Hip fracture spinal cocktail

Discussion in 'Anesthesiology' started by dilaudid, Feb 10, 2019.

  1. dilaudid

    dilaudid ASA Member
    7+ Year Member

    Joined:
    Mar 1, 2009
    Messages:
    36
    Likes Received:
    3
    Just curious what different folks prefer. What is your cocktail of choice for a spinal in elderly hip fx? Positioning, drugs, etc.
     
  2. DocVapor

    DocVapor Big Schwartz
    Physician Gold Donor Verified Account 5+ Year Member

    Joined:
    Oct 4, 2012
    Messages:
    2,382
    Likes Received:
    3,989
    Status:
    Resident [Any Field]
    Still in residency, but:

    20-30 mg Ketamine IV. Roll onto fractured side. 2 ml 0.75% Hyperbaric Bupiv. Position as per surgeon then low-dose propofol sedation. Log case. Rinse, repeat.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  3. facted

    facted ASA Member
    10+ Year Member

    Joined:
    Dec 15, 2008
    Messages:
    883
    Likes Received:
    436
    Status:
    Attending Physician
    30 of ketamine or so. Rotate, 1.5-2 ml of 0.5 bupi, small amount of prop remainder of the case if necessary.
     
    nimbus likes this.
  4. Psai

    Psai This space for lease
    Removed 5+ Year Member

    Joined:
    Jan 2, 2014
    Messages:
    11,524
    Likes Received:
    23,402
    Status:
    Resident [Any Field]
    Same as above. Maybe 3 mL if I think it will take awhile vs cse
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  5. dhb

    dhb Member
    Lifetime Donor Verified Account 10+ Year Member

    Joined:
    Jul 12, 2006
    Messages:
    3,695
    Likes Received:
    888
    Status:
    Attending Physician
    15mg ketamine 20-30mg propofol wait 2min sit them up (somebody has to be at the feet of the bed to pull their arms) +-1.2ml of 0.5 bupivacaine.
     
  6. dannyboy1

    10+ Year Member

    Joined:
    Aug 11, 2008
    Messages:
    494
    Likes Received:
    382
    Status:
    Attending Physician
    Honestly, it’s such a pain getting these patients positioned properly ( for some reason ortho decides that when the patient rolls into the OR is the best time to review imaging) that I do GA on these cases unless there is a compelling reason to avoid it...
     
    lymphocyte, okayplayer and dr doze like this.
  7. Newtwo

    2+ Year Member

    Joined:
    Jun 10, 2015
    Messages:
    416
    Likes Received:
    221
    Tube a lot of the time.
    If spinal then lido FNB followed by spinal with 10-15mg iso bupiv with 15 fent.

    I see someone uses Heavy bupiv? Thats not very kind is it? And wont last as long either.
    But honestly just tube
     
  8. Psai

    Psai This space for lease
    Removed 5+ Year Member

    Joined:
    Jan 2, 2014
    Messages:
    11,524
    Likes Received:
    23,402
    Status:
    Resident [Any Field]
    I think regional is better for the elderly than general although I have looked at the studies. I think iso works better than heavy because even though you have fracture side down for placement of spinal, you have to turn them for the surgery.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  9. facted

    facted ASA Member
    10+ Year Member

    Joined:
    Dec 15, 2008
    Messages:
    883
    Likes Received:
    436
    Status:
    Attending Physician
    There is data that regional is better than GA but it does go back and forth. It's not totally conclusive.
     
  10. facted

    facted ASA Member
    10+ Year Member

    Joined:
    Dec 15, 2008
    Messages:
    883
    Likes Received:
    436
    Status:
    Attending Physician
    Not to mention less hypotension.
     
  11. Newtwo

    2+ Year Member

    Joined:
    Jun 10, 2015
    Messages:
    416
    Likes Received:
    221
    Ive asked this q here and at my shop many times and everyone gives a different answer. It was my understanding that elective joints the evidence was for spinal due to less DVT but everything else was a wash. And fractures were a wash too.
    Esp if your surgeon takes 3 hours
     
  12. FFP

    FFP Wiseguy
    Gold Donor Verified Account 10+ Year Member

    Joined:
    Oct 17, 2007
    Messages:
    6,494
    Likes Received:
    6,140
    Status:
    Attending Physician
    GA.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
    Urzuz and okayplayer like this.
  13. facted

    facted ASA Member
    10+ Year Member

    Joined:
    Dec 15, 2008
    Messages:
    883
    Likes Received:
    436
    Status:
    Attending Physician
    What people tell you and what the evidence suggests are not always the same. I suggest you pubmed for yourself and see what's out there rather than listening to your attendings or people on here. You'd be surprised how often attendings are wrong.

    For elective total joints, there are very large database studies that also show significantly lower EBL and some also show lower mortality rates and pulm complications.

    As for fx, you can certainly find studies that go both ways, but if you believe that regional offers protection from DVT which has been demonstrated for Ortho (total joints) as well as abdominal (thoracic epidurals), then why not offer that to a segment of the population that is literally the highest risk for DVT of any patient you'll see (bedbound long bone fracture)?

    I also have to believe that spinal and mild sedation decreases delirium rates in the cognitively impaired and the data for that is there, but it is mixed.

    In the end, do what you're comfortable with, but it's not exactly hard to take give them 20 of ketamine, roll them over, put a spinal in, and give them a small amount of prop for the rest of the case.
     
  14. Urzuz

    7+ Year Member

    Joined:
    Aug 24, 2011
    Messages:
    418
    Likes Received:
    495
    Status:
    Attending Physician
    Fascia iliaca block in preop + 0.5 MAC sevo through an LMA

    If for whatever reason I do a spinal, titrate ketamine in until desired sedation level, ~1.2-1.5 ml of 0.75% bupivacaine depending on who my surgeon is and what they’re doing. Why heavy bupivacaine? Because that’s what comes in the kit and it doesn’t make a lick of difference at the end of the day.
     
    #14 Urzuz, Feb 11, 2019
    Last edited: Feb 11, 2019
    dipriMAN and nimbus like this.
  15. Newtwo

    2+ Year Member

    Joined:
    Jun 10, 2015
    Messages:
    416
    Likes Received:
    221
    What makes you think i havent done that already?
    You seem to think there is a clear answer?
     
  16. SaltyDog

    SaltyDog Homey O'Stasis
    10+ Year Member

    Joined:
    Aug 10, 2007
    Messages:
    3,175
    Likes Received:
    5,082
    Status:
    Attending Physician
    Why all the ketamine for positioning? If you feel the need to do a spinal, then a whiff of prop works just fine.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  17. Psai

    Psai This space for lease
    Removed 5+ Year Member

    Joined:
    Jan 2, 2014
    Messages:
    11,524
    Likes Received:
    23,402
    Status:
    Resident [Any Field]
    It just seems to work best. Keeps em still and comfy despite jumping when the stretcher is lightly tapped prior to administration. I've tried prop, versed, versed/fent, no sedation.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  18. facted

    facted ASA Member
    10+ Year Member

    Joined:
    Dec 15, 2008
    Messages:
    883
    Likes Received:
    436
    Status:
    Attending Physician
    Works really really well and I don't have to worry sky their airway. Also long lasting enough that one small dose gets you through the spinal and all the positioning and often a good amount of the surgery.
     
  19. anbuitachi

    anbuitachi ASA Member
    10+ Year Member

    Joined:
    Oct 26, 2008
    Messages:
    4,090
    Likes Received:
    1,270
    Status:
    Resident [Any Field]
    Also like the ketamine prior to spinal if they cant tolerate.
    Usually do a lateral spinal with 3ml 0.5% bupivicaine. Prefer 0.5% since i think they cause less hypotension than 2ml 0.75. and all these old hip fractures have Aortic stenosis
     
  20. eikenhein

    eikenhein Supreme Commander Anesthesiologist
    Physician Lifetime Donor Verified Account 10+ Year Member

    Joined:
    Apr 9, 2006
    Messages:
    1,562
    Likes Received:
    421
    Status:
    Attending Physician
    usually tube, otherwise 12.5 mg of 0.5% isobaric bupi
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  21. SaltyDog

    SaltyDog Homey O'Stasis
    10+ Year Member

    Joined:
    Aug 10, 2007
    Messages:
    3,175
    Likes Received:
    5,082
    Status:
    Attending Physician
    I'll agree that it works well. Just seems totally unnecessary. 0.5mg/kg of prop will get grandma napping for 15', and if you can't get a spinal in a LOL in 15' you've got other issues.

    All this to avoid GA for reasons which are dubious at best, yet you slug her with a dose of K that gorks them for 1/2 the procedure and then top off with prop after that? Sounds a lot like a GA to me.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
    nimbus likes this.
  22. SaltyDog

    SaltyDog Homey O'Stasis
    10+ Year Member

    Joined:
    Aug 10, 2007
    Messages:
    3,175
    Likes Received:
    5,082
    Status:
    Attending Physician
    Why such a large dose? A CRPP/DHS/TFN is a 30-60' case. (Personal best I've seen was a 7' TFN - I swear the Othopod just threw it from the doorway like a Javelin). 15mg of Iso Bupi will last 4-5+ hours in this patient population. If you believe that a spinal helps reduce DVT risk - which these patients are high risk for due to immobility - well you just guaranteed they ain't gettin' outta bed for the rest of the day despite their newly fixed hip.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  23. anbuitachi

    anbuitachi ASA Member
    10+ Year Member

    Joined:
    Oct 26, 2008
    Messages:
    4,090
    Likes Received:
    1,270
    Status:
    Resident [Any Field]
    Oh oops i was thinking of hip replacements for some reason. Def less for nails
    though the last few hip fractures requiring fixing by ortho... none of them were walking prior to fracture anyway.. i dont even remember how they broke it. one had severe dementia
     
  24. facted

    facted ASA Member
    10+ Year Member

    Joined:
    Dec 15, 2008
    Messages:
    883
    Likes Received:
    436
    Status:
    Attending Physician
    I typically give 20-30mg of ketamine and sometimes (though not usually) give 25 mcg/kg/min prop after the spinal. You telling me that's a GA?

    I know the evidence is unclear, but if it were my loved one and they were elderly, etc..., I'd pick a spinal for them all day long.
     
  25. SaltyDog

    SaltyDog Homey O'Stasis
    10+ Year Member

    Joined:
    Aug 10, 2007
    Messages:
    3,175
    Likes Received:
    5,082
    Status:
    Attending Physician
    I think the difference between that and the 0.X% sevo you need via LMA is minuscule.
     
    Stop hovering to collapse... Click to collapse... Hover to expand... Click to expand...
  26. Southpaw

    Southpaw ASA Member
    10+ Year Member

    Joined:
    Aug 12, 2004
    Messages:
    1,076
    Likes Received:
    494
    Status:
    Attending Physician
    There’s probably no difference between a well thought out (simple!) GA and a SAB with ketamine and/or prop for sedation. I lean more toward the SAB myself, but I’m almost sure that I could just as easily do a FNB or FI block pre, place LMA, and run a whiff of propofol and likely use less than 200mg prop for the whole case and achieve the same or better than the SAB. The problem I see in these cases is when anesthesiologists or CRNAs do GA w benzo and/or narcotic. That’s ugly for the hip fracture population. But I know no self-respecting SDN anesthesiologist would do such a ghastly act.
     
  27. nimbus

    nimbus Member
    10+ Year Member

    Joined:
    Jan 14, 2006
    Messages:
    3,518
    Likes Received:
    3,153

    IMO, in a lot of 80 and 90yo’s, it is a GA.

    Still a good technique though.
     

Share This Page