Joint replacement spinal cocktail?

[loveumms]

It's been a while since I've done joints. Had a patient this week who wanted spinal only - she was otherwise healthy and 5'4''. I put in 1.6ml of 0.75% bupi with an epi wash, 100mcg duramorph and 20mcg fentanyl. I warned the surgeon he gets three hours … you would think that would be enough.

Spinal was working great until about 2.5 hours into the case when pt started "moving her leg" according to surgeon. I doubt she was actually moving but we still had over an hour left so we just converted to GA.

Was just wondering what everyone uses in their spinals for joints - would like to know both knees and hips.

Thanks.

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[B-Bone]

Bupivacaine 0.75% 2 cc. Never had one wear off during total joints. Even done bilateral knees.

 

[psychbender]

That sounds like my hospital's joint guy. He can't seem to do any total joint in under four hours (only slight exaggeration).

 

[OB1🤙]

Would do a CSE for a surgeon that slow.

I keep my joint spinals simple- 12.5 mg 0.5% PF bupivacaine (isobaric). Nothing else, though on rare occasions will throw in 100 mcg duramorph.

 

[batina17]

I do a lot of joints and use: 12.5 - 15mg of bupiv (heavy) with epi wash. I stopped adding fentanyl and removed all narcotics intra-op bc of PONV and now it's a rare occurrence. This is important bc we get our pts up and walking just hours post-op.

If surgeons takes a little longer and the pt gets figgety I might just give a little ketamine to avoid GA.

 

[BuzzPhreed]

Spinal was working great until about 2.5 hours into the case when pt started "moving her leg" according to surgeon.

I think your surgeon needs to get faster. Until then just stick a tube in. There was nothing wrong with your anesthetic choice for >95% of the PP orthopods out there. Or if the patient doesn't need to be up quick and your hospital has it, you can use 2ml of 1% tetracaine and that will get you 4-6 hours. Of course it's an esther so avoid in pts with allergy.

 

[Planktonmd]

15 mg Isobaric Bupivacaine will give you more than 3 hours

 

[somedumbDO]

One surgeon who is super slow get tetracaine w an epi wash rest heavy marcaine 15mg

 

[UBCmed09]

Can I quickly ask, what is this "epi wash" you guys are mentioning?

 

[pgg]

An "epi wash" = drawing up the 1:1000 epi into the syringe and squirting it all out. There's a bit left in the syringe, about 0.1 mL or 100 mcg. It's an easy/rough way to add a bit of epi to the mix.

 

[loveumms]

Thanks everyone - I told him 2.5 hours and he nodded. I assumed that meant he thought he would get it done in that time. Lesson learned.

 

[RxBoy]

An "epi wash" = drawing up the 1:1000 epi into the syringe and squirting it all out. There's a bit left in the syringe, about 0.1 mL or 100 mcg. It's an easy/rough way to add a bit of epi to the mix.

Why do they provide those vials? Is it in case of a total spinal? I never quite understood the 1 mg epi in spinal trays.

Anyways
Total knee joints:
Age <60 15 mg heavy
Age >60 ... 12 mg heavy

Total Hip Joints:
<60 15 mg iso (so u dont have to worry about positioning)
>60 12 mg iso

Inject slowly
If >60 always go straight to the 22g Q
Add fentanyl occasionally. Never add duramorph (too many sides)

Bad cardiac disease:
12 mg heavy injected in lateral position slowly. Almost never get BP issues because unilateral sympathectomy.

 

[BLADEMDA]

65 year old patients and younger should be getting non cutting needles for their spinals. A 22Q should be avoided if possible. These days I reserve my 22Q for age 75 and older and even then I still use a 22 Whitacre most of the time.

Ortho patients may be getting LMWH postop so a PDPH should be avoided whenever possible.

 

[UBCmed09]

An "epi wash" = drawing up the 1:1000 epi into the syringe and squirting it all out. There's a bit left in the syringe, about 0.1 mL or 100 mcg. It's an easy/rough way to add a bit of epi to the mix.

Thanks, that's interesting. I've never seen epi in our spinal trays here in Canada and in 5 years of residency have never heard a single mention of this 'epi wash' technique.

 

[Foodie]

I think your surgeon needs to get faster. Until then just stick a tube in. There was nothing wrong with your anesthetic choice for >95% of the PP orthopods out there. Or if the patient doesn't need to be up quick and your hospital has it, you can use 2ml of 1% tetracaine and that will get you 4-6 hours. Of course it's an esther so avoid in pts with allergy.

Ditto on tetracaine. For longer joint surgeries, I use tetracaine 12-16mg + epi 100mcg + fent 20 mcg. Tetracaine + epi yields longer motor and sensory block compared to bupi + epi.

 

[BuzzPhreed]

65 year old patients and younger should be getting non cutting needles for their spinals. A 22Q should be avoided if possible. These days I reserve my 22Q for age 75 and older and even then I still use a 22 Whitacre most of the time.

Ortho patients may be getting LMWH postop so a PDPH should be avoided whenever possible.

I unfailingly use a 25g Sprotte/Pencan (pencil point for the uninitiated). It's rare that I have to grab something different even with the fatties.

However I still find PDPH a rare occurrence in this population, even with a colleague who routinely puts in spinal catheters for some of these (and has done so for years). Can't remember the last PDPH he had.

 

[BLADEMDA]

I unfailingly use a 25g Sprotte/Pencan (pencil point for the uninitiated). It's rare that I have to grab something different even with the fatties.

However I still find PDPH a rare occurrence in this population, even with a colleague who routinely puts in spinal catheters for some of these (and has done so for years). Can't remember the last PDPH he had.

Yes, it's rare as I've had about 3 patients out of many thousands over the age of 70 get a PDPH requiring intervention. That said, I have seen a few 65 year old women get PDPH from 22 gauge Quincke needles so I avoid using a Quincke needle under the age of 70-75.

a 22 Whitacre needle is the way to go in the elderly population (over 65) as it avoids the H/A with the placement speed (30 seconds) of a 22 Q. In my career I have seen only one H/A requiring intervention with the use of a 22 Whitacre in this patient population. If you don't have this needle in stock then order some.

 

[BLADEMDA]

Ditto on tetracaine. For longer joint surgeries, I use tetracaine 12-16mg + epi 100mcg + fent 20 mcg. Tetracaine + epi yields longer motor and sensory block compared to bupi + epi.

I agree with you and that's my combination for a reliable 4 hour spinal block with most lasting over 5 hours. I keep it simple and utilize 15 mg isobaric tetracaine, 0.1 mg epi and 15-20 ug of Fentanyl for a 4+ hour spinal. If you want 6 hours then consider Tetracaine 20 mg plus 0.1 mg epi.

 

[dhb]

Anyways
Total knee joints:
Age <60 15 mg heavy
Age >60 ... 12 mg heavy

Total Hip Joints:
<60 15 mg iso (so u dont have to worry about positioning)
>60 12 mg iso

Slow surgeons? i don't use more than 10mg

 

[Noyac]

Tetracaine is the way.

 

[BIS40]

Not a huge tetracaine fan, do a lot of joints and have resorted to 15 mg (3cc) isobaric bupivicaine/ epi wash force of habit. No narcs. Guaranteed over 3 hours and very little hypotension.

 

[BLADEMDA]

Not a huge tetracaine fan, do a lot of joints and have resorted to 15 mg (3cc) isobaric bupivicaine/ epi wash force of habit. No narcs. Guaranteed over 3 hours and very little hypotension.

Your not a fan because you haven't done enough cases. Try 100 with Bupivacaine (Isobaric) and another 100 with Tetracaine (Isobaric) then return here and post your opinion. Tetracaine gives a much better motor block with significantly enhanced duration by adding Epi. Isbobaric Tetracaine (15 mg) with NO EPI will give you a reliable 3-4 hour surgical block.

Once you exceed 15 mg of tetracaine hypotension becomes more likely but block duration is 7-8 hours with 20 mg of Tetracaine and 0.2 mg epi.

Since I work with CRNAs Tetracaine is a better choice because the motor block keeps the CRNA from blasting the patient with Propofol or placing an LMA in response to some minor muscle twitches.

 

[VolatileNavyDoc]

Would do a CSE for a surgeon that slow.

I keep my joint spinals simple- 12.5 mg 0.5% PF bupivacaine (isobaric). Nothing else, though on rare occasions will throw in 100 mcg duramorph.

That's exactly what I do as well. However, our joint guys' operative times are usually less than 60 minutes. That makes everything a little easier.

 

[BLADEMDA]

That's exactly what I do as well. However, our joint guys' operative times are usually less than 60 minutes. That makes everything a little easier.

For operative times of 60 minutes or less you don't even need Isobaric Bupivacaine. Heavy Bupivacaine 12 mg works just as well and PACU time will be less. Hypotension is a bit more common with 12 mg of Heavy Bupivacaine than Isobaric Bup but nothing that can't be treated easily in the OR

 

[VolatileNavyDoc]

Totally agree. Some of the older guys just use 40mg of isobaric lidocaine. I'm still pretty junior, so I like to hedge my bets just in case. I use the isobaric for a few reasons... No positioning delays. The techs know what to set up for me every time. Less potential for hypotension. We have a gentleman's agreement with the surgeons that if the spinal is taking more than 10 minutes (in room to start prep), we go to general, so I try to do the exact same thing every time. PACU times haven't been an issue, as I usually use 10-12.5 mg.

 

[BLADEMDA]

Totally agree. Some of the older guys just use 40mg of isobaric lidocaine. I'm still pretty junior, so I like to hedge my bets just in case. I use the isobaric for a few reasons... No positioning delays. The techs know what to set up for me every time. Less potential for hypotension. We have a gentleman's agreement with the surgeons that if the spinal is taking more than 10 minutes (in room to start prep), we go to general, so I try to do the exact same thing every time. PACU times haven't been an issue, as I usually use 10-12.5 mg.

NO issues with your approach. 10 mg of Isobaric Bup should be enough for surgical times of 60 minutes or less. I use 10 mg of Isobaric Bup for slow surgeons doing a Troch Nail who take 70-80 minutes. FYI, Isoabric Bup at 7.5 mg has worn off around 80 minutes (surgical time) so I've learned to go to 10 mg if I need more than 1 hour surgical time.

 

[BLADEMDA]

Totally agree. Some of the older guys just use 40mg of isobaric lidocaine. I'm still pretty junior, so I like to hedge my bets just in case. I use the isobaric for a few reasons... No positioning delays. The techs know what to set up for me every time. Less potential for hypotension. We have a gentleman's agreement with the surgeons that if the spinal is taking more than 10 minutes (in room to start prep), we go to general, so I try to do the exact same thing every time. PACU times haven't been an issue, as I usually use 10-12.5 mg.

Maybe you can try Isobaric Mepivacaine? 60 mg should do the trick.


http://www.jcafulltextonline.com/article/S0952-8180(11)00422-3/abstract

 

[BLADEMDA]

Anesth Analg. 2000 Sep;91(3):580-4.
The anesthetic and recovery profile of two doses (60 and 80 mg) of plain mepivacaine for ambulatory spinal anesthesia.
Pawlowski J1, Sukhani R, Pappas AL, Kim KM, Lurie J, Gunnerson H, Corsino A, Frey K, Tonino P.
Author information

• 1Departments of Anesthesiology and Orthopedics, Loyola University Medical Center, Maywood, IL 60153, USA.

Abstract
Reports of transient neurological symptoms with the use of subarachnoid lidocaine has generated interest in alternate local anesthetics of intermediate duration, such as mepivacaine. This prospective randomized, double-blinded, dose-response study examined the anesthetic and recovery profiles of 60- and 80-mg doses of preservative-free plain mepivacaine for ambulatory spinal anesthesia. Sixty patients undergoing ambulatory anterior cruciate ligament repair of the knee under spinal anesthesia were randomized into two groups; Group 1 (29 patients) received 4 mL of 1.5% (60-mg dose) and Group 2 (31 patients) received 4 mL of 2% (80-mg dose) of plain mepivacaine. All patients received a combined spinal-epidural anesthetic technique. The epidural catheter was used only in the event the surgery outlasted the duration of surgical anesthesia with subarachnoid mepivacaine. Epidural supplementation was administered in three patients (12%) in Group 1 and one patient (3%) in Group 2 when the sensory block regressed to L-1 with surgery expected to last longer than 15 min. The cephalad dermatome level of the block and degree of motor block was comparable in the two groups. Times to two-segment and T-10 regression were comparable in the two groups (112 +/- 26 min in Group 1 versus 122 +/- 28 min in Group 2). Time to L-1 regression was significantly longer in Group 2 (146 +/- 28 min in Group 1 versus 159 +/- 19 min in Group 2). All of the ambulatory milestones were significantly faster in Group 1. Side effects, such as hypotension and emesis were negligible, severe bradycardia and urinary retention did not occur, and none of the patients in the two groups reported transient neurological symptoms over 24 h. In conclusion, plain mepivacaine in a 60- or 80-mg dose is a suitable local anesthetic choice for ambulatory spinal anesthesia with respect to anesthetic, as well as recovery profiles.
IMPLICATIONS:
We evaluated the anesthetic and recovery profiles of 60- and 80-mg doses of plain mepivacaine for ambulatory spinal anesthesia. Both doses produced comparable sensory and motor block. Sensory and motor regression and ambulatory milestones were 20-30 min longer with the 80-mg dose. Side effects were negligible and transient neurological symptoms were not reported during a 24-h follow-up

 

[DrBeaker]

This thread is interesting to me. For most of my total knees, we use Iso bupiv 15mg +/- 25 fent. I have never used lido for a spinal, nor chloroprocaine. At my academic center, surgeons are too slow. I have used mepivacaine a few times for cysto or TURBT. 50-60mg was the dose I believe. Got us 1.5-2hrs. Thanks for posting all these other spinal cocktails. When I finish in a few short weeks, I hope to be using other recipes.

 

[Noyac]

Anyone using Demerol spinals? Not for total joints or cases much longer than an hour but for the shorter cases.

 

[pgg]

Anyone using Demerol spinals? Not for total joints or cases much longer than an hour but for the shorter cases.

The day I see some PF meperidine anywhere is the day I find a case to try it out on. Some day ... seems like it'd be a great option to have.

In residency we used mepivacaine for short spinals and it worked great. I think the main reason we didn't have problems with TNS though is because RNs (not us) did the postop phone calls to those outpatients. Now I just use a reduced dose of bupivacaine + fentanyl.

 

[jwk]

We're using mepivicaine 1.5% x3cc for virtually all our outpatient total joints. Patients for the few 4-hr surgeons we have usually get GA.

 

[Southpaw]

We're using mepivicaine 1.5% x3cc for virtually all our outpatient total joints. Patients for the few 4-hr surgeons we have usually get GA.

How long is this lasting until motor/sensory return in your experience? Also, I’m guessing you’re using the stuff that says ‘not for spinal’ on the vial?

 

[San Marzano]

Joint replacement can help relieve pain and enable you to live a fuller, more active life. If you and your orthopedic surgeon have decided that you are a good candidate for joint replacement, you are in good company: In 2011, almost 1 million hip and knee replacement surgeries were performed in the United States, making it one of the most common orthopedic procedures performed today.

Wow that’s remarkable. I want to know more.

 

[jwk]

How long is this lasting until motor/sensory return in your experience? Also, I’m guessing you’re using the stuff that says ‘not for spinal’ on the vial?

We're good for 2-3 hrs tops. They're walking out the door for the ride home four hours post-op. And yes.

 

[bourne]

Preop: PO celebrex, gabapentin, acetaminophen, oxycontin

OR: 2-3 hour cases gets 2mL 0.5% bupivicaine PF or MPF (labelled for epidural but "NOT" for spinal because no one wanted to fund the FDA approval process); 4-5 hour cases get 3mL of same solution. Spinal is placed in sitting position and since it is isobaric I just have patient lay down afterwards for positioning for operation (none of this lay on your side for 5 minutes stuff). I'm letting the IVF from preop run wide in to get the first liter in asap as they don't come to the OR pre-bolused but I haven't found much hemodynamic instability with this approach.

The 25g 3.5" PENCAN that comes in our kits gets most patients but on some of the thicker-backed patients there was significant tenting of the skin to reach the space. For those with thick backs we have 25g 4.5"? PENCAN in the room ready to open and for technical difficult I have a 22g 4 or 5" whiticare.

All patients are being admitted so I err on the side of having a longer block as there is little consequence.

 

[Aether2000]

Because we had a spate of many failed spinals with some bad bupivicaine throughout the department and the other area hospitals, I converted to either tetracaine (if I can get it) for the longer surgeries and use ropivacaine plus dexmedetomidine for medium length surgeries and ropivacaine alone for shorter surgeries. Now we have some good bup that works well, but I continue ropivacaine. We actually have no idea what we were actually injecting into the patients with the bad bup since we did not get even a sensory block even with good CSF efflux by many anesthesiologists. Scary!

 

[Psai]

Because we had a spate of many failed spinals with some bad bupivicaine throughout the department and the other area hospitals, I converted to either tetracaine (if I can get it) for the longer surgeries and use ropivacaine plus dexmedetomidine for medium length surgeries and ropivacaine alone for shorter surgeries. Now we have some good bup that works well, but I continue ropivacaine. We actually have no idea what we were actually injecting into the patients with the bad bup since we did not get even a sensory block even with good CSF efflux by many anesthesiologists. Scary!

I mean it does tell you right on the bottle that it's not for spinals

 

[Aether2000]

No, this was Spinal Bupivicaine in D7.5W ampoules that was failing. 0.75% bupivicaine in large vials does say on the label not for spinal use. Ropivacaine has no such warning.

 

[facted]

I mean it does tell you right on the bottle that it's not for spinals

0.5% bupi is super dependable and safe for spinals. It's been used worldwide for many, many years without safety issues.

 

[Psai]

0.5% bupi is super dependable and safe for spinals. It's been used worldwide for many, many years without safety issues.

It was a bad joke

 

[Foodie]

Because we had a spate of many failed spinals with some bad bupivicaine throughout the department and the other area hospitals, I converted to either tetracaine (if I can get it) for the longer surgeries and use ropivacaine plus dexmedetomidine for medium length surgeries and ropivacaine alone for shorter surgeries. Now we have some good bup that works well, but I continue ropivacaine. We actually have no idea what we were actually injecting into the patients with the bad bup since we did not get even a sensory block even with good CSF efflux by many anesthesiologists. Scary!

Thanks for saying this. It happened three times at our hospital in the past couple months. When it happened the first time, we chalked it up to either a suboptimal technique or presence of dural sac. The pts had very little to no block despite getting good CSF aspiration/birefringence before and after injection of spinal cocktail of 0.75% heavy bupi 1.6ml from spinal kit + 20 mcg fent + 100mcg morphine. I started using 0.75% heavy bupi dispensed from Omnicell for C/S, and have had no issues since. I may use 0.5% bupi instead from now on for all my spinals. We don't have tetracaine here.

Seems wasteful to get a separate med instead using one from the kit but miles better than a spinal redo or GA conversion.

An oldie but a goodie review article on failed spinals.

 

[anbuitachi]

Because we had a spate of many failed spinals with some bad bupivicaine throughout the department and the other area hospitals, I converted to either tetracaine (if I can get it) for the longer surgeries and use ropivacaine plus dexmedetomidine for medium length surgeries and ropivacaine alone for shorter surgeries. Now we have some good bup that works well, but I continue ropivacaine. We actually have no idea what we were actually injecting into the patients with the bad bup since we did not get even a sensory block even with good CSF efflux by many anesthesiologists. Scary!

what is your dosing for ropivicaine? i've never seen ropivicaine before

 

[Aether2000]

20mg 0.5% ropivacaine. This lasts approximately two-thirds as long as lidocaine and if you want to double that, add precedex 5mcg

 

[Gas]

20mg 0.5% ropivacaine. This lasts approximately two-thirds as long as lidocaine and if you want to double that, add precedex 5mcg

Never used ropivacaine in a spinal before, but we may have to start. We have been low on 0.75% hyperbaric bupivacaine kits for months now, and pharmacy says they are running low on 0.5% bupivacaine as well.

When you say two-thirds as long as lidocaine, that doesn't sound like very long. What are you getting in terms of time? Going to post separate thread too about what others are doing because of these shortages.

 

[anbuitachi]

why heavy for Knees and iso bupi for hips? We just use iso bupi x3ml for both

 

[PapaDosh]

Has anybody using tetracaine, chloro, mepivicaine, etc seen TNS in a patient in the last 10 years? Or is it more of a board question and related to the preservatives that used to be present in the preparations in the past?

 

[lakersbaby]

Has anybody using tetracaine, chloro, mepivicaine, etc seen TNS in a patient in the last 10 years? Or is it more of a board question and related to the preservatives that used to be present in the preparations in the past?

Have not seen or heard of an incidence of TNS in the thousands of hips and knees done with chloroprocaine spinal

 

[kmurp]

Have not seen or heard of an incidence of TNS in the thousands of hips and knees done with chloroprocaine spinal

Chloroprocaine for a total joint.? Or do you mean other, shorter procedures?

 

[lakersbaby]

Chloroprocaine for a total joint.? Or do you mean other, shorter procedures?

all same day total joints are done with 40-45 mg of chloroprocaine. patient is moving by time we get to pacu and PT is there within 30 mins of pacu arrival. go home a couple hours later.