Epidural Clonidine

[sevoflurane]

Any body routinely use epidural clonidine? Why or why not? Do you add narcs to your solution? I'm thinking of trying some out in my patients. I know it's not ideal for chronic pain... but for THA or VATS or even labor?

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[dhb]

Any body routinely use epidural clonidine? Why or why not? Do you add narcs to your solution? I'm thinking of trying some out in my patients. I know it's not ideal for chronic pain... but for THA or VATS or even labor?

More hypotension in labor epidurals apparently

 

[sevoflurane]

So... I'm in the middle of a R. THA:

2 midaz, 100 fentanyl in holding. 2L of crystalloids + antibiosis and 2g of Mag. 50 mg of ketamine into 1rst liter.
Lumbar epidural: 7cc of .5% bupivicaine after negative test dose. T10 level bilateral. Followed that with 75mcg of clonidine bolus (.1mcg/kg). Then .25% bupivicaine with 3.3 mcg/ml fentanyl at 7.5 cc/hr.


Pre-op BP 117/64

Intra-op: Tube, MAC = .5

deliberate hypotension 85/60's. I think it's the clonidine not sure....

So far so good. I suspect she will wake up very comfortable.

 

[Planktonmd]

So... I'm in the middle of a R. THA:

2 midaz, 100 fentanyl in holding. 2L of crystalloids + antibiosis and 2g of Mag. 50 mg of ketamine into 1rst liter.
Lumbar epidural: 7cc of .5% bupivicaine after negative test dose. T10 level bilateral. Followed that with 75mcg of clonidine bolus (.1mcg/kg). Then .25% bupivicaine with 3.3 mcg/ml fentanyl at 7.5 cc/hr.


Pre-op BP 117/64

Intra-op: Tube, MAC = .5

deliberate hypotension 85/60's. I think it's the clonidine not sure....

So far so good. I suspect she will wake up very comfortable.

May I ask you why you needed to combine GA with your ultra fancy epidural anesthetic?
This is the kind of patient I do several times a day with a single shot marcaine spinal with a little astramorph and they do great
Maybe I should start using: Midazolam, Fentanyl,Ketamine, Magnesium, IV and a Marcaine/Fentanyl/Clonidine epidural with GA and ETT
Did you say that you are doing the case and browsing the internet at the same time?

 

[Noyac]

So... I'm in the middle of a R. THA:

2 midaz, 100 fentanyl in holding. 2L of crystalloids + antibiosis and 2g of Mag. 50 mg of ketamine into 1rst liter.
Lumbar epidural: 7cc of .5% bupivicaine after negative test dose. T10 level bilateral. Followed that with 75mcg of clonidine bolus (.1mcg/kg). Then .25% bupivicaine with 3.3 mcg/ml fentanyl at 7.5 cc/hr.


Pre-op BP 117/64

Intra-op: Tube, MAC = .5

deliberate hypotension 85/60's. I think it's the clonidine not sure....

So far so good. I suspect she will wake up very comfortable.

Well as you know, if you post your technique you will get questions and opinions. I was wondering where you got your MG/Ketamine in the IV bag technique? Also, do your surgeons start coumadin or lovenox post-op and if so when do you pull your epidural?

My technique is, spinal with marcaine and duramorph or dilaudid. +/- GA depending on the surgeon. If the surgeon is slow, I get tired of babysitting the pt and they get tired of lying on one side for 3hrs. I will frequently put 2gm Mg in the 1st bag with about 150-200 mg Ketamine. I don't want to mess with anticoagulants and epidural catheters so I use a spinal and it gives at least 24hrs good pain control with the MS and longer with dilaudid. Thats all that is needed really at my facility. I do applaud your technique. It is creative (another word for fancy).

 

[sevoflurane]

Last 15 minutes of the case with .1 of ISO and 2/1 O2/N2O. 4mg of Duramorph and then I pulled her epidural. She was breathing on her own with RR of 10 and TV 400. 100 % O2 after last stictch. Lateral to supine and then pulled the tape from her eyes. Whispered her name, she opened her eyes and pulled the tube. No bucking. NC and to PACU. Pain 0/10. Vitals: 107/50, HR 62, 100%, RR12, temp 36.7.

The reason I chose this "fancy anesthetic" is because I'm in residency. You really don't know about how different drugs work unless you try them out and develop your own understanding of them. Clonidine duration of action is 4-6 hours. Duramorph will hang around longer ( up to 24 hrs). Synergism for pain relief? I don't know, but I will see her before I leave today. Ketamine has a half-life of 2.5 hours and is potentiated with magnesium. Marked reduction in post-op narcotics.

Additionally, at my institution everyone who gets an epidural or peripheral nerve block gets 1200 of gabapentin, 1000 tylenol and 400 of colecoxib. We have a regional guru at our institution. His mentality is that pain is a multi receptor process so.... try and block them all- opiod, nmda, gaba, etc...

Mg/ketamine in the bag technique I first heard from other residents... then I mentioned it to the regional attending and he was alright with it (he usually will do all his cases with block + ketafol). The reason I gave Mag and ketamine into the same bag is because of potentiation. 50mg before a 3 hour case will not delay your awakaning- at least not in my experience.

Anticoagulation is attending dependant. This particular one received her first dose of coumadin last night.

I freakin' love this job! Very gratifying. Questions and comments welcome. I'm always up for new Ideas.

 

[sevoflurane]

Oh yeah... I also give everybody 8mg of decadron not just for cheap anti-emesis but also for anti-inflamatory effect.

Noy... how's your board treating you? I'm heading out to summit county for vaca. April ridin' baby!. Will be staying at keystone village. Been out about 25 X on my wana be hill and am so ready for the real deal. Oh yeah... tool is back on tour- you should try and catch them this time around.

I wonder what vail hospital does for their ortho cases?

 

[dhb]

Anticoagulation is attending dependant. This particular one received her first dose of coumadin last night.

Wow coumadin for short term anti-coagulation never heard of that before are they briged until it's effective?

 

[Noyac]

yeah, a few surgeons still use coumadin for DVT prophylaxis.

 

[Noyac]

Oh yeah... I also give everybody 8mg of decadron not just for cheap anti-emesis but also for anti-inflamatory effect.

Noy... how's your board treating you? I'm heading out to summit county for vaca. April ridin' baby!. Will be staying at keystone village. Been out about 25 X on my wana be hill and am so ready for the real deal. Oh yeah... tool is back on tour- you should try and catch them this time around.

I wonder what vail hospital does for their ortho cases?

Dude, you better pray for some cold weather and alot more snow. Historically, March is a good month and April is almost as good. Right now, the snow here is pretty bare. Its still good for the spring breakers who don't know the difference. But I'm not riding it until we get some more good dumps. As far as the board goes, I love it.
And I heard that Danny Carey torn his biceps. I have tickets to see TOOL in Albuquerque on the 23rd but I don't know if the tour is on hold or not.

 

[Noyac]

As far as the epidural vs intrathecal duramorph, I find that the epidurally administered duramorph doesn't last nearly as long as intrathecal. Let me know what you experience.

 

[sevoflurane]

Dude, you better pray for some cold weather and alot more snow. Historically, March is a good month and April is almost as good. Right now, the snow here is pretty bare. Its still good for the spring breakers who don't know the difference. But I'm not riding it until we get some more good dumps. As far as the board goes, I love it.
And I heard that Danny Carey torn his biceps. I have tickets to see TOOL in Albuquerque on the 23rd but I don't know if the tour is on hold or not.

I was having a good day!

 

[dhb]

yeah, a few surgeons still use coumadin for DVT prophylaxis.

When you start coumadin you actually have a pro-coagulable state because of protein C and S inhibition can occur before II VII etc.. so you usually have to bridge the gap with LMWH do they take that into account or do they just go with coumadin only?

 

[TheSandMan]

Mg/ketamine in the bag technique I first heard from other residents... then I mentioned it to the regional attending and he was alright with it (he usually will do all his cases with block + ketafol). The reason I gave Mag and ketamine into the same bag is because of potentiation. 50mg before a 3 hour case will not delay your awakaning- at least not in my experience.

Nice smooth case man. I agree with you, now is the time to play around with all these meds.
Could someone please explain the ketamine/ mag comination. never heard of it before.

 

[TheSandMan]

When you start coumadin you actually have a pro-coagulable state because of protein C and S inhibition can occur before II VII etc.. so you usually have to bridge the gap with LMWH do they take that into account or do they just go with coumadin only?

though this is a theoretical risk, dont think it is really clinically relevant unless patients have a protein C deficiency to begin with. Most internal medicine docs will start coumadin without heparin bridge unless there is a past history or family history of hypercoaguability.

 

[Noyac]

Nice smooth case man. I agree with you, now is the time to play around with all these meds.
Could someone please explain the ketamine/ mag comination. never heard of it before.

NMDA antagonist.

 

[TheSandMan]

NMDA antagonist.

Thanks Noy. knew about ketamine's effects at the nmda receptor, but for some reason dont think i ever heard of magnesium's such effect.

an article referring to the "super-additive interactions of Ketamine and Mag".

will have to give it a shot

 

[VolatileAgent]

in the private practice world, clonidine used this way is gonna proved to be WAY too expensive for routine use. it's not a panacea for any neuraxial techinque (ie., you modestly prolong a good block) in lieu of using plain old epinephrine.

so, effective? yes. practical? no. you gotta get this mix special, as it is not an "approved" formulation. and, with that, comes a lot of extra cost.

 

[Noyac]

in the private practice world, clonidine used this way is gonna proved to be WAY too expensive for routine use. it's not a panacea for any neuraxial techinque (ie., you modestly prolong a good block) in lieu of using plain old epinephrine.

so, effective? yes. practical? no. you gotta get this mix special, as it is not an "approved" formulation. and, with that, comes a lot of extra cost.

Not exactly. At my institution they stopped using it b/c it was only moderately longer acting than without. It was not very expensive but it did require some work on pharmacy's behalf. It also caused too much hypotension.

I am a fan of regional as you all know. But I am not much of a fan of blocks lasting more than 24hrs. The numbness begins to be really annoying. Trust me I have had more than one knee surgery under regional and I was more than ready for the block to wear off even at the expense of some plan. Everyone is different and for those that are poor at tolerating pain then I use long acting stuff and catheters but for most 24 hrs is plenty. Also, nerve injury is real. I had an epidural in for 3 days on a pt for TKA and manipulation under anesthesia of the contralateral knee. When I turned off the epidural the pt began to complain of foot pain. He was 350 lbs and the tourniquet was up for 90 mins. He developed RSD (or CRPS for you pain guys). His ******* attorney sued me only b/c of the epidural. I got an EMG which showed the nerve injury at mid thigh level. Area of the tourniquet. Case dropped but the pt didn't get to sue the orthopod as far as I know b/c statute of limitations. It was more than a year out and his attorney was an idiot. I felt really bad for the guy.