Hip surgery

[Gimlet]

My grandpa is going in for hip replacement surgery next week, and I just heard that he won't be put under general anesthesia. I guess his emphysema is so bad that they are concerned about the effectiveness the inhaled anesthetics would have in his lungs.

I'm assuming he'll be having some sort of epidural or other nerve block, correct? Would it also be the anesthesiologist's responsibility to get him doped up on enough drugs to make sure he doesn't know what's going on during the surgery? I've seen a video of a hip replacement, and it didn't seem like something I would want to be awake through, what with all the hammering and sawing.

Anyway, I just thought it might be interesting to discuss. Maybe this is a very common way to do hip replacements...I dunno, is it? I have only heard about this third-hand, so I might have the details confused.

Vent is right...this forum has been rockin' lately, and all of the awesome technical discussions have really piqued my interest in anesthesiology (even though I have no idea what is going on in said discussions 90% of the time! 😀 )

Thanks,
Andy
MS-0, Medical College of WI

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[jetproppilot]

My grandpa is going in for hip replacement surgery next week, and I just heard that he won't be put under general anesthesia. I guess his emphysema is so bad that they are concerned about the effectiveness the inhaled anesthetics would have in his lungs.

I'm assuming he'll be having some sort of epidural or other nerve block, correct? Would it also be the anesthesiologist's responsibility to get him doped up on enough drugs to make sure he doesn't know what's going on during the surgery? I've seen a video of a hip replacement, and it didn't seem like something I would want to be awake through, what with all the hammering and sawing.

Anyway, I just thought it might be interesting to discuss. Maybe this is a very common way to do hip replacements...I dunno, is it? I have only heard about this third-hand, so I might have the details confused.

Vent is right...this forum has been rockin' lately, and all of the awesome technical discussions have really piqued my interest in anesthesiology (even though I have no idea what is going on in said discussions 90% of the time! 😀 )

Thanks,
Andy
MS-0, Medical College of WI

Nice post, Andy. Heres the lowdown.

If my grandpa was having hip surgery, even if he didnt have COPD, I'd do a spinal or an epidural. It is now literature-proven that geriatric patients suffer cognitive deficit after GA (albeit subtle, like decreased ability to do the New York Times crossword puzzle as well as before the surgery). Yes, you can put everyone to sleep and most likely they'll survive, but why not invest the extra time to optimize their post-operative life?
A spinal or epidural will be the best thing for your elderly relative, and intravenous agents will assuredly be used during the case to keep him snoring. I guess thats a common misnomer about regional anesthesia...our goal is not to numb the site of surgery and let you remember everything...to the contrary. Regional anesthesia= numbing the site of surgery + providing intravenous hypnotics to keep you comfortable/asleep during the procedure.

 

[militarymd]

As above.. 👍

 

[Gimlet]

Thanks JPP 👍 👍

 

[Alpha_Male]

Nice post, Andy. Heres the lowdown.

If my grandpa was having hip surgery, even if he didnt have COPD, I'd do a spinal or an epidural. It is now literature-proven that geriatric patients suffer cognitive deficit after GA (albeit subtle, like decreased ability to do the New York Times crossword puzzle as well as before the surgery). Yes, you can put everyone to sleep and most likely they'll survive, but why not invest the extra time to optimize their post-operative life?
A spinal or epidural will be the best thing for your elderly relative, and intravenous agents will assuredly be used during the case to keep him snoring. I guess thats a common misnomer about regional anesthesia...our goal is not to numb the site of surgery and let you remember everything...to the contrary. Regional anesthesia= numbing the site of surgery + providing intravenous hypnotics to keep you comfortable/asleep during the procedure.

Right on........this is what I do for almost every hip surgery. 👍

 

[boysetsfire]

Hey, could one of you guys point me in the direction of a journal article or other resource that lists those proven benefits of doing spinal versus general anesthesia for total hip/knee replacements. I understand anecdotaly the benefits of regional versus general, but I just wanted an actual paper or article which proves these benefits. Thanks

 

[Justin4563]

spinal all the way.. also decreases the incidence of DVT which is major morbidity in orthopedics.. and i believe it decreases blood loss as well..

 

[militarymd]

Hey, could one of you guys point me in the direction of a journal article or other resource that lists those proven benefits of doing spinal versus general anesthesia for total hip/knee replacements. I understand anecdotaly the benefits of regional versus general, but I just wanted an actual paper or article which proves these benefits. Thanks

Ahhh..unfortunately hard data is lacking. Only indirect data exists. Level I (prospective randomized controlled trials) do not exist.

But as Jet pointed out...GA is bad for brain in old people....so indirect data exists.

As for DVT prevention...that data is old....If you don't give effective DVT prophylasis...ie don't use SCDs, don't use early PT/mobilization, don't use heparin and coumadin....then neuroaxial anesthesia is probably better than GA in DVT prevention.

 

[jetproppilot]

Ahhh..unfortunately hard data is lacking. Only indirect data exists. Level I (prospective randomized controlled trials) do not exist.

But as Jet pointed out...GA is bad for brain in old people....so indirect data exists.

As for DVT prevention...that data is old....If you don't give effective DVT prophylasis...ie don't use SCDs, don't use early PT/mobilization, don't use heparin and coumadin....then neuroaxial anesthesia is probably better than GA in DVT prevention.

Yes, the data for DVT prohylaxis was mostly with epidural infusion of neuraxial local anesthetic infusion continued after the surgery. Most orthopedists like to start low molecular weight heparin right after the operation so this is hard to do, considering the risk of covert epidural hematoma with an epidural catheter in place during LMWH administration.

BTW Military, hows the nephrectomy lady doing?

 

[jetproppilot]

Ahhh..unfortunately hard data is lacking. Only indirect data exists. Level I (prospective randomized controlled trials) do not exist.

.

Are you sure, dude? I'm gonna hafta to an internet search.

Regardless, sometimes I think the non-academic docs are way ahead of the literature sometimes. We just don't care about publishing.

Like CSE labor analgesia, for example. Birnbach's OB anesthesia text says "few OB anesthesiologists advocate the use of CSE for all labors"...goes on to express concern about drug leakage through the dural hole...etc etc.
I've been doing CSE on every laboring patient now for five years and have yet to see a high level, I have to give ephedrine about twice a year, its faster (no catheter dosing, just hook up an infusion when youre done), its safer (no catheter dosing), and most important, the patients love it, and the nurses love it.
Some academic dude will probably read this, do a trial, and publish it as his great idea. Thats OK, I'd rather be out on my boat.... 👍

 

[Justin4563]

Are you sure, dude? I'm gonna hafta to an internet search.

Regardless, sometimes I think the non-academic docs are way ahead of the literature sometimes. We just don't care about publishing.

Like CSE labor analgesia, for example. Birnbach's OB anesthesia text says "few OB anesthesiologists advocate the use of CSE for all labors"...goes on to express concern about drug leakage through the dural hole...etc etc.
I've been doing CSE on every laboring patient now for five years and have yet to see a high level, I have to give ephedrine about twice a year, its faster (no catheter dosing, just hook up an infusion when youre done), its safer (no catheter dosing), and most important, the patients love it, and the nurses love it.
Some academic dude will probably read this, do a trial, and publish it as his great idea. Thats OK, I'd rather be out on my boat.... 👍

why go out of your way to make a hole in someones dura???? I can get someone comfortable maybe 30 seconds after someone who uses cse can.. and i dont make a hole in your dura.. i dont care how small it is.. plus you have an untested catheter.........

 

[jem04]

Anyone else using depodur on THR yet?

 

[militarymd]

BTW Military, hows the nephrectomy lady doing?

I don't know. That case was 3 years ago. She is "lost" to followup.
🙂

 

[militarymd]

Are you sure, dude? I'm gonna hafta to an internet search.

I 'm pretty sure, but then I've been out of academics for a year and kind of stopped reading intensively....so...I'm sure I could be uninformed.

You are definitely right about how the literature is a skewed representation of actual practice....like "GA is unsafe for pregnant women"

 

[jetproppilot]

why go out of your way to make a hole in someones dura???? I can get someone comfortable maybe 30 seconds after someone who uses cse can.. and i dont make a hole in your dura.. i dont care how small it is.. plus you have an untested catheter.........

I can tell you that if you gave CSE a trial and did it for, say a month, you'd like it better than what you are doing now. Thats what happened to me; our "senior of equals" at my previous gig pressured us into trying it, we did, and liked it. Heres the answers to your skepticisms:

1)making a hole in the dura with a 26" spinal needle has no sequalae that I've seen in 5 years of doing it. My headache incidence is no higher than doing a straight epidural.
2)I actually think its safer, since you are never giving a bolus, so theres no chance of an abrupt high level. Even if your catheter was intrathecal, the dilute LA concentration at 12 mL hr would have an insidious onset, not over 30 seconds, like after an epidural bolus.
3)If you're getting the patient comfortable in "30 seconds after someone doing CSE can" then you're putting the patient at risk of a high level since the only way you can have a lady comfortable that quick dosing an epidural is to either dose through the needle or slam in 12-14 mL LA through the catheter over 30 seconds.
Don't get me wrong, I'm not saying that sometimes with an MD thats been doing epidurals for years and years (putting in an epidural is such a tactile procedure that once one gets the needle started you can almost close your eyes, since the feeling of LOR at the epidural space is very distinct) that you can't do that with some degree of safety, because I think you can. But don't imply CSE is frought withh many problems and what you are doing is safer, because it is not.
4) Incidence of "patchy" epidurals is almost zero.

 

[jetproppilot]

I can tell you that if you gave CSE a trial and did it for, say a month, you'd like it better than what you are doing now. Thats what happened to me; our "senior of equals" at my previous gig pressured us into trying it, we did, and liked it. Heres the answers to your skepticisms:

1)making a hole in the dura with a 26" spinal needle has no sequalae that I've seen in 5 years of doing it. My headache incidence is no higher than doing a straight epidural.
2)I actually think its safer, since you are never giving a bolus, so theres no chance of an abrupt high level. Even if your catheter was intrathecal, the dilute LA concentration at 12 mL hr would have an insidious onset, not over 30 seconds, like after an epidural bolus.
3)If you're getting the patient comfortable in "30 seconds after someone doing CSE can" then you're putting the patient at risk of a high level since the only way you can have a lady comfortable that quick dosing an epidural is to either dose through the needle or slam in 12-14 mL LA through the catheter over 30 seconds.
Don't get me wrong, I'm not saying that sometimes with an MD thats been doing epidurals for years and years (putting in an epidural is such a tactile procedure that once one gets the needle started you can almost close your eyes, since the feeling of LOR at the epidural space is very distinct) that you can't do that with some degree of safety, because I think you can. But don't imply CSE is frought withh many problems and what you are doing is safer, because it is not.
4) Incidence of "patchy" epidurals is almost zero.

Additionally
5)less hypotension
6)less required preload. You almost don't need a preload. 250-500 mL is plenty.