Anestheeeesher is fun!

[epidural man]

Between chronic pain service and acute pain service, I don't get to spend a lot of time doing anesthesia. Sometimes because I don't do it exclusively, I don't feel as adroit as I was when I did it everyday all day.

But yesterday it reminded me why I love it and how fun it can be. Don't know why...it just was that kind of day.

For one, I think a spinal is such a great anesthetic - did some yesterday, some with 2-cholorprocaine.

Then had a sick SBO, old lady - who looks like a champ today - probably from my intraop ketamine and lidocaine infusions, and post-op epidural. I should have done intraop methadone, that has been great when I have used that.

Also did some general surgery cases that were just bread and butter stuff - lap chole for example.

Anyway, I left work with a smile. (Not that when I have to deal with the 23 y/o who 'lost his oxycontin' for the third time...its not as if those days make me smile as well...)

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[Jeff05]

I do acute/chronic/office/procedures/administrative stuff/education/research. Being back in the OR about 5 days/month and OB/gen calls are really needed to maintain skills.

I also love doing anesthesia when I go back to the OR.

Between chronic pain service and acute pain service, I don't get to spend a lot of time doing anesthesia. Sometimes because I don't do it exclusively, I don't feel as adroit as I was when I did it everyday all day.

But yesterday it reminded me why I love it and how fun it can be. Don't know why...it just was that kind of day.

For one, I think a spinal is such a great anesthetic - did some yesterday, some with 2-cholorprocaine.

Then had a sick SBO, old lady - who looks like a champ today - probably from my intraop ketamine and lidocaine infusions, and post-op epidural. I should have done intraop methadone, that has been great when I have used that.

Also did some general surgery cases that were just bread and butter stuff - lap chole for example.

Anyway, I left work with a smile. (Not that when I have to deal with the 23 y/o who 'lost his oxycontin' for the third time...its not as if those days make me smile as well...)

 

[jetproppilot]

Between chronic pain service and acute pain service, I don't get to spend a lot of time doing anesthesia. Sometimes because I don't do it exclusively, I don't feel as adroit as I was when I did it everyday all day.

But yesterday it reminded me why I love it and how fun it can be. Don't know why...it just was that kind of day.

For one, I think a spinal is such a great anesthetic - did some yesterday, some with 2-cholorprocaine.

Then had a sick SBO, old lady - who looks like a champ today - probably from my intraop ketamine and lidocaine infusions, and post-op epidural. I should have done intraop methadone, that has been great when I have used that.

Also did some general surgery cases that were just bread and butter stuff - lap chole for example.

Anyway, I left work with a smile. (Not that when I have to deal with the 23 y/o who 'lost his oxycontin' for the third time...its not as if those days make me smile as well...)

Nicely said.

Enjoyed reading that.

Thanks for sharing, dude.

Reenforces why (how) I somehow for whatever reason spontaneously awaken a few minutes before my 0510 alarm is set

I know the answer....wait for it....wait for it....

I love my job.

All you Yale economics professors out there

Try and put a price tag on that.

 

[Coastie]

Between chronic pain service and acute pain service, I don't get to spend a lot of time doing anesthesia. Sometimes because I don't do it exclusively, I don't feel as adroit as I was when I did it everyday all day.

But yesterday it reminded me why I love it and how fun it can be. Don't know why...it just was that kind of day.

For one, I think a spinal is such a great anesthetic - did some yesterday, some with 2-cholorprocaine.

Then had a sick SBO, old lady - who looks like a champ today - probably from my intraop ketamine and lidocaine infusions, and post-op epidural. I should have done intraop methadone, that has been great when I have used that.

Also did some general surgery cases that were just bread and butter stuff - lap chole for example.

Anyway, I left work with a smile. (Not that when I have to deal with the 23 y/o who 'lost his oxycontin' for the third time...its not as if those days make me smile as well...)

Talk to us about intraop lidocaine infusions...you use them for pain control?

 

[cfdavid]

A newly minted CA1 here, but I can honestly say I love this job. Almost every day, I leave work with a sense of accomplishment. We all gamble to some extent when choosing a specialty. There's only so much you can ascertain from a couple months of electives in med school and some shadowing....

This forum really helped me make the decision to enter the field. Lots of dudes with passion for the "biz" and that's contagious.

As to the OP, this gig is FUN indeed!

 

[Dhanwanthari]

I use these (lidocaine infusions) as well. Have done several narcotic free anesthetics for my BMI>45 patients w/ known OSA patients having abdominal procedures. The volatile agent alone at subanesthetic doses relaxes the muscles of the upper airway.

Des or Sevo, +IV tylenol, toradol, low dose ketamine bolus up front, lidocaine infusion... continued in pacu 2mg/kg/h w/ 1 to 1.5mg/kg bolus up front.

If they've got active chronic pain issues... I swap out half of my volatile for propofol gtt. (volatile=hyperalgesic).

As for lidocaine infusions:

From this year, comparing post op analgesia w/ epidural v. lidocaine infusion for abdominal surgery (systemic local).

http://www.ncbi.nlm.nih.gov/pubmed/21519309

Systematic Review of RCT's from 2010:

http://www.ncbi.nlm.nih.gov/pubmed/20518581

"Administration of intravenous lidocaine infusion did not result in toxicity or clinically significant adverse events. Lidocaine had no impact on postoperative analgesia in patients undergoing tonsillectomy, total hip arthroplasty or coronary artery bypass surgery. In conclusion, intravenous lidocaine infusion in the perioperative period is safe and has clear advantages in patients undergoing abdominal surgery. Patients receiving lidocaine infusion had lower pain scores, reduced postoperative analgesic requirements and decreased intraoperative anaesthetic requirements, as well as faster return of bowel function and decreased length of hospital stay. "

And I love this gig...


If I didn't, I wouldn't spend part of my Saturday off on pubmed and SDN.

 

[imfrankie]

Between chronic pain service and acute pain service, I don't get to spend a lot of time doing anesthesia. Sometimes because I don't do it exclusively, I don't feel as adroit as I was when I did it everyday all day.

But yesterday it reminded me why I love it and how fun it can be. Don't know why...it just was that kind of day.

For one, I think a spinal is such a great anesthetic - did some yesterday, some with 2-cholorprocaine.

Then had a sick SBO, old lady - who looks like a champ today - probably from my intraop ketamine and lidocaine infusions, and post-op epidural. I should have done intraop methadone, that has been great when I have used that.



Also did some general surgery cases that were just bread and butter stuff - lap chole for example.

Anyway, I left work with a smile. (Not that when I have to deal with the 23 y/o who 'lost his oxycontin' for the third time...its not as if those days make me smile as well...)

It is fun work. And for me nothing like, "thanks for taking such good care of me doc."

 

[epidural man]

We all gamble to some extent when choosing a specialty. There's only so much you can ascertain from a couple months of electives in med school and some shadowing....

Ain't that the truth. I talked my younger bro into following me into anesthesia - and then my sister was SOOOO bent on going into medicine because she wanted to do critical care. I spent sooo much time bending her ear, and she was a tough sell, but she eventually caved and did it - doing residency now and has a ICU fellowship lined up. She did medicine internship, and during that, every time I was able to talk to her, she thanked me for talking her out of doing medicine.

It's tough to know what to do...and to figure it out.

By the way, I tried to tell them both to not go to medical school and become a dentist. (Not that I don't love it all, but that was when I was in the middle of all the training, 1000 years into it, and looked at the life and money dentists had - and only after 4 post grad years).

 

[epidural man]

I am buying off on the idea that we should try to minimize intraoperative opioid - there is data about the acute tolerance that develops, so the more opioid you use intraop, the more they require post op. Also, all the retrospective data on cancer surgery (essentially less opioid intraop = less reoccurance of cancer) is compelling.

The review article above is a good start. It doesn't seem to do much for ortho cases, and for same day surgery, probably not a big difference either. However, that being said, I use it for most everything because it is so simple to do, so little downside, and really smoothes the anesthetic and wake up.

A lot of the studies run the infusion post op - anywhere from 4 hrs to 24 hrs. I never do. I extubate, and turn it off - mostly because I don't know how to write the order in our computer system for the infusion in the PACU

For dosing, I run the dose up until I obtain seizure activity, then I back off some.

 

[cfdavid]

Ain't that the truth. I talked my younger bro into following me into anesthesia - and then my sister was SOOOO bent on going into medicine because she wanted to do critical care. I spent sooo much time bending her ear, and she was a tough sell, but she eventually caved and did it - doing residency now and has a ICU fellowship lined up. She did medicine internship, and during that, every time I was able to talk to her, she thanked me for talking her out of doing medicine.

It's tough to know what to do...and to figure it out.

By the way, I tried to tell them both to not go to medical school and become a dentist. (Not that I don't love it all, but that was when I was in the middle of all the training, 1000 years into it, and looked at the life and money dentists had - and only after 4 post grad years).

Just about every day last year, I reflected on how glad I didn't choose medicine (would have been my second choice if pressed). Now, I FULLY realize what a great choice I made.

 

[checkov]

Just about every day last year, I reflected on how glad I didn't choose medicine (would have been my second choice if pressed). Now, I FULLY realize what a great choice I made.

Amen. CA-1 rocks the socks out of intern year. No more pages for colace and senna makes me a happy soldier.

 

[Arch Guillotti]

Then had a sick SBO, old lady - who looks like a champ today - probably from my intraop ketamine and lidocaine infusions, and post-op epidural. I should have done intraop methadone, that has been great when I have used that.

Did you do the TEA before or after the case?

 

[epidural man]

Did you do the TEA before or after the case?

After in the PACU. I was in a hurry and didn't want to spend the time before the case. I am usually quick and I don't think anyone in my group has anything over me as far as my ability to get them in, but sometimes they take a long time, no matter how good you are. In the end, it worked out well...ran 20th or 10th percent bupivicaine (can't remember...) which is 0.05 or 0.1, with 10mcg/cc of hydromorphone.

Had I put it in before hand, I would have used that instead of the lidocaine infusion.

 

[proman]

I am buying off on the idea that we should try to minimize intraoperative opioid - there is data about the acute tolerance that develops, so the more opioid you use intraop, the more they require post op. Also, all the retrospective data on cancer surgery (essentially less opioid intraop = less reoccurance of cancer) is compelling.

The review article above is a good start. It doesn't seem to do much for ortho cases, and for same day surgery, probably not a big difference either. However, that being said, I use it for most everything because it is so simple to do, so little downside, and really smoothes the anesthetic and wake up.

A lot of the studies run the infusion post op - anywhere from 4 hrs to 24 hrs. I never do. I extubate, and turn it off - mostly because I don't know how to write the order in our computer system for the infusion in the PACU

For dosing, I run the dose up until I obtain seizure activity, then I back off some.

I agree with you completely. Methadone is probably ok. Most anesthesiologists think we are nuts. I've never done a lidocaine infusion for pain but will have to read more about it. As an attending told me, esmolol is my favorite opioid.

 

[dhb]

I agree with you completely. Methadone is probably ok. Most anesthesiologists think we are nuts. I've never done a lidocaine infusion for pain but will have to read more about it. As an attending told me, esmolol is my favorite opioid.

I also agree, the more experienced i get the less opioids i use: rarely more than 10mcg of sufenta.
I like to give 2g Mg2+, 50mg of K and 150mcg of clonidine on induction then a lidocaine infusion if there isn't some kind of block involved, iv acetaminophen, nsaids some more K and the case is over.

 

[baller71457]

I agree with you completely. Methadone is probably ok. Most anesthesiologists think we are nuts. I've never done a lidocaine infusion for pain but will have to read more about it. As an attending told me, esmolol is my favorite opioid.

How do the pts do post op?

 

[proman]

How do the pts do post op?

They seem just fine. More awake, comfortable. I do give opioid, just at the beginning and end of cases. I also don't dose opioid by toxic effect (hypercarbia, bradypnea). That approach leads to much lower total doses.

 

[sevo85288]

I also agree, the more experienced i get the less opioids i use: rarely more than 10mcg of sufenta.
I like to give 2g Mg2+, 50mg of K and 150mcg of clonidine on induction then a lidocaine infusion if there isn't some kind of block involved, iv acetaminophen, nsaids some more K and the case is over.

Where/how do you get IV clonidine?
Thanks

 

[Bertelman]

Where/how do you get IV clonidine?
Thanks

He gets it in Belgium.

In the states, I would get it from the pharmacy. Used it for epidural boluses, but I imagine you could push it IV. FDA says it is approved for epidural infusion, so I guess this would be an off-label use.

Or you could just use dex.

 

[epidural man]

Where/how do you get IV clonidine?
Thanks

IV clonidine - just use the epidural formula if you dare.

However, be aware - there are case reports of serious and dramatic cases of hypertension with it - i think mostly in kids and probably in too large of doses. Case series have been done with it IV as well. I bet like anything, it is pretty safe if you do it correctly - who knows.

I have done it twice, but probably won't do it again anytime soon. I loved the effects when I used it though - helluva smooth anesthetic.

I have used intranasal precedex a bunch. That seems to work about the same - and a lot easier than setting up an infusion.

100 mcg each nostril after intubation.

 

[dhb]

However, be aware - there are case reports of serious and dramatic cases of hypertension with it.

Hyper ot hypo?

Hypertension typically occurs early due to the peripheral effect kicking in before the central effect. Usually mild and short lasting.
Hypo othh is fairly common like systolic in the 80's but patients rarely complain. doesn't occur in hypertensive patients.

Funny you can use it for epidurals but not iv.
Btw i love to give an epidural bolus (generally 150mcg) when i have patients complaining of "the spot" in the pelvis or sacrum which i believe to be caused by compression from the baby's head.

 

[sevoflurane]

I've used tons of IV clonidine.

It's another great drug... especially for that HTNive, Tachy 22 y/o for ORIF of whatever.

50-100mcs for a 2 hour case.

 

[sevoflurane]

Love anesthesia BTW.... I don't know if I'd even be in medicine if I wasn't in this specialty (maybe oral surgeon or interventional radiologist... but these are a far 2nd choice... not even close to the fulfillment I get with anesthesia).

Freag'n great specialty. I'm blessed.

 

[epidural man]

Hyper ot hypo?

Hypertension typically occurs early due to the peripheral effect kicking in before the central effect. Usually mild and short lasting.
Hypo othh is fairly common like systolic in the 80's but patients rarely complain. doesn't occur in hypertensive patients.

Funny you can use it for epidurals but not iv.
Btw i love to give an epidural bolus (generally 150mcg) when i have patients complaining of "the spot" in the pelvis or sacrum which i believe to be caused by compression from the baby's head.

HyPERertension. A guy in my department told me about it after I told him I used it IV - he really freaked me out and showed me some case reports.

However, like I said, it may not be a big deal - I shouldn't base my practice on a few case reports.

It sounds like sevo has used it a lot with no problems.

 

[Lightwand]

I use IV Clonidine all the time. Intra-op for chronic pain patients to try and hit another receptor. I also use it as Sevo said for the young, wild guys. It tends to make for a much smoother wake-up than without it.

I've also given it in the PACU for people that are super squirrely, or chronic pain patients that can't quite get comfortable and also happen to be hypertensive. Works quite nicely.



I haven't seen the hypertension, but maybe I just haven't given it enough to see that.

 

[silvester78]

I've used tons of IV clonidine.

me too!!
Every anxious tachycardic young patient gets 150 mcg clonidine IV deliverd throughout the case. They all wake up very smoothly.
I also use intrathecal clonidine when I want to prolong the effects of a single shot spinal. Just 30 mcg's added to levobupivacaine work fine. It also reduces post op analgesics

I also LOVE ANESTHESIOLOGY!!!!
does a good ischemic myocardial preconditioning!!!

 

[dhb]

me too!!

I also use intrathecal clonidine when I want to prolong the effects of a single shot spinal. Just 30 mcg's added to levobupivacaine work fine. It also reduces post op analgesics

Yes, i almost don't use intrathecal opiods anymore, clonidine is better imho less itching less paperwork etc..