Epidural infusions for abdominal surgey

[pencan]

Hemi-colectomy and bowel resection surgery. What infusion concentrations do you use for intraop/post-op epidural infusions. I was contemplating utilizing straight 0.1% ropivacaine intraop or possibly 0.25% bupivacaine. Postop I was planning an infusion of 0.1% ropivacaine with 2-4mcg/kg fentanyl or possibly 0.1% bupivacaine with 2-4mcg/kg fentanyl. What do most of you use in the post operative period as far as infusions are concerned? Do you leave out the narcotics and use straight local and perhaps a little morphine at the end of surgery?

Thanks,

Pencan

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[huktonfonix]

why bother? I dont think the data shows a benefit for most patients undergoing surgery for a lower abdominal incision. If you're gonna do it though.....For an intraop infusion, it depends on what your goals are. Is the operation under pure regional or is it a supplement to GA? As a pure regional 0.5 bupi or 2% lido +/- narcotic. As a supplement, run whatever you want from 0.25 bupi/0.2 ropi or just run your post op infusion. post op your mentioned mix should do fine.

 

[dhb]

high concentration low volume no narcs

 

[pencan]

would you consider using a one shot intrathecal narcotic dose before induction? 20mcg fentanyl with 200mcg of astramorph? Most of the surgeons put in a pain pump in the incisional area but it doesn't seem to kick in until a good 16-24 hours.

why bother? I dont think the data shows a benefit for most patients undergoing surgery for a lower abdominal incision. If you're gonna do it though.....For an intraop infusion, it depends on what your goals are. Is the operation under pure regional or is it a supplement to GA? As a pure regional 0.5 bupi or 2% lido +/- narcotic. As a supplement, run whatever you want from 0.25 bupi/0.2 ropi or just run your post op infusion. post op your mentioned mix should do fine.

 

[pencan]

0.2% ropivacaine would be a good choice then or do you prefer bupivacaine?

high concentration low volume no narcs

 

[cchoukal]

We use 0.1% bupivicaine with 20 mcg/mL hydromorphone. We do a lot of surgery for Crohn's and UC, so these people are on lots of opiates pre-op. Sometimes, these folks are so opiate dependent that you can have a great block/level post-op, but they're still uncomfortable. For them, I often switch to 0.125% bupiv and let them use a PCA, either HM or morphine. They often don't use much, but their brains tell them they need SOME. Akternatively, some diazepam is a really nice supplement of their discomfort is from "cramping," which we seem to hear a lot of in this population. Not so much with the cancer colectomies, though.

We have a couple folks that like the IT narcotics and, in this way, they avoid the potential complications of thoracic epidural. I'm just not seeing pain relief for more than the first 12-18 hours or so. In contrast, many of ouor epidural patients keep their catheters 3-5 days.

 

[huktonfonix]

We use 0.1% bupivicaine with 20 mcg/mL hydromorphone. We do a lot of surgery for Crohn's and UC, so these people are on lots of opiates pre-op. Sometimes, these folks are so opiate dependent that you can have a great block/level post-op, but they're still uncomfortable. For them, I often switch to 0.125% bupiv and let them use a PCA, either HM or morphine. They often don't use much, but their brains tell them they need SOME. Akternatively, some diazepam is a really nice supplement of their discomfort is from "cramping," which we seem to hear a lot of in this population. Not so much with the cancer colectomies, though.

We have a couple folks that like the IT narcotics and, in this way, they avoid the potential complications of thoracic epidural. I'm just not seeing pain relief for more than the first 12-18 hours or so. In contrast, many of ouor epidural patients keep their catheters 3-5 days.

this is one of the exceptions where I'll place an epidural for lower abdominal surgery. The chronic pain population may be relatively resistant to narcotics and benefit from the epidural. Regarding IT narcotics, they work although you still have to watch for delayed resp depression. Again I tend not to do it unless I believe the patient will truly benefit from IT vs PCA narcotics. I guess on the + side, you can bill for it. On the - side in most places you are responsible for pain management unless you have a pain service.

 

[Noyac]

0.2% ropivacaine would be a good choice then or do you prefer bupivacaine?

You are not getting what high concentration is.

Tell me, how does 0.1% Ropiv compare to 0.25% Bupiv with regards to conc?

0.1% ropiv for the case is way too low. But you seem to be using it like you would use the 0.25% Bupiv. Huge difference.

So what is high concentration to you?

 

[pencan]

0.25%-0.5% bupivacaine would be a high concentration for me as well as 1.5%-2% lido. I just worry about the possible cardiac effects of high concentrations of bupivacaine. (which I'm sure people will say are overrated). I figure if 0.2% ropivacaine is good enough for a screaming primip it would be good enough for a large belly case, plus with the added benfit of no cardiovascular effects. I would prefer to use something without narcotic since I do not feel real confident in the post op monitoring on the floor.

You are not getting what high concentration is.

Tell me, how does 0.1% Ropiv compare to 0.25% Bupiv with regards to conc?

0.1% ropiv for the case is way too low. But you seem to be using it like you would use the 0.25% Bupiv. Huge difference.

So what is high concentration to you?

 

[Noyac]

0.25%-0.5% bupivacaine would be a high concentration for me as well as 1.5%-2% lido. I just worry about the possible cardiac effects of high concentrations of bupivacaine. (which I'm sure people will say are overrated). I figure if 0.2% ropivacaine is good enough for a screaming primip it would be good enough for a large belly case, plus with the added benfit of no cardiovascular effects. I would prefer to use something without narcotic since I do not feel real confident in the post op monitoring on the floor.

So many problems with this post, where do I start?

.25 and .5% are high conc? Really? Is .5% not twice the conc of .25%? then how can they both be high conc? And why are we even talking about "high" conc? Why not just talk about the conc?

Next, Bupiv does have negative cardiac effects if you inject it in a vessel. So don't inject in a vessel. But do you really think Ropiv does not? Really? You know why ropiv is less cardiotoxic? Usually its b/c you are using a lower conc. .25% bupiv vs .2% ropiv. Otherwise, they can be very similiar.

And when you say "no cardiovascular effects", what exactly are you talking about?

Are you talking about using .2% ropiv in primip's in labor or for a c/s. It sounds like you are comparing labor to a belly case. I guess if you are putting the belly case to sleep then it doesn't matter but you are missing the picture here.

YOu want to know what I think? I think we have another nurse trying to play DOCTOR.

 

[Arch Guillotti]

To the OP:

I am a little confused as well.

You profile states that you are a non-student.

What are you?

 

[periopdoc]

Hemi-colectomy and bowel resection surgery. What infusion concentrations do you use for intraop/post-op epidural infusions.

At the hospitals where I work, the intraoperative management is quite variable and practitioner dependent. Personally I figure if the epidural is there I am going to use it for operative level analgesia and minimize other anesthetics. Thus, I typically bolus ~5cc 1.5-2% lido q 60-90 minutes depending on patient CV status and response. I will stop dosing 1-2 hours before skin closure and start my postoperative infusion. With this I can typically do a whipple, hemicolectomy, or LAR with <100 mcg of fentanyl IV and ~0.5 MAC of volatile during the case and have a comfortable, wide awake patient in PACU. Some of our docs will just run the postoperative infusion from the get go and some will just do the test dose then wait for PACU to start an infusion. Both of those techniques require higher levels of opiates and volatiles sometimes resulting in longer wakeups and PACU stays.

For postoperative management, we use two standard concentrations in order to reduce the possibility of pharmacy/ nursing error. By protocol we use either 0.0625% or 0.1% bupivacaine with 2-4 mcg/ml fentanyl. Some will choose to use morphine 1 mg/ml or hydromorphone 0.2 mg/ml depending on the effect they are looking for.

This works pretty well although I find the 1/16 to be pretty homeopathic so I just use 1/10 for almost every one unless they have some other pathology putting them at risk for hypotension. If I want coverage of 1-2 dermatomes more than I think my epidural will cover, I will use hydromorphone. If I think that the patient will have pain issues well outside of the epidural dermatomes, I will either use fentanyl or split them to plain LA and a opiate IV PCA.

There are times when I would like to do things a little differently, but for patient safety, it is more important to have a uniform approach and therefore less thinking for the nurses/ pharmacists.

-pod

 

[periopdoc]

Postop I was planning an infusion of 0.1% ropivacaine with 2-4mcg/kg fentanyl or possibly 0.1% bupivacaine with 2-4mcg/kg fentanyl.

I hope you mean 2-4 mcg/ml fentanyl... Otherwise that is an A**LOAD of fent and I would be worried about infusing that too.

would you consider using a one shot intrathecal narcotic dose before induction? 20mcg fentanyl with 200mcg of astramorph? Most of the surgeons put in a pain pump in the incisional area but it doesn't seem to kick in until a good 16-24 hours.

I would prefer to use something without narcotic since I do not feel real confident in the post op monitoring on the floor.

So you would feel comfortable with a 200 mcg IT morphine injection but not a epidural opiate infusion on the floor? I am confused by that. Which has a higher chance of running into problems on poorly monitored floors? If we assume an infusion rate of 10 cc/ hour for ease of math that would mean 20 to 40 mcg per hour of fentanyl being infused. As lipophilic as fentanyl is, that is essentially a continuous IV infusion of 20-40 mcg/hr fentanyl. There aren't too many folks who are going to be depressed by that. You can make some argument about neuraxial effects of fentanyl here, but I personally don't buy it.

Why do your pain pumps start working after 16-24 hours? Is anyone else noticing this problem? I don't manage them so I don't know, but it sounds suspicious.

I just worry about the possible cardiac effects of high concentrations of bupivacaine. (which I'm sure people will say are overrated). I figure if 0.2% ropivacaine ... plus with the added benfit of no cardiovascular effects.

You know why ropiv is less cardiotoxic? Usually its b/c you are using a lower conc. .25% bupiv vs .2% ropiv. Otherwise, they can be very similiar.

As has been noted, Ropi does have cardiac toxicity ( I assume that is what you mean by cardiovascular effects.) Like Noy says, we typically use Ropi in lower concentrations. Also, ropivacaine is ~40% less potent than bupivacaine. The studies looking at toxicity used equal concentrations of bupi and ropi. However, to make the studies correct you would need to use ~40% higher concentrations of ropi. I suspect that at equipotent doses, the toxicity profile is indistinguishable despite the marketing literature.

Like Noy says, of the commonly used local anesthetics, bupi has the highest therapeutic window and is the least cardiotoxic if it is not infused directly into the vasculature. Ropi probably is equivalent to bupi.

- pod

 

[coprolalia]

Yeah, I picked up on the mg/kg thing too...

In general, we run 0.125% bupivicaine with 2mcg/ml epi in all of our belly cases post-op. Intra-op, I use 0.25% bupivicaine at 6-8 ml/hr on the pump after a bolus. Seems to work well.

Ropivicaine is just more expensive. No other real advantages, IMHO. And, if you have a problem with hypotension, give fluids. Don't change your solution... unless they have a small AV or an EF<25%, in which case switch to opiod only (preferably hydromorphone... but I'm sure others will do just fine). It's hard to convince the surgeons sometimes that turning off the epidural is a bad idea. Sure, the patient's pain, and endogenous catecholamine release as a result, will bring their pressure up. But, is that really how you want to accomplish that?

We never use DepoDur anymore, and pull the catheter Anyone still use that stuff/do that technique? Also, timing can be challenging in pulling the epidural post-op because a lot of these patients get anti-coagulated. We pretty much follow ASRA guidelines as far as stopping LMWH and re-starting after pull. No epi hematomas so far...

-copro

 

[coprolalia]

Oh, and I completely agree with Noy. I think certain healthcare providers probably use this forum to try to understand why they are doing what they're being told to do. I don't inherently have a problem with that provided that they are forthright in their reasons for being here and let everyone know who they really are.

-copro

 

[huktonfonix]

At the hospitals where I work, the intraoperative management is quite variable and practitioner dependent. Personally I figure if the epidural is there I am going to use it for operative level analgesia and minimize other anesthetics. Thus, I typically bolus ~5cc 1.5-2% lido q 60-90 minutes depending on patient CV status and response. I will stop dosing 1-2 hours before skin closure and start my postoperative infusion. With this I can typically do a whipple, hemicolectomy, or LAR with <100 mcg of fentanyl IV and ~0.5 MAC of volatile during the case and have a comfortable, wide awake patient in PACU. Some of our docs will just run the postoperative infusion from the get go and some will just do the test dose then wait for PACU to start an infusion. Both of those techniques require higher levels of opiates and volatiles sometimes resulting in longer wakeups and PACU stays.


-pod

I agree, although I tend to run at least 0.7 MAC of anesthetic for both tube tolerance and recall prevention. Seems like 0.5 MAC might be a touch low unless the patient is elderly, or has other meds on board.

 

[drccw]

I use 1% lidocaine intraop. Bolus about 8 cc upfront, run it at about 8 cc/hr during the case. I do try to get the post operative infusion and get it going towards the end of the case. I prefer lidocaine because it's a little more forgiving (plus you can turn it off). There have been a couple of time when I have had to uh turn my local anesthetic infusion off... Elective open AAA repairs gone bad typically. I prefer using either morphine or hydromorphone post operatively in my infusions since in my mind if you are going to use neuraxial opiates, then I prefer to pick ones that work better at the neuraxial level...

Our surgeons typically like our thoracotimes run quite dry... Less than 2 litres for any resections... I never use the epidural intraop, and sometimes we have trouble with out local anesthetic infusions post op... I typically bolus them with 3 mg of PF-morphine during the case and if they can tolerate it (ie plenty of blood pressure) then at the end of the case about 5cc of 0.25% bupivicaine... sometimes though all they get is the morphine and find it definitely helps to sort some of the pain out.

 

[militarymd]

Narcotic only infusions.....0.1 mg of morphine per hour.

Excellent pain relief....

patients can get up and about...

you can run them for days.

 

[dhb]

Narcotic only infusions.....0.1 mg of morphine per hour.

Excellent pain relief....

patients can get up and about...

you can run them for days.

fo' real? in what volume? never heard of this...

 

[militarymd]

fo' real? in what volume? never heard of this...

10 cc / hr ...0.01 mg /ml

learned it from a guy from ucsf and a guy from u penn.

 

[Arch Guillotti]

I agree, although I tend to run at least 0.7 MAC of anesthetic for both tube tolerance and recall prevention. Seems like 0.5 MAC might be a touch low unless the patient is elderly, or has other meds on board.

I aim for about .5 MAC as well, lower if I can.

I think that .7 MAC of volatile anesthetic is going overboard for prevention of recall.

 

[CambieMD]

I don't care who the op is. This is a good topic. I initiate my epidurals with lidocaine2%-7cc plus 1cc sodium bicarb and 100mcg of fen. This gives a total volume of 10cc. I dose with this before we get the pt back to the or. Patients are the best monitors. I like to take every advantage of that fact.
I determine if the epdural is one sided or not working. After I get the pt back to the OR I switch to bupiv.5% infused @ a rate of 5cc/hr. I run the pt at a mac of .6-.7 .

Cambie

 

[CambieMD]

I agree, although I tend to run at least 0.7 MAC of anesthetic for both tube tolerance and recall prevention. Seems like 0.5 MAC might be a touch low unless the patient is elderly, or has other meds on board.

I agree.

Cambie

 

[dhb]

10 cc / hr ...0.01 mg /ml

learned it from a guy from ucsf and a guy from u penn.

thx

What i'm used to is PCEA with l-bupi 0.5% 4cc/h bolus 1ml q20 no lock out if you are going to use local anesthetics higher concentration will give you better analgesia and the small volume will give you less motor block. Although if you need to cover more dermatomes it makes sense to do the opposite.

Didn't go into more details in the first post because of the nature of the op

 

[CanGas]

For surgery I use Bupi 0.5%, 5-8cc up front with an additional 3-5cc if HR/BP bumps with surgical incision then 4-6cc/hr as an infusion. The higher concentration provides muscle relaxation as well. (Bup 0.5% = Lido 2%, Bup 0.25% = Lido 1%). Run 0.7 MAC for the case with no narcotics other than those given at induction for intubation. At the end of the case I load 8-10cc Bupi 0.1% then start infusion Bup 0.1% + Fent 2mcg/ml at 6-8cc/hr for mid thorasic, 10cc/hr for low thorasic. Ropi\levo bupi is too expensive and I think the cardiotoxicity is related to the decreased potency, not an intrinsic difference in the molecule.

We don't have PCEA for surgical pt's only OBS. Dosing is not evidence based, just what works in my hands and does not give too much hypotension but good pain control. I've got one staff who slams in 20cc Bup 0.5% for every surgical epidural. I'm always sure to have a Neo infusion ready when working with him. I'm intrigued by the epimorp infusion but I have to say that all the epimorph patients I have done have had pretty good rest pain but crappy dynamic pain.

CanGas