Joint replacement spinal cocktail?

[nimbus]

all same day total joints are done with 40-45 mg of chloroprocaine. patient is moving by time we get to pacu and PT is there within 30 mins of pacu arrival. go home a couple hours later.

How long are your cases? Prep time? Surgical time?

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[deleted162650]

How long are your cases? Prep time? Surgical time?

Yes, I’d like to know how long your getting from the time spinal is placed till you hit PACU. What are you doing for sedation during the case?

 

[Arch Guillotti]

Yes, I’d like to know how long your getting from the time spinal is placed till you hit PACU. What are you doing for sedation during the case?

LMA?😉

 

[kmurp]

all same day total joints are done with 40-45 mg of chloroprocaine. patient is moving by time we get to pacu and PT is there within 30 mins of pacu arrival. go home a couple hours later.

While that wouldn’t work where I am, I’d love to hear what you are doing for pain control for these cases

 

[skypilot]

Since I work with CRNAs Tetracaine is a better choice because the motor block keeps the CRNA from blasting the patient with Propofol or placing an LMA in response to some minor muscle twitches.

Do you use any sedation other a little midaz?

 

[lakersbaby]

How long are your cases? Prep time? Surgical time?

preop: meloxicam, tylenol, ms contin
versed for block
intraop: chloroprocaine spinal, propofol infusion ~75-150 mcg/kg/min
Surgeon injects bupivicaine + toradol into joint
TXA x 2
can lift leg off bed by time in pacu

with our faster surgeons into OR and out to PACU about 1 hour 15 mins - 1.5 hours
slightly slower surgeons 1.5-2 hours, rarely have to go to put LMA in

the same day joint patients are hand picked though, the ones not eligible for same day we will sometimes still use chloroprocaine or go with the hyperbaric/isobaric bupi

 

[hippuppy]

It's been a while since I've done joints. Had a patient this week who wanted spinal only - she was otherwise healthy and 5'4''. I put in 1.6ml of 0.75% bupi with an epi wash, 100mcg duramorph and 20mcg fentanyl. I warned the surgeon he gets three hours … you would think that would be enough.

Spinal was working great until about 2.5 hours into the case when pt started "moving her leg" according to surgeon. I doubt she was actually moving but we still had over an hour left so we just converted to GA.

Was just wondering what everyone uses in their spinals for joints - would like to know both knees and hips.

Thanks.

Number 1 limiting step...patient absolutely refusing a spinal attempt...Number 2 limiting step...surgeons who take entirely too long to do the surgery. We are doing spinal with anterior hips as well. Sounds like you may have a surgeon problem.

 

[kmurp]

For operative times of 60 minutes or less you don't even need Isobaric Bupivacaine. Heavy Bupivacaine 12 mg works just as well and PACU time will be less. Hypotension is a bit more common with 12 mg of Heavy Bupivacaine than Isobaric Bup but nothing that can't be treated easily in the OR

Do you feel there’s any difference in the incidence of urinary retention with iso vs hyperbaric? The iso doesn’t go quite as high but I wonder if it pools on the sacral roots as much as the hyperbaric stuff.

 

[OneFellSwoop]

I've used chloroprocaine for our semi-same day total joints at the ASC, but found knees in particular are pretty uncomfortable when they hit the pacu and we are playing catch up. our preop cocktail with po meds and block is similar to lakersbaby. We are often using 5-7mg of 0.5% isobaric bupiv for TKA and THA. They are wiggling toes well upon PACU arrival, leaving within 1-2h after PACU arrival (the spinal has to resolve prior to leaving the facility), and with a slower onset of pain that's easier to get ahead of. As far as I can remember, I've never had to place an LMA because of the spinal wearing off. But we have very reliable and speedy surgeons who almost all operate in a 1-1.5h timeframe.

 

[kmurp]

I've used chloroprocaine for our semi-same day total joints at the ASC, but found knees in particular are pretty uncomfortable when they hit the pacu and we are playing catch up. our preop cocktail with po meds and block is similar to lakersbaby. We are often using 5-7mg of 0.5% isobaric bupiv for TKA and THA. They are wiggling toes well upon PACU arrival, leaving within 1-2h after PACU arrival (the spinal has to resolve prior to leaving the facility), and with a slower onset of pain that's easier to get ahead of. As far as I can remember, I've never had to place an LMA because of the spinal wearing off. But we have very reliable and speedy surgeons who almost all operate in a 1-1.5h timeframe.

What is your protocol for urination for these patients?

 

[deleted126335]

Anybody using the product Clorotekal?

Clorotekal ® (Chloroprocaine HCI Injection, USP)