Hip # ga vs spinal

[ToKingdomCome]

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Ever do a shoulder with an ISB+LMA? The quality of those wakeups and recovery are phenomenal.

I Don’t think this is the same as doing a Spinal + LMA. A spinal can be the primary anesthetic. You would do just an ISB for a shoulder and sedation?

 

[sbmed100]

I Don’t think this is the same as doing a Spinal + LMA. A spinal can be the primary anesthetic. You would do just an ISB for a shoulder and sedation?

shoulder surgery in the beach chair (sitting) position - I always do under brachial plexus block (supraclav) and sedation. Literally done over a thousand this way.

 

[deleted87051]

Modified RSI is an oxymoron

I agree but it’s a thing.

 

[UscGhost]

Guys baby spinals + GA are a nonsense. Show some evidence pls?

Depends. What type of data are you looking for?

Intraop opioids use?
With a baby spinal, there is 0 intraop opioids vs 300- 500mcg fent or 1-2 mg Dilaudid.

Intraop BP control? Unless you are running a high dose esmolol, labetalol set up, if that would even work, you will be relying on very high sevo/prop or opioids to get the BP under control

PONV? Much higher with GA due to the elevated intraop opioids requirements and higher sevo or delayed awakening with opioids + prop

Postop opioid use at 24/48hrs? Not sure and the goal is to get them out comfortably. If the total 48 hr opioid is similar, that's fine.

A spinal plus GA (LMA or Oral airway) is a very smooth and slick case

 

[PpfSuxTube]

Depends. What type of data are you looking for?

Intraop opioids use?
With a baby spinal, there is 0 intraop opioids vs 300- 500mcg fent or 1-2 mg Dilaudid.

Intraop BP control? Unless you are running a high dose esmolol, labetalol set up, if that would even work, you will be relying on very high sevo/prop or opioids to get the BP under control

PONV? Much higher with GA due to the elevated intraop opioids requirements and higher sevo or delayed awakening with opioids + prop

Postop opioid use at 24/48hrs? Not sure and the goal is to get them out comfortably. If the total 48 hr opioid is similar, that's fine.

A spinal plus GA (LMA or Oral airway) is a very smooth and slick case

You just made every word of that up didnt you?

Including the slick part... sometimes spinals are very challenging.

An oral airway isn't part of a general anesthetic, are you proposing GAWA?

 

[Arch Guillotti]

An oral airway isn't part of a general anesthetic

Why not?

 

[UscGhost]

You just made every word of that up didnt you?

Including the slick part... sometimes spinals are very challenging.

An oral airway isn't part of a general anesthetic, are you proposing GAWA?

So when you do a TKA without a spinal. How much opioids do you use on average? How do you control BP? Hows the PONV and sedation level in pacu upon arrival?

Lots of ways to do GA. Not defined by the airway you use. mask, LMA, nasal cannula, ett..all can be GA. It's defined by the patients level of response to painful stimuli

 

[psychbender]

So when you do a TKA without a spinal. How much opioids do you use on average? How do you control BP? Hows the PONV and sedation level in pacu upon arrival?

Lots of ways to do GA. Not defined by the airway you use. mask, LMA, nasal cannula, ett..all can be GA. It's defined by the patients level of response to painful stimuli

-100mcg fentanyl (with ACB and IPACK)
-I don't need to control the BP, it's fine
-Awake while signing out to PACU, minimal nausea

TKA without spinal doesn't mean 1.2 MAC gas and hundreds of mcgs of fentanyl or dilaudid.

 

[UscGhost]

-100mcg fentanyl (with ACB and IPACK)
-I don't need to control the BP, it's fine
-Awake while signing out to PACU, minimal nausea

TKA without spinal doesn't mean 1.2 MAC gas and hundreds of mcgs of fentanyl or dilaudid.

I would be very surprised if a TKA or hip could be done with GA and with 100mcg fent. You are going to give 50mcg on incision and 50mcg total over the next 3 hrs??

A simple knee scope takes 100-300mcg of fent.

 

[DocMcCoy]

Personally:
1: I don't want to sit and talk to a patient during a total joint
2: I don't like half sedated patients
3: when properly sedated I don't like doing chin lifts/jaw thrusts

It's just much easier for everyone in the room to just pop an LMA inside after the spinal and it's a good fail safe if for some reason today's bupivacaine decides to not work. I don't think there's a reason to do awake total joints

This is the way

 

[cchoukal]

Ever do a shoulder with an ISB+LMA? The quality of those wakeups and recovery are phenomenal.

This is my primary move for these cases.

 

[Twiggidy]

I just personally don't want to risk hearing an "ouch" tourniquet goes up or that saw hits the hip. A majority of my patients after I explain the neuraxial/regional anesthesia follow up with "Im still gonna be knocked out right?". Yes sir you will be. I feel no shame sleeping people.

 

[deleted87051]

An oral airway isn't part of a general anesthetic, are you proposing GAWA?

When I was a resident, LMAs were just coming out. Our attendings would make us mask GA cysto cases with an oral airway all day long to get our masking skills up. We’d do 8 hours of mask GAs. It’s a skill to mask all day without your hand cramping up. At the time we also used reusable black rubber masks so you couldn’t see them fog.

 

[PpfSuxTube]

When I was a resident, LMAs were just coming out. Our attendings would make us mask GA cysto cases with an oral airway all day long to get our masking skills up. We’d do 8 hours of mask GAs. It’s a skill to mask all day without your hand cramping up. At the time we also used reusable black rubber masks so you couldn’t see them fog.

I started 2013 so I had to do that with some staff. It was good for skills and muscle development for sure but idk what relevance it has once you have 'gotten' it.
I do 80% cardiac with tee, and almost never bvm anymore...

 

[CopaceticOne]

When I was a resident, LMAs were just coming out. Our attendings would make us mask GA cysto cases with an oral airway all day long to get our masking skills up. We’d do 8 hours of mask GAs. It’s a skill to mask all day without your hand cramping up. At the time we also used reusable black rubber masks so you couldn’t see them fog.

One of the attendings in my med school SubI had me mask a full day of ASC general cases. His reasoning was masking is what saves lives and this was a way to ensure you learned that lesson and skill. Will never forget those hand craps from that day.

But also, he was probably one of the most engaged old school attendings for junior residents - nice and loved teaching. He had been around sooooo long that absolutely no one else in the OR ever tried to pull shenanigans and interrupt him when he took time for teaching - including the attending surgeons. (Probably because he had been in the department for longer than the majority had been alive.)

 

[GravelRider]

I would be very surprised if a TKA or hip could be done with GA and with 100mcg fent. You are going to give 50mcg on incision and 50mcg total over the next 3 hrs??

A simple knee scope takes 100-300mcg of fent.

3 hrs? Sounds like you need new surgeons. A TKA is a 45 minute cases…60 if the patient is fat.

 

[abolt18]

3 hrs? Sounds like you need new surgeons. A TKA is a 45 minute cases…60 if the patient is fat.

My thoughts exactly.

 

[GravelRider]

I just personally don't want to risk hearing an "ouch" tourniquet goes up or that saw hits the hip. A majority of my patients after I explain the neuraxial/regional anesthesia follow up with "Im still gonna be knocked out right?". Yes sir you will be. I feel no shame sleeping people.

I remember I used to to take over cases from people who had nasal trumpets blowing boogers out of the nose or patients fidgeting and fussing. I said “nope,” and have done LMAs ever since. I have Wordles to do. I don’t need to be making things harder than they need to be.

 

[UscGhost]

I just personally don't want to risk hearing an "ouch" tourniquet goes up or that saw hits the hip. A majority of my patients after I explain the neuraxial/regional anesthesia follow up with "Im still gonna be knocked out right?". Yes sir you will be. I feel no shame sleeping people

3 hrs? Sounds like you need new surgeons. A TKA is a 45 minute cases…60 if the patient is fat.

I would be in heaven if it was 45. Usually tourniquet time alone is 45-60. Skin to skin is about 2-2.5 hrs

 

[psychbender]

I would be very surprised if a TKA or hip could be done with GA and with 100mcg fent. You are going to give 50mcg on incision and 50mcg total over the next 3 hrs??

A simple knee scope takes 100-300mcg of fent.

I think you just have bad surgeons. Our knee scopes are 30 minutes, and get less than 100mcg fentanyl (plus preop Tylenol and surgeon's local cocktail into the joint and field). Robotic TKRs can take a bit of time (1-2hrs), but still don't require much more than 100mcg fentanyl (crack a second vial less than half the time), because we're doing regional and multimodal, as well.

 

[PpfSuxTube]

Will never forget those hand craps from that day.

My boy did a hand crap a few days ago, ill never forget it either

 

[Sriddymopboi]

I remember I used to to take over cases from people who had nasal trumpets blowing boogers out of the nose or patients fidgeting and fussing. I said “nope,” and have done LMAs ever since. I have Wordles to do. I don’t need to be making things harder than they need to be.

Can I ask you something though - you said you run them like 0.3-0.5 MAC with LMA? Isn't that too light for a LMA?

 

[DocMcCoy]

Can I ask you something though - you said you run them like 0.3-0.5 MAC with LMA? Isn't that too light for a LMA?

20-50 prop for spinal, prop induction, lma, 0.8 mac sevo, antiemetics. Usulally nothing else.

 

[DocVapor]

Why gas at all? Just run propofol with an LMA. It doesn't take much at all when the patient is spinalized.

 

[DocMcCoy]

Why gas at all? Just run propofol with an LMA. It doesn't take much at all when the patient is spinalized.

Probably could. Awareness obviously less of an issue with a 100 percent working spinal. Still, I don’t run bis and we have ****ty old school propofol pumps. 0.8 mac sevo is pretty predictable and reliable.

 

[Twiggidy]

All versions of sleep work. I personally only don't touch the gas if there's a history of PONV, otherwise it's some version of all said above.

 

[deleted1130227]

When I was a resident, LMAs were just coming out. Our attendings would make us mask GA cysto cases with an oral airway all day long to get our masking skills up. We’d do 8 hours of mask GAs. It’s a skill to mask all day without your hand cramping up. At the time we also used reusable black rubber masks so you couldn’t see them fog.

I did as well. That technique has gone the way of the Dodo for a reason. Getting good at mask anesthesia requires finding its limits and resulting near misses or worse.

 

[Twiggidy]

I did as well. That technique has gone the way of the Dodo for a reason. Getting good at mask anesthesia requires finding its limits and resulting near misses or worse.

I agree. Advances have given us reasons to not do certain things anymore so there's no point to mask people for 8 hrs a day when we have perfectly (per se) functioning LMAs. People also used to blindly place PNB but now that we have ultrasound machines it would crazy to do so, and borderline malpractice.

 

[circleK]

We should start a thread of us older docs sharing extinct techniques we learned. Had one attending who intubated everyone with the light wand and made us learn. I guess if I ever find one and all my laryngoscopes and FOB’s are missing I’ll be good to go.

 

[pgg]

We should start a thread of us older docs sharing extinct techniques we learned. Had one attending who intubated everyone with the light wand and made us learn. I guess if I ever find one and all my laryngoscopes and FOB’s are missing I’ll be good to go.

Ah, the light wand.

The difficult airway technique that doesn't work on thick short necks (i.e. difficult airways). And you have to turn the room lights off to use it.


I did a trans-arterial axillary block once.

 

[deleted1130227]

We should start a thread of us older docs sharing extinct techniques we learned. Had one attending who intubated everyone with the light wand and made us learn. I guess if I ever find one and all my laryngoscopes and FOB’s are missing I’ll be good to go.

Ah, the light wand.

The difficult airway technique that doesn't work on thick short necks (i.e. difficult airways). And you have to turn the room lights off to use it.


I did a trans-arterial axillary block once.

That was the best part. Freaked out the OR staff.

 

[psychbender]

Ah, the light wand.

The difficult airway technique that doesn't work on thick short necks (i.e. difficult airways). And you have to turn the room lights off to use it.


I did a trans-arterial axillary block once.

Ahh, the anesthesia rave light. I absurdly caused a difficult airway with one once. It didn't work, gouged up the back of the pharynx, and made everything a nasty mess.

 

[deleted87051]

Ahh, the anesthesia rave light. I absurdly caused a difficult airway with one once. It didn't work, gouged up the back of the pharynx, and made everything a nasty mess.

At my first practice out of training, I said to an old timer, “Intubation is not so hard. There are only 2 holes, you have a 50-50 shot.”

His reply, “Well, you can always make a 3rd hole.”

 

[deleted1130227]

At my first practice out of training, I said to an old timer, “Intubation is not so hard. There are only 2 holes, you have a 50-50 shot.”

His reply, “Well, you can always make a 3rd hole.”

Seen that. Not good.

 

[GravelRider]

Can I ask you something though - you said you run them like 0.3-0.5 MAC with LMA? Isn't that too light for a LMA?

I never said that. Probably more like 0.6-0.8 MAC.