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Just wondering if anyone knows any data of using epidurals + GA vs GA alone vs regional alone for hips in terms of decreasing pe and blood loss risks. Is the consensus just GA vs regional?
Just wondering if anyone knows any data of using epidurals + GA vs GA alone vs regional alone for hips in terms of decreasing pe and blood loss risks. Is the consensus just GA vs regional?
only one of our Ortho guys wants epidurals/spinals for their hips. the rest either think its not worth the wasted time in the OR or they don't really believe the evidence. very frustrating
The reason I say this is that surgeons generally only pay attention to time in room til time to prep. You spinal might take an extra 60 seconds. They don't pay attention to the extra 10 minutes on the wake up which is equally important when they have 5-6 cases in the same room all day.
An ortho I work with started doing all of her total hips via the anterior approach. With straight GA, transfusion was a given. Routinely lost 500 cc of blood or more. I did some research and found the papers Blade posted. I started putting spinals in every patient, and have yet to require a transfusion since.
I do intubate these patients because they are positioned with the arm of the opposite side secured across their chest, making intra op intubation very difficult should the operation last longer than the spinal.
An ortho I work with started doing all of her total hips via the anterior approach. With straight GA, transfusion was a given. Routinely lost 500 cc of blood or more. I did some research and found the papers Blade posted. I started putting spinals in every patient, and have yet to require a transfusion since.
I do intubate these patients because they are positioned with the arm of the opposite side secured across their chest, making intra op intubation very difficult should the operation last longer than the spinal.
Do you have issues with hypotension? How light do you run them in terms of their inhalational anesthetic?My surgeon only does anterior total hips now. I place a spinal when we get into the room, then I lay the patient down and intubate. Before when I did general only, I had to transfuse every patient. Now that I use the combined technique, I have not had to transfuse anyone.
Theoretically, I could do the case under spinal alone, but the patient is positioned with an arm secured over their chest. This makes accessing the airway in the middle of the case for whatever reason (apnea, code, case outlasts the spinal, patient complaining, etc) damn near impossible without reprepping. Thus I intubate these patients as well. I guess I could use an LMA, but if it became dislodged then I'd be back to the same problem.
I haven't done a regular hip in years.
My surgeon only does anterior total hips now. I place a spinal when we get into the room, then I lay the patient down and intubate. Before when I did general only, I had to transfuse every patient. Now that I use the combined technique, I have not had to transfuse anyone.
Theoretically, I could do the case under spinal alone, but the patient is positioned with an arm secured over their chest. This makes accessing the airway in the middle of the case for whatever reason (apnea, code, case outlasts the spinal, patient complaining, etc) damn near impossible without reprepping. Thus I intubate these patients as well. I guess I could use an LMA, but if it became dislodged then I'd be back to the same problem.
I haven't done a regular hip in years.
I run them at .75-1 MAC. I also have narcotics on board to prevent coughing. I preload with a bag of fluid, and often inject 25 mg of ephedrine IM. I'm not going to say I've never had an issue with hypotension, but its nothing that wasn't quickly managed.Do you have issues with hypotension? How light do you run them in terms of their inhalational anesthetic?
I think my surgeon's skill level increase has just as much to do with the lack of bleeding than the spinal. That being said, she has started requesting the spinal for her patients, and I oblige.Spinal + GA has been linked to higher morbidity. I don't see why you would have less bleeding apart from the fact that your surgeon has become more experienced in the technique.
I guess I could use an LMA, but if it became dislodged then I'd be back to the same problem.
I run them at .75-1 MAC. I also have narcotics on board to prevent coughing.
The last time I heard someone claim to use narcotics to prevent coughing it was a resident who got caught with a saline lock under his scrubs.I also have narcotics on board to prevent coughing.
GA for a routine, healthy patient is 3-5 min from entering the OR to completion of induction, securing of airway, and turning patient over to surgeon. It takes me closer to 10 min to get a regional anesthetic in and get the patient turned over to surgeon.
We have an electronic database with 100s of thousands of anesthetic records (approaching a million) of which plenty are joints. Entering the OR until anesthesia ready time of 3-5 minutes is somewhere around 4-6 standard deviations better than the norm in a hospital based setting. At an outpatient center you can get a little closer to that but still won't average that on a case like a hip. Moving from stretcher to OR bed, placing monitors, preoxygenating, inducing, masking, DL, intubation, confirming intubation, taping tube, etc. take an average of 10-15 minutes depending on case type in our database. And this is in fast private practice setting with OR turnover times that are well faster than average for comparable institutions.
Total OR time with general anesthesia or spinal anesthesia for a hip is almost identical with a trend towards being faster in the spinal because on the back end of the case you can have the patient on the bed and out the door as soon as the dressing is on. And in a world in which many hip patients are old and frail the wake up from GA isn't as consistently rapid as you can achieve with a spinal. And for most situations the time from entering the OR until turning the patient over to the surgeon is within 1-2 minutes difference between a spinal and a GA.
I was thinking about this a little more last night and realized that the difference between a 3 minute vs a 5 minute start or a 5 minute vs a 7 minute start could be as little as 2 seconds. e.g. If you came into the OR at 08:00:01 and induction was complete at 08:03:59, you have a 3 minute door to induction complete time, but that is only two seconds longer than the 5 minute time of 07:59:59 to 08:04:00.
Soooo, for gits and shiggles, I timed my case starts today.
I am not doing joints, but I am working with the fluoro table in in the cysto room which requires some care in positioning. I am also working with nurse Brownian, as in Brownian motion. The opposite of efficiency of movement. I have never seen somebody move so fast yet accomplish so little with all of that frenetic motion. It really is amazing to watch.
Anyway, here are my times.
Ignore the lap time in the first three cases, I was timing something else simultaneously.
I have visited the practices of a couple of other docs here on SDN and watched them accomplish similar induction times.
- pod
Somewhat back to the original topic, and my general skepticism of the purported benefit of regional anesthesia for hips, I will just leave this here.
Anesthesia Technique, Mortality, and Length of Stay After Hip Fracture Surgery
-pod