2 chloroprocaine spinals

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Colba55o

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Questions for those who have done these. Wound up having to do a spinal in the ASC after patient insisted.
I have read about 2 chloroprocaine spinals being effective for short procedures but what concentration do you use?
Our pharmacy carries this: "NESACAINE-MPF 3% chloroprocaine HCL injection"

Is there a difference between chloroprocaine and 2-chloroprocaine? I always thought the 2 referred to 2%
Has anyone used this 3% concentration at a volume of 1cc to achieve 30mg in your spinal?
Also do we just ignore the fact that it says not for spinal on the bottle?
Is the MPF referring to preservative free or Methylparaben free? The literature I'm reading says it must be preservative free.
Thanks in advance...I freely admit I'm unfamiliar with this
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I've done very few but my old notes say I used 1.5-2 mL of the 3%. 30-60 min duration.

The 2 in 2-chloroprocaine is where the Cl atom is on the ring.

If it's preservative free, I'd use it. The 0.25% 30 mL bottles of bupivacaine say "not for spinal use" but most of us use it for spinals anyway. I think the manufacturer puts that on there because 30mL is not an appropriate spinal dose 😉 and it's not a multi-dose package.


I've done more mepivacaine spinals for short cases than chloroprocaine, but in truth there's probably just as much TNS with mepivacaine as for lidocaine.

Most of the chloroprocaine I've ever used was to augment labor epidurals for urgent sections.
 
The only chloroprocaine I know about is 2-, meaning that the chlorine atom is connected to the second carbon atom in the benzene ring (C1 is the one with the side chain). It's not FDA approved for intrathecal use because of h/o neurological deficits in the past (the hypothesis that they were due only to the preservatives is controversial).

I have never used it in a spinal, just epidurals, but there are people who use them intrathecally and love them (I remember one who gave a grand rounds presentation during my residency). It's a different story from bupi, where it's the non-hyperbaric forms that are not FDA-approved for spinal use, not the substance. I don't know of ANY version of 2-CP that is FDA-approved for spinals.

tl;dr: I personally don't give 2-CP intrathecally because I think it opens one up to lawsuits. I would rather use small doses of bupivacaine.
 
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It's been a while but if I remember correctly
1cc=45min
2cc=60.
That's the stuff (3%).
Some believe the incidence of radicular irritation is no different. I don't know.
 
I've done a few. Gave 60mg both times. Lasted a bit longer than expected.
 
I have done them in the past for short cases. It's great for short urology cases, GYN, cerclage and hemorrhoids. 1-2mls depending on length of case. I never saw TNS.
 
FFP said:
It's a different story from bupi, where it's the non-hyperbaric forms that are not FDA-approved for spinal use, not the substance. I don't know of ANY version of 2-CP that is FDA-approved for spinals.
Click to expand...

None of the local anesthetics are FDA approved for intrathecal use.

Morphine, baclofen, and ziconotide are the only drugs with FDA approval.

Sort of funny, since the very first drug anyone was bold enough to object into CSF was a local anesthetic (cocaine).
 
pgg said:
None of the local anesthetics are FDA approved for intrathecal use.

Morphine, baclofen, and ziconotide are the only drugs with FDA approval.

Sort of funny, since the very first drug anyone was bold enough to object into CSF was a local anesthetic (cocaine).
Click to expand...
I thought hyperbaric bupivacaine was... Wrong! You win. Neither bupi nor 2-CP are FDA-approved for spinal use.

Still, I trust spinal bupivacaine much more, since everybody uses it.
 
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I use 2% 2-cp for just about every knee scope. 40mg (2cc) for a case <1hr. Prone butt cases too (fistulas, hemorrhoids....). Place it while they're prone, diluted with equal part 1/2NS (can use sterile water, but risk osmotic neural damage).
Commonly used for years in our department. Never an issue.

In addition to the concerns mentioned about the preservative, many (all?) of the cases of catastrophic neurologic deficits were after GIGANTIC intrathecal doses that were meant to be epidural. Doses that would be toxic intrathecally with ANY local. There isn't evidence that it's any more dangerous than any other local when given in standard IT doses.
 
I use it daily. 3% at hospital and 2% at ASC. If you have reliably quick knee scope surgeons, 30mg (1-1.5cc depending on concentration) allows for quick PACU discharge as well (as fast or faster than general). Also no PONV. We've ran the numbers and it's as quick or quicker for OR metrics as GA. We save 3-5 min on anesthesia time at the end of the case (no slow emergence time) and costing maybe a minute at induction. We compared it to another similar center as well with the same results. Haven't seen clinically significant complications.


Sent from my iPhone using SDN mobile app
 
pgg said:
None of the local anesthetics are FDA approved for intrathecal use.

Morphine, baclofen, and ziconotide are the only drugs with FDA approval.

Sort of funny, since the very first drug anyone was bold enough to object into CSF was a local anesthetic (cocaine).
Click to expand...
I wonder if Cocaine is FDA approved for spinals?
 
OneFellSwoop said:
I use it daily. 3% at hospital and 2% at ASC. If you have reliably quick knee scope surgeons, 30mg (1-1.5cc depending on concentration) allows for quick PACU discharge as well (as fast or faster than general). Also no PONV. We've ran the numbers and it's as quick or quicker for OR metrics as GA. We save 3-5 min on anesthesia time at the end of the case (no slow emergence time) and costing maybe a minute at induction. We compared it to another similar center as well with the same results. Haven't seen clinically significant complications.


Sent from my iPhone using SDN mobile app
Click to expand...
Great info. Wish they hadn't taken it off my formulary.
 
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Why not.
I just think it's funny all the fuss about comparing local anesthetics for spinals when the comparison is not made between equipotent doses.
 
Colba55o said:
Questions for those who have done these. Wound up having to do a spinal in the ASC after patient insisted.
I have read about 2 chloroprocaine spinals being effective for short procedures but what concentration do you use?
Our pharmacy carries this: "NESACAINE-MPF 3% chloroprocaine HCL injection"

Is there a difference between chloroprocaine and 2-chloroprocaine? I always thought the 2 referred to 2%
Has anyone used this 3% concentration at a volume of 1cc to achieve 30mg in your spinal?
Also do we just ignore the fact that it says not for spinal on the bottle?
Is the MPF referring to preservative free or Methylparaben free? The literature I'm reading says it must be preservative free.
Thanks in advance...I freely admit I'm unfamiliar with this View attachment 211135
Click to expand...

Concentration doesn't matter....dose does.

Use 40-50mg.

It's safe ... been shown by lots of peer reviewed sources despite that guy in LA (can't remember who) always spatting off very old data.

You want the stuff in the brown bottle (not the clear bottle).

It is way better than bupivicaine because of reproducibility. Bupiv (no matter the concentration) has tremendous variability in its pharmacokinetics.

If we are talking pharmacodynamics- yes all likely the same.

Oh. Is chloroprocaine even an available drug?
 
Oh regarding FDA off label....

Does anyone else find it strange how sometimes physician will talk so emphatic about their fears of off label use in some drugs but be so willing to use other drugs off label (i.e...sevo in kids)? Where does that even come from?

Why does a physician ever see themselves as so high and mighty that they can decide which drugs are ok off label, and which ones aren't?

A better way to practice is to not worry about the FDA, who's job was never intended to dictate clinical practice, and just focus on clinically relevant info - like safety profiles and efficacy.

Since we are in the subject, I wish we could all band together and boycott journals or societies that have come out and said they wouldn't publish articles on off label use (i.e..,RAPM and ASRA). That is so ridiculous. It totally supports big pharma.
 
Did 1 2-chloroprocaine spinal for a knee scope, decided to go lowish: 30mg, had a solid 2h motor block! FTS
0.25% bupivacaine gives you a reliable 1h spinal with little motor block.
 
dhb said:
Did 1 2-chloroprocaine spinal for a knee scope, decided to go lowish: 30mg, had a solid 2h motor block! FTS
0.25% bupivacaine gives you a reliable 1h spinal with little motor block.
Click to expand...
Wow - that's crazy.

If that is the case - time and time again - do a case series and publish. This is good information.
 
The bigger question is do you pronounce it PRYlocaine or PRILLocaine...?

I always thought it was PRYlocaine, but then I heard some asshat call it PRILLocaine and wondered how small his junk was in SONOmeteres.
 
sigrhoillusion said:
The bigger question is do you pronounce it PRYlocaine or PRILLocaine...?

I always thought it was PRYlocaine, but then I heard some asshat call it PRILLocaine and wondered how small his junk was in SONOmeteres.
Click to expand...
I've only heard it pronounced pry locaine
 
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