Hip # ga vs spinal

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unc04 said:
It made me not watch any more of his videos and will avoid his website in the future.

Since he is making money by making videos discussing RA

It undermines his credibility.
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I have to be honest everything about that post made me feel the same.
He didn't even allow comments on his own site.

Very dodgy
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unc04 said:
I saw this video a couple weeks ago. He is clearly biased and agree there is no reason to say any general anesthesiologist doesn’t have the ability to do spinals correctly. It made me not watch any more of his videos and will avoid his website in the future.

Since he is making money by making videos discussing RA it seems he is pulling at straws to try to support his claims that regional is superior to GA which is not supported by that trial.

It undermines his credibility. I’ve suspected for years that there is no significant difference in RA vs GA for most patients and procedures unless they have bad lung disease or heart failure as said above.
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Studies also show no difference in postop delirium. Thoughts?
 
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cchoukal said:
It’s not the anesthesia, but the neurohumoral response to surgical stress that causes delirium. That delirium happens in the same organ where the anesthesia goes is just a red herring.
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I know I’ve said this on here before, but some octogenarian that just fell and broke their hip +/- a mild TBI, in acute pain, anxious, sleep deprived from getting woken up poked/prodded every other hour, thrown out of their routine, missing doses of home meds, getting new meds… more than half are delirious in pre-op. I’m far more surprised when they aren’t.

Surgery/anesthesia is just the icing on the cake. We need to stop owning this problem like it’s ours to fix/prevent. Get ‘em through safely and call it a day.

Edit: maybe don’t give 10 of versed though…
 
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On one hand, spinals are fine, blah blah. On the other hand the guy's a zealot with significant financial gain that is not always disclosed (investments, conferences, wife's job... etc) from peddling his questionable conclusions.

I work at an institution that runs 2 #NOF theatres from 0800-2000 every day. I GA 90% of them. Years ago I was supervising a pulmonary HTN case that arrested in the context of missed hypoventilation + hypercapnia with incredibly light sedation and a spinal. That anecdote made me review the literature in more detail. I've also been called to assist in multiple vent/hemodynamic catastrophes in the context of spinal and sedation.

My current practice is if they are sick (most of them) and they will need any sedation at all --> I give them the tube. I've had cement syndrome, air locks, massive haemorrhage, anaphylaxis, etc doing it this way and very good outcomes.
 
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cchoukal said:
When I used to teach residents, it would always blow their minds when I would ask them to find a randomized trial in any setting that showed benzodiazepines caused delirium. They’ve never found one.

But 10 is a lot!
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Reminds me of one of my CV attendings in fellowship. Full professor, been there forever. Not changing. 10 versed and 20 fentanyl was the starting point. The real ‘go getter’ residents would draw up another 10 and 20 without checking. If he saw narcs sitting out, he’d immediately dump them in the buretrol. If the resident pulled more, he’d give that too. I’m convinced he would do this ad infinitum.

It got to the point where his practice was so disparate from the rest of the (increasingly younger) CV anesthesia team that CVICU did an internal QI project looking at time to extubation by anesthesia attending.

There was no difference.

It was really annoying.
 
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Often, the greatest determinant is the nursing and intensivist. Some like to run out the clock and have a quiet shift, extubating right before 6hrs, regardless of the anesthetic. Without a concerted push to earlier extubations, how anesthetic choices affect this will be lost in the weeds.
 
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Beeftenderloin said:
Reminds me of one of my CV attendings in fellowship. Full professor, been there forever. Not changing. 10 versed and 20 fentanyl was the starting point. The real ‘go getter’ residents would draw up another 10 and 20 without checking. If he saw narcs sitting out, he’d immediately dump them in the buretrol. If the resident pulled more, he’d give that too. I’m convinced he would do this ad infinitum.

It got to the point where his practice was so disparate from the rest of the (increasingly younger) CV anesthesia team that CVICU did an internal QI project looking at time to extubation by anesthesia attending.

There was no difference.

It was really annoying.
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Had one attending who would regularly give very high dose narcotics and run a patient on maybe 0.1-0.2% iso. For a fellow's "educational benefit" he induced a patient with 100mcg/kg of fentanyl. Now, that guy took a while to wake up in the ICU!

As a secondary measure, I'd be curious if there were other markers affected other than just time to extubation, like incidence of ileus?
 
abolt18 said:
Had one attending who would regularly give very high dose narcotics and run a patient on maybe 0.1-0.2% iso. For a fellow's "educational benefit" he induced a patient with 100mcg/kg of fentanyl. Now, that guy took a while to wake up in the ICU!

As a secondary measure, I'd be curious if there were other markers affected other than just time to extubation, like incidence of ileus?
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So 7-10mg of fentanyl? 140-200 ml? I trained during a time when 2-3mg (40-60ml) was “normal”. We never cracked open the vaporizer.
 
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circleK said:
We do a lot of really old, sick hips. I do isobaric spinals for nearly every hip fracture unless contraindicated or unable to position properly for it. Rarely need much sedation on top of it. Once the pain is gone for the first time since the fracture happened they’ll nap with just a whiff. Also no narcotics needed intraop or in PACU is a huge positive.
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How much iso? 1.2cc?
If you can’t get a SAB, what’s your typical GA recipe?
Just curious
 
nimbus said:
So 7-10mg of fentanyl? 140-200 ml? I trained during a time when 2-3mg (40-60ml) was “normal”. We never cracked open the vaporizer.
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Yeah it was 9.3mg. No volatile anesthetic was administered during that case.
 
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abolt18 said:
Yeah it was 9.3mg. No volatile anesthetic was administered during that case.
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How was it done? Really can't imagine 186 ml of (50 mcg/ml) fentanyl. Was it multiple 20cc syringes? The same 20cc syringe over and over? 3 big 60cc syringes? Also, quick infusion? Slowly? How long did it take? How about chest rigidity? And the induction? Just fentanyl (how much?) and neuromuscular blocker? Or any other hypnotic?
 
bourg said:
How was it done? Really can't imagine 186 ml of (50 mcg/ml) fentanyl. Was it multiple 20cc syringes? The same 20cc syringe over and over? 3 big 60cc syringes? Also, quick infusion? Slowly? How long did it take? How about chest rigidity? And the induction? Just fentanyl (how much?) and neuromuscular blocker? Or any other hypnotic?
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Back in the day they used to induce with 100 cc fentanyl.
 
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Arch Guillotti said:
Back in the day they used to induce with 100 cc fentanyl.
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I’m not quite that old but in residency we induced with versed 20-25mg, fentanyl 40-60ml, and pancuronium 10mg. I still couldn’t imagine cracking 10x 20ml vials of fentanyl.
 
Anesthetizing a spinal cord vs having grandpa huffing a solvent - no difference. Out of your mind if you believe that.
 
nimbus said:
I’m not quite that old but in residency we induced with versed 20-25mg, fentanyl 40-60ml, and pancuronium 10mg. I still couldn’t imagine cracking 10x 20ml vials of fentanyl.
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50ml vial. 60 ml syringe. Drew it up with needle from a 14g angiocath. Biggest needle in the cart.
 
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coffeebythelake said:
Well do u ever do just anesthetizing the spinal cord? No. They always end up getting some sedation on top
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I once gave a spinal for a laser TURP to a 90yo retired surgeon who was the father of a surgeon I worked with. He had a bupiv only spinal and propofol 30mcg/kg/min for sedation during the case. Received no intraop benzos or opioids, no anticholinergics. He was very clear headed in the PACU and the afternoon of surgery. But he sundowned badly later that night and never fully recovered. Died about 6 months later. There is so much happening when a patient has surgery which makes it difficult to attribute POCD to any particular thing.
 
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nimbus said:
I once gave a spinal for a laser TURP to a 90yo retired surgeon who was the father of a surgeon I worked with. He had a bupiv only spinal and propofol 30mcg/kg/min for sedation during the case. Received no intraop benzos or opioids, no anticholinergics. He was very clear headed in the PACU and the afternoon of surgery. But he sundowned badly later that night and never fully recovered. Died about 6 months later. There is so much happening when a patient has surgery which makes it difficult to attribute POCD to any particular thing.
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Or just being 90 years old?
 
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