Anesthesia for spinal surgery with evoked potential monitoring

[cfdavid]

Any tricks for a good anesthetic for spine surgery when SSEP's AND MEP's are being monitored?

I just started doing some neuro/spine cases and frankly I've gotten away with using both regular old iso/sevo with N20. My attending (on both days) suggested that doing things like running a remifentanyl infusion was unnecessary.

What do you guys do?

Do you run remifentanyl and keep MAC's at or below 0.5?

The Neuro-monitoring dude was kind of suprised that we were getting away with that, versus running remi which seems to be more commonplace.

Any input is greatly appreciated.

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[W222]

Propofol infusion, remi infusion, sevo/iso/des whatever. The monitoring guys here typically don't like nitrous where I am, so I don't use it except during the closure. The remi w/low sevo is probably my favorite; such a smooth wake-up. The propofol infusion is tough to time, typically you shut it off 30-45 mins before the flip and even then they may not wake up quickly if you gave them alot of narcs.

 

[psychbender]

I'm a fan of remi with half-MAC of iso (easy, fast, surgeons can get a good exam at the end), but I've also tried replacing the remi with sufenta, or going TIVA with propofol, sufenta, and ketamine. The last technique requires a bit more practice, timing when to stop each part of the infusion (or when to stop adding each ingredient to the propofol bottle). I'm looking forward to my neuro months, so I can experiment more with these and other techniques, as its been a bit since I've done a good spine.

 

[BLADEMDA]

CF David,

Your PM box is FULL. How about deleting a few messages so others such as myself can PM you?

 

[Idiopathic]

many threads on this topic. whatever keeps the patient asleep and still is acceptable, occasionally the neuromonitoring techs prefer no volateile with MEPS or <0.5 MAC with SSEPS, and I am happy to help them, often by adding IV agents like propofol/ketamine/lidocaine/remifentanil/sufentanil infusions, sometimes dexmedetomidine.

typically, for SSEPS only, I use 0.5 MAC iso in O2 with paralytic, ketamine infusion, and intermittent bolus fentanyl. for MEPS, I do TIVA with propofol/remifentanil/lidocaine infusions, adding ketamine for patients with more baseline pain, and a BIS.

 

[btbam]

Half mac of gas, prop infusion usually around 100 mcg/kg/min, fentanyl infusion 2 mcg/kg/hr, put a BIS on titrate as needed. My hospital is poor, so no remi but I'm sure that works just dandy for these.

 

[cchoukal]

I grew up doing dex, sufentanil, and a half-mac of des. I've also done them with just sevo and methadone. I have a friend in PP who just does sevo. I've been "complimented" twice by the neurophysiologist as a resident for a "great" anesthetic doing 70% nitrous and a boat-load of fentanyl. The moral of the story? I think it's all crap and you can do whatever you want.

 

[MTGas2B]

Propofol, remi, and dexmedetomidine. I use the dexmedetomidine to run my propofol lower. I like the wake up with dexmedetomidine on board. This is one of the few times I use a BIS.

 

[jwk]

Half mac of gas, prop infusion usually around 100 mcg/kg/min, fentanyl infusion 2 mcg/kg/hr, put a BIS on titrate as needed. My hospital is poor, so no remi but I'm sure that works just dandy for these.

Ditto, except my hospital isn't poor - we just consider dex and remi an unnecessary expense. We haven't had remi on formulary since about a year after it was released.

 

[jwk]

I grew up doing dex, sufentanil, and a half-mac of des. I've also done them with just sevo and methadone. I have a friend in PP who just does sevo. I've been "complimented" twice by the neurophysiologist as a resident for a "great" anesthetic doing 70% nitrous and a boat-load of fentanyl. The moral of the story? I think it's all crap and you can do whatever you want.

I often wonder this myself. As long as whatever signals they want to see are OK, it doesn't seem to matter much what we're using. I rarely have any of the neuro techs ask for me to change my settings.

 

[W222]

I would love to try the dex/remi technique but unfortunitely we don't have alot of access to dex, its reserved for certain cases and spines don't qualify.

 

[MTGas2B]

I would love to try the dex/remi technique but unfortunitely we don't have alot of access to dex, its reserved for certain cases and spines don't qualify.

That was the case at my old place. I can remember putting people on dex in the unit and everyday my pharmacist was telling me how much we're spending on it. At my current place we use it all the time for tons of stuff, and no one is concerned.

 

[jwk]

That was the case at my old place. I can remember putting people on dex in the unit and everyday my pharmacist was telling me how much we're spending on it. At my current place we use it all the time for tons of stuff, and no one is concerned.

They will be.

 

[fabfive5]

Our surgeon injects intrathecal clonidine and duramorph so we shy away from Precedex. It's only in the big scoliosis cases, but other cases I use Precedex like water with great results.

 

[cchoukal]

Our surgeon injects intrathecal clonidine and duramorph so we shy away from Precedex. It's only in the big scoliosis cases, but other cases I use Precedex like water with great results.

One of our locums guys does IT morphine before the case. I was surprised the surgeon doesn't seem to mind, and the patients (who are frequently on chronic opioid therapy and are a drag to keep comfortable post-op) seem to do pretty well.

 

[ssmallz]

Spines - Pt on chronic narcs get a shot of ketamine up front from me and I run Sufent w/0.5 mac of gas. The sufent hangs around and keeps em from waking up screaming.

You can toss in a prop drip if ya want but I haven't found that it makes much of a difference. Mostly I'd do it per attending request who were worried about recall in pts getting only 0.5mac of gas + narc. IMO it's over the top b/c if you are doing the technique right you only need to give paralytic for intubation and can let it wear off. Once it's warn off they will move way before they remember stuff and they don't move when you've got enough narcotic on board.

Heads - Remi + Des - wake up real quick and since the procedure isn't too painful they don't need much narcs at the end

 

[W222]

Is it just me or do people just wake up bonkers from Des? I may have said this before on here, but I have had more people take swings at me and go insane after Des than any other drug.

 

[cfdavid]

CF David,

Your PM box is FULL. How about deleting a few messages so others such as myself can PM you?

yo Blade. Sorry man. Cleaned out now.

Thanks for all the wonderful, insightful responses studs/studettes.

 

[MTGas2B]

They will be.

Doubt it. Its a teaching program and our chair wants our residents to be able to try out other agents. Plus, our thoracic guys love it. All of their post-op open hearts, on it, plus with their thoracotomies, they hate epidurals, sent them out on dex.

 

[fakin' the funk]

Half mac of gas, prop infusion usually around 100 mcg/kg/min, fentanyl infusion 2 mcg/kg/hr, put a BIS on titrate as needed. My hospital is poor, so no remi but I'm sure that works just dandy for these.

The way I've done it so far is very similar. Half MAC iso, half "MAC" propofol usually 100-125mcg/kg/min, either remi 0.2-0.5mcg/kg/min or fentanyl 2mcg/kg/h.

Neurophysiologists usually have EEG also which I titrate the propofol to (i.e. limit propofol as permitted by EEG), turn off propofol as soon as last evokes tested, go to 70% nitrous and do a nice nitrous-narcotic wakeup with just the tail of the iso on board.

 

[Idiopathic]

Is it just me or do people just wake up bonkers from Des? I may have said this before on here, but I have had more people take swings at me and go insane after Des than any other drug.

+1, hate it