Hips and Knees

usually none. prop/sux/tube - Fem block for knees for postop pain. sab only if patient wants it or a particular reason I want to avoid ga.

 

Knees 10-15 mg. I will usually use 12.5 on a knee with a good surgeon, but our best knee guy could do these with a lidocaine, maybe even chloroprocaine spinal and I will go to 10 mg with him. It seems like we have a number of patients that sit and sit and sit in the PACU waiting for the block to wear off, so I don't have a problem going lower if I know the surgeon is slick. And knees are supine anyways so any supplemental anesthesia is easy.

Hips are almost always 15 mg. Sometimes epi as well 0.2 mg. One slower surgeon I don't hesitate to use tetracaine.

Does anyone else have trouble selling the spinal to patients? Our surgeons love them both for post op comfort and DVT prophylaxis, so they tell them in the office that they will likely get a spinal. By the time I talk to them I'd say a good 25% want "to go to sleep". I tell them that we give moderate to heavy IV sedation after the spinal is in, most patients take a nap, but there are no guarantees that they will have total amnesia. Maybe it's because I'm new, but if someone tells me that they absolutely want to remember nothing, then they will get GA. Period. Thoughts?

 

why does everybody want to do spinals for all these cases? Most of the patients would prefer GA so unless there is a reason not to ie pulm cripple etc, they get the prop and then tube or lma.

 

One of my attendings told me this and it works really well. I tell patients who I want to do a spinal for that they can still go to sleep in the OR. They will get medicines that will give them a nice nap and like normal sleep, if I called their name loudly or shook them, they'd probably open their eyes and then fall back asleep. I am upfront about the fact that I cannot guarantee that they won't remember anything. I then tell them that general anesthesia is more than sleep, it's like being in a coma in which I have to put a breathing tube in for them, put them on a ventilator, and breath for them during the surgery. I also like to point out the significant pain control advantages with a spinal over general. I then tell them that if it were me, I would have a spinal (totally a true statement. I would always choose regional over general unless a tourniquet was involved.)

Do they want to go to sleep and have a spinal with versed or a propofol gtt and have much better pain control or do they want to go into a coma and have general anesthesia?

When you put it that way, you get more positive response with the spinal option. While it certainly makes one option seem more attractive than the other, I do not believe it is misleading.

In response to thegasman, I know I want to do spinals for as many cases as possible simply because I'm a CA-1 and need the practice. I do generals all the time. I don't do a ton of spinals and while I'm sure I'll get plenty of practice in OB, I'd like to become somewhat proficient before then.

 

dont forget other risks/benefits for both. PONV, sore throat, PDPH, TNS, etc..... also the possibility of conversion to GA. You can always tell them that if they are not comfortable with sedation, you can always convert to GA

 

yes, all that, too.