Quick prone MAC colorectal cases: what do you use?

[NoTalentGasClown]

Recently out from residency into private practice. We didn’t do these prone cases (fistula, hemorrhoids, etc) much in residency. I was just curious what you all do for them. Seems like the only painful part is the local injection. So I was thinking maybe versed and propofol would be best, but was also thinking of using remifentanil? Seems like it would wear off faster that propofol if patient went apneic. The operating time for these cases is usually less than 5 minutes.

---

Members don't see this ad.

 

[deleted875186]

Fentanyl and prop

 

[nimbus]

We do lots of those. I like prone positioning, then Prop/lma/sevo

 

[coffeebythelake]

Recently out from residency into private practice. We didn’t do these prone cases (fistula, hemorrhoids, etc) much in residency. I was just curious what you all do for them. Seems like the only painful part is the local injection. So I was thinking maybe versed and propofol would be best, but was also thinking of using remifentanil? Seems like it would wear off faster that propofol if patient went apneic. The operating time for these cases is usually less than 5 minutes.

versed, propofol, fentanyl
yep -- surgeon injecting the local anesthetic is the most stimulating part
stun the patient a little bit for that
then you can back off
usually we do head turned to side w pillow, occasionally in line with a square foam block
keep the pt cart in room in case you need to quickly flip in an emergency

 

[anbuitachi]

same with above. prop fent versed. i have done spinals for these patients when i know the surgeon is slow as hell and is awful at giving local

 

[Zekchar]

propofol and fentanyl +/- versed. start infusion 150 mcg/kg/min, 50mcg fentanyl, hold patient down a bit during injection, back off on propofol once local is done. Dont make it more complicated than it has to be.

 

[hununuh]

Do patients go apneic with 150mcg/kg/min infusion? Or is it such a short duration that it doesnt matter? I guess 100kg patient would be getting 15mg every minute, which is way less than the induction doses.

 

[Iso4ane]

Maybe because it’s California, but inthe Midwest they are big. In residency we convinced the surgeons to do it in lithotomy if possible, otherwise prop/sux/tube/flip/get them breathing spontaneously/flip back/pull tube.

 

[Ronin786]

Saddle block is great for these cases if you have a slow surgeon.

 

[jeesapeesa]

flip the patient into the jacknife position then 2 mg of versed once monitors/o2/etco2 connected and head positioned properly. about 20 seconds before local injection i do about 40-50 mg of propofol. they usually don't flinch and if the surgeon's fast enough that's basically all i use.

 

[Zekchar]

Do patients go apneic with 150mcg/kg/min infusion? Or is it such a short duration that it doesnt matter? I guess 100kg patient would be getting 15mg every minute, which is way less than the induction doses.

As with everything in anesthesia, it depends ... but generally no they dont. Its ultimately a 20-25 minute case. I find that the biggest enemy is the lazy CRNA who does not get situated in time and slugs the patient with a big dose of propofol and fentanyl just before the surgeon does the local, then calls me because the patient is too deep. I prefer to let the propofol set in as an infusion, give a small bump right before local injection, then decrease the infusion dose once local has set in. That means ~5 min of infusion at 150mcg/kg/min during the prep, drape, and time that it takes to timeout, 20-30mg bolus just before local, then cut the propofol to 75-100mcg/kg/min.

 

[AdmiralChz]

Our surgeons do these high lithotomy here. Only very rarely do we do them prone jackknife anymore, mostly for highly posterior lesions. These cases suck, and a few times in training we had near-respiratory codes doing these as MACs (aka room air generals) - remember, it’s OK if they move SOME with local infiltration. Discussion with the surgeon ahead of time is helpful especially it’s a giganto coming in

 

[deleted162650]

Seems like a good place to remind everyone of this little gem:

 

[sevo00]

I have done these with giving ketamine 30mg at time. A little versed in the beginning and then just intermittent ketamine boluses. Works great and don't have to worry about them getting apneic

 

[Mikkel]

I use only propofol for these. No apnea or hypoventilation from concurrent opioids or benzos. Occasional jaw thrust, usually with initial boluses.

 

[nimbus]

Seems like a good place to remind everyone of this little gem:

A classic. I forgot how good that is.

 

[2Fast2Des]

I do ketamine and prop bolus with prop infusion, occasionally oral airway to support. They do great, no moving except maybe a little bit every now and then with local injection. On more than one occasion I've been complimented by the surgeons who make it a point to say how smooth it went, whatever I'm doing is apparently amazing compared to whatever the academic residency people do, which I guess is not that great.

 

[2Fast2Des]

Saddle block is great for these cases if you have a slow surgeon.

What would you do for your spinal and positioning? I've never done a saddle spinal yet for anything

 

[NoTalentGasClown]

I do ketamine and prop bolus with prop infusion, occasionally oral airway to support.

What kind of doses are you using?

 

[Ronin786]

What would you do for your spinal and positioning? I've never done a saddle spinal yet for anything

Have them sit on the edge of the cart. 1cc of 0.75% bupi, let them sit for 3-5 minutes after the spinal. Then just help flip them prone onto the OR table.

 

[2Fast2Des]

Have them sit on the edge of the cart. 1cc of 0.75% bupi, let them sit for 3-5 minutes after the spinal. Then just help flip them prone onto the OR table.

How long does it last? About an hour or so? and since these are ambulatory cases any problem with urinary retention or such to get them out of pacu quickly? Would love to do it for the super huge people who would not be a great idea to do jacknife with only sedation

 

[2Fast2Des]

What kind of doses are you using?

Usually 0.5mg\kg of ketamine bolus, 1mg\kg ish propofol bolus and 100-150 rate on the prop

 

[UscGhost]

0.5mg versed
50 fentanyl
Position patient prone.
Propofol until unconscious and then additional bolus with local injection

If the patient reacts too strongly to the pain with the local injection..they will likely cough or spasm and you run into issues. If you overdo it....they will obstruct and go apneic

 

[deleted162650]

0.5mg versed
50 fentanyl
Position patient prone.
Propofol until unconscious and then additional bolus with local injection

If the patient reacts too strongly to the pain with the local injection..they will likely cough or spasm and you run into issues. If you overdo it....they will obstruct and go apneic

What’s the point of the Versed??

 

[epidural man]

Recently out from residency into private practice. We didn’t do these prone cases (fistula, hemorrhoids, etc) much in residency. I was just curious what you all do for them. Seems like the only painful part is the local injection. So I was thinking maybe versed and propofol would be best, but was also thinking of using remifentanil? Seems like it would wear off faster that propofol if patient went apneic. The operating time for these cases is usually less than 5 minutes.

Alfenta for the patient,

versed for me (so I don’t remember how much I hate doing these cases)

 

[UscGhost]

What’s the point of the Versed??

A small dose helps reduce recall as patients generally dont like to remember positioning prone. Also less likely that the patients feel groggy and lethargic afterwards. These are generally 30 min cases.

Helps smooth out the propofol as well and provide some synergistic sedative characteristics.

Sometimes. I use no versed or 1-2mg depending on their anxiety and history of benzos exposure

 

[nimbus]

I’ve tried most of these variations. Why do a big MAC in the prone position? That’s certainly not safer than a GA/LMA in the prone position.

Have them turn prone, turn their head to their left, fent 50, propofol 200, slip in LMA, Sevo, jackknife the bed. Patient is deep, doesn’t move, doesn’t obstruct, doesn’t cough or sputter or desaturate. Your hands are free to click away on epic, draw up ancef, etc.

 

[DrZzZz]

0.5mg versed
50 fentanyl
Position patient prone.
Propofol until unconscious and then additional bolus with local injection

If the patient reacts too strongly to the pain with the local injection..they will likely cough or spasm and you run into issues. If you overdo it....they will obstruct and go apneic

I have a hard time believing 0.5mg versed does anything for the patient, unless you're giving it to a malnourished 45kg 90 year old with baseline dementia.

 

[deleted875186]

Prone sedation is actually easier than supine .... they don’t obstruct as much. Just go slower because obviously apnea requiring PPV means your screwed.

 

[Ezekiel2517]

I’ve tried most of these variations. Why do a big MAC in the prone position? That’s certainly not safer than a GA/LMA in the prone position.

Have them turn prone, turn their head to their left, fent 50, propofol 200, slip in LMA, Sevo, jackknife the bed. Patient is deep, doesn’t move, doesn’t obstruct, doesn’t cough or sputter or desaturate. Your hands are free to click away on epic, draw up ancef, etc.

I do a MAC for these bc the surgeons I work with who do them in this position are super fast. 10 min or less. Doing them with MAC means no wake up time. You turn them onto their back (or they turn themselves bc they're already pretty awake) and roll out of the room. When the surgeon has like 5 or more of these cases lined up, it makes a big difference. You can knock them out super fast bc the turnover is quick.

 

[nimbus]

I do a MAC for these bc the surgeons I work with who do them in this position are super fast. 10 min or less. Doing them with MAC means no wake up time. You turn them onto their back (or they turn themselves bc they're already pretty awake) and roll out of the room. When the surgeon has like 5 or more of these cases lined up, it makes a big difference. You can knock them out super fast bc the turnover is quick.

Same....5-10min cases. I just tilt the OR table, roll them onto gurney, and take them to pacu with the LMA in. Usually pull the LMA as I’m waiting for first set of vitals. They wake up fast because they haven’t been asleep long.

 

[Ezekiel2517]

Same....5-10min cases. I just tilt the OR table, roll them onto gurney, and take them to pacu with the LMA in. Usually pull the LMA as I’m waiting for first set of vitals. They wake up fast because they haven’t been asleep long.

The pacu nurses where we do many of these cases in the ASC's are definitely not comfortable with LMA's (some don't even know what they are) and want the patients awake. Faster discharges from the pacu compared with GA's.

 

[woopedazz]

Do you guys have alfentanil over there?
Propofol bolus/TIVA and then ~250microg of alfentanil (+/- 100microg) 30-60 seconds prior to local. It peaks at 90 seconds and clears by 5 minutes.

 

[nimbus]

The pacu nurses where we do many of these cases in the ASC's are definitely not comfortable with LMA's (some don't even know what they are) and want the patients awake. Faster discharges from the pacu compared with GA's.

You can always help them get comfortable