Case Discussion

[Echo33]

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Not a super sexy case but I'm interested to hear some thoughts on this everyday scenario.

70 year-old male for total hip arthroplasty in lateral position. Surgeon requesting spinal (as she does for every hip).
120kg (BMI 36)
History of lumbar spinal stenosis with chronic back pain (no surgical history)
OSA uses BiPAP nightly
HTN, HLD, no other major issues and no worrisome cardiopulmonary symptoms, stone cold normal EKG
Airway: Likely 2 person mask, should be easy glidescope.

FYI, surgeon is good and quick, approx 1 hour cut to close

What's your plan?

Thanks in advance

 

[shepardsun]

Lumbar spinal stenosis associated with (slightly) increased risk of neuraxial complications. Would discuss with surgeon and patient that association and weigh it against the potentially favorable airway benefits of neuraxial. If electing for spinal and OSA is severe, could consider use of high flow nasal cannula during the case.

 

[coffeebythelake]

I would do the spinal, maybe a lower dose than usual 15 mg of 0.5% bupi given the fast operation time.

 

[Urzuz]

Seems like a pretty standard case, what part are you concerned about?

I would just do a spinal and prob slip an LMA in.

 

[deleted171991]

Most likely won't need an LMA (with a spinal) in lateral position. Think colonoscopy.

Given that 15 mg of isobaric 0.5% bupi last about 3 hours, probably 7.5-10 would be enough.

This patient is an ASA 2 in my group. What are we missing, @Echo33, besides the need for a good consent?

 

[bellevueperson]

Spinal with 1.2-1.4 mL of hyperbaric bupi +/- fentanyl. Low-dose propofol vs. ketafol depending on how bad the back pain and OSA are.

 

[Echo33]

Most likely won't need an LMA (with a spinal) in lateral position. Think colonoscopy.

Given that 15 mg of isobaric 0.5% bupi last about 3 hours, probably 7.5-10 would be enough.

This patient is an ASA 2 in my group. What are we missing, @Echo33, besides the need for a good consent?

Thanks for the responses.

I should clarify that I work in ACT model and cover 3-4 rooms. These seem like standard cases (they are) but my daily concerns are:

Surgeon expects timely start, maybe even at the expense of the spinal. He does A LOT of cases. Large guy with spinal stenosis, should I bother poking? After all, other rooms to start within close time. My spinals typically take all but 1-2 minutes but these seem to be the guys that can sneak up on you and give you hell.

I’ve got to rely on the CRNA getting this large guy in a good piston and not over sedating him, since I’m often out gettin the next case started. No problem with experienced CRNAs. But what about a newbie?

This is more just a discussion of what everyone’s typical approach would be in the context of their setup. Keeping the “routine” cases of out trouble

Thanks again

 

[ethilo]

Spinal with 1.2-1.4 mL of hyperbaric bupi +/- fentanyl. Low-dose propofol vs. ketafol depending on how bad the back pain and OSA are.

Probably just being nit-picky and sharing my personal preference, but I don't do hyperbaric spinals in patients that are positioned lateral decubitus for surgery, ever since watching the glass spine video on YouTube.

 

[coffeebythelake]

Thanks for the responses.

I should clarify that I work in ACT model and cover 3-4 rooms. These seem like standard cases (they are) but my daily concerns are:

Surgeon expects timely start, maybe even at the expense of the spinal. He does A LOT of cases. Large guy with spinal stenosis, should I bother poking? After all, other rooms to start within close time. My spinals typically take all but 1-2 minutes but these seem to be the guys that can sneak up on you and give you hell.

I’ve got to rely on the CRNA getting this large guy in a good piston and not over sedating him, since I’m often out gettin the next case started. No problem with experienced CRNAs. But what about a newbie?

This is more just a discussion of what everyone’s typical approach would be in the context of their setup. Keeping the “routine” cases of out trouble

Thanks again

if sedation overdone
oral airway saves the day
no need for LMA

 

[bellevueperson]

Probably just being nit-picky and sharing my personal preference, but I don't do hyperbaric spinals in patients that are positioned lateral decubitus for surgery, ever since watching the glass spine video on YouTube.

I've also seen that video. If it's a broken hip, we'll stun with propofol and turn to the operative/broken side for a hyperbaric spinal and leave them in that position for a few minutes after the block is in. Works great. Isobaric works, too, since that's what I used in residency.

 

[Urzuz]

Not a super sexy case but I'm interested to hear some thoughts on this everyday scenario.

70 year-old male for total hip arthroplasty in lateral position. Surgeon requesting spinal (as she does for every hip).
120kg (BMI 36)
History of lumbar spinal stenosis with chronic back pain (no surgical history)
OSA uses BiPAP nightly
HTN, HLD, no other major issues and no worrisome cardiopulmonary symptoms, stone cold normal EKG
Airway: Likely 2 person mask, should be easy glidescope.

FYI, surgeon is good and quick, approx 1 hour cut to close

What's your plan?

Thanks in advance

Most likely won't need an LMA (with a spinal) in lateral position. Think colonoscopy.

Given that 15 mg of isobaric 0.5% bupi last about 3 hours, probably 7.5-10 would be enough.

This patient is an ASA 2 in my group. What are we missing, @Echo33, besides the need for a good consent?

if sedation overdone
oral airway saves the day
no need for LMA

I’ve discussed this with people on here before ad nauseam, but especially for sleep apnea patients who are having hips, IMO, an LMA makes your life easier with little to no downside. I usually still run a TIVA with straight propofol to further decrease risk of PONV. Furthermore it provides a safeguard against weird stuff happening (eg: we had a batch of bad bupivacaine a couple months back that was wearing off quickly despite easy placements).

I agree it is still easy to do with a face mask though and an equally viable/safe option.

 

[jwk]

Not a super sexy case but I'm interested to hear some thoughts on this everyday scenario.

70 year-old male for total hip arthroplasty in lateral position. Surgeon requesting spinal (as she does for every hip).
120kg (BMI 36)
History of lumbar spinal stenosis with chronic back pain (no surgical history)
OSA uses BiPAP nightly
HTN, HLD, no other major issues and no worrisome cardiopulmonary symptoms, stone cold normal EKG
Airway: Likely 2 person mask, should be easy glidescope.

FYI, surgeon is good and quick, approx 1 hour cut to close

What's your plan?

Thanks in advance

Pretty common case in our shop.

SAB with mepivicaine 1.5%, 3-3.5ml - small doze of midaz for the spinal (we do it in pre-op with the anesthetist present, who can then move the pt to the OR when they're ready).
Ketamine 0.25mg/kg, IV acetaminophen 1000mg, dexamethasone 0.15mg/kg
Low dose propofol infusion - 20-40mcg/kg/min, more if tolerated or needed
Nasal O2 vs NRB vs new nasal CPAP thingy (can't remember the brand name).

GA always an option, possible to slide in LMA on their side if problem during the case.

Our ace ortho brings >120 total joints a month to us - but we do what's best for the patient, period. He already knows we bust our asses to get his cases done. If it takes a few extra minutes for blocks, spinal, or conversion to general, it is what it is.

 

[LineAndBerry]

Hypobaric tetracaine 1cc, 10mg with equal volume CSF; position bad hip up from the start. Position --> spinal --> prep -->cut without any positioning delays. Onset time and duration same as bupiva. Epidural like segmental block that preserves BP well in frail elderly patients. Old school (I learned this from a Penn grad in 1980's) but I've not seen a better spinal choice in these patients.

 

[TheLoneWolf]

Second the tetracaine spinal.

 

[MoMoGesiologist]

Pretty common case in our shop.

SAB with mepivicaine 1.5%, 3-3.5ml - small doze of midaz for the spinal (we do it in pre-op with the anesthetist present, who can then move the pt to the OR when they're ready).
Ketamine 0.25mg/kg, IV acetaminophen 1000mg, dexamethasone 0.15mg/kg
Low dose propofol infusion - 20-40mcg/kg/min, more if tolerated or needed
Nasal O2 vs NRB vs new nasal CPAP thingy (can't remember the brand name).

GA always an option, possible to slide in LMA on their side if problem during the case.

Our ace ortho brings >120 total joints a month to us - but we do what's best for the patient, period. He already knows we bust our asses to get his cases done. If it takes a few extra minutes for blocks, spinal, or conversion to general, it is what it is.

How long does this mepiv spinal last?

 

[jwk]

How long does this mepiv spinal last?

A couple good hours, long enough for our fast guys. The slower ones get bupivicaine.

 

[deleted162650]

SAB with mepivicaine 1.5%, 3-3.5ml

Any TNS reports with the Mepi? The literature says same incidence as Lido, but I’m curious to know what the real world experience is.