Hip fracture spinal cocktail

[dilaudid]

Just curious what different folks prefer. What is your cocktail of choice for a spinal in elderly hip fx? Positioning, drugs, etc.

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[DocVapor]

Just curious what different folks prefer. What is your cocktail of choice for a spinal in elderly hip fx? Positioning, drugs, etc.

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.

 

[facted]

30 of ketamine or so. Rotate, 1.5-2 ml of 0.5 bupi, small amount of prop remainder of the case if necessary.

 

[Psai]

Same as above. Maybe 3 mL if I think it will take awhile vs cse

 

[dhb]

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.

 

[dannyboy1]

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...

 

[deleted697535]

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

 

[Psai]

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

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.

 

[facted]

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

There is data that regional is better than GA but it does go back and forth. It's not totally conclusive.

 

[facted]

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.

Not to mention less hypotension.

 

[deleted697535]

There is data that regional is better than GA but it does go back and forth. It's not totally conclusive.

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

 

[deleted171991]

Just curious what different folks prefer. What is your cocktail of choice for a spinal in elderly hip fx? Positioning, drugs, etc.

GA.

 

[facted]

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

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.

 

[Urzuz]

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.

 

[deleted697535]

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.

What makes you think i havent done that already?
You seem to think there is a clear answer?

 

[deleted162650]

Why all the ketamine for positioning? If you feel the need to do a spinal, then a whiff of prop works just fine.

 

[Psai]

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.

 

[facted]

Why all the ketamine for positioning? If you feel the need to do a spinal, then a whiff of prop works just fine.

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.

 

[anbuitachi]

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

 

[coffeebythelake]

usually tube, otherwise 12.5 mg of 0.5% isobaric bupi

 

[deleted162650]

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.

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.

 

[deleted162650]

Usually do a lateral spinal with 3ml 0.5% bupivicaine.

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.

 

[anbuitachi]

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.

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

 

[facted]

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.

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.

 

[deleted162650]

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.

I think the difference between that and the 0.X% sevo you need via LMA is minuscule.

 

[Southpaw]

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.

 

[nimbus]

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.

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

Still a good technique though.

 

[vsl5]

If you guys are using 0.5% isobaric bupivacaine for the spinal, do you usually position fracture side up (so the patient doesn't have to lie on their fracture)? Obviously you would want Fx side down for heavy bupiv but does it matter for isobaric? Another consideration is that most "isobaric" solutions are actually slightly hypobaric, which would lead me to think Fx side up would be better.

 

[DrZzZz]

If you guys are using 0.5% isobaric bupivacaine for the spinal, do you usually position fracture side up (so the patient doesn't have to lie on their side)? Obviously you would want Fx side down for heavy bupiv but does it matter for isobaric? Another consideration is that most "isobaric" solutions are actually slightly hypobaric, which would lead me to think Fx side up would be better.

Generally, patients are actually more comfortable lying fracture side down. So that's how I roll regardless of what I'm using. I just make sure to have them roll onto their back when using isobaric a little bit quicker than if I'm using hyperbaric.

 

[anbuitachi]

Generally, patients are actually more comfortable lying fracture side down. So that's how I roll regardless of what I'm using. I just make sure to have them roll onto their back when using isobaric a little bit quicker than if I'm using hyperbaric.

Why does it feel better to crush the fracture? Just curious

 

[DrZzZz]

This is all what I've been told from my ortho counterparts. I don't trust them with much, but we're talking bones so I think it's a safe bet here. Basically, it hurts more to have the fractured leg dangling when that side is up than it does to be lying directly on it. The movement when dangling causes more pain than the pressure lying on it. I'm sure you could support the fractured leg with pillows if you wanted that side up, but a little Ketamine +/- propofol usually keeps them quiet anyway with the fracture side down.

 

[OTCAwesome]

Most of our hip fx patients are 90+ and sick AF, generally most of us just stick with GA and fascia illiaca block, really don't have the desire to irreversibly tank the preload in someone with undiagnosed critical AS, or one that's underestimated on TTE.

 

[oldguy55]

GA if they are reasonably healthy or on Plavix or won't consent to a spinal. A little propofol, LMA, sevo. I don't push too hard to convince most folks to accept a spinal. The evidence that one is better than the other is just not strong.

If they're sicker or older or have mild-moderate dementia, I tell them (or the family) that I think the best anesthetic is spinal. Recovery seems smoother than with GA and the surgeons think they have less postop confusion. A touch of propofol to turn lateral, injured side up, a little more propofol and a finger under the chin to keep the airway open while the CRNA struggles with the spinal. Then, a few minutes later we trade places and I pop it it in a few seconds: spinal with 22ga Quinke, 2ml 0.5% bupivacaine, no skin local needed. We can turn to supine and move to the OR table immediately. Minimal propofol sedation.

 

[IMGASMD]

...while the CRNA struggles with the spinal....


Say what?!

 

[MaximusD]

1. Roll onto non-painful side
2. Get the spinal
3. Inject 2-3mL of isobaric 0.5% bupivacaine
4. Coffee break