I love spinals

[epidural man]

I think a spinal is such a great anesthetic.

I came on call today at 4pm and started my duty as the "floor walker" as we call it. Lots of rooms running and it is my job to get the staff out - so I have my resident take over a room that has an I&D of a prepatellar bursa coming up. I tell him - "really sell the spinal"

(The problem is...since our department has become so regional-centric, spinals are a rarity now-a-days)

So he is getting ready, asking me if I would use 1.2cc's or 1 or 1.4 or whatever. I said.."What are you talking about? We are using 2-cholorprocaine." We had to break into the OR pharmacy to get the stuff (it closes around 3pm). But whatever...

So the spinal goes great - case is going great...I am walking around, doing the floor walker thing, and sometime during the case, I pop my head in the room (patient asked the resident if he could be more awake...so resident abliged of course) to check on things....

A Cracker song (Euro-Trash Girl) is playing...so I say to the room "Great song, I think I'll stick around for it" and sit down. "Everyone on the chorus..." I say.

When the chorus comes up, along with everyone else, the patient blares ..."EURO-TRASH GIRL".

It made me smile...and it was way cool.

Spinals are cool.


[YOUTUBE]http://www.youtube.com/watch?v=uPoOIANzhzc&feature=related[/YOUTUBE]

---

Members don't see this ad.

 

[sevoflurane]

Hmmm... I would have taken you for an epidural man...

But I agree. Spinals are an easy safe anesthetic with great post-op pain control and minimal complications.

GA for everyone is not my style.

 

[PMPMD]

I've always loved the simplicity of a good SAB. Even after doing many, when I see the CSF flowing I get happier than Jed Clampett when he saw the Texas T flowin up from the ground.

 

[urge]

I hate spinals.

 

[TrustMe]

First off....nice Beverly Hillbillies reference!!

I totally agree. Spinals are great. I wish I would have done more short acting spinals (i.e. lidocaine) during residency. I only had a couple of attendings even willing to try. But when I did do them they were great. So many uses for the short acting stuff but nobody wants to use it. Cysto, knee scope, hemrrhoids, cerclage, I&D's, hernia's. I guess pent, sux, tube is good too.

 

[DreamLover]

First off....nice Beverly Hillbillies reference!!

I totally agree. Spinals are great. I wish I would have done more short acting spinals (i.e. lidocaine) during residency. I only had a couple of attendings even willing to try. But when I did do them they were great. So many uses for the short acting stuff but nobody wants to use it. Cysto, knee scope, hemrrhoids, cerclage, I&D's, hernia's. I guess pent, sux, tube is good too.

My residency may have been in the minority, but we had a hand full of OB attendings that were fine with lidocaine SABs for cerclages, BTLs, etc....for what it's worth, no known TNS...and we post op'd everyone...but, if you do enough of anything, something is bound to show up....the hospitals I work at now don't even stock spinal lidocaine

 

[periopdoc]

Chlorprocaine for short acting.

Lots of SAB's and regional in residency. Had fun with them then, but now.

"That's not my bag baby"

I think the benefits are overplayed by people who have secondary gain in performing the blocks.

My patients and I both prefer that they are asleep for surgery.


- pod

 

[sevoflurane]

For every situation where regional is an option, I think we should at least consider it rather than default to GA.

GA is easy. Spinal or regional takes a little more effort. But patients may appreciate it. Evaluate the sceanario and then decide.

For me, as a patient..... I prefer spinal with midaz over PVC.... EVERY SINGLE TIME. Spare me the vent/ppv and inhaled vapor +/- the sore throat, nausea, etc.

Lma is ite, but not necessary. Dealers/patients choice.

For those who want lights out = GA.

No need to x out regional as an option.

It's an excellent option and one that should not be forgotten.

 

[sevoflurane]

I think the benefits are overplayed by people who have secondary gain in performing the blocks.



- pod

As a sole anesthetic you have nothing to gain (except the issues associated with GA).... unless you add spinal morphine which works very well.

Or do you mean regional in general?

I like dropping happy patients off in the Pacu with little to insignificant IV narcs + no GA + hours of great pain control. Shoulders and tka's for example...

 

[periopdoc]

I mean the benefits of regional in general... Wait that doesn't sound right.

I mean the benefits of regional techniques, be they neuraxial or peripheral, tend to be overstated by those who have secondary gain (either financial or emotional. i.e. the enjoyment of a well done regional case). Of course I get the secondary gain of not being blamed when the surgeon bungs up a nerve with a retractor etc. Fool me once...

Admittedly, regional is more fun than a boring, easy GA, but is it really better for the patient?

I prefer dropping off happy patients who have an appropriate opiate load that they can maintain and who will not get the experience of sudden onset 8/10 pain at 3am when the local in their regional block abruptly wears off (specifically shoulders).


- pod

 

[periopdoc]

Oh and I don't mean that as a dig at you Sevo, just a general observation.

I came out of residency in love with regional. Planned on introducing outpatient catheters to wherever I ended up. Landed in a place where regional isn't as prevalent and started questioning whether there really is a significant benefit to regional. Sure there are specific cases where it is optimal, but I mean as a plan for all comers. Realized that the most vocal proponents of regional during my training realized a significant secondary gain of one sort or another.

I still love a good regional anesthetic. It is more fun for me and I generally get to bill more. It is fun to drop them off wide awake and pain free in PACU, but I am not convinced that it is actually better for the patient then a well executed GA.

- pod

 

[BLADEMDA]

Oh and I don't mean that as a dig at you Sevo, just a general observation.

I came out of residency in love with regional. Planned on introducing outpatient catheters to wherever I ended up. Landed in a place where regional isn't as prevalent and started questioning whether there really is a significant benefit to regional. Sure there are specific cases where it is optimal, but I mean as a plan for all comers. Realized that the most vocal proponents of regional during my training realized a significant secondary gain of one sort or another.

I still love a good regional anesthetic. It is more fun for me and I generally get to bill more. It is fun to drop them off wide awake and pain free in PACU, but I am not convinced that it is actually better for the patient then a well executed GA.

- pod

There are subgroups that benefit from Regional:http://www.mayoclinicproceedings.com/content/85/1/18.full

As for post op pain blocks only a single shot femoral nerve block after a total knee replacement has been shown to possibly reduce length of stay; other studies hint at benefits of additional/other regional techniques like Thoracic epidurals, paravertebral blocks, etc for reducing morbidty post op.

http://acutepayne.com/Documents/1234.full.pdf

http://journals.lww.com/anesthesiol...rve_Block_Improves_Analgesia_Outcomes.29.aspx

http://www.ncbi.nlm.nih.gov/pubmed/9661552

http://www.anesthesia-analgesia.org/content/105/1/238.full

 

[BLADEMDA]

A good Regional Block combined with low dose propofol may help prevent memory loss. Perhaps, more baby boomers will be requesting this technique in the future.

http://todaysseniorsnetwork.com/memory_loss_after_surgery.htm

 

[BLADEMDA]

The common feature was that all of the individuals either had memory impairment after a prior surgical procedure with general anesthesia or had a relative with Alzheimer's disease.


http://www.asaabstracts.com/strands...B4A62B30DBB6372?year=2011&index=5&absnum=6241

 

[BLADEMDA]

Inhaled anaesthetic agents remain the mainstay for patients undergoing major surgical operations, especially in elderly patients. Clinically, relevant concentrations of isoflurane induce apoptosis, alter APP processing, and increase Aβ production in human cell lines. Because altered processing of APP leading to accumulation of Aβ is a key event in the pathogenesis of AD, these findings may have implications for use of this anaesthetic agent in individuals with excessive levels of cerebral Aβ, and elderly patients at increased risk for postoperative cognitive dysfunction.15 In addition, isoflurane interacts with Aβ40 peptides and promotes Aβ oligomerization and cytotoxicity.1617
On the basis of his experimental published data, Mandal2 suggested that ‘the inhaled anaesthetics halothane and isoflurane encourage clumping of beta amyloid protein. Halothane interacts directly with a pocket in the beta amyloid protein, changing its shape and encouraging neighbouring proteins to bind. Giving elderly patients certain general anaesthetics could increase their risk of developing Alzheimer's disease and other memory and attention problems'. Therefore, anaesthesia for elderly patients is considered as a risk factor in AD as they frequently experience deterioration in cognitive function with long exposure to anaesthetics during surgery.3

 

[BLADEMDA]

Several possible explanations exist for why such different outcomes have been seen. All the studies used different measures for cognitive assessment, and the measures used by Jones et al6 may be less sensitive to cognitive change than those used in the other studies. Also, the ISPOCD1 study found no difference between the control and surgery groups after one to two years.
Scant evidence exists about what may contribute to long term postoperative cognitive dysfunction even if it does exist. The two studies comparing general and epidural anaesthesia found no difference in outcome,6 7 and the ISPOCD1 study found no link between long term cognitive dysfunction and either hypoxaemia or hypotension.4 Four out of the five studies found that increasing age was a statistically significant risk factor in the development of long term postoperative cognitive dysfunction. However, higher age also increases the risk of developing dementia, emphasising the need for studies with adequate control groups. Other factors included a low educational level, a history of cognitive dysfunction before surgery, and cognitive dysfunction at one week after surgery. Even so, most patients showing cognitive dysfunction after one week recovered after several months. The only indication of a possible preventive measure would be to reduce postoperative infection rates in surgical wards, and such measures are already standard practice.
Whether or not major surgery or general anaesthesia increases the risks of long term cognitive dysfunction remains unclear. The research so far has had methodological problems, and so it is not possible to draw conclusions. Future research needs to include validated, reliable, and sensitive cognitive assessments and well matched control groups to take into account the possible influences of disability, pain, and depression on cognitive function. Until such studies have been conducted and sufficient evidence is available it will be difficult to provide older patients with informed advice about the potential long term risks of surgery.

 

[pgg]

As for post op pain blocks only a single shot femoral nerve block after a total knee replacement has been shown to possibly reduce length of stay

Ironically, femoral blocks for TKAs are the only regional technique our orthopods absolutely forbid. They're convinced that anyone who gets a femoral block will get out of bed, fall on their weak leg, and break a hip.

 

[periopdoc]

Still not convinced. Still not enough data for me to go to my colleagues (surgical and anesthetic) and say see, here is the proof, let's change our technique. Still keeping my eyes open.

There are a lot of tantalizing articles that hint at benefit... "The data suggests, there was a trend towards, possibly decreases the risk of..." Yet despite years of looking at this issue, no one has been able to definitively demonstrate the superiority of regional techniques in terms of outcomes and complications, just surrogate benefit.

There should be a "Blade Bomb" smiley.

- pod

 

[BLADEMDA]

Ironically, femoral blocks for TKAs are the only regional technique our orthopods absolutely forbid. They're convinced that anyone who gets a femoral block will get out of bed, fall on their weak leg, and break a hip.

Orthopods. Just give the Ancef

 

[BLADEMDA]

Still not convinced. Still not enough data for me to go to my colleagues (surgical and anesthetic) and say see, here is the proof, let's change our technique. Still keeping my eyes open.

There are a lot of tantalizing articles that hint at benefit... "The data suggests, there was a trend towards, possibly decreases the risk of..." Yet despite years of looking at this issue, no one has been able to definitively demonstrate the superiority of regional techniques in terms of outcomes and complications, just surrogate benefit.

There should be a "Blade Bomb" smiley.

- pod

I'm just Suggesting that there may be a benefit to certain subgroups and the use of Regional techniques. The 60 year old patient who is struggling with his memory already won't be helped with a general anesthetic; perhaps, you would be kind enough to give him a Regional.

 

[BLADEMDA]

Ironically, femoral blocks for TKAs are the only regional technique our orthopods absolutely forbid. They're convinced that anyone who gets a femoral block will get out of bed, fall on their weak leg, and break a hip.

As the CV surgeons say, orthopedic surgeons think the function of the heart is to pump Ancef to the bones... this joke I heard from a neurosurgeon that when trying to hold the elevator door from closing, a radiologist uses their foot/leg, a internist uses his hand, and an orthopedic surgeon uses his head)

 

[BLADEMDA]

Preemptive and multimodal pain control protocols have been introduced to enhance rehabilitation after total knee arthroplasty (TKA). We determined the complication rate associated with preoperative femoral nerve block (FNB) for TKA. Among 1018 TKA operations, we performed 709 FNBs using a single-injection technique into the femoral nerve sheath and confirming position with nerve stimulation before induction. After TKA, weightbearing as tolerated was initiated using a walker or crutches on postoperative Day 1. Twelve patients (1.6%) treated with FNB sustained falls, three (0.4%) of whom underwent reoperations. Five patients had postoperative femoral neuritis, which may have been secondary to the block. One patient had new onset of atrial fibrillation after FNB, and the TKA was postponed. Femoral nerve block before TKA is not a harmless intervention. We recommend postoperative protocols be modified for patients who have FNB to account for decreased quadriceps function in the early postoperative period, which can lead to falls.

 

[periopdoc]

This

A good Regional Block combined with low dose propofol may help prevent memory loss.

is at least three good solid steps away from having anything to do with this

http://todaysseniorsnetwork.com/memory_loss_after_surgery.htm

a lay article about an article on using L-655,708 (α5GABAA receptor inverse agonist) in mice to reduce memory impairment following isoflurane anesthesia.


I am still waiting for good evidence that the 60-year-old is going to have a reduced long-term risk of worsening memory dysfunction from the regional/ sedation technique. Sure I do it, but every time I ask myself is this really of any benefit to the patient?

- pod

 

[pgg]

Orthopods. Just give the Ancef

Hah, we've got one that insists on redosing the Ancef right before the tourniquet goes down, and again at the end of the case. I used to argue, dude, does this person really need to get 4 g of Ancef in the span of 2 hours, but now I just give the Ancef.

As the CV surgeons say, orthopedic surgeons think the function of the heart is to pump Ancef to the bones... this joke I heard from a neurosurgeon that when trying to hold the elevator door from closing, a radiologist uses their foot/leg, a internist uses his hand, and an orthopedic surgeon uses his head)

I like the "where do you hide $100 from ..." series

internist - under a sterile bandage
orthopod - in a book
plastic surgeon - you can't
etc

 

[BLADEMDA]

Preemptive and multimodal pain control protocols have been introduced to enhance rehabilitation after total knee arthroplasty (TKA). We determined the complication rate associated with preoperative femoral nerve block (FNB) for TKA. Among 1018 TKA operations, we performed 709 FNBs using a single-injection technique into the femoral nerve sheath and confirming position with nerve stimulation before induction. After TKA, weightbearing as tolerated was initiated using a walker or crutches on postoperative Day 1. Twelve patients (1.6%) treated with FNB sustained falls, three (0.4%) of whom underwent reoperations. Five patients had postoperative femoral neuritis, which may have been secondary to the block. One patient had new onset of atrial fibrillation after FNB, and the TKA was postponed. Femoral nerve block before TKA is not a harmless intervention. We recommend postoperative protocols be modified for patients who have FNB to account for decreased quadriceps function in the early postoperative period, which can lead to falls.

Where do they get this data? In my center we have performed well over eight thousand Single Shot femoral nerve blocks for total knee replacement, ACL repairs, Patella tendon repairs, etc.

To my knowledge there have been only 2 cases of patients in this subgroup falling following surgery requiring surgical correction: Two

Femoral Neuritis? Really? Again, I'm not aware of more than a few complaints beyond 8 weeks post op. In other words, by 8 weeks 99.9% of all and any complaints related to the block are gone.

A. Fib? Come on. These patients are an older group with some in their 80s or 90s.


http://www.anesthesia-analgesia.org/content/early/2010/10/01/ANE.0b013e3181fb9507.full.pdf


http://www.springerlink.com/content/1q2276m712161qw3/


http://www.josonline.org/pdf/v16i3p381.pdf

 

[periopdoc]

The same way I feel when I read about the incidence of post-operative cognitive dysfunction. I don't have nearly the case experience that you do, but I still wonder where they come up with these numbers. Even my on-pump cardiac surgical patients have a lower POCD rate than most of the quoted numbers for the general surgical population.

- pod

 

[BLADEMDA]

http://journals.lww.com/anesthesiol...cal_or_Electrophysiologic_Evidence_of.25.aspx

http://www.ncbi.nlm.nih.gov/pubmed/18945716

My hunch is there are more potential complications from Continuous nerve blocks than single shot.

 

[BLADEMDA]

A Prospective, Randomized, Controlled Trial Comparing Ultrasound Versus Nerve Stimulator Guidance for Interscalene Block for Ambulatory Shoulder Surgery for Postoperative Neurological Symptoms

 

[sevoflurane]

Oh and I don't mean that as a dig at you Sevo, just a general observation.

I know dude.

You know I like to discuss these types of issues.

Honestly, I'm kinda surprised to hear your thoughts on the subject. Didn't you do a month at Virginia Mason?

You are starting to sound like most of the CT anesthesiologists I know....

FWIW, In my practice patient satisfaction scores are always higher when RA is used by itself or in conjunction with GA when compared to GA alone.

It is a service/option I provide to my patients when applicable.

 

[sevoflurane]

Where do they get this data? In my center we have performed well over eight thousand Single Shot femoral nerve blocks for total knee replacement, ACL repairs, Patella tendon repairs, etc.

To my knowledge there have been only 2 cases of patients in this subgroup falling following surgery requiring surgical correction: Two

Femoral Neuritis? Really? Again, I'm not aware of more than a few complaints beyond 8 weeks post op. In other words, by 8 weeks 99.9% of all and any complaints related to the block are gone.

A. Fib? Come on. These patients are an older group with some in their 80s or 90s.


http://www.anesthesia-analgesia.org/content/early/2010/10/01/ANE.0b013e3181fb9507.full.pdf


http://www.springerlink.com/content/1q2276m712161qw3/


http://www.josonline.org/pdf/v16i3p381.pdf

I agree with you.

RA is EXTREMELY safe.

One must have a plan in place when dealing with quad weakness... ie PT needs to be aware of the weakness + knee stabilizer should be used. Patients shouldn't be falling over at any time in their care.

One thing to keep in mind is that tourniquet pressures and times can lead to post-op nerve dysfunction... it is more common than you think when you are inflating to 350 mmhg and have a slow surgeon.

Afib? That's a joke right?

 

[periopdoc]

Honestly, I'm kinda surprised to hear your thoughts on the subject. Didn't you do a month at Virginia Mason?

Yep, two months in fact. That's where I learned about managing outpatient nerve catheters. Loved regional, still do. Even applied for their fellowship (it was filled the week before I submitted my application). I knew it would be a waste of money, but thought it would be a fun year.

While there, I started looking at the outcomes data with a skeptical eye and I was kind of surprised at how weak the data is. It just makes sense that outcomes should be superior with regional, and it should be simple to demonstrate superiority, but the only area I could find definitive evidence for an improvement in outcomes was with TEP for supra-umbilical surgery.

Interestingly enough, one of the morning report questions for the residents was something along the lines of what outcomes are proven to be improved with regional followed by a list of neuraxial and peripheral techniques. I was the only resident in the room who had the correct answer and they gave their residents a hard time that "only the UW guy knew the answer to that one." Understand that, in addition to the residents, this is a room full of some of the top regional faculty in the country and there was no argument from them after the correct answer was revealed/ discussed.

I agree with you. RA is EXTREMELY safe.

I completely agree. Unfortunately, the reality is that no matter the actual causation of damages, the first stop on the blame train game is going to be the regional technique. Weakness? Must have been a intraneural injection. Pain? Must have been trauma from the needle. Lumbar plexopathy following a technically difficult colectomy where it was noted on multiple occasions that the surgical team was leaning on the retractor and pushing it into the patient? Must be from incredibly precise placement of the Tuohy needle into the descending motor pathway after successfully navigating the posterior half of the spinal cord without doing any damage. Granted those examples are all from UW and not my current institution, but like I said "fool me once..."

One thing to keep in mind is that tourniquet pressures and times can lead to post-op nerve dysfunction... it is more common than you think when you are inflating to 350 mmhg and have a slow surgeon.

Thankfully, almost never will I have to worry about the blame for this being inappropriately placed on me.

Afib? That's a joke right?

Why not. I could certainly see an inadvertent vascular injection of epi setting off an episode of a-fib.

- pod

 

[sevoflurane]

Yep, two months in fact. That's where I learned about managing outpatient nerve catheters. Loved regional, still do. Even applied for their fellowship (it was filled the week before I submitted my application). I knew it would be a waste of money, but thought it would be a fun year.

While there, I started looking at the outcomes data with a skeptical eye and I was kind of surprised at how weak the data is. It just makes sense that outcomes should be superior with regional, and it should be simple to demonstrate superiority, but the only area I could find definitive evidence for an improvement in outcomes was with TEP for supra-umbilical surgery.

Interestingly enough, one of the morning report questions for the residents was something along the lines of what outcomes are proven to be improved with regional followed by a list of neuraxial and peripheral techniques. I was the only resident in the room who had the correct answer and they gave their residents a hard time that "only the UW guy knew the answer to that one." Understand that, in addition to the residents, this is a room full of some of the top regional faculty in the country and there was no argument from them after the correct answer was revealed/ discussed.




I completely agree. Unfortunately, the reality is that no matter the actual causation of damages, the first stop on the blame train game is going to be the regional technique. Weakness? Must have been a intraneural injection. Pain? Must have been trauma from the needle. Lumbar plexopathy following a technically difficult colectomy where it was noted on multiple occasions that the surgical team was leaning on the retractor and pushing it into the patient? Must be from incredibly precise placement of the Tuohy needle into the descending motor pathway after successfully navigating the posterior half of the spinal cord without doing any damage. Granted those examples are all from UW and not my current institution, but like I said "fool me once..."




Thankfully, almost never will I have to worry about the blame for this being inappropriately placed on me.




Why not. I could certainly see an inadvertent vascular injection of epi setting off an episode of a-fib.

- pod

Wow... almost did regional instead... Close one.

I bet you are far better off with your regional background and doing CT fellowship instead. Nice.

 

[sevoflurane]

Why not. I could certainly see an inadvertent vascular injection of epi setting off an episode of a-fib.

- pod

Inadvertent intravascular injection is something that shouldn't happen if you aspirate and have proper technique +/- usd.

I guess if you accidentally inject a couple of cc's of .5% bupi or rop you can block enough fast channel sodium (and possibly potassium) receptors in an already vulnerable heart that could lead to atrial fibrillation. Additionally, it appears that bupivicaine and LA not only blocks Na and K channels but is directly toxic to cardiac myocytes.

However, not many anesthesiologists inject such small amounts. If it's a true inadvertent injection you are more likely talking about a minimum of 10 and up to 40cc's of LA (lumbar plexus for example).... if not aspirating and checking for heme.

As you know, a fib is not the typical picture. Intravascular bupivicaine administration (particularly venous injections) is more commonly associated with progressive QRS/QTc widening, culminating in ventricular fibrillation and cardiac arrest. ST elevations have also been shown to occur with bupi toxicity and can indicate impending cardiovascular collapse. I have not read much on a fib as a manifestation of intravascular injections. Maybe I need to look for it a bit more.

QRS widening:

http://www.anesthesia-analgesia.org/content/90/6/1308/F3.expansion.html

ST elevations:

http://bja.oxfordjournals.org/content/early/2010/08/02/bja.aeq197/F3.large.jpg

A routine block with good technique (aspiration q 5cc's) is unlikely to cause atrial fibrillation unless you have exceeded maximum dosage, in which case toxicity may manifest as cardiac irritability and afib.

It appears to me that if you have a true intravascular injection, with common regional doses, you are likely to see a lot more than atrial fibrillation.

 

[sevoflurane]

I completely agree. Unfortunately, the reality is that no matter the actual causation of damages, the first stop on the blame train game is going to be the regional technique. Weakness? Must have been a intraneural injection. Pain? Must have been trauma from the needle. Lumbar plexopathy following a technically difficult colectomy where it was noted on multiple occasions that the surgical team was leaning on the retractor and pushing it into the patient? Must be from incredibly precise placement of the Tuohy needle into the descending motor pathway after successfully navigating the posterior half of the spinal cord without doing any damage. Granted those examples are all from UW and not my current institution, but like I said "fool me once..."

- pod

This is an unfortunate truth... which causes many anesthesiologists to take a defensive stance when considering regional anesthesia.

 

[sevoflurane]

Why not. I could certainly see an inadvertent vascular injection of epi setting off an episode of a-fib.

- pod

Just re-read your post.

I do agree that epi may trigger a tachyarrythmia. Which is one reason I don't use epi any more.

 

[BLADEMDA]

Just re-read your post.

I do agree that epi may trigger a tachyarrythmia. Which is one reason I don't use epi any more.

Many of us don't use Epi any longer in our blocks. In the elderly age group A.Fib is simply a common, daily occurrence.

 

[sevoflurane]

Definitely. In a healthy heart 5ccs of 1:200k would likely just cause tacycardia. In the 80 y/o with cardiomyopathy/EF of 20% + RWMA's/ dyskenetic walls, that same 25 mcgs of epi + local might trigger something like A fib or worse.

In general, these elderly patients flip in and out of a fib all the time and if it does pop up, it is certainly NOT a clear indicator of an intravascular injection and the likelihood that it is related to your block is extremely low... Especially with correct technique.

A fib just happens in this subgroup of patients.

 

[periopdoc]

Agreed. In all likelihood it is true, true and unrelated. They likely happened to catch him flipping into another paroxysm of a-fib.

Just saying it is theoretically plausible that inadvertent injection of a small portion of the injectate (say the needle went through both walls of the vessel yielding an appropriate lack of heme on aspiration but allowing a small amount of epi to enter the vessel on withdrawal of the needle) put the patient into a-fib. As unlikely as it is, it is still responsible to include it in the report.

Given the scenario of a patient with previously unknown afib who develops it in the preop holding area (whether after a block or not) I would be a little reluctant to proceed with an elective knee replacement without an echo at minimum.

- pod

 

[dhb]

I think a spinal is such a great anesthetic.

As a patient i disagree: good enough to get the job done yes, great no.

 

[epidural man]

While there, I started looking at the outcomes data with a skeptical eye and I was kind of surprised at how weak the data is. It just makes sense that outcomes should be superior with regional, and it should be simple to demonstrate superiority, but the only area I could find definitive evidence for an improvement in outcomes was with TEP for supra-umbilical surgery.


- pod

I think Joe Neal's recent review shows that it is true that single shots offer no advantage, but catheters show a decrease in opioid usage and side effects.

Julia Pollock (another VM allum) discusses in her Audio Digest lecture that spinal is the cheapest anesthetic.

I'm not really talking about outcomes data anyway. I know they are similar - and similar in morbidity or mortality.

However, it is hard pill for me to swallow that a 2-chloroprocaine spinal, for a short procedure - where the patient has no LMA or tube and no post-GA side effects, and leaves the PACU quicker - (and probably the time to start the case, and leave the OR room) isn't better for the hospital and the patient.

I could be treating myself - no doubt. I mean I do get a kick out of the idea that 2cc's of medicine make an almost perfect anesthetic - the room remains clean...I don't have to change the suction canister, the circuit, etc - and all my drugs and airway equipment remain completely untouched.

I bet not everyone loves black licorice either. I do. I had a friend nurse once tell me (after I offered to buy her some black licorice in the cafeteria) "of course I like black licorice. I don't think you can trust someone that doesn't like it."

That made me chortle.

 

[BLADEMDA]

I've done more than 2 dozen total knees under straight block: Lumbar Plexus plus Sciatic Or Femoral/Sciatic.

The Femoral/Sciatic sometimes need more Propofol as the 3 in 1 isn't usually 3 but more like 1 (Femoral). The Lumbar Plexus/Sciatic works extremely well and discharge from PACU is under 30 minutes.

I usually do combined techniques for speed and simplicity so this means a LMA plus blocks, SAB plus a block or two or simply a GA/ET Tube with Block in PACU.

My catheters are basic but work well (99% success). I stick with Femoral and ISB. No Lumbar Plexus, Sciatic or popliteal catheters. I'm mostly a single shot guy but I'm happy to provide a catheter when requested.