anesthesia/post-op pain management case

[powermd]

30's male with ankylosing spondylitis and chronic severe pain (no other SPMH) treated with massive doses of methadone and oral dilaudid to have consecutive hip replacements a week apart. Patient has an intrathecal morphine pump (unsure what level the anchors sit in). Neck extension is poor, but pharynx is large and Mallampati 1, and likelihood of placing a spinal through his heavily ossified ligaments/fused vertebrae fair/poor. Given time to plan anesthesia and post-op pain mangement well, what would you choose to do?

I liked the idea of a fluroscopically guided CSE placement... what do you think?

 

[PainPhysicians]

30's male with ankylosing spondylitis and chronic severe pain (no other SPMH) treated with massive doses of methadone and oral dilaudid to consecutive hip replacements a week apart. Patient has an intrathecal morphine pump (unsure what level the anchors sit in). Neck extension is poor, but pharynx is large and Mallampati 1, and likelihood of placing a spinal through his heavily ossified ligaments/fused vertebrae fair/poor. Given time to plan anesthesia and post-op pain mangement well, what would you choose to do?

I liked the idea of a fluroscopically guided CSE placement... what do you think?

Fluoro guided CSE is a good choice but the epidural part may or may not work. Depending on how much of the epidural space is still intact, you may not get adequate spread. You could do a continuous spinal catheter though. You probably should remove it though within the first or second post op day to minimize chance of infection given he already has an ITP pump. Given he has had a lumbar fusion, you may want to try a continuous caudal infusion, however if there is really bad scar tissue, the LA may not get to the desired levels. Or just place a regular epidural above the lumbar fusion and pray the LA gets down to the levels you want. Another choice is a fluoroguided caudal that is guided up to the levels you want.

This doesnt sound like an easy case... at least post-operatively.

Let us know what you decide.

 

[Noyac]

I would probably avoid the epidural/spinal route. You could do a continuous Psoas compartment block and a GETA. I would not do a Psoas block on the side of the IT pump as it tunnels through the SQ space from the abdomen to the spine. I understand that you can guide it under flouro but why risk it. the last thing you want to do is hit or damage the catheter. Post-op just give him his usually daily pain meds and then start from there. I would consider a low dose ketamine PCA with Dilaudid.

 

[jetproppilot]

30's male with ankylosing spondylitis and chronic severe pain (no other SPMH) treated with massive doses of methadone and oral dilaudid to have consecutive hip replacements a week apart. Patient has an intrathecal morphine pump (unsure what level the anchors sit in). Neck extension is poor, but pharynx is large and Mallampati 1, and likelihood of placing a spinal through his heavily ossified ligaments/fused vertebrae fair/poor. Given time to plan anesthesia and post-op pain mangement well, what would you choose to do?

I liked the idea of a fluroscopically guided CSE placement... what do you think?

Paramedian approach with 22" SN, 15mg HB bupiv with a splash of epi, dex or propofol for intraop sedation.

If that doesnt work, lay him down, preoxygenate, propofol 200mg, LMA #4.

Great idea with fluoroscopically guided regional but the anesthetic will take longer to orchestrate than the case itself so is kinda impractical.

 

[militarymd]

LUmbar plexus block with marcaine....then go to sleep.

clonidine po 0.2 mg po tid post-op plus IVPCA.

 

[jetproppilot]

clonidine po 0.2 mg po tid post-op plus IVPCA.

agree.

Dilaudid PCA

concurrent with intrathecal pump

start with

demand dose .5mg
interval 10 min
continuous infusion 0
4 hour limit: 12mg

disclaimer: for entertainment only. Not intended for clinical use.

 

[jetproppilot]

agree.

Dilaudid PCA

concurrent with intrathecal pump

start with

demand dose .5mg
interval 10 min
continuous infusion 0
4 hour limit: 12mg

disclaimer: for entertainment only. Not intended for clinical use.

if supplementation needed, consider Duragesic patch.


disclaimer: for entertainment only. Not intended for clinical use.