I need a short spinal

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
Status
Not open for further replies.
J

jumpin bean

Junior Member
10+ Year Member
5+ Year Member
15+ Year Member
Joined
May 30, 2005
Messages
16
Reaction score
0
Members don't see this ad.
I've been in private practice for 3 weeks now and I'm adjusting to the speed of the surgeons. My partners use 5% lido for everything including D&C's and knee arthroscopy, but in my second week on the job I saw a man with severe TNS after a lido spinal for a knee arthroscopy. He's feeling better now, but his pain left a big impression on me. After reading the ASRA statement on spinal lidocaine, I've decided to continue to use lido for anything but knee surgeries and procedures using lithotomy position. From what I've read, changing the concentration or baricity of lido does not decrease the incidence of TNS. Basically, I need a spinal that will wear off and have the patient ready for discharge within 2 hours of injection. I don't want my patients clogging up the PACU. I tried 0.8cc 0.75% bup with dextrose for a D&C, but the block wasn't dense enough. I tried 1.2cc of the same with 20 mcg of fentanyl and the damn thing lasted over 4 hours. I will continue to try doses inbetween, but if anyone has a recipe for a short spinal without using lidocaine, I would like to try it.
 
Try procaine 10%, the duration is even shorter than lidocaine 5%. (45-60 minutes)

You could also try decreasing the concentration of the lidocaine to 2-2.5% and experiment with the dose. There is supposed to be less TNS with lower concentrations.
 
jumpin bean said:
I've been in private practice for 3 weeks now and I'm adjusting to the speed of the surgeons. My partners use 5% lido for everything including D&C's and knee arthroscopy, but in my second week on the job I saw a man with severe TNS after a lido spinal for a knee arthroscopy. He's feeling better now, but his pain left a big impression on me. After reading the ASRA statement on spinal lidocaine, I've decided to continue to use lido for anything but knee surgeries and procedures using lithotomy position. From what I've read, changing the concentration or baricity of lido does not decrease the incidence of TNS. Basically, I need a spinal that will wear off and have the patient ready for discharge within 2 hours of injection. I don't want my patients clogging up the PACU. I tried 0.8cc 0.75% bup with dextrose for a D&C, but the block wasn't dense enough. I tried 1.2cc of the same with 20 mcg of fentanyl and the damn thing lasted over 4 hours. I will continue to try doses inbetween, but if anyone has a recipe for a short spinal without using lidocaine, I would like to try it.
Click to expand...

Hey bean,

How's life in private practice? Try seattledoc's recipe as well as the lower concentrations of lido with 10-20 mcg fentanyl. The procaine with fentanyl is also a good choice and lasts about 1.5 hours for me.

The positioning of the patient as the spinal sets up still makes a big difference for me when I use spinals. Don't want a saddle block, but don't want them getting to high before the surgery starts as well. Low thoracic should be more than enough and give you enough of a decrement time to prevent premature evaporation of your spinal.

Drop me an e-mail. Would like to discuss a couple of things with you.
 
Try doing the block at a higher level.

Just move up the vertebral spaces.

Up above C1.

At the brainstem.

Usually 200mg of isopropyphenol is enough to start the block.

Follow this with some fluorinated hydrocarbons to supplement your block.

Doing the spinal that way will never leave you with a block that lasts longer than you want.

S.A.R.A.
president
 
militarymd said:
Try doing the block at a higher level.

Just move up the vertebral spaces.

Up above C1.

At the brainstem.

Usually 200mg of isopropyphenol is enough to start the block.

Follow this with some fluorinated hydrocarbons to supplement your block.

Doing the spinal that way will never leave you with a block that lasts longer than you want.
Click to expand...

I took me until "up above C1" before I knew what the he11 you were saying. :laugh:
 
If you're brave you can try chloroprocaine. Kopacz at Virginia mason has a few papers out on this. Here's a reference to one of them.

Spinal 2-chloroprocaine: a comparison with small-dose bupivacaine in volunteers.

Anesth Analg. 2005 Feb;100(2):566-72
 
I do a brain block whenever I can, but the culture of the practice is very regional heavy. The surgeons like/expect the regional. Thanks for the unhelp.
 
jumpin bean said:
I do a brain block whenever I can, but the culture of the practice is very regional heavy. The surgeons like/expect the regional. Thanks for the unhelp.
Click to expand...

For knee scopes have you considered blocks along with local infiltration at the trocar sites, combined with heavy continuous IV sedation? You'll get the same quick PACU discharge you seek as with a lido spinal.

One small Navy hospital where I did some reservist time did all their knee scopes this way, since the OR circulators were also the PACU staff. Doing it this way, the pts went straight from OR back to the ward, and the circulator/PACU nurse could straight back to the next case in the OR.
 
jumpin bean said:
I do a brain block whenever I can, but the culture of the practice is very regional heavy. The surgeons like/expect the regional. Thanks for the unhelp.
Click to expand...

change the culture.

Compare a very skilled anesthetist to a very skilled needle jockey.....going to sleep give you faster room turnovers every time....all things being equal...
 
hi bean, we started using preservative free 2 chlorprocaine in our asc , we like it specifically for knee scopes, 2 cc 's (40 mg) will give you a t8-6 level for ca. 45-60 min. typical discharge time is 2 hours after placement of the block.
initially the crna's were hesitant to use it because of its off-label use but now they're happy with it.....
fasto
 
dump in a little fentanyl, get upto 1hr 15 min..just make sure surgeon is in the room when you perform the spinal.....my choice for achilles repairs and other 1hr procedures.......
 
UTSouthwestern said:
Hey bean,

How's life in private practice? Try seattledoc's recipe as well as the lower concentrations of lido with 10-20 mcg fentanyl. The procaine with fentanyl is also a good choice and lasts about 1.5 hours for me.

The positioning of the patient as the spinal sets up still makes a big difference for me when I use spinals. Don't want a saddle block, but don't want them getting to high before the surgery starts as well. Low thoracic should be more than enough and give you enough of a decrement time to prevent premature evaporation of your spinal.

Drop me an e-mail. Would like to discuss a couple of things with you.
Click to expand...

Have you tried procaine spinals for PPBTL's? I have been using 1.5 cc of bupivacaine for my BTL's, but now that I am in private practice, the procedure takes about 10 minutes and then the patient hangs out in the PACU for 4 hours. They do them like one hour post partum, so I don't want to do a general - what do you think?
 
Laurel123 said:
Have you tried procaine spinals for PPBTL's? I have been using 1.5 cc of bupivacaine for my BTL's, but now that I am in private practice, the procedure takes about 10 minutes and then the patient hangs out in the PACU for 4 hours. They do them like one hour post partum, so I don't want to do a general - what do you think?
Click to expand...

Put them to sleep....that's what we do.
 
militarymd said:
Put them to sleep....that's what we do.
Click to expand...

I'm a regional advocate but I agree with Mil on this one....for short cases (BTL, knee scope, etc) GA, preferably LMA whenever possible is the way to go. Patients leave the hospital less than an hour after the surgery in an efficient institution. Cant touch the efficiency either...

I used to do lidocaine spinals for hernias a long time ago but got tired of patients sitting in PACU too long and/or urinary retention problems.
 
Meperidine 50-75 mg preservative-free. Mix it with 1cc (equal parts D10). THey can usually still move their legs but they don't feel a thing. It lasts about 45-60min. No TNS.
 
Noyac said:
Meperidine 50-75 mg preservative-free. Mix it with 1cc (equal parts D10). THey can usually still move their legs but they don't feel a thing. It lasts about 45-60min. No TNS.
Click to expand...

What level of surgical anesthesia can you achieve with that? How dense is the block?
 
militarymd said:
Put them to sleep....that's what we do.
Click to expand...


Just curious, but in residency, we learned that postpartum patients are essentially 'full stomach' for about 24 hours (though I have never read anything to verify that). Also, all the airway and respiratory changes of pregancy are still in effect immediately postpartum. Thus, we always did spinals for post-partum BTL's. What are your thoughts about that?
 
Laurel123 said:
Just curious, but in residency, we learned that postpartum patients are essentially 'full stomach' for about 24 hours (though I have never read anything to verify that). Also, all the airway and respiratory changes of pregancy are still in effect immediately postpartum. Thus, we always did spinals for post-partum BTL's. What are your thoughts about that?
Click to expand...

They need to stop teaching some of that stuff that they teach in residency.

Seriously.

So tell me how the airway/respiratory changes is going to affect anything. They go to sleep and wake up just like anybody else.

For all the thousands of pptl that get done in the US under GA....if what they taught you in residency were true....we would have an epidemic of orphaned babies with unhappy single fathers.
 
Laurel123 said:
What level of surgical anesthesia can you achieve with that? How dense is the block?
Click to expand...


You can do most minor surgeries (TURP, Cysto, knee scope) with it alone.
 
militarymd said:
They need to stop teaching some of that stuff that they teach in residency.

Seriously.
.
Click to expand...

Someone please review all my posts and report back how many times I've said this. Ohhh, probably about 17 times. 😀
 
MTGas2B said:
If you're brave you can try chloroprocaine. Kopacz at Virginia mason has a few papers out on this. Here's a reference to one of them.

Spinal 2-chloroprocaine: a comparison with small-dose bupivacaine in volunteers.

Anesth Analg. 2005 Feb;100(2):566-72
Click to expand...

I heard about people using this on an audio digest. I thought it sounded wonderful, but haven't been brave enough to use it. Why do I need to be "brave" anyway? What are the downsides? It sounds like a great spinal

It is suprising to me that some on this forum advocate general over regional for everything (including a clearly full stomache patient who is at 8-15 times the risk of dying under general). I would say that the reason residency teachers teach the things that they do is perhaps because they read the literature and are current on understanding the whole picture. Maybe it is a little different in private practice where tunnel vision can perhaps predominate.
 
Watch out for the greetings of the president of the SARA 😀:meanie:

Thanks for digging out this post i was thinking about it recently
 
dhb said:
Even if you can do the spinal in a holding room?
Click to expand...


vs awake intubation in holding.


Actually, at BI in Boston they have an induction room. Pt goes to sleep while they are cleaning the room. After pt is intubated they push the OR table to the room. This way their turn over time is reduced. At the end of procedure they transfer the pt still intubated to pacu where nurses/pacu resident extubate them.
​
 
epidural man said:
I heard about people using this on an audio digest. I thought it sounded wonderful, but haven't been brave enough to use it. Why do I need to be "brave" anyway? What are the downsides? It sounds like a great spinal

It is suprising to me that some on this forum advocate general over regional for everything (including a clearly full stomache patient who is at 8-15 times the risk of dying under general). I would say that the reason residency teachers teach the things that they do is perhaps because they read the literature and are current on understanding the whole picture. Maybe it is a little different in private practice where tunnel vision can perhaps predominate.
Click to expand...

That's right...the literature is ONLY available at teaching centers...

Wait...I forgot...all us PP guys actually forgot how to read....

Oh wait....I forgot again....we actually never learned how to read...we just do a ton of cases...instead of reading like the academic guys who "supervise" one or 2 cases at a time.
 
militarymd said:
Oh wait....I forgot again....we actually never learned how to read...we just do a ton of cases...instead of reading like the academic guys who "supervise" one or 2 cases at a time.
Click to expand...

Touche......

Actually, my post was a little over the top. What I meant was that there are certainly differences in practice styles from private to academic. I asked Dr. Gambling, a well known Obstetric anesthesiologist who works at a very busy private hospital in San diego, if he puts a-lines in the severe-preeclamptic patients (as the text books and literature say we should do). He kind of laughed and said - "No. For what? For the three or four blood pressures we are going to get while we are in the OR?" His point being that private physicians are much faster than residents at academic settings. He then went on to discuss how much different practice is in the private practice setting, yet complained that the "pundits" who sit on the stand and say how things "should be" all come from the adacemic centers where practice is vastly different from the private sector where most of the work is done.

But I still think a spinal is much safer in the above mentioned patient population.
 
epidural man said:
His point being that private physicians are much faster than residents at academic settings. He then went on to discuss how much different practice is in the private practice setting, yet complained that the "pundits" who sit on the stand and say how things "should be" all come from the adacemic centers where practice is vastly different from the private sector where most of the work is done.
Click to expand...

I WANT THAT SAN DIEGO DUDE TO SIGN MY SHIRT. AND I WANNA GET MY PICTURE TAKEN WITH HIM.


👍
 
epidural man said:
It is suprising to me that some on this forum advocate general over regional for everything (including a clearly full stomache patient who is at 8-15 times the risk of dying under general).
Click to expand...


HAHHAHAHAHAHAHAHAHAHAHAHAHAHAH

I'm a regional advocate as everyone knows.

Youre saying that a full stomach patient has an 8-15 times risk if you do a GA over a regional technique??????

HAHAHAHAHAHAHAHAHAHAHAHHAHHA

Man, would the oral board examiners here in the US have a field day with you.

If you said that (absolutely false) info, heres what you'd hear next:

ORAL BOARD EXAMINER: "OK, Slim, you decided to "save the patient's life" by not exposing them to general anesthesia for this emergent surgery. You put in a spinal, and your level rises to a C2 level."

"NOW WHAT, SLIM?"
 
jetproppilot said:
HAHHAHAHAHAHAHAHAHAHAHAHAHAHAH

I'm a regional advocate as everyone knows.

Youre saying that a full stomach patient has an 8-15 times risk if you do a GA over a regional technique??????

HAHAHAHAHAHAHAHAHAHAHAHHAHHA

Man, would the oral board examiners here in the US have a field day with you.

If you said that (absolutely false) info, heres what you'd hear next:

ORAL BOARD EXAMINER: "OK, Slim, you decided to "save the patient's life" by not exposing them to general anesthesia for this emergent surgery. You put in a spinal, and your level rises to a C2 level."

"NOW WHAT, SLIM?"
Click to expand...

Actually, I wasn't referring to just any full stomach pt, but I was referring to a specific type of full stomache pt - a fully pregnant pt - which if you follow the thread is what was being referred to - and in this case, there is an 8-15 times risk of death for general anesthesia in this population for multiple reasons. Are you saying that you disagree with this?
 
epidural man said:
Actually, I wasn't referring to just any full stomach pt, but I was referring to a specific type of full stomache pt - a fully pregnant pt - which if you follow the thread is what was being referred to - and in this case, there is an 8-15 times risk of death for general anesthesia in this population for multiple reasons. Are you saying that you disagree with this?
Click to expand...


Although the lawyers and the hallowed academics would say it is so.....I think this is completely bogus.

The data is flawed....we only put gravid patients to sleep in emergent situations....whereas any other time we stick needles in their backs.

But yet, we compare mortality data in emergent cases with elective cases....wtf????

Of course mortality will be higher...I'm surprised it's not 50 x higher.

The germans do 70% of their elective sections under GA....no problems.

The academics will disagree...the lawyers will listen to the academics....so who suffers.....only the patients...because an option in anesthesia has been taken away from them.
 
epidural man said:
Actually, I wasn't referring to just any full stomach pt, but I was referring to a specific type of full stomache pt - a fully pregnant pt - which if you follow the thread is what was being referred to - and in this case, there is an 8-15 times risk of death for general anesthesia in this population for multiple reasons. Are you saying that you disagree with this?
Click to expand...

Yes.

I absolutely disagree.
 
Laurel123 said:
Have you tried procaine spinals for PPBTL's? I have been using 1.5 cc of bupivacaine for my BTL's, but now that I am in private practice, the procedure takes about 10 minutes and then the patient hangs out in the PACU for 4 hours. They do them like one hour post partum, so I don't want to do a general - what do you think?
Click to expand...

If you don't want to do GA, do an Epidural with Lido 2 %.
 
jumpin bean said:
I've been in private practice for 3 weeks now and I'm adjusting to the speed of the surgeons. My partners use 5% lido for everything including D&C's and knee arthroscopy, but in my second week on the job I saw a man with severe TNS after a lido spinal for a knee arthroscopy. He's feeling better now, but his pain left a big impression on me. After reading the ASRA statement on spinal lidocaine, I've decided to continue to use lido for anything but knee surgeries and procedures using lithotomy position. From what I've read, changing the concentration or baricity of lido does not decrease the incidence of TNS. Basically, I need a spinal that will wear off and have the patient ready for discharge within 2 hours of injection. I don't want my patients clogging up the PACU. I tried 0.8cc 0.75% bup with dextrose for a D&C, but the block wasn't dense enough. I tried 1.2cc of the same with 20 mcg of fentanyl and the damn thing lasted over 4 hours. I will continue to try doses inbetween, but if anyone has a recipe for a short spinal without using lidocaine, I would like to try it.
Click to expand...
GA is my choice also, but you can always do an epidural with 2 % Lidocaine and keep the regional culture 🙂
 
ncstudentdoc said:
But I remember when people used to be more helpful, less arrogant, and much less condescending when answering questions. I guess when you finish residency, you suddenly know everything and the fact that you have not seen a particular complication in your very limited practice means it just doesn't happen and everyone in academia is wrong. Great, just what I want, a few more dingus know-it-all anesthesiologists to make my job even harder.

I don't know the perfect recipe for a short spinal--like I think you alluded to in your original post, there is no perfect recipe. Some of the above posts have pretty good ideas. My advice would be to continue read the literature, continue asking questions but ask some other anesthesiologists you know and respect, and ignore the pricks on here who know everything because they have done a few cases for a few years and nothing bad has happened so they now think they know it all. We don't need studies, just ask some hot shot ******* a couple of years out of residency: GA is so safe that they can never have a complication. Spoken like a true CRNA who thinks they can practice without all that messy medical knowledge and "evidence" of complications. If these clowns haven't actually seen it in a couple of years of practice, well then it just can't happen. Who needs evidence anyway when you are a such a god? Besides these guys here are so good, they can intubate a 600 lb achdroplastic dwarf with a c1-t1 fusion while blindfolded and holding their breath and juggling....no, really. Just ask them. You guys are so cool. I wish I didn't go to an decent residency, I should have just followed one of you around for a day and I am sure I would have learned everything I need: GA for everyone, one size fits all; besides, I have a hair appointment at 3:00 and we have to get done before then. Good grief, I hope these pricks never have a shot at one of my relatives; I would trust our 70-year-old half-blind CRNA who cannot stay awake long enough to give breaks before I trusted them.
Click to expand...

Dude needs a hug. :scared:
 
ncstudentdoc said:
I guess when you finish residency, you suddenly know everything and the fact that you have not seen a particular complication in your very limited practice means it just doesn't happen and everyone in academia is wrong. Great, just what I want, a few more dingus know-it-all anesthesiologists to make my job even harder.
Click to expand...

No, Slim, everyone in academia is not wrong. They're just out of touch with how the real world practices.

Read the post about the San Diego anesthesiologist, Dr. Gambling.

That about somes it up.
 
jetproppilot said:
No, Slim, everyone in academia is not wrong. They're just out of touch with how the real world practices.

Read the post about the San Diego anesthesiologist, Dr. Gambling.

That about somes it up.
Click to expand...

Yes, but as far as this subject - the hospital that he works at recently reported their data and they had something like 4000 deliveries in 2006 and I think less than 15 general anesthetics. They are VERY aggresive about avoiding general in this population because the data is VERY clear that general is much more dangerous in the land of falopia. I'm suprised you disagree with this, but militarymd does make a good point.
 
epidural man said:
Yes, but as far as this subject - the hospital that he works at recently reported their data and they had something like 4000 deliveries in 2006 and I think less than 15 general anesthetics. They are VERY aggresive about avoiding general in this population because the data is VERY clear that general is much more dangerous in the land of falopia. I'm suprised you disagree with this, but militarymd does make a good point.
Click to expand...

His numbers are probably commensurate with most United States institutions.

Very few hospitals do generals for elective C sections.

But thats not the point.

The point is....residents emerge from residency scared s hitless to put a parturient to sleep when in fact, while there are risks, it is no where near the 8-15-fold-increase in mortality that you quoted.
 
A Proseal LMA may be a sound approach to these short procedures - in theory you can protect the airway from regurgitation with a 14Fr NGT through the gastric port. Use a propofol drip and they'll probably wake up nice, not need antiemetics.

That being said, I've noticed that the Proseal LMA's seem to cause more oral trauma than the normal disposables, no matter how gently I try to place them. Not too long ago I used one for an IHR in a large muscular young man - he began bucking at the last stitch, went into laryngospasm and negative pressure pulm edema while swinging his arms wildly - not fun....
 
jumpin bean said:
I've been in private practice for 3 weeks now and I'm adjusting to the speed of the surgeons. My partners use 5% lido for everything including D&C's and knee arthroscopy, but in my second week on the job I saw a man with severe TNS after a lido spinal for a knee arthroscopy. He's feeling better now, but his pain left a big impression on me. After reading the ASRA statement on spinal lidocaine, I've decided to continue to use lido for anything but knee surgeries and procedures using lithotomy position. From what I've read, changing the concentration or baricity of lido does not decrease the incidence of TNS. Basically, I need a spinal that will wear off and have the patient ready for discharge within 2 hours of injection. I don't want my patients clogging up the PACU. I tried 0.8cc 0.75% bup with dextrose for a D&C, but the block wasn't dense enough. I tried 1.2cc of the same with 20 mcg of fentanyl and the damn thing lasted over 4 hours. I will continue to try doses inbetween, but if anyone has a recipe for a short spinal without using lidocaine, I would like to try it.
Click to expand...


for a knee scope...try intraarticular injection and femoral block....you may have to suppliment with propofol infusion or fentanyl....but if you want speed and fast turnover this will definitely work out for you....
 
trinityalumnus said:
For knee scopes have you considered blocks along with local infiltration at the trocar sites, combined with heavy continuous IV sedation? You'll get the same quick PACU discharge you seek as with a lido spinal.

One small Navy hospital where I did some reservist time did all their knee scopes this way, since the OR circulators were also the PACU staff. Doing it this way, the pts went straight from OR back to the ward, and the circulator/PACU nurse could straight back to the next case in the OR.
Click to expand...



good suggestion...i would do intraarticular with femoral
 
I posted a couple of other pithy replies but I realize this is just a silly flame war and even some of the mods here encourage it. I don't know how to delete these posts, so I just edited everything out. The moderators can delete them. You guys enjoy your forums however you want them. Maybe students who want advice can find another place. Good luck.
 
Status
Not open for further replies.

Similar threads

T
Mepivicaine spinal for ortho
Replies
23
Views
2K
ans2021
A
S
Short term health insurance coverage between residency and attending job?
Replies
5
Views
900
maxxor
M
C
Kidney Transplant under spinal
2
Replies
79
Views
5K
MalloryWeiss
MalloryWeiss
P
Hip # ga vs spinal
2 3
Replies
134
Views
9K
GravelRider
GravelRider
M
Difficult Spinals coverage?
Replies
33
Views
3K
psychbender
psychbender
Top