Short acting spinals

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I'm hoping to get some input on what others are doing with regard to short acting spinals (1 - 2 hours) for knee scopes, GU, etc... I'm getting pressure from my partners to stop using lidocaine for fear of TNS. I have limited experience with chlorprocaine and mepivicaine. I've found cutting back on the bupivicaine dose still gives a pretty lasting block. Any advice? Thanks.

I like 3% chloroprocaine (1.6-2 cc) for the 45 min to 1 hour cases and 2% mepivacaine 2 cc diluted to 3 cc with saline for around 90 minute cases. Never did it before starting PP, but my partners got me hooked!

What about ropivicaine? Is that available to you? I believe it's much more expensive but supposedly has less motor block. I don't think it's the long-lasting effects of a block that are detrimental so much as the long-lasting MOTOR block.

I don't have much experience with ropivicaine. But I would be interested to hear from people who do.

Originally Posted by B-Bone

I like 3% chloroprocaine (1.6-2 cc) for the 45 min to 1 hour cases and 2% mepivacaine 2 cc diluted to 3 cc with saline for around 90 minute cases. Never did it before starting PP, but my partners got me hooked!

Ditto on the Chloroprocaine.

For the last 3 years I've been using a 1 cc of hyperbaric bupi + 25 ug fentanyl for cerclages/cystos under spinal. I always get at least a T10 level, and thus avoid lido/TNS. May want to give Zofran prior to injecting the spinal to avoid the rare PONV from the fentanyl.

http://summaries.cochrane.org/CD0030...l-anaesthetics

the above article stated that mepivacaine had the same incidence of TNS as lidocaine.

What about just fentanyl with astromorph spinals? I might be mistaken but I think I heard an attending tell me that he used to do that in another country and it worked well.

[QUOTE=RussianJoo;12006892.......What about just fentanyl with astromorph spinals? I might be mistaken but I think I heard an attending tell me that he used to do that in another country and it worked well.[/QUOTE]

I'm pretty open minded, but that just sounds nuts.

Besides the fact that most procedures for which you are doing spinals will probably need some local anesthetic component, more importantly you are talking about giving a long acting agent (Astromorph) for a short procedure. Besides the fact that Astromorph takes about 30 minutes to kick in, most short procedures result in patients being discharged to home. So they would be going to an unmonitored setting. While the risk of respiratory depression is incredibly low, especially in the right patient population, it is not zero.

High incidence of TNS was only reported with higher concentrations of mepivacaine (i.e. >2%, worst with 4%).

The Incidence of Transient Neurologic Symptoms After Spinal Anesthesia with Mepivacaine
Jacques T. YaDeau, MD, PhD, Gregory A. Liguori, MD and Victor M. Zayas, MD
A & A September 2005 vol. 101 no. 3 661-665

Per this article, mepivacaine is the short-acting spinal anesthetic of choice at Hospital for Special Surgery (as of 2005).

Awesome information. Thanks for the input everyone.

Anyone doing meperidine spinals?

Originally Posted by soorg

For the last 3 years I've been using a 1 cc of hyperbaric bupi + 25 ug fentanyl for cerclages/cystos under spinal. I always get at least a T10 level, and thus avoid lido/TNS. May want to give Zofran prior to injecting the spinal to avoid the rare PONV from the fentanyl.

I've done that every now and then although the patients don't seem to have a very speedy discharge from the PACU.

How about 1cc of 10% novocaine with and 1cc of dextrose. Good for short cases. Or, can dilute the novocaine with csf before injecting because otherwise could be toxic. I like using this for knee scopes that last all of 10 minutes because I can have the patients leave the ambulatory cente quickly without nausea.

2 ml 0.25% macaine with 1 ml 10% dextrose works great. I use this combo frequently, most commonly for hemorrhoids. The patient gets a good sensory block with only partial motor block. They can usually move themselves back onto the stretcher after the surgery. You look like a stud having a comfy patient and a quick d/c from recovery.

Originally Posted by pgg

Anyone doing meperidine spinals?

Demerol spinals are the sh*t.

75mg meperidine (1cc) diluted with 1cc D10 dextrose. Works fantastically for GU cases lasting around 1 hr. oh, and don't worry that they can still move their legs when the surgeon gets started.

Originally Posted by Noyac

Demerol spinals are the sh*t.

75mg meperidine (1cc) diluted with 1cc D10 dextrose. Works fantastically for GU cases lasting around 1 hr. oh, and don't worry that they can still move their legs when the surgeon gets started.

my preferred agent of choice for short cases. PONV can be common and normally I prophylax .

I used to do this, but we cant get procaine anymore. You guys still getting it?

I would like to use 3% chloroprocaine, but all the vials in my institution are labeled as "Not for spinal use". Since it isn't currently approved for spinals because of prior problems with preservatives, what would one use?

Originally Posted by Impromptu

I would like to use 3% chloroprocaine, but all the vials in my institution are labeled as "Not for spinal use". Since it isn't currently approved for spinals because of prior problems with preservatives, what would one use?

Pretty much everything we are discussing is labeled "not for spinal use". That just means it's not FDA approved for this. even fentanyl isn't FDA approved for spinal use. also, don't use chlora prep to prep for spinals, as that is also not FDA approved we, as physicians, can make the decision to use these drugs off label. As far as legal liability, we are held to the local standard of care rather than FDA rulings with respect to malpractice, so that shouldn't really be a concern. Finally, the 2-Chloroprocaine problems were with a preservative that is no longer used in formulation, so the clinical point is moot as well.

I am still trying to get a handle on the local anesthetic properties of demerol and have little experience with it to date.

Do you guys notice a sympathectomy with demerol spinals?
Also, it sounds as if the block is sensory>motor as with bupivicaine/ropivicaine? Are you able to elicit a level?
I also have heard of profound PONV when using demerol spinals that I thought had precluded its usage. Have you found pretreating with zofran or another antiemetic effectively minimizes this risk?

Originally Posted by Lurch

I am still trying to get a handle on the local anesthetic properties of demerol and have little experience with it to date.

Do you guys notice a sympathectomy with demerol spinals?
Also, it sounds as if the block is sensory>motor as with bupivicaine/ropivicaine? Are you able to elicit a level?
I also have heard of profound PONV when using demerol spinals that I thought had precluded its usage. Have you found pretreating with zofran or another antiemetic effectively minimizes this risk?

I havent used it in a few years bc we don't have the right demerol preparation. Plus if my pt needs a short acting spinal they get an even shorter acting general, its done as soon as the case is done.

But the motor block is not nearly as impressive as Lidocaine and it can be difficult to illicit a sensory level. But I don't recall any PONV. Sounds hokey doesn't it? But it works great.

At our VA we use Sufenta only spinals for ESWL's (I'll have to check on the dosing). They work great in this situation since there's no cutting involved, but I think it's probably limited to this application.

Originally Posted by Impromptu

I would like to use 3% chloroprocaine, but all the vials in my institution are labeled as "Not for spinal use". Since it isn't currently approved for spinals because of prior problems with preservatives, what would one use?

i think morphine is the only drug that is FDA approved for spinal use.

fyi this group (GU, knees) would be at fairly high risk for TNS following lidocaine spinal, id probably avoid it and use chlorprocaine

Originally Posted by Impromptu

I would like to use 3% chloroprocaine, but all the vials in my institution are labeled as "Not for spinal use". Since it isn't currently approved for spinals because of prior problems with preservatives, what would one use?

.5% bupi says the same thing.

Originally Posted by Arch Guillotti

.5% bupi says the same thing.

So does our 025% PF bupivacaine.

Originally Posted by Noyac

Demerol spinals are the sh*t.

75mg meperidine (1cc) diluted with 1cc D10 dextrose. Works fantastically for GU cases lasting around 1 hr. oh, and don't worry that they can still move their legs when the surgeon gets started.

Cool, I'm going to see about trying that ... finding PF Demerol might be the buzz killer though.

Originally Posted by Arch Guillotti

.5% bupi says the same thing.

So does our 0.25% PF bupivacaine. I still use it all the time though.

Originally Posted by Noyac

Demerol spinals are the sh*t.

75mg meperidine (1cc) diluted with 1cc D10 dextrose. Works fantastically for GU cases lasting around 1 hr. oh, and don't worry that they can still move their legs when the surgeon gets started.

Cool, I'm going to see about trying that ... finding PF Demerol might be the buzz killer though.

Originally Posted by pgg

Cool, I'm going to see about trying that ... finding PF Demerol might be the buzz killer though.

I believe the carbujet (?) is PF. the problem i have is that we only have 50mg and i used 75 mg every time i used it. I'll have to check into it again.

Originally Posted by pgg

So does our 0.25% PF bupivacaine. I still use it all the time though.

Do you use .25% for spinals? I use the .5% bupi (despite the warning) for stuff all the time.

Originally Posted by Noyac

Plus if my pt needs a short acting spinal they get an even shorter acting general, its done as soon as the case is done

+1. Especially for off site ASC's where you potentially need to stick around. Never done a meperidine spinal. All I know is that it's molecular structure is similar to atropine and local anesthetics. Pretty sweet considering it was first synthesized in the early 1930's.
I've been curious for some time now.

Good to see you posting. Keep it up!

Originally Posted by sevoflurane

+1. Especially for off site asc's where you potentially need to stick around.

+2?

Originally Posted by Arch Guillotti

Do you use .25% for spinals? I use the .5% bupi (despite the warning) for stuff all the time.

Yes, for labor CSEs. Intrathecal dose 1cc 0.25% bupiv + 15 mcg fentanyl.

Originally Posted by B-Bone

I like 3% chloroprocaine (1.6-2 cc) for the 45 min to 1 hour cases and 2% mepivacaine 2 cc diluted to 3 cc with saline for around 90 minute cases. Never did it before starting PP, but my partners got me hooked!

May be a silly question, but what about 3cc 2% chloroprocaine for a spinal? I have little experience with chloroprocaine except for bolusing 3% in an epidural for a stat c-section, I always wondered what the vial of 2% in the drawer was for........

we ran out of 3% last week, so a few of us tried the 2% for knee scopes, and it worked just fine. 3 cc got us through about 45 minutes without a hitch.

I am on my OB rotation and we will sometimes use the 2% chloroprocaine for redosing epidurals if the patient is about to deliver. (When the PCEA just isn't enough for that patient and I decide not to use 0.25% bupivacaine or a few other local anesthetics).

An off-label thing we do is using 2 mg/mL demerol at 10mL/hr in the epidural for post C-section pain control. Leave the epidural in for 2 days. From what I have heard we are probably one of the only hospitals in the country to use demerol in the epidural like this, but the satisfaction ratings are amazing. One of the busiest OB hospitals in the country. We should probably publish some of this in-house data.

Originally Posted by Impromptu

An off-label thing we do is using 2 mg/mL demerol at 10mL/hr in the epidural for post C-section pain control. Leave the epidural in for 2 days. From what I have heard we are probably one of the only hospitals in the country to use demerol in the epidural like this, but the satisfaction ratings are amazing. One of the busiest OB hospitals in the country. We should probably publish some of this in-house data.

Interesting. Presumably they're ambulatory, I wouldn't think you'd get any motor block from that amount of Demerol. Do they itch or puke much (is this tracked)?

There's a place near us that puts 3 mg of epidural morphine in after delivery and pulls the catheter, and they say patients love it. (And they bill for another day of pain management too.)

I don't do any of that, just pull the catheter 2 hrs postpartum. When I check up on them the next day for the post visit they all seem to be doing fine on Motrin, so I haven't felt compelled to do anything different.

Originally Posted by pgg

Interesting. Presumably they're ambulatory, I wouldn't think you'd get any motor block from that amount of Demerol. Do they itch or puke much (is this tracked)?

There's a place near us that puts 3 mg of epidural morphine in after delivery and pulls the catheter, and they say patients love it. (And they bill for another day of pain management too.)

I don't do any of that, just pull the catheter 2 hrs postpartum. When I check up on them the next day for the post visit they all seem to be doing fine on Motrin, so I haven't felt compelled to do anything different.

They appear to have less itching than with morphine or hydromorphone. A few still require nubain or benadryl. Nausea is pretty rare. It is a walking epidural. A rare few will have a little tingling on their bilateral anterior thighs, but I have not seen any that couldn't walk.

For those epidurals that are going to be pulled immediately post-op we will often put in some preservative free morphine then pull. If we are doing a straight spinal without an epidural we will use the 0.75% bupivacaine, 15-20 mcg fentanyl, and 200 mcg morphine PF.

Of course I am still learning what I find most effective.

Oops, my mistake, I thought you were talking about labor epidurals, even though your post clearly says post c-section pain. I always (barring allergy) give epidural or intrathecal morphine for that.

I'm actually doing my MOCA-required practice assessment/improvement bit now, looking at changing my spinal narcotic dose for c-cection pain.

Originally Posted by Impromptu

If we are doing a straight spinal without an epidural we will use the 0.75% bupivacaine, 15-20 mcg fentanyl, and 200 mcg morphine PF.

That's exactly what I settled on as a CA2 and have done ever since - 0.75% hyperbaric bupivacaine (usually 1.6 mL) + 15 mcg fentanyl + 200 mcg morphine for scheduled c-sections. Then periopdoc put a thought in my head in this recent Duramorph/Bupiv Spinals thread about dropping the fentanyl and using just 100 mcg of morphine ... There is published data supporting the notion that 100 mcg is just as good as 200 mcg for pain control, with fewer side effects.

So I decided to try it. I dug up charts for my last 20 scheduled sections and mined the postop pain scores, postop PRN pain nausea and pruritis meds given. Since then I've done 11 out of 20 planned sections with just the 100 mcg morphine dose. (Our OB census is very dry right now so god only knows how much longer it'll take me to do another 9.)

I'm unimpressed with 100 mcg morphine instead of 200 mcg + 15 fentanyl so far. Comparing the two groups, there 100 mcg group has had more pain for the entirety of the first 24 hours postop (edging toward statistical significance in the 8-12 and 12-16 hour postop time periods), more pain meds requested, and similar rates of nausea and pruritis. Caveats - small sample size, not prospective/randomized/blinded/etc, but it looks like I'll go back to the 200 + 15 dosing when I'm done with this project.

Originally Posted by pgg

Yes, for labor CSEs. Intrathecal dose 1cc 0.25% bupiv + 15 mcg fentanyl.

same here. I have never thought about using the .25% stuff for a hemorrhoid case per a previous poster.

Originally Posted by Magnus67

May be a silly question, but what about 3cc 2% chloroprocaine for a spinal? I have little experience with chloroprocaine except for bolusing 3% in an epidural for a stat c-section, I always wondered what the vial of 2% in the drawer was for........

2 or 3%, doesn't matter.

40-60mg either way.

Originally Posted by soorg

For the last 3 years I've been using a 1 cc of hyperbaric bupi + 25 ug fentanyl for cerclages/cystos under spinal. I always get at least a T10 level, and thus avoid lido/TNS. May want to give Zofran prior to injecting the spinal to avoid the rare PONV from the fentanyl.

I sit em up and do the same. I omit the Opiods. I just give slightly less than 1 cc of hyperbaric Bup and let it really settle in the sacral dermatomes (3 min). Then, we do the case. Block usually lasts about an hour though while the procedure takes 15 min.

Originally Posted by Arch Guillotti

Do you use .25% for spinals? I use the .5% bupi (despite the warning) for stuff all the time.

Me too. It's Isobaric. Lasts longer in equal dosage compared to the heavy stuff.

Originally Posted by Arch Guillotti

same here. I have never thought about using the .25% stuff for a hemorrhoid case per a previous poster.

It's the total Milligram dose that matters here not the %.

Here is what I propose:

7.5 mg of Ropivacaine with Dextrose. It should last about 30-45 minutes.

http://journals.lww.com/rapm/Citatio...thesia.62.aspx

CONCLUSIONS:

'Hyperbaric' ropivacaine provides reliable spinal anaesthesia of shorter duration than bupivacaine or levobupivacaine, both of which are clinically indistinguishable. The recovery profile of ropivacaine may be useful where prompt mobilization is required

How about 45mg of 1.5% Mepivacaine? Lasts 1.5 hour. Maybe 30 mg gives you 45 minutes?

http://journals.lww.com/anesthesiolo...Spinal.10.aspx

The duration of effect was shorter with chloroprocaine than with an equal dose of lidocaine (22), and institutional discharge criteria were achieved more rapidly with chloroprocaine than with lidocaine (22), procaine (20), or small-dose bupivacaine (19). As expected, anesthesia could be prolonged or enhanced by the coadministration of fentanyl (24), epinephrine (23), or clonidine (18). Somewhat surprisingly, reliable anesthesia could be achieved with doses of chloroprocaine as small as 30 to 40 mg (21), and the duration of anesthesia with a 60-mg dose was longer than that reported by Foldes and McNall despite the use of larger doses (82.5–100 mg) by these earlier investigators (14,23). Another unexpected, and potentially important, finding is the occurrence of “flu-like” symptoms in volunteers receiving chloroprocaine containing epinephrine (23), the implications of which we will return to shortly.

Chloroprocaine 30 or 40 mg, with or without fentanyl (10–20 μg), was the most common (92%) dose combination used. Mean peak block height averaged T6 to T8. The surgical procedure time was 32.3 ± 18.4 min. Time from placement of the block to the end of the surgical procedure was 53.1 ± 20.7 min. Times to ambulation and discharge were 155.1 ± 34.7 min and 207.9 ± 69.4 min, respectively. 2-CP spinal anesthesia has proven to be a safe and effective alternative to lidocaine and procaine for ambulatory surgical procedures of ≤1 h, with a predictable regression of block height. No patients reported TNS after surgery.

Originally Posted by pgg

Oops, my mistake, I thought you were talking about labor epidurals, even though your post clearly says post c-section pain. I always (barring allergy) give epidural or intrathecal morphine for that.

I'm actually doing my MOCA-required practice assessment/improvement bit now, looking at changing my spinal narcotic dose for c-cection pain.


That's exactly what I settled on as a CA2 and have done ever since - 0.75% hyperbaric bupivacaine (usually 1.6 mL) + 15 mcg fentanyl + 200 mcg morphine for scheduled c-sections. Then periopdoc put a thought in my head in this recent Duramorph/Bupiv Spinals thread about dropping the fentanyl and using just 100 mcg of morphine ... There is published data supporting the notion that 100 mcg is just as good as 200 mcg for pain control, with fewer side effects.

So I decided to try it. I dug up charts for my last 20 scheduled sections and mined the postop pain scores, postop PRN pain nausea and pruritis meds given. Since then I've done 11 out of 20 planned sections with just the 100 mcg morphine dose. (Our OB census is very dry right now so god only knows how much longer it'll take me to do another 9.)

I'm unimpressed with 100 mcg morphine instead of 200 mcg + 15 fentanyl so far. Comparing the two groups, there 100 mcg group has had more pain for the entirety of the first 24 hours postop (edging toward statistical significance in the 8-12 and 12-16 hour postop time periods), more pain meds requested, and similar rates of nausea and pruritis. Caveats - small sample size, not prospective/randomized/blinded/etc, but it looks like I'll go back to the 200 + 15 dosing when I'm done with this project.

I use 150 ug-200ug Duramorph with No Fentanyl. I doubt the Fentanyl has anything to do with pain relief beyond 6 hours.

Originally Posted by BLADEMDA

It's the total Milligram dose that matters here not the %.

I beg to differ. There is a big time difference between 1 ml 0.5% vs 2 ml of 0.25%.

Why the difference? I don't know, but I have observed a much shorter duration and less motor block with 0.25.

Originally Posted by ICd8U

I beg to differ. There is a big time difference between 1 ml 0.5% vs 2 ml of 0.25%.

Why the difference? I don't know, but I have observed a much shorter duration and less motor block with 0.25.

0.5% Bup (5mg) mixed with 1 ml of CSF vs 0.25% ( 2mls=5mg) mixed with CSF and there is a difference of duration? It must be the Dextrose added which explains the duration difference. Dextrose will shorten the block compared to pure Isobaric Bup.

In published studies comparing different formulations of tetracaine the duration of the block was the SAME based on total mg of drug given via CSF. It was important to mix CSF with the tetracaine to ensure adequate spread of the local. Hence, I doubt in a large trial 5mg of Bup given via 1ml or 2ml formulation would make any difference. There is tremendous patient variability in how long a spinal lasts for an individual.