Position for Spinal Anesthesia

[Outrigger]

What is everyone's preferred position for spinals? In residency, I did them all in the sitting position. Now I continue that except for broken hips (lateral decubitus position) where having them sit up isn't as realistic. Of course, those are the ones I have the hardest time placing. So does it depend on what surgery you're doing (THA or TKA, etc.)? Just trying to get an idea of what everyone else is doing.

---

Members don't see this ad.

 

[nimbus]

Same. Sitting whenever possible.

 

[deleted59964]

i prefer sitting too, but it's good to be good at lateral - some obstetric patients wont sit still, and I seem to get faster onset of block when done in lateral position.

 

[psychbender]

I pretty much concur with the rest here. My preference is sitting, but if they can't sit up for whatever reason, it goes in with them lying on their side.

 

[BLADEMDA]

Morbidly obese (BMI over 40-45) I prefer sitting. For the typical patient with BMI under 35 i prefer lateral as I can sedate the patient more.

In Ob most providers sit the woman up for the SAB.

In the end the choice comes down to your skill level and experience with the spinal. Do what works for you.

 

[nap$ter]

nearly always sitting. i don't do hip fractures with spinals.

 

[BLADEMDA]

nearly always sitting. i don't do hip fractures with spinals.

Elderly patients who are exposed to general anesthesia have a 35% higher risk of developing dementia, researchers from INSERM and University of Bordeaux, France, reported at Euroanaesthesia, the annual congress of the European Society of Anaesthesiology (ESA). Dr Francois Sztark and team explained that POCD (post-operative cognitive dysfunction), a common complication of major surgery, could be linked to dementia several years after the procedure.

 

[BLADEMDA]

Anesthesia exposure has not only been found to affect the brains of older people. Scientists from the Mayo Clinic reported in Mayo Clinic Proceedings (Feb 2013 issue) that children exposed to anesthesia many times have a higher risk of developing ADHD (attention-deficit/hyperactivity disorder).

 

[BuzzPhreed]

This is an oft-perpetuated myth that was thoroughly shot down in numerous presentations across the board at the last ASA meeting last October. I attended three excellent sessions where the supposed post-operative cognitive dysfunction (POCD) myth was completely debunked. The general consensus? It has to do with the inflammatory milieu along with perioperative changes and stress, and nothing to do with the anesthetic itself. POCD is just as likely to occur under regional anesthetics as in general anesthetics indicating there are other mechanisms at play, likely uncovering or exacerbating some baseline subclinical cognitive impairment - not creating it.

However, to date, clinical studies comparing regional and general anesthesia have not shown a difference in the incidence of POCD or delirium. This suggests that general anesthesia may not cause clinically significant postoperative central nervous system dysfunction or that drugs used for sedation offset any brain-sparing effects of the regional anesthetic. There is insufficient evidence on the exact etiology of delirium and POCD at this point, and future research is needed

http://www.sagahq.org/images/FAQs.pdf

Please stop perpetuating bad data and giving ammo to the plaintiffs attorneys, patients, and family members who already have little understand of what we do. It's wreckless.

 

[BuzzPhreed]

POCD is just as likely to occur after operations under loco-regional anesthesia as under general anesthesia (Hanning 2005, Neubauer 2005).

• More likely after major operations than minor operations (Hanning 2005, Neubauer 2005, Monk 2008).
• More likely after heart operations than other types of surgery ( van Dijk 2002).
• More likely in aged than in younger patients (Neubauer 2005, Monk 2008).
• More likely in older patients with high alcohol intake / abuse (Hudetz 2007).
• People with higher preoperative ASA-scores, (see page Is General Anesthesia Dangerous?), are more likely to develop POCD (Monk 2008).
• People with lower educational level are more likely to develop POCD than those with a higher educational level (Newman 2007, Monk 2008).
• People with prior history of a stroke, even though there is complete functional recovery, are more likely to develop POCD (Monk 2008).
• More likely in the elderly with pre-existing declining mental functions, termed MCI (Mild Cognitive Impairment) (Silverstein 2007). MCI is a transitional zone between normal mental function and evident Alzheimer's disease or other forms of dementia. It is insidious, and seldom recognized, except in retrospect after affected persons are evidently demented.
• Delirium and severe worsening of mental function is very likely in those with clinically evident Alzheimer's disease or other forms of dementia, as well as those with a history of delirium after previous operations (Meagher 2001).

http://www.anesthesiaweb.org/dementia.php

Pay attention to that point. A lot of even expert clinicians miss this. You will be using a lot of haloperidol in the PACU if you don't recognize this.

 

[BLADEMDA]

There is much controversy in this area and I'm sure a bunch of experts would disagree with your statements on the stand. Second, there is preliminary data that reducing the amount of inhalational anesthesia during a case with the use of a BIS (elderly patients) may reduce the incidence of POCD/Delirium.

I have had a few over 85+ patients get GA with Post op Delirium who then returned for another procedure several months later. These same patients got Regional with low dose propofol and did not have postop delirium in the PACU. The low dose Propofol combined with Regional is likely superior to a GA with high dose vapor for elderly patients at risk of POCD/Post op Delirium.


http://www.ncbi.nlm.nih.gov/pubmed/23027226

http://www.ncbi.nlm.nih.gov/pubmed/23539235

 

[BLADEMDA]

POCD is just as likely to occur after operations under loco-regional anesthesia as under general anesthesia (Hanning 2005, Neubauer 2005).

• More likely after major operations than minor operations (Hanning 2005, Neubauer 2005, Monk 2008).
• More likely after heart operations than other types of surgery ( van Dijk 2002).
• More likely in aged than in younger patients (Neubauer 2005, Monk 2008).
• More likely in older patients with high alcohol intake / abuse (Hudetz 2007).
• People with higher preoperative ASA-scores, (see page Is General Anesthesia Dangerous?), are more likely to develop POCD (Monk 2008).
• People with lower educational level are more likely to develop POCD than those with a higher educational level (Newman 2007, Monk 2008).
• People with prior history of a stroke, even though there is complete functional recovery, are more likely to develop POCD (Monk 2008).
• More likely in the elderly with pre-existing declining mental functions, termed MCI (Mild Cognitive Impairment) (Silverstein 2007). MCI is a transitional zone between normal mental function and evident Alzheimer's disease or other forms of dementia. It is insidious, and seldom recognized, except in retrospect after affected persons are evidently demented.
• Delirium and severe worsening of mental function is very likely in those with clinically evident Alzheimer's disease or other forms of dementia, as well as those with a history of delirium after previous operations (Meagher 2001).

http://www.anesthesiaweb.org/dementia.php

Pay attention to that point. A lot of even expert clinicians miss this. You will be using a lot of haloperidol in the PACU if you don't recognize this.

I've read all that data and am aware of the ASA statements. Perhaps, you need to look at the most recent data.

 

[BLADEMDA]

CONCLUSION: The use of light propofol sedation decreased the prevalence of postoperative delirium by 50% compared with deep sedation. Limiting depth of sedation during spinal anesthesia is a simple, safe, and cost-effective intervention for preventing postoperative delirium in elderly patients that could be widely and readily adopted.


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800291/

 

[BLADEMDA]

The fact is that those over 80 may experience cognitive decline regardless of anesthetic technique or even if they undergo a procedure. The risk of clinical dementia does not decline as we age and in fact remains a real issue in the elderly. Just because a person doesn't have dementia at age 82 doesn't mean he/she won't have it at age 85.

I realize that this subject is a hot area of debate right now but ignoring the type of anesthetic and the amount of vapor/propofol simply isn't the best anesthetic care based upon the current data.

 

[BLADEMDA]

Some preliminary evidence suggests that Desflurane may be less Neurotoxic to the brain than Isoflurane. This is an interesting area of research right now.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3972614/

 

[BLADEMDA]

Age remains the strongest risk factor for dementia, particularly for Alzheimer disease (AD) [1,2]. In a community-based study, for example, the estimated annual incidence of AD was 0.6 percent for individuals ages 65 to 69 years, 1.0 percent for those 70 to 74 years, 2.0 percent for those 75 to 79 years, 3.3 percent for those 80 to 84 years, and 8.4 percent for those 85 years and older [3]. In a meta-analysis of 23 studies from around the world, AD increased exponentially with age up until the age of 90 years with no signs of leveling off [4]. Dementia is estimated to be present in one-half to two-thirds of nursing home residents [5].
Studies estimating dementia incidence in the very old have been limited by low numbers in this age group. A number of studies have found that dementia incidence continues to increase with age after 85 years [2,6-9]. These cumulative increases in incidence rates result in the prevalence of dementia approaching or exceeding 50 percent in individuals over 90 years [2,6,9-11].

 

[BLADEMDA]

IMHO, the elderly patient with mild cognitive impairment or no obvious cognitive impairment is the one most likely to benefit from a reduction in Vapor use with BIS or a Regional anesthetic with low dose propofol. The group with obvious dementia will likely not do well regardless of anesthetic technique and in fact, worsening of the dementia is likely to occur.

I see this daily in my practice where the average age of a fractured hip patient is over 85. I discuss the risk of cognitive decline with the family prior to the anesthetic as even with the BEST technique POCD/Cognitive decline will occur in this group of patients.

 

[BLADEMDA]

IMHO, the type of anesthesia plays a minor role in whether the patient gets POCD or Postop delirium but it does play a role. The major factor for POCD is the patient's underlying risk factors and baseline cognitive status. Even without any surgery this subgroup will experience cognitive decline due to stress factors, illness, pre-existing mild cognitive impairment, etc.

For those not wanting to change their technique (LMA and high dose Vapor) the BEST study to date in support of that argument is this one:

http://www.ncbi.nlm.nih.gov/pubmed/21474666

For those who would like to possibly reduce the incidence of postop delirium or cognitive decline in the elderly then the use of Desflurane with a BIS or a Regional block with low dose propofol are the preferred techniques. Regardless, the family must understand the likelihood of cognitive decline postoperatively is a likely occurrence.

Since I anesthetize those over 85 on a daily basis I will continue to use Regional Anesthesia when appropriate in this group of patients at risk of Delirium/POCD

 

[BLADEMDA]

CONCLUSIONS:
In neonatal mice, equipotent doses of the three commonly used inhaled anesthetics demonstrated similar neurotoxic profiles, suggesting that developmental neurotoxicity is a common feature of all three drugs and cannot be avoided by switching to newer agents


http://www.ncbi.nlm.nih.gov/pubmed/21293251


CONCLUSIONS:
In an animal model, neonatal desflurane exposure induced more neuroapoptosis than did sevoflurane or isoflurane and impaired working memory, suggesting that desflurane is more neurotoxic than sevoflurane or isoflurane.

http://www.ncbi.nlm.nih.gov/pubmed/21956042

 

[BLADEMDA]

This is an oft-perpetuated myth that was thoroughly shot down in numerous presentations across the board at the last ASA meeting last October. I attended three excellent sessions where the supposed post-operative cognitive dysfunction (POCD) myth was completely debunked. The general consensus? It has to do with the inflammatory milieu along with perioperative changes and stress, and nothing to do with the anesthetic itself. POCD is just as likely to occur under regional anesthetics as in general anesthetics indicating there are other mechanisms at play, likely uncovering or exacerbating some baseline subclinical cognitive impairment - not creating it.



http://www.sagahq.org/images/FAQs.pdf

Please stop perpetuating bad data and giving ammo to the plaintiffs attorneys, patients, and family members who already have little understand of what we do. It's wreckless.

I'm assuming anyone graduating LAW SCHOOL has access to Google:

General Anaesthetic May Increase Risk Of Dementia, Extensive Study Says

http://www.huffingtonpost.co.uk/2013/07/25/dementia-general-anaesthe_n_3650944.html

Of course this study has tremendous holes in it and I'm not on board with its conclusions.

 

[BLADEMDA]

I'm assuming anyone graduating LAW SCHOOL has access to Google:

General Anaesthetic May Increase Risk Of Dementia, Extensive Study Says

http://www.huffingtonpost.co.uk/2013/07/25/dementia-general-anaesthe_n_3650944.html

Of course this study has tremendous holes in it and I'm not on board with its conclusions.

Commenting on the findings for Medscape Medical News, Roderic G. Eckenhoff, MD, professor and vice-chair of research, Department of Anesthesia and Critical Care, University of Pennsylvania in Philadelphia, who was not involved in the study, said that sometimes surgery is necessary, but in cases of elective surgery, patients may want to think twice.
However, he cautioned that the study has some "big red flags" and said this "is an area in need of further clarification."
"If it's surgery, is it the actual surgery, or the anesthesia, or is it the stress of being in the hospital? It's probably all those things combined, but it's probably the surgical procedure itself that causes the largest risk, at least that's what we believe," Dr. Eckenhoff said.
"This is a good additional study, and its real strength is its size," Dr. Eckenhoff said.
"Even when corrected for comorbidity, they found a significant effect of having had surgery in the past and risk for dementia. The level of risk is about consistent with some of the other studies performed," he noted.
What's "very concerning," he said, is that the demographics and comorbidity are "significantly different" in the surgery group and the control group, "although they did try to correct for that."
Still, "a big red flag and qualifier with this study is that the patients needing surgery are in fact different than the patients who don't need surgery. It may be those differences and not the fact that they had surgery itself that account for the difference in propensity for getting dementia," Dr. Eckenhoff said.
"I think in the end we are going to find that there are small populations of people that are more vulnerable to another insult like surgery and who go downhill more quickly afterwards. The challenge is to figure out who those people are, and that's going to require really good biomarkers," said Dr. Eckenhoff.

 

[nap$ter]

thanks for the posts. good discussion.

i'll stick c fascia iliacus block and lma for now. i think the amount/type of sedation required to make a (pre)demented patient with a fracture comfortable for a spinal success isn't worth it for now imho. just talking hip fractures here. 99% of other cases i'm totally pro neuraxial/regional.

 

[pgg]

i prefer sitting too, but it's good to be good at lateral - some obstetric patients wont sit still, and I seem to get faster onset of block when done in lateral position.

I make all of my OB patients sit now. Everyone can sit still for the minute or two the needle's in the back. The ones who can't are just being drama queens and I'm happy to stand there and wait for them to decide they really do want the epidural enough to sit still. I tell them the procedure is faster, easier, and more likely to be a success if they're upright. Somehow they all manage to do it. I do CSEs on every OB patient so onset is always immediate.


On those occasions that I find myself struggling with a procedure (any procedure), it's usually because I didn't optimize positioning to start. Sitting is the optimal position for a spinal. I'm nice about it, but absent a hip fracture or other reason they truly can't sit, I make them sit.

 

[BLADEMDA]

thanks for the posts. good discussion.

i'll stick c fascia iliacus block and lma for now. i think the amount/type of sedation required to make a (pre)demented patient with a fracture comfortable for a spinal success isn't worth it for now imho. just talking hip fractures here. 99% of other cases i'm totally pro neuraxial/regional.

How hard would it be for you to add a BIS to the case and titrate to 50-60?
If it helps reduce Postop delirium then why not do it?

 

[deleted171991]

How hard would it be for you to add a BIS to the case and titrate to 50-60?
If it helps reduce Postop delirium then why not do it?

Because there is no proof that BIS actually helps. Some people swear by it, some people swear at it.

 

[BLADEMDA]

Because there is no proof that BIS actually helps. Some people swear by it, some people swear at it.

There is proof it helps in reducing POCD. The question is whether you believe the data.

http://www.ncbi.nlm.nih.gov/pubmed/23027226


CONCLUSIONS:
BIS-guided anesthesia reduced anesthetic exposure and decreased the risk of POCD at 3 months after surgery. For every 1000 elderly patients undergoing major surgery, anesthetic delivery titrated to a range of BIS between 40 and 60 would prevent 23 patients from POCD and 83 patients from delirium.

 

[nap$ter]

How hard would it be for you to add a BIS to the case and titrate to 50-60?
If it helps reduce Postop delirium then why not do it?

because i don't believe the data, and never have.

i run geriatric anesthesia as light as i can, and am vigilant about BP and avoidance of deliriogenics.

 

[BLADEMDA]

Editorial from May 2014 Anesthesia and Analgesia:


In this issue of the Journal, Brown et al14 from John Hopkins Medical Institutions, Baltimore, MD, present the results of a study comprising 114 patients aged ≥65 years undergoing hip fracture surgery under spinal anesthesia who received either light or deep sedation as defined by BIS levels of >80 or approximately 50, respectively. Patients were randomized to either BIS level. The authors demonstrate that those patients with serious comorbidities (Charlson comorbidity index >4) randomized to light sedation had a lower 1-year mortality of 22.2% compared with 43.6% for those receiving deep sedation. The hazard ratio was 0.43 [95% confidence interval, 0.19–0.97], decreasing to 0.33 [95% confidence interval, 0.12–0.94] among patients with a Charlson index >6. There was no difference among healthier patients (Charlson index <4).15

There are a few points worthy of particular note, especially in any study looking at depth of sedation or anesthesia as determined by BIS values and a subsequent effect on mortality. First, the patients were elderly patients with a mean age of 81.7 years. All patients were undergoing emergency surgery for hip fracture repair. The median ASA physical status was III. These are all recognized risk factors for increased postoperative mortality.16 Importantly, both groups were similar with regard to these confounders.

The only differences between the groups other than BIS levels were that those in the deep sedation group received a median of 8.1 mg/kg propofol vs 1.3 mg/kg for the light group and a median of 2 mg midazolam compared with 10 mg in the light group.

The authors, limited by a short Discussion required of a Brief Report, do not provide any explanation. Why might older patients undergoing emergency surgery under spinal anesthesia with different depths of sedation have a different 1-year mortality rate? We know that propofol causes significantly more hypotension than midazolam when used for sedation in older patients undergoing a spinal anesthetic17; however, there were no differences in duration of hypotension in this study (P = 0.76). The effects of electroencephalogram burst suppression, found at lower BIS values, on increased mortality have been demonstrated in critically ill patients18 and may play a role. We might postulate that clinical levels of anesthetic agents such as propofol and volatile agents acting at γ-aminobutyric acid receptors may be neurotoxic to developing or “deteriorating” brains.16 There are now experimental data19 to show this as well as clinical data that patients at the extremes of life have postoperative cognitive problems after general anesthesia.2,20,21 Regardless of underlying mechanism, we are presented with a study that demonstrates the possibility of a link between mortality and level of sedation when combined with spinal anesthesia.

So what does the reader do with this new information? A 2005 study by Monk et al4 in this journal demonstrating an association between BIS values <45 and increased 1-year mortality in noncardiac surgery generated considerable debate including a reproach of the Editorial Board.22

Dismissing this current study on the grounds of bias and unknown confounders is not easy. Unlike previous nonrandomized studies4–7that have demonstrated increased mortality in those with low BIS (<45) values, the randomization process in this study14 means that the chances that low BIS values merely represent sicker patients who are therefore at greater risk of dying are remote.

Those seeking statistical flaws in this study may point out that randomization originally occurred in this study to compare the incidence of delirium not mortality in patients undergoing spinal anesthesia under light or deep sedation. Returning to the original randomized data to determine mortality rates as opposed to delirium is appropriate and statistically valid.

The debate, controversy, and ongoing research on the question “does deeper general anesthesia result in greater mortality” cannot be answered here. The data from those studies4–7 leave us with an association that compels us to look further and call for further studies.

This is not the case with the findings that Brown et al14 present us with.

Their data are valid, and their findings are of immense clinical importance. Many of us will provide sedation for older patients with multiple comorbidities undergoing emergency hip surgery with spinal anesthesia this week. This article suggests that those having deeper sedation with high doses of propofol are more likely to die than if lighter sedation is used. Why this might be the case needs research, but that must not delay anesthesiologists from reflecting on their clinical practice today.

Unlike the potential increased risk of awareness with “lighter” general anesthesia, there is no such serious outcome arising from changing from deep to light sedation with spinal anesthesia. Anxiety and patient comfort are multifactorial and can often be managed through a variety of means including lighter sedation, reassurance, and positioning, without apparent additional risk to the patient. As anesthesiologists, we cannot change the age, ASA physical status, or comorbidities of our patients; we can however change how softly we tread on their dreams.

 

[BLADEMDA]

Their data are valid, and their findings are of immense clinical importance. Many of us will provide sedation for older patients with multiple comorbidities undergoing emergency hip surgery with spinal anesthesia this week. This article suggests that those having deeper sedation with high doses of propofol are more likely to die than if lighter sedation is used. Why this might be the case needs research, but that must not delay anesthesiologists from reflecting on their clinical practice today.

 

[deleted171991]

That's truly a badly-designed study. First of all, it's not clear whether it's the BIS or the meds. One doesn't give a ton of propofol to one set of patients, and a ton of midaz to the other, and then draw conclusions about the value of B(I)S monitoring.

The only differences between the groups other than BIS levels were that those in the deep sedation group received a median of 8.1 mg/kg propofol vs 1.3 mg/kg for the light group and a median of 2 mg midazolam compared with 10 mg in the light group.

If one wants to show the value of BIS, one does the study with propofol only. Because all I get from this study is that midaz might be less associated with bad outcomes than propofol.

 

[BLADEMDA]

That's truly a badly-designed study. First of all, it's not clear whether it's the BIS or the meds. One doesn't give a ton of propofol to one set of patients, and a ton of midaz to the other, and then draw conclusions about the value of B(I)S monitoring.

If one wants to show the value of BIS, one does the study with propofol only. Because all I get from this study is that midaz might be less associated with bad outcomes than propofol.

I'm not sure if they got the meds correct in the editorial. I analyzed the study and midazolam was barely used for either group.

Median amount of midazolam used was Zero for both groups.

 

[deleted171991]

I'm not sure if they got the meds correct in the editorial. I analyzed the study and midazolam was barely used for either group.

Median amount of midazolam used was Zero for both groups.

The numbers in the editorial are correct. What you see as almost zero midaz dose was measured in mg/kg. The absolute values were indeed 2 mg versus 10 mg (same table, previous row). Not only that, but they used midaz in 22% of the light sedation cases, versus 5% deep sedation ones. Incredibly bad design, totally inconsistent to be able to draw conclusions. (I didn't check, but I hope the study was retrospective, otherwise the authors should look for a different line of work.)

 

[pgg]

10 mg of midazolam was the median total dose in a bunch of 80 year olds, and that was the light sedation group? Man, they used more midazolam in each lightly sedated octogenarian than I use in a week or longer for all comers.

 

[deleted171991]

"Lightly-sedated" as defined by the BIS values.

Conclusion: BIS is affected more by propofol than midaz.

 

[pgg]

(I didn't check, but I hope the study was retrospective, otherwise the authors should look for a different line of work.)

I just read the editorial Blade posted, but it says

randomization originally occurred in this study to compare the incidence of delirium not mortality in patients undergoing spinal anesthesia under light or deep sedation. Returning to the original randomized data to determine mortality rates as opposed to delirium is appropriate and statistically valid.

So prospective and randomized. However, just because it's statistically valid to later look at mortality rates in the different groups doesn't mean that a study designed to look at a high-incidence event like delirium is appropriately powered to compare a low-incidence event like mortality.

What I mean is 114 patients might've been OK looking for differences in delirium, but more might be needed to look for differences in mortality.

More study is needed! Someone needs more grant money.

 

[deleted171991]

Randomized as in "we randomly gave whatever crap we considered appropriate". You cannot have 2 mg of midaz in one group, 10 in the other (with opposite propofol doses), and you cannot mix multiple agents when BIS is at least suspected to have different sensitivities to various anesthetic agents. At minimum, they should have excluded the cases where midaz was also used.

Another study in the long list of "let's waste some more national debt to produce another smoke-and-mirrors paper that is too slippery even for its proper restroom use".

 

[pgg]

Randomized as in "we randomly gave whatever crap we considered appropriate". You cannot have 2 mg of midaz in one group, 10 in the other, and you cannot mix multiple agents when BIS is known to have different sensitivities to various anesthetic agents. Another study in the long list of "let's waste some more billions of national debt".

Admittedly I have not RTFA'd, but my guess is that this is what happened:

The deep sedation group got a bunch of propofol to make the random number generator read 45, those patients lay still for surgery, and the surgeon happily hammered away.

The light sedation group got almost no propofol to keep the random number generator above 80, they squirmed and wiggled like hell, and the surgeon told the SRNA to put down the romance novel on the iPad Kindle app and do something, so they snowed the hell out of them with midazolam and more midazolam and then some more midazolam until the patient lay still, and then the surgeon happily hammered away.

And of the 114 patients, some number much less than 114 had a comorbidity index >4, and of that small group more died in the snowed-with-midaz group than the snowed-with-propofol group.

I guess I should go read the actual article.

 

[deleted171991]

I haven't RTFA'd either, but I understand that the snowed-with-midaz group (so-called "light sedation" with 10 mg of midaz) did better.

Anyway, they compared apples with oranges.

P.S. I love your theory.

 

[pgg]

I haven't RTFA'd either, but I understand that the snowed-with-midaz group (so-called "light sedation" with 10 mg of midaz) did better.

I understand that as well, I'm just supremely skeptical that it means anything. I will now cease 'ing this article until tomorrow when I will read it.

 

[Shake_yabooties]

http://www.ncbi.nlm.nih.gov/pubmed/24384981

read this excellent review article on uptodate info of POCD.

 

[BLADEMDA]

Their data are valid, and their findings are of immense clinical importance. Many of us will provide sedation for older patients with multiple comorbidities undergoing emergency hip surgery with spinal anesthesia this week. This article suggests that those having deeper sedation with high doses of propofol are more likely to die than if lighter sedation is used. Why this might be the case needs research, but that must not delay anesthesiologists from reflecting on their clinical practice today.

Still, the data strong suggest that "less in more" in the 80+ year old age group. Using Regional anesthesia with light sedation may have benefits over a deep GA with Vapor using an LMA. I still think many of us should be doing more Neuraxial/Regional anesthesia with light sedation for our 80+ year old patients whenever possible. Of course, severely demented patients may require GA and those on AntiCoagulants (fairly common these days) can't get a SAB but we can slap on a BIS and keep the BP up.

 

[pgg]

I read the study this morning.

The guy who wrote the editorial screwed up the data. This is wrong:

The only differences between the groups other than BIS levels were that those in the deep sedation group received a median of 8.1 mg/kg propofol vs 1.3 mg/kg for the light group and a median of 2 mg midazolam compared with 10 mg in the light group.

It wasn't 10 mg, it was 10 patients. The light group didn't get a median dose of 10 mg of midazolam, and the deep group didn't get a median dose of 2 mg. 10 patients (out of 45) in the light group received midaz, and the range was reported as 0 - 0.06 mg/kg. If these were typical 50 kg LOL's then Table 1 would indicate that the max dose of midaz any of the lightly sedated patients got was 3 mg. Only 2 patients (out of 39) in the deep group got midazolam.

The N for the Charlson Morbidity Index >4 was 84 patients.

In light of this, I find the study a little harder to dismiss as garbage. However, there's another editorial that mentions the power issue I brought up a few posts back:

For the follow-up survival analysis, 80% power was estimated to detect a hazard ratio of 0.58 for survival in lightly sedated compared with deeply sedated patients. Although these powers are commonly accepted in the medical literature, it is instructive to recall that such studies will miss 14% and 20% of “true” results, respectively.

Even in the presence of excellent study design, small trials with low power can produce unreliable findings due to low prior probabilities of finding true effects, low positive predictive values for claimed effects, and exaggerated estimates of effect size for true effects, the so-called “winner’s curse.” In the anesthesia literature, this curse is illustrated by spectacular risk reductions for myocardial infarction in early [beta]-blocker trials that were not replicated by large trials or meta-analyses.

It's a controversial subject with a lot of conflicting data over many years, and this N=84 statistical rehash hasn't sold me.

 

[nap$ter]

Still, the data strong suggest that "less in more" in the 80+ year old age group. Using Regional anesthesia with light sedation may have benefits over a deep GA with Vapor using an LMA. I still think many of us should be doing more Neuraxial/Regional anesthesia with light sedation for our 80+ year old patients whenever possible. Of course, severely demented patients may require GA and those on AntiCoagulants (fairly common these days) can't get a SAB but we can slap on a BIS and keep the BP up.

i find no convincing data to support your statements in red (and most folks aren't going to aim for a "deep GA" in an 80+ yo) when it comes to hip fractures.

i completely agree with your statements in blue.

i also agree with your statement in green, although for hip fracture i find an asleep fascia iliacus block to be far superior to neuraxial.

 

[deleted59964]

I make all of my OB patients sit now. Everyone can sit still for the minute or two the needle's in the back. The ones who can't are just being drama queens and I'm happy to stand there and wait for them to decide they really do want the epidural enough to sit still. I tell them the procedure is faster, easier, and more likely to be a success if they're upright. Somehow they all manage to do it. I do CSEs on every OB patient so onset is always immediate.


On those occasions that I find myself struggling with a procedure (any procedure), it's usually because I didn't optimize positioning to start. Sitting is the optimal position for a spinal. I'm nice about it, but absent a hip fracture or other reason they truly can't sit, I make them sit.

I give plenty of tough love to get them to sit still too - but if you get someone who doesnt speak english (or the occaisonal nutter) - lateral it is for me.