Its been a while since there has been a thread like this, and I see some names I haven't before.
Did a fair number of spine cases as a resident and continue to do them now in pp. As a resident, we almost always used Remi, until my third year. It is very easy to do a case with remi, no movt, quick wake ups for neuro checks etc. But we found, anectdotely (sp?), that those pts were hurting and requiring a lot of post op narcotics (esp. the scoliosis/harrington rod cases). Then the article came out that essentially supported that intuition. So we stopped using it on backs, but continued with necks, who didn't seem to be complaining as much.
Interestingly, at the academic center, it was almost always just SSEPs and rarely MEPs, if anything. The reason we were using the Remi wasn't just to prevent movt without NMB, but for the quick wakeup at the end.
I forgot, we also used a fair amount to Dex depending on the attending. Some thought this helped to avoid mov't without NMB. Based on one horrifying incident after taking over a case at 7pm where I continued with the day's anesthetic plan that included Dex, I disagree.
Anyway, now in pp, most of the surgeons are requesting MEPs, thus no NMB, and, interestingly, they still don't want the pt to move 🙂. Well, the techs insist on no more than 0.5 mac of volatile. Whatever.
Prior to the propofol drought, my pp recipe was:
Lido, fent (MEP techs insist no BZD), 2mg of vec to soften them up for positioning/defasiculation, then Prop, succ tube.
Sevo at approx 1.2-1.4 ET
Prop at 100-200 depending on BIS
Phenylephrine gtt to maintain a good BP without flooding the pt with fluids so the face/eyes/tongue don't swell up.
Fent 3mcg/kg the first hour, and 2mcg/kg for each hour after--maybe a little more or less depending on the pt's gestalt
Hyperventilation to etco2 of about 30 to blunt respiratory drive.
Breathing spontaneously during closing, then pull the tube deep with an oral airway in place. Titrating narcotic for a comfortable emergence.
Less sexy than the academic setting with remi, dex, ketamine, tiva etc. but it works well. Surgeons and pts happy. And it is something I can tell an AA to do without getting eye-rolls and passive-aggressive behavior in return. The phenylephrine gtt pisses them off, apparently they don't see the value in maintaining good bps for several hours. What the heck? Like this is so much trouble to set up one drip?
Pt is typically awake, moving all 4 in under 5 minutes of going supine or neck brace on.
Just curious, you guys doing the remi, dex, ketamine etc., at academic or pvt settings?
I did all that stuff for years, and honestly the outcomes seem just as good without it. But what do I know? I rarely do my own post-ops anymore😉
PS,
Last week doing a case myself (not supervising that day) with no prop (still not avail!) and Sevo at about 1.4 ET, I ended up using 57mLs of fent on a 5 hour 4 level ACDF. I was chasing my tail wondering if it was merely htn or pain. But the BP really only responed to more fent, about 250mcg q 30-45 mins. That sucker breathed spontaneously at the end, woke up right on time, moved, slapped him with 5ml of prop, some versed and dilaudid and brought him to the SICU to leave the tube in overnight at the surgeon's request.
I was sweating wondering if he'd ever wakeup and warned the surgeon we may need to wait a while, but we didn't. Made me look good.
