A new one to me

[propadope]

So I had a fairly lengthy discussion with this pt. At least as lengthy as I can tolerate. He seemed pretty calm and reasonable. I told him I had no magic potion for him but I had a plan. We would see how it goes and adjust on the fly if necessary.

I went with a CSE and Midaz for sedation. Told him hat he would be awake but sedated some for the case and he was fine with this. I was really curious if he would show any rapid metabolism characteristics. I suspected the spinal would be all he would need and that any rapid metabolism would not effect the spinal since it works locally. I don't have any thing to confirm this theory though. I wanted the epidural as a back up if needed.

In the OR, I placed the CSE and dosed the spinal with 15mg isobaric bupiv and 200mcg dilaudid. He got 5 mg versed for this and he became sedated. Laid him down and we began to place the foley and position him. The spinal seemed to take about 5 minutes to setup but I got a good block and we proceeded as usual. Within 5 minutes he was as if I had given him no sedation. So I gave more which worked but didn't last as long as expected. He got 20mg of versed for the entire case and remembers most of the case which was fine and we had discussed preop.

When the surgeon made incision the pt looked up at me and said, "they're cutting on me?" I asked if it hurt and he said it sort of burned a bit. So I dosed the epidural with 2% lido. Once past the skin he was fine. No pain or feeling. We chatted throughout the case and all was good. Towards the end they put a femoral retractor in and he felt it. I gave more in the epidural and all was good again. At the end I gave .25% Marcaine I the epidural and pulled it. I could have left it but the pt was fine with pain meds as long as we gave them more frequently and he would get DVT prophylaxis. I saw him the next day and he was extremely pleased with the approach. He remembered a lot of the case but not everything. Pain was well controlled post op as well.

So those that want to use volatile agent on this guy, why? What makes you think it would work this time if it didn't work in the past? Can anyone explain how the P450 system works when volatile is used? How about the spinal I did? It seemed to wear off rather fast as well. I can't explain that one. I'm damn glad I had the epidural as back up tho. Maybe it was just the isobaric marcaine. I've seen this stuff come on slow but it lasts longer usually. Maybe it wasn't wearing off but wasn't fully active yet, I have no clue.

Bottom line is we have a very happy pt and therefore, a very happy surgeon as well. Surgeon wanted me to just put him to sleep but said, it's your call I trust you.

What would you have done if you just did a spinal? (Great idea to do the epidural BTW). This confirms that there are patients like this out there and it seems to include medications from a wide range of drug classes including local anesthesics.

Volatile is minimally metabolized and is eliminated mostly by exhalation so I don't think CYP would matter.

No BIS?

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[urge]

1 Towards the end they put a femoral retractor in and he felt it.

2 He remembered a lot of the case but not everything. Pain was well controlled post op as well.

3 So those that want to use volatile agent on this guy, why? What makes you think it would work this time if it didn't work in the past?

4 Can anyone explain how the P450 system works when volatile is used? .

1 How long was the case?

2 Now he is going to say he was awake during 3 surgeries.

3 You could have achieved the same with GA and no paralysis. Squirming on the bed would have been the same as vocalizing he is in pain.

4 Can anyone explain how volatiles work?

 

[Noyac]

What would you have done if you just did a spinal? (Great idea to do the epidural BTW). This confirms that there are patients like this out there and it seems to include medications from a wide range of drug classes including local anesthesics.

Volatile is minimally metabolized and is eliminated mostly by exhalation so I don't think CYP would matter.

No BIS?

But he had volatile agents in the previous 2 surgeries. So something matters, I'm just not smart enough to know what it is.

No BIS because he was already awake as we had discussed. He wasn't anxious about being awake for the case so it was fine.

 

[Noyac]

1 How long was the case?

2 Now he is going to say he was awake during 3 surgeries.

3 You could have achieved the same with GA and no paralysis. Squirming on the bed would have been the same as vocalizing he is in pain.

4 Can anyone explain how volatiles work?

1) typical duration a little over an hour.

2) yep you are probably correct.

3)true but 2 other anesthesia persons had attempted this approach with poor results and I didn't want to be the next one. At least this way he was prepared well and we could talk about what he was experiencing. Rather than sitting back spinning tunes and then, "Oh ****, he's moving." Plus, he directly stated that the propofol really makes him feel hung over for days. The last pt that told me this ended up getting propofol induced hepatitis. I chose to avoid it all.

4) I asked the question first.

 

[propadope]

But he had volatile agents in the previous 2 surgeries. So something matters, I'm just not smart enough to know what it is.

No BIS because he was already awake as we had discussed. He wasn't anxious about being awake for the case so it was fine.

Maybe its just a question of how much volatile. That first study I linked (albeit only one and a small one) showed a 20% increase in MAC in redheads to prevent movement. It must be something more than CYP and your question on how volatile works must be the key...


What would you have done if you didn't have the foresight to place the epidural?

Would have been interesting to test the BIS on this patient...

 

[Mman]

Having done a lot of total joints, I must admit neuraxial is so much better for pts, especially postop.

What is your definition of "much better"? I believe the best evidence you can find will suggest they have a slightly lower chance of major morbidity and perhaps a slight decrease in narcotic requirement. For any given patient the benefit is generally minimal, but over 1000s of them you will see some benefits in the long term.

 

[propadope]

I wonder how remimazolam would work on someone like this? Also remifentanil....

 

[Noyac]

What would you have done if you didn't have the foresight to place the epidural?

If I had just placed a spinal and it seemed to be wearing off I would have probably induced with propofol, slipped in an LMA and slapped a BIS on him. I would then crank the gas and hit him with some versed (or propofol) every time his BIS got above 60. Definitely no muscle relaxant.

 

[scudrunner]

Great case. I almost said CSE. That backup epidural was clutch. Thanks for sharing.

 

[pgg]

So those that want to use volatile agent on this guy, why? What makes you think it would work this time if it didn't work in the past?

I'd be interested in reviewing his previous anesthetic records. But without them, I interpret the failure of his previous anesthetics to be a matter of dose, not the impossibility of anesthetizing him with volatile anesthetic. Because I don't believe there are any mammals that can't be sufficiently anesthetized with enough des/iso/sevo.

I'd be pretty confident that the patient is asleep with 1.3+ MAC or so and a Bis reading in the 40s. (And I'd use the Bis less because I think it's needed, more for the chart value if he claims recall again, and because I'd frankly be curious to see what it says in a patient like this.)

Can anyone explain how the P450 system works when volatile is used?

I would argue that it's not really relevant at all when a non-metabolized volatile anesthetic is used. What's the figure for desflurane? 0.02% metabolized?


Nicely done with the CSE. Communication and expectation management is key with regional and it sounds like the patient was pretty happy with the outcome.

 

[Ezekiel2517]

What is your definition of "much better"? I believe the best evidence you can find will suggest they have a slightly lower chance of major morbidity and perhaps a slight decrease in narcotic requirement. For any given patient the benefit is generally minimal, but over 1000s of them you will see some benefits in the long term.

With neuraxial, we have found shorter hospital stays, significantly less pain, less time in rehab, much less postop N/V, much higher pt satisfaction, reduced postop complications such as aspiration, MI, PE, etc. It shouldn't take multiple studies (many of which are poor and unreliable) to figure this out. It's just common sense, to me anyways. Most of these total joints are old sick pts with many comorbidities. Obviously they are not going to do as well when you put them under GA with paralysis. I used to do joints under GA but started doing neuraxial b/c some surgeons preferred it. These are surgeons who do a lot of joints so clearly they prefer it for a reason. Honestly it's more of a hassle for me. But there is a difference. I don't think there's anything wrong with GA, it's just that neuraxial is better.

 

[Mman]

With neuraxial, we have found shorter hospital stays, significantly less pain, less time in rehab, much less postop N/V, much higher pt satisfaction, reduced postop complications such as aspiration, MI, PE, etc. It shouldn't take multiple studies (many of which are poor and unreliable) to figure this out. It's just common sense, to me anyways. Most of these total joints are old sick pts with many comorbidities. Obviously they are not going to do as well when you put them under GA with paralysis. I used to do joints under GA but started doing neuraxial b/c some surgeons preferred it. These are surgeons who do a lot of joints so clearly they prefer it for a reason. Honestly it's more of a hassle for me. But there is a difference. I don't think there's anything wrong with GA, it's just that neuraxial is better.

And I don't think you have that level of improved outcomes. I do them both ways and we do tons of joints (somewhere between 3000-4000 a year). No LOS difference. And how do you get "much less PONV" on a group of patients that has an insanely low level of PONV after GA? How many postop MIs are you having in patients that had GA? How many PEs? Those events should be so rare that anecdotally you can't even begin to measure the difference.


I LIKE doing them under spinal. I just haven't seen any evidence (in the literature or in our hospital doing them by the boat load) that it makes a big difference either way. It can make a small difference here or there and for the occasional patient there is a good reason to do it one way or the other, but any claim that it's massively better one way or the other is just flat wrong IMHO.

 

[Ezekiel2517]

And I don't think you have that level of improved outcomes. I do them both ways and we do tons of joints (somewhere between 3000-4000 a year). No LOS difference. And how do you get "much less PONV" on a group of patients that has an insanely low level of PONV after GA? How many postop MIs are you having in patients that had GA? How many PEs? Those events should be so rare that anecdotally you can't even begin to measure the difference.


I LIKE doing them under spinal. I just haven't seen any evidence (in the literature or in our hospital doing them by the boat load) that it makes a big difference either way. It can make a small difference here or there and for the occasional patient there is a good reason to do it one way or the other, but any claim that it's massively better one way or the other is just flat wrong IMHO.

Dude, if you don't believe there's a difference, more power to you buddy and keep doing what you're doing. I could care less how other people like to do it, do whatever the fuk you want. Seriously, I could give two shts.
This is private practice, and the orthopods are big moneymakers for not only the hospital but also, in turn, our group. If they say they want spinals cuz they've seen better outcomes and they believe it's better for their pts, I'm not gonna argue or convince them otherwise. Especially when they are the ones who are most closely following and invested in their pts postoperatively.

 

[Noyac]

 

[dhb]

I would have had him drink a tall glass of grapefruit juice 4h before the surgery

 

[Mman]

Dude, if you don't believe there's a difference, more power to you buddy and keep doing what you're doing. I could care less how other people like to do it, do whatever the fuk you want. Seriously, I could give two shts.
This is private practice, and the orthopods are big moneymakers for not only the hospital but also, in turn, our group. If they say they want spinals cuz they've seen better outcomes and they believe it's better for their pts, I'm not gonna argue or convince them otherwise. Especially when they are the ones who are most closely following and invested in their pts postoperatively.

Sorry you are offended. I'm not telling you how to do your job. Like I said, I enjoy doing joints under regional. I do lots of them that way. I also do a decent amount under GA. I'm also in PP and make a ton of money off those procedures, though mainly in volume obviously not per patient since most are medicare.

I'm just saying any argument that patients do so much better is simply false and not supported by evidence or anecdote. The best you can say is they might do a teeny bit better.

 

[Arch Guillotti]

Stadium style!

 

[propadope]

How about that BIS?

 

[urge]

With neuraxial, we have found shorter hospital stays, significantly less pain, less time in rehab, much less postop N/V, much higher pt satisfaction, reduced postop complications such as aspiration, MI, PE, etc. It shouldn't take multiple studies (many of which are poor and unreliable) to figure this out. It's just common sense, to me anyways. Most of these total joints are old sick pts with many comorbidities. Obviously they are not going to do as well when you put them under GA with paralysis. I used to do joints under GA but started doing neuraxial b/c some surgeons preferred it. These are surgeons who do a lot of joints so clearly they prefer it for a reason. Honestly it's more of a hassle for me. But there is a difference. I don't think there's anything wrong with GA, it's just that neuraxial is better.

Do you guys know how to do GA properly?

One would guess no from your diatribe.

 

[pgg]

Do you guys know how to do GA properly?

One would guess no from your diatribe.

Yo, I think he just dissed pent-sux-tube. Get 'im!

 

[Ezekiel2517]

Do you guys know how to do GA properly?

One would guess no from your diatribe.

hahaha sorry I hurt your feelings.

 

[Vaporized]

I think this was the best outcome. Of the expectation is that you will not feel the pain of surgery but you will be sedated, i.e., not unconscious so you will remember people talking, yet not feel surgical pain is the answer. The biggest problem is the surgeons. You do a perfect ISB for AVF and the patient feels nothing, but they want the patient asleep so they don't hear or remmwber, they just don't get it. I would have voted for CSE with preceded gtt and boulus the epidural more frequently than normal as BP would allow. Midaz as well. That is mostly for the surgeons. From a purist point of view having just a CSE without giving anything else, with patient awake listening to iPod is a success and bolus as dictated by patient. where I work, unfortunately, even with regional or neuraxial they want patient asleep.
Good case and management

 

[pgg]

The biggest problem is the surgeons. You do a perfect ISB for AVF and the patient feels nothing, but they want the patient asleep so they don't hear or remmwber, they just don't get it.

They don't want the patient listening to them gripe about instruments missing from their setup, or their preference cards, or the clank of something getting dropped on the floor, or their plans for the weekend. That's all, they want to do technical work on a piece of meat, not interact with the patient while they work. (Fair enough ... I chose anesthesia in part so I could take care of patients without talking to them the whole time.)

I'd just settle for the periop nurse not talking about her boob job and her "great cleavage" during emergence so the teenage girl patient's first words upon extubation aren't "yeah I have great cleavage" ... that was hysterically awkward.

 

[chmd]

They don't want the patient listening to them gripe about instruments missing from their setup, or their preference cards, or the clank of something getting dropped on the floor, or their plans for the weekend. That's all, they want to do technical work on a piece of meat, not interact with the patient while they work. (Fair enough ... I chose anesthesia in part so I could take care of patients without talking to them the whole time.)

I'd just settle for the periop nurse not talking about her boob job and her "great cleavage" during emergence so the teenage girl patient's first words upon extubation aren't "yeah I have great cleavage" ... that was hysterically awkward.

You can't explain that away. Just grab the scopolamine.

 

[urge]

In case you didn't get it, let me explain to you:
1. You do a pre-induction spinal (because ortho needs to be happy).
2. ...

Is that really the case? Regional is what they want?

All I hear is orthopods complain about epidurals and femoral blocks which is what would keep those pts pain free longer. A 4 hr spinal seems to play little role in their pain management.

 

[deleted171991]

Is that really the case? Regional is what they want?

All I hear is orthopods complain about epidurals and femoral blocks which is what would keep those pts pain free longer. A 4 hr spinal seems to play little role in their pain management.

In my department, it depends on the surgeon. Some want regional, some wouldn't even hear about it. Whatever they want happens, even if there is/were scientific proof to the contrary. As long as it does not prolong hospitalization/recovery, this decision should belong to the anesthesiologist, based on informed consent from the patient.

Personally, I find that being dictated the anesthesia/pain management technique is as abnormal as me imposing the surgical technique. But, of course, I am not the one bean counters bend over backwards for.

From where I stand, if a surgeon refuses regional for post-op pain control, s/he should manage the patient's pain beginning in the PACU. Then they would learn. This also goes for the geniuses who are too lazy to do even a field block with local.

This is 2015. I am very good at titrating IV analgesia, but patients should not be subjected either to it or to general anesthesia just because the surgeon/anesthesiologist is incompetent. Anybody who tells me that (usually) GA is same as/preferable to regional gets a ***** tag in my book. I personally wouldn't have general if I had a choice, the same way I wouldn't accept a retrobulbar block for a cataract surgery.

We need to educate the public, write anesthesia books/blogs for patients, so that they will know what to ask for. Or maybe write a Jaffe-equivalent for surgeons.

 

[wickedskillz]

Great case Noyac, thanks for sharing.

 

[deleted50478]

Is that really the case? Regional is what they want?

All I hear is orthopods complain about epidurals and femoral blocks which is what would keep those pts pain free longer. A 4 hr spinal seems to play little role in their pain management.

They want regional so you'll get called at night if the pt is in pain instead of them. Pt's pain has little if anything to do with it in my experience and opinion. Hopefully that isn't true everywhere, but...

 

[deleted682700]

Codeine doesn't work for 7-10 percent of the population because they lack the enzyme to convert codeine to morphine.
May be some percentage of the population has resistance to halogenated anesthetics?

 

[btbam]

Codeine doesn't work for 7-10 percent of the population because they lack the enzyme to convert codeine to morphine.
May be some percentage of the population has resistance to halogenated anesthetics?

Think about how halogenated anesthetics work and you'll have the answer to your hypothesis.

 

[deleted682700]

Think about how halogenated anesthetics work and you'll have the answer to your hypothesis.

Halogenated anesthetics are highly lipophillic and probably interact at the nervous cell membrane. It's more likely to be a physical chemistry mechanism, meaning a stretch in nerve membranes blocking initiation/conduction of the nerve signal?
But amino acid 12g, arachnidonic acid interaction ? This may be different in the population that are resistant to anesthetics?
How is the action of xenon different from halogenated anesthetics, anyone here has used xenon?