulating down the hall . Now what I will say is epidurals went out of style for the total joint patient . We saw primarily total joints in New York .

We also had spine patients but total joints in the PACU . All of a sudden epidurals went out of style . When we were in New York I had the most syncopal episodes of my entire career . Now eventually I got good and could predict it and we didn't syncope anymore . But anytime there was a new PT on board , like we had to go through the whole .

Like these patients pass out . You need to be aware and people kind of think that you're crazy and you know you're over . You know you're over emphasizing that they're not going to do well and then they pass out .

I can't tell you how many rooms I've been passing in that career , in that job , where PT gets someone up for the first time and all of a sudden you hear can I get some help in here Always was the one kind of passing the room and you just it's part of it , right , as soon as you lay down there they come back to and you know all of all of the usual

syncopal episode things . But we were very good at um total of two like under the arms , under the legs , back in the bed move , had that move down pat . Honestly , I haven't had to do that in so long and I recently had to do like the full fireman carry over a recliner chair for the first time in a really long time .

So you have to just know , right , you have to .

This is part of I talk about like the crystal ball is what I think in my second episode on this podcast , something I always taught my students , because predicting all you know all the things we have to predict , predicting discharge , predicting response that is part of what you learn from experience .

It's clinical decision-making , clinical knowledge , clinical experience that's what your crystal ball is . It's not magic , it's knowledge , right . So being aware of what could happen can help prevent syncope or something worse . I'll tell you a quick story syncope or something worse . I'll tell you a quick story . My first student . He was a first year PT .

He did not have acute care . You know didactic information under his belt . It was probably a poor placement for him , but we knew that and we worked through it and so very observational for a little bit of time , very co-treat . He didn't see patients independently . I couldn't go see my own caseload , there was no way .

So this is part of why I mentor the way that I do , because the only way that you're going to learn to do something , the way that it should be done or correctly or safely , is by having oversight .

So even when I was hands off , I was nearby , because if you can't give feedback and you can't say , oh , this is what I would have done differently or you did that really nice , this is maybe how you could tweak your verbiage . If you're not there , you don't know . Like , that's just my opinion .

Anyway , it was a patient total joint , it was a total hip and I remember that because we had these high chairs , which I loved and I really something that we never saw again , right , so we had them on the East Coast .

We had these like high chairs for our total hips and they were fantastic because patient wouldn't break precautions and they had like a little step , whatever . It was great . It was not a recliner . We did not have recliners in New York . When we got to Michigan we were like what is the deal with the recliner chair ?

But apparently that's like that's the thing , I don't know . So he's seeing his patient , he's leading , he's like probably leading one of his first patients . We discussed all of the things that he might have . The person has an epidural and these are the things to expect and he did a really great job of assessing vitals and the patient did not bottom out .

But I always say do not trust an epidural until they prove you wrong or right . Right , you don't trust that epidural . You always have to have your guard up . So he kind of stand , pivots to the chair and he's like I think we could try walking . Kind of stand , pivots to the chair and he's like I think we could try walking .

And I was like still looks okay , you know , I let him , I let him lead . We probably got three feet and I was just watching the patient . I was watching him , um , and I was like I'm going to call it , we're going to sit down , we're going to slide him back to the bed and we're just going to like reassess his blood pressure .

We got him to the chair and lights went out . So we scooted him back to the side of the bed . We got him back in bed , reassess his vitals . As soon as he laid in supine he popped right back up . No big deal . No , you know , no harm , no foul . This wasn't uncommon in this setting .

I expect it , right , I'm waiting for it , but you have to try to prevent it , right ? So if you can prevent syncope , prevent syncope . His response was by far maybe the best response , and I only know this because Nikki and I worked together in New York . So he was sitting at a table at a nurse's station because I told him take a minute , you're fine .

Like , take a breath , take a beat , go get a drink . It's scary , right , it was just syncope , but you get the adrenaline rush , you get the like sympathetic response .

This is another point for my new grads , my students on affiliation If you have an episode of syncope or something worse , make sure you take a minute before you come back in , because you have to kind of undo all of that , right , you got to clear your head before you're working with your next patient .

So he was sitting at the nurse's station and he had his head down and he must have looked in distress and Mickey passed by and she's like , uh , everything okay . And he's like she knew . She knew the whole time . I had no idea , I thought we were good .

She knew , and it was just that moment that , no matter what , when you are new at something , your reaction time isn't going to be quick . This was a really big learning experience for both of us . Right . It solidified that I need to observe patients in the acute care setting . I pretty much never left a student independent , 100% .

Right , there was always supervision . I don't care if you're a third year , something can go wrong . And when something goes wrong , are you able to respond ? You don't know until you're in the moment period . Right , and it's always nice to have backup if something goes wrong .

Whether you have to total assist someone back into bed , whether you need to do a controlled you know lift to the ground , whatever it might be . He understood 100% at that point that epidurals cause syncope and even when your blood pressure doesn't bottom out , you have to proceed with caution . You have to look at the other signs as well and he did great .

He did great from that point forward . He had like two or three weeks left . He was amazing . He was probably one of my favorite students . He learned so much . His learning curve was just tremendous because he was literally learning all of the things on the job .

So that's a long story to say don't trust the epidural , expect it , and if it doesn't happen , that's awesome . But have that cautionary proceeding throughout .

Okay , now the one thing I will say , especially now the epidurals that I see are typically in for like two , three , sometimes sometimes four days , but like two to three days is common in the post-op liver kidney transplant population .

So you start progressing those epidurals right , and if they're bottoming out , then you need to have conversations with the team as well . We can't progress mobility because he keeps dropping whatever it might be . And they can do different things . They might take away the PCA button , they might lower the rate control coming through the actual epidural .

So there's things that they can do . Sometimes they turn it off for a short period and see if that kind of undoes the numbness or the heaviness in the legs or improve the blood pressure or whatever their symptom is . But a lot of times they'll restart it right .

So if someone is showing hypotension with their epidural , expect it the whole time and really proceed with caution , like if you're going to start ambulating , have a chair follow , just in case .

With that being said , especially on day two or three , these patients are potentially ambulating good distances in the hallway like all the way , and so for this patient population it's probably one of the better pain management type things that they can use because of the placement of the surgery .

So I don't think epidurals are going to go out of fashion in this population . But I was surprised because I hadn't seen them for quite some time and then when I came onto the transplant units I was like wow , we have epidurals . All right , here we are , and the same rules apply .

I think in general they do better than the total joints 15 years ago who were just like syncope after syncope . But I still have that like don't trust it , just don't trust it . Let them prove the whole way and check in and watch the color and you know that kind of stuff .

One more thing about epidurals , especially in the joint population , and I'm going to tell you why I'm specific about that .

So in the joint population we're talking lower extremities right , if they have numbness , weakness in their legs and it starts creeping up the trunk , you have to let the team know right away Because you don't want that to creep in towards diaphragm , affect breathing , that kind of thing .

It's specific to joints because it shouldn't be coming upwards With the transplant patients . They sometimes have numbness around the rib cage , but it's placement and it's purposeful . So , you know , still pay attention to their breathing , but that is more common . So just kind of want to throw that out there . So just a quick recap on general spinal and epidurals .

Your generals are going to puke , your spinals are going to buckle and your epidurals are going to bottom out on a blood pressure . The last extra piece and I'm only going to spend a little bit of time on this are peripheral nerve blocks and you'll see them kind of , you know , on different extremities in different places pending the surgery .

Same thing I've watched the trend of peripheral nerve blocks . When we started in York and the epidurals were going out of fashion , spinal plus femoral nerve block was like that was like the next thing , and so DM had really good pain management and their you know , non-op leg was doing great and their blood pressure was typically better controlled .

But they just had rubber band legs and so we used to go in on post-op day zero with two people and we had a femoral nerve block because we knew what we were going to get and basically one person was supporting lower extremity while the second person was really supporting trunk and if you were able to do sidesteps that was like a big deal .

They have gotten better and then they switched to adductor blocks , which tend to just do better in general . So just make sure that if you are dealing with a nerve block , that you're checking sensation and you're checking MMT prior to trusting that leg , especially if it's lower extremity .

If it's upper extremity and they're non-weight bearing , you know it doesn't really affect anything , but I just wanted to throw that piece out . All right , I think that was what I wanted to hit . So your generals they're your usually projectile vomiting patient , like if they say they're nauseous do not try to . You know , assume it's going to go away .

You better have a basin nearby because it could be next level vomiting your spinals . They just usually need more time but if anything is going to happen they're typically going to buckle . Always check the non-op leg to ensure that that spinal has worn off and obviously assess your vitals and your epidural has got a whole bag of tricks .

We have nausea , vomiting , we have lower extremity numbness , weakness , aka buckling , and the big , the big one is orthostatic hypotension . So just kind of proceed with caution . They can do really great and , like I said , they might ambulate a good distance , but don't trust an epidural until it proves you wrong . That's all I'm going to say about that .

z All right , I hope this was helpful for you . If you have any questions , dm me on Instagram . I forgot where you could talk to me . Dm me on Instagram . I forgot where you could . I forgot where you could talk to me . Dm me on Instagram . Send me a text . I'll drop my number in the show notes and thank you . Thank you for being here .

Thank you for listening . Totally appreciate each and every one of you . If you got something out of this episode , drop me some stars write a great review . It is 100% appreciated . All right , I hope you all have a wonderful day and whatever you have to do , get after it .