Dosing for spinals

[Outrigger]

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Hi,

I'm new to the forum and am trying to get a feel for what others dose for their spinals for THA's, TKA's and C-sections. If you're outside the US, please mention that as well as there may be significant differences.

Please include drug name, concentration, hypo/hyper/iso and mg amount. Also include what narcotics you like to place.

As an example, for C-sections I dose
Bupivacaine 0.75%, hyperbaric, 13.5-15 mg (those 5'3" or under get the lesser amount). Fentanyl 10 mcg, morphine 0.3 mg.

 

[2ndyear]

You'll see a lot of variation based on surgeon and institution. In residency sections take two hours. Private practice 45 min. I usually go 12 mg of hyperbaric bupiv 10 mcg fent 0.2 morphine. Hips and knees vary by surgeon. We have some do a knee skin to skin in an hour. 12.5 bupiv is fine. Some hips take three hours and 15 mg is needed. I usually use isobaric for most eldery joints which seem to be our population mostly.

 

[Jay K]

I'll apologize for the presumption that you're up to no good, but since you're "new," have not identified who/what you are, your intentions for this information, where in the world YOU are, then I'd advise others in this forum not to reply to you.

Again, I apologize for the presumption, pessimism and paranoia, but in an anonymous online world where you haven't established your "identity" via posts or replies at the very least, it can be dangerous.

Of course, it's a free speech country (in the US).

 

[rsgillmd]

As 2ndyear said, it depends on the patient and the surgeon.

During residency:

C/S: Usually Bupivacaine 0.75% (hyperbaric) 1.3-1.4 ml (approx. 10 mg) + Fentanyl 15 mcg + Duramorph 0.2 mg

TKA: Usually Bupivacaine 0.5% (isobaric) 2.5 ml (12.5 mg) + Fentanyl 15 mcg. We usually used a nerve femoral block for post-op pain with PCA for breakthrough. Occasionally when we didn't do a block, we would give Duramorph 0.2 mg in the spinal. If we did a CSE then we would reduce the dose of Bupivacaine to 10 mg. Then on the rarer occasions, GA +/- block. Twice I used tetracaine (hyperbaric -- I had to mix the powder with the dextrose manually), of which once was with Epi wash. I forget the dose now -- I think it was 10 mg. The case with the Tetracaine + Epi wash was numb for many hours -- never did that again (but as a 1st year you listen to your attendings).

Current institution:

C/S: Usually doing a CSE because we have a more obese population and resident driven cases (even then rarely have to bolus the epidural but I gave up trying to convince the CRNAs). Duramorph is in its infancy -- it was a bureaucratic struggle for me to start it, even with the support of the OB physicians and nurses. Right now we are using Duramorph only in our preeclamptics because I know they will be observed for 24 hours. So the typical CRNA regimen is Bupivacaine 0.75% (hyperbaric) 1.4-1.6 ml + Fentanyl 25 mcg. If one of my colleagues, one of the more experienced CRNAs, or I do the spinal then they only get 7.5 mg of Bupivacaine (1 ml) -- by the time the residents get the patient ready there is already a block and little to no hypotension.

TKA: GA +/- block. They take way too long here -- again resident driven cases.

 

[rsgillmd]

I'll apologize for the presumption that you're up to no good, but since you're "new," have not identified who/what you are, your intentions for this information, where in the world YOU are, then I'd advise others in this forum not to reply to you.

Again, I apologize for the presumption, pessimism and paranoia, but in an anonymous online world where you haven't established your "identity" via posts or replies at the very least, it can be dangerous.

Of course, it's a free speech country (in the US).

Good point. I replied I guess as you were posting yours. As you and I know, there is a fair degree of variation anyway even in the same institution -- I used different doses with different attendings. Will obviously also vary on the case, the surgeon, and the patient. Even if Outrigger is a lawyer, I guarantee someone else will find an anesthesiologist who would say X dose is acceptable.

I looked at his post innocently because it was a confusing topic when I was a CA-1.

 

[Jay K]

Good point. I replied I guess as you were posting yours. As you and I know, there is a fair degree of variation anyway even in the same institution -- I used different doses with different attendings. Will obviously also vary on the case, the surgeon, and the patient. Even if Outrigger is a lawyer, I guarantee someone else will find an anesthesiologist who would say X dose is acceptable.

I looked at his post innocently because it was a confusing topic when I was a CA-1.

True and I really wanted to give [him] a benefit of a doubt and not this type of welcome for [his] initial post. Again, not to scare anyone new away and apologize for fostering any "negativity" in this forum.

 

[Outrigger]

I'm an MD just trying to get a feel for what everyone else out there is doing since there's so much variety and even the textbooks hedge on this topic. Modern textbooks will even promote fentanyl/N20 anesthesia which sounds like a cookbook for intraoperative awareness to me. If I was a lawyer, I can only imagine the look on the judge or the jury's face as I show him/them a printout of studentdoctor.net in order to defend or prosecute someone.

 

[Arch Guillotti]

old thread on spinals

 

[foshizzo]

C-section in a university hospital with slow OB residents, minimal OB attending involvement, not infrequent medical student closure:

2ml 0.75% bupiv + 15mcg fentanyl + 100mcg duramorph +/- 200mcg epinephrine

Usually get a nice T2 level to pinprick regardless of patient height. May need to go through several sticks of phenylephrine to maintain BPs.

Even with this the OB's don't always finish in time! 🙁

 

[OB1🤙]

Sounds like CSEs might be useful in that environment...

C-section in a university hospital with slow OB residents, minimal OB attending involvement, not infrequent medical student closure:

2ml 0.75% bupiv + 15mcg fentanyl + 100mcg duramorph +/- 200mcg epinephrine

Usually get a nice T2 level to pinprick regardless of patient height. May need to go through several sticks of phenylephrine to maintain BPs.

Even with this the OB's don't always finish in time! 🙁

 

[Idiopathic]

who still uses epi in spinals? i was under the impression that: a) it doesnt work, and b) it worsens your hypotension.

12-15mg heavy marcaine, 100mcg duramorph, 25mcg fentanyl here, get reliably 100+ minutes

 

[pgg]

who still uses epi in spinals?

Not I. Usually 1.6 mL 0.75% bupiv (12 mg) + 15 mcg fentanyl + 200 mcg morphine. If it's a primary or she's short I'll cheat toward 1.4 mL, but there aren't residents or med students operating/closing here.

 

[DRJ37]

20 mcg of clonidine added into your spinal can help extend your block for those S-L-O-W OB's (they're the majority at my institution). Also adds a little sedation for some of those anxious moms.