CSE in a high-risk case

Enrico81 said:

Would you ever do that? The case was as following: 25-year-old woman, 45 kgs, huge renal tumor with adherence to liver, small bowel, vena cava and posterior abdominal wall. The surgeons make it clear that they don't know if there will be room enough to identify the renal artery and that they fear massive blood loss. My attending decides to put her to sleep and then performs CSE with hyperbaric bupivacaine 8 mg and clonidine 30 mcg... sure enough, her systolic BP dropped to low 70s and required vasopressors for nearly an hour to keep it within an acceptable range.
Would you have done that? I don't think I would 😕

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Wawawewa,
So you're doing a CSE at the lumbar level for a renal tumor 😕 when the patient is asleeep 😱
I'd do a thoracic epidural awake and GETA

Any case where I fear hemodynamic embarassment or big EBL, I don't use my ED. I dose it the last hr or so of a case after the hemostasis is good.

Obviously, if they are not under GETA, that's another story.

DOing neuraxial on an adult asleep? Are you in Italy or the US?

why asleep?

Enrico81 said:

Would you ever do that? The case was as following: 25-year-old woman, 45 kgs, huge renal tumor with adherence to liver, small bowel, vena cava and posterior abdominal wall. The surgeons make it clear that they don't know if there will be room enough to identify the renal artery and that they fear massive blood loss. My attending decides to put her to sleep and then performs CSE with hyperbaric bupivacaine 8 mg and clonidine 30 mcg... sure enough, her systolic BP dropped to low 70s and required vasopressors for nearly an hour to keep it within an acceptable range.
Would you have done that? I don't think I would 😕

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Giving a combined epi/gen or spinal/gen is a mistake you only make early in your practice. You will eventually get burned. When they lose their blood volume they drop like a rock. Doing a regional on an anesthetized patient is another potential mistake.

You will find in your career that people often make judgement errors in their practice, but just because they get away with it doesn't mean that they made the right call.

What the hell do you need a friggen SPINAL for a GA case? Makes no sense unless your doing it to inject duramorph only for post-op pain.

If you really want to help for POST OP pain then put in a Thoracic Epidural (as stated above). Dose it up towards the end of the case.

I've been burned before w/ that technique. Why give both? What major benefit does adding a regional give you that a straight general does not?
I don't get it.

numbmd said:

I've been burned before w/ that technique. Why give both? What major benefit does adding a regional give you that a straight general does not?
I don't get it.

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Yes,
In anesthesia the more interventions you do to the patient the more likely you will cause a problem.
So, I think the best question to ask before doing something is: Do I really need this to give a safe and effective anesthetic?

Enrico81 said:

Do you mean starting regional anesthesia intraoperatively vs postoperatively or regional anesthesia on the whole? Of course, you don't want me to go over all the supposed benefits of a combined technique (fewer perioperative AMIs, shorter ileus, lower pulmonary morbidity, fewer DVTs, etc. etc.). I see that many studies supporting these advantages are controversial, and that there are many issues that have to be taken into consideration before drawing conclusions. For instance, to avoid being underpowered, many studies included heterogeneous patients, anesthesiologic managements, and so on. Moreover, some are limited to intraoperative regional anesthesia, while others extend it into the postoperative period. Not to mention the dilemma of whether to use opioids in the epidural, possibly incurring the same untoward effects you tried to prevent in the first place, or not, running the risk of inadequate analgesia... So, I'm not trying to state this is an easy matter, I have full respect for your opinions, but combined regional/general has lots of strong advocates, and while I was keen to share views about its "odd" use in the case in question, I think that at least in selected patients it may prove really useful, as long as the "user" is a sensible guy 😉

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Why do you need to do a SPINAL on someone is under GA?

Most of the benefits of Neuraxial anesthesia have been unimpressive so far. yes there is a slight decrease in Postop Pulm Complications in a select population. Again, no change in MORTALITY.

The ileus is a no-brainer....or is it? If you use a combo of narcotic and local in your epidural that benefit is highly marginalized, or worse, lost. Does bupivicaine alone really cut it? My thinking is that you'd need a narcotic PCA as well, or at least orals for breakthrough....there goes that benefit.

Who doesn't get DVT prophylaxis anyways? Those studies about lower DVT's came about (as I understand it) before the advent of our current stringent and universal DVT prophylaxis protocols. Nobody gets a epidural for DVT prophylaxis. It ain't gonna beat heparin, lovenox, or even SCD's.

The greatest benefit may come from earlier discharge (perhaps up to 2 days)
IF used in combination with a strict early mobility/rehab/nutrition/bowel regime/etc protocol. And again, this is in a select group of patients.

I like neuraxial for abdominal cases. Early coughing is good. In a select group of patients it can really help them out. However I'm far from sold on the technique.

Its a shame that the studies so far haven't blown anyone's mind. Or worse yet, have actually been a severe let down.

Vent