Did my MOCA "practice performance assessment and improvement"

[pgg]

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So a while back in a thread about spinal doses, we were talking about optimal morphine doses spinal doses for c-sections, and whether or not using fentanyl in the spinal concoction makes any sense.

Periopdoc said he thought 0.1 mg morphine plain was as good or better than 15 mcg fentanyl + 0.2 mg morphine I'd been using, and I should try it because I and the patients would like it. Jeff05 mentioned that this would make a good MOCA project. A chance to prove periopdoc wrong about something for the first time, ever, and checking the MOCA box were all the motivation I needed, so I eventually got around to doing exactly that.

FOr those of you doing MOCA - one of the new requirements is to monitor your practice style, change something and see if it makes a difference (and write about it). This could be a really good project. Just start adding a little fent to your spinals.

mmhmm and when it doesn't make a difference can I write that up and get my MOCA checkbox checked? Does "tested it, didn't see a difference, what I am doing is working fine, so I am not changing my practice style" count?

🙂

Slightly superior pain control the entire first 24 hours, statistically significant after 16 hours. More PRN pain meds (Toradol and Percocet) needed in the group that got less IT morphine. No difference in side effects. Sample size was 40 consecutive patients.

I did write it up, and the result was "tested it, did see a difference, what I was doing was working fine, so I am not changing my practice style" ...

Box checked 😀 and I'm back to 15 mcg fentanyl + 0.2 mg morphine for everybody.

 

[BLADEMDA]

Nice job. Someone else can delete the Fentanyl and use 200 microgramns of Duramorph as one arm vs. keeping the Fentanyl plus Duramorph in the other.

 

[periopdoc]

Nice work.

- pod

 

[pgg]

Nice work.

- pod

Would've been better if I'd only changed one variable, but good enough for government MOCA work. 🙂

 

[Idiopathic]

love it, very nice

 

[sevoflurane]

Well done PGG.

I woulda thought that the .1mg of duramorph arm would have less pruritus. 😳

I'm still thinking .15mg duramorph + 10 mcgs of fent. though. 😉

Maybe I'll do my practice performance assesment with those doses and compare them to .2 mg duramorph and 15 mcg fent.

Although I know there are some IT fent haters out there...

Did you track .75% bupi doses? I'm guessing not.

Either way.

Nice work dawg!

 

[pgg]

Did you track .75% bupi doses? I'm guessing not.

12 mg for everyone. Since residency I've always given everybody 1.6 mL of the 0.75% hyperbaric bupiv in the kits. Tall or short, obese or not ...

As a resident sometimes I'd use more (or even do CSEs) for repeat sections when new interns/residents were operating and med students were closing.

 

[DrRobert]

I recall from residency that no benfefit was gained above 150 mcg, only more side effects. And I thought there was evidence to support it, but I'm too lazy to look it up now.

Anyway, I use 150 mcg Duramorph and 15 mcg Fentanyl for all my C-sections and have had anecdotal success in regards to pain control and side effects over the past couple years.

 

[dhb]

Good work 👍

 

[periopdoc]

I believe that my primary contention in that thread was that fentanyl adds nothing to a morphine/ bupi spinal except for increased side effects, although I did specifically encourage pgg to try 0.1 mg of IT morphine as a dose that would give similar results with fewer side effects to 0.2.

How about it Sevo, 10 or 15 vs 0 fent?

- pod

 

[Idiopathic]

i have excellent anecdotal results with 12.5 bupi/25 mcg clonidine/25 mcg fentanyl/0.1 mg duramorph but i havent looked at it in depth

 

[sevoflurane]

I believe that my primary contention in that thread was that fentanyl adds nothing to a morphine/ bupi spinal except for increased side effects, although I did specifically encourage pgg to try 0.1 mg of IT morphine as a dose that would give similar results with fewer side effects to 0.2.

How about it Sevo, 10 or 15 vs 0 fent?

- pod

🙄

hmmm... tempting.

🙂

 

[BLADEMDA]

12 mg for everyone. Since residency I've always given everybody 1.6 mL of the 0.75% hyperbaric bupiv in the kits. Tall or short, obese or not ...

As a resident sometimes I'd use more (or even do CSEs) for repeat sections when new interns/residents were operating and med students were closing.

I use 10mg for midgets and 13 for giants (6') with pretty much zero conversions to GA.

JPP used 15 mg a lot and the studies show Little risk of a high spinal but more hypotension.

If you add Fentanyl then you need less Bupivacaine. Since I don't add Fentanyl I prefer at least 11-12 mg for the average patient along with Duramorph 200 mics.

This isn't rocket science so if you like to add Fentanyl then 10 mg is probably enough for your patients.

 

[BLADEMDA]

http://www.biomedcentral.com/1471-2253/5/5


http://www.ncbi.nlm.nih.gov/pubmed/15477049

 

[BLADEMDA]

In conclusion, Intrathecal Fentanyl 12.5μg added

to 8mg bupivacaine enhances quality of intraoperative

analgesia, prolongs the duration of analgesia, without

affecting the newborn clinical status. It has no action on

onset of either sensory or motor block. There are no

side effects in our study probably because of low dose of

12.5μg of fentanyl


They used Bup 8mg plus Fentanyl in this study.

http://www.saarcjoa.org/vol1issue2/page142_145.pdf

 

[BLADEMDA]

So, why do I prefer 11-12 mg of Bup for my patients? Because Failure is not an option and low dose Bup increases the chance for failure.


http://www.ncbi.nlm.nih.gov/pubmed/21764820


This meta-analysis demonstrates that low-dose bupivacaine in spinal anaesthesia compromises anaesthetic efficacy (risk of analgesic supplementation: high grade of evidence), despite the benefit of lower maternal side-effects (hypotension, nausea/vomiting: moderate grade of evidence).

 

[dhb]

There is a difference EU vs US: i've never seen 0.75% bupi so i suppose most countries have the standard 0.5% so 8mg is 1.6ml. If i wanted to do 12.5 or 15mg spinals i'd be at 2.5 or 3ml without the opiate increasing the risk of a high spinal. Most people do 10mg (2cc) + opiate.

 

[periopdoc]

and, as I have responded to Blade in the past, (I think we are pretty close to agreement on this) sure, if you want to under-dose your spinal Bupi, you can get away with it if you add fentanyl supplementation. However, you are placing yourself at increased risk of failed block duration. If you are using an adequate dose of Bupi, I do not believe the addition of fentanyl gives you anything but side effects.

Who else is using isobaric Bupi?

- pod

 

[BLADEMDA]

There is a difference EU vs US: i've never seen 0.75% bupi so i suppose most countries have the standard 0.5% so 8mg is 1.6ml. If i wanted to do 12.5 or 15mg spinals i'd be at 2.5 or 3ml without the opiate increasing the risk of a high spinal. Most people do 10mg (2cc) + opiate.

That's fine. Good technique. Like I said if Fentanyl is added reduce the Bup. If no Fentanyl give a bit more.

Here is study looking at plain Bup 15mg. It works. More hypotension and nausea but it definitely works. For those adding Fentanyl you NEVER need 15 mg Bup unless she is 6'11".


http://www.mdlinx.com/obstetrics-gynecology/news-article.cfm/3903878/cesarean-section

 

[periopdoc]

I dose exactly like Blade does, but add 0.1 cc of Epi 1:1000 cause my OB's need the duration.

- pod

 

[BLADEMDA]

http://journals.lww.com/anesthesiol...m_Local_Analgesic_Dose_of_Intrathecal.25.aspx

Look at this study. If you decide to use Isobaric Bup I wouldn't go with less than 10 mg. I know there are published studies out there showing a lot less but FAILURE IS NOT AN OPTION so don't do it.

 

[BLADEMDA]

 

[BLADEMDA]

 

[periopdoc]

Iso or heavy, I use the same dose.

Just finished a day of Hips and Knees. All got 10 mg IT isobaric bupi then an LMA.

Great combo.

- pod

 

[BLADEMDA]

Iso or heavy, I use the same dose.

Just finished a day of Hips and Knees. All got 10 mg IT isobaric bupi then an LMA.

Great combo.

- pod

Isobaric lasts longer.

 

[Arch Guillotti]

Isobaric lasts longer.

I think so too.

 

[sevoflurane]

I use hyperbaric .75% bupi for spinals exclusively, cuz that's what we have up in OB. I don't do spinals for my joints. I'm a nerve block low flow LMA @ .5 mac kinda dude.

What .5% isobaric solution is being used?
I'm guessing you guys arent' diluting .75% bupi with sterile water. Regular .5% bupi for nerve blocks and fabricating your own kits or using a .5% bupi spinal kit?

I'm assuming both blocks are equally as dense.
Doesn't isobaric cause less hypotension? I think I remember reading that somewhere.

 

[BLADEMDA]

I use hyperbaric .75% bupi for spinals exclusively, cuz that's what we have up in OB. I don't do spinals for my joints. I'm a nerve block low flow LMA @ .5 mac kinda dude.

What .5% isobaric solution is being used?
I'm guessing you guys arent' diluting .75% bupi with sterile water. Regular .5% bupi for nerve blocks and fabricating your own kits or using a .5% bupi spinal kit?

I'm assuming both blocks are equally as dense.
Doesn't isobaric cause less hypotension? I think I remember reading that somewhere.

I just use the preservative free 0.5 percent Bupivacaine commonly found in most departments. The same stuff you do your blocks with. If you prefer 0.25 percent Bup works aso (4mls). Isobaric lasts longer and usually has less hypotension than hyperbaric Bupivacaine. The BP drop is dosage related as well.

 

[periopdoc]

Since I don't do nerve blocks for joints, I do spinal/ low flow LMA @ 0.5 MAC (I also don't like "sedation" or as I call it general anesthesia without airway control).

I use the PF 0.5 that comes out of the Pyxis and carries the same warning as the PF Chlorprocaine. I would use tetracaine powder if we could get it.

Lay the patient down, operative side up, drop in the spinal then go to sleep with LMA. If male then nurse puts foley in on side. If female, turn onto back for foley if necessary.

You get a great dense block on one side. When the patient wakes up they have full CMS of the "down" leg. It seems like there is less hypotension (theoretically because you are only blocking one leg), but you have to be vigilant to ensure that the block doesn't move up too high and give you profound bradycardia and hypotension.

Also a nice technique for surgery on a broken leg/ hip. You get the one sided spinal without having to lay them on the injured extremity.

- pod

 

[dhb]

Isobaric lasts longer.

I think you should say the block duration is longest at the point of maximal concentration: isobaric bupi will last longer at the dermatome of injection but if you do a saddle block with heavy bupivacaine it will last just as long.

 

[BLADEMDA]

I think you should say the block duration is longest at the point of maximal concentration: isobaric bupi will last longer at the dermatome of injection but if you do a saddle block with heavy bupivacaine it will last just as long.

Here is what I am saying. Simple. Easy. Basic. If you are doing a Total hip and want the patient to remain comfortable 10 mg of Isobaric Bupivacaine lasts longer than the same dosage in Hyperbaric form. The regression is slower so the patient doesn't require SEVO or massive doses of Propofol to stay on the table.

IMHO, those who are adding EPI to their hyperbaric Bup for Knees and HIPS can get by without the EPI by switching to ISOBARIC Bup. I've been using 12.5 mg of Isobaric Bup for our slow arse Ortho surgeons and getting 3 hours of surgical anesthesia. No epi is needed.

Even for re-dos taking 4-6 hours Isobaric Bup or Tetracaine (15-17.5 mg) really LASTS a long time. If you add Epi to the Tetracaine you are going to get a 6 hour surgical block. Your PACU nurses will curse your name.

 

[dhb]

If you are doing a Total hip and want the patient to remain comfortable 10 mg of Isobaric Bupivacaine lasts longer than the same dosage in Hyperbaric form.

Yes