Kidney Transplant under spinal

[deleted1183938]

Next time u do a kidney transplant maybe u should suggest this.

This is America. We aren’t that forward thinking because of our patient population and malpractice environment.

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[circleK]

I don’t think the animus is toward the anesthesiologist, it’s more at the insinuation that this is A) a novel technique that they discovered and B) was the main factor is the patient’s ability to be discharged earlier; when the main factor was the fact he was 28yo. You could prob do the same thing with a block and GA and an ERAS protocol. Also in my experience patients’ fear of being awake during surgery is 1000x more common than the fear of GA.

 

[Maz777]

I have had this request probably more than a hand full of times in my career. Really shows a level of misunderstanding with regards to what happens at the top of the bed. 😂

Just say there are no twitches and move on with life. They will never understand. Have them put their head down and stop taking so long. This is the point at which I raise the drapes even higher. As high as they will go.

 

[ans2021]

One of my highlights from residency was an ortho-bro asking for more relaxation during a THA under spinal. So I told him not possible, he’s not paralyzed, he’s got a spinal. He looked over to his rep with a “help me” look in his eyes, and the rep shrugged his shoulders and said “yeah, you and I were chatting in the room while he did the spinal”

I know this was discussed in another thread, but we have ortho bros asking for spinal and GA because the spinal doesn't relax them and request roc to be given. I don't see why I should do both, so I do a GA and the ortho legit asked how I was going to manage BP changes and if I had some magic up my sleeve to make sure the patient woke up comfortable. I worked some magic for him.

 

[Maz777]

I know this was discussed in another thread, but we have ortho bros asking for spinal and GA because the spinal doesn't relax them and request roc to be given. I don't see why I should do both, so I do a GA and the ortho legit asked how I was going to manage BP changes and if I had some magic up my sleeve to make sure the patient woke up comfortable. I worked some magic for him.

Ortho can fix bones. We will anesthetize. There's not a single orthopedic operation that requires paralysis except for maybe, just maybe a difficult closed reduction. I would never entertain their nonsensical plan. I'd just laugh and tell them the patient in preop has no twitches at their baseline. Stop bothering me and hurry the hell up.

 

[gunnershow]

Ortho can fix bones. We will anesthetize. There's not a single orthopedic operation that requires paralysis except for maybe, just maybe a difficult closed reduction. I would never entertain their nonsensical plan. I'd just laugh and tell them the patient in preop has no twitches at their baseline. Stop bothering me and hurry the hell up.

Don't agree with this. You're telling me a difficult hip exposure doesn't require paralysis? They'll have to compensate with bigger incisions, more distraction/tension, and more soft tissue trauma. How hard is it to paralyze an intubated patient? No one needs zero twitches til the end but if you really want them to hurry the hell up, it might help to give them good operating conditions.

 

[kidthor]

Ortho can fix bones. We will anesthetize. There's not a single orthopedic operation that requires paralysis except for maybe, just maybe a difficult closed reduction. I would never entertain their nonsensical plan. I'd just laugh and tell them the patient in preop has no twitches at their baseline. Stop bothering me and hurry the hell up.

That's my impression too. I just do peds these days and the peds ortho surgeons only ask for relaxation for closed reductions - never for anything else. It's odd to me that the adult ortho (and other) surgeons keep asking for more relaxation when the patient has zero twitches and physically cannot be any more relaxed!

 

[Maz777]

That's my impression too. I just do peds these days and the peds ortho surgeons only ask for relaxation for closed reductions - never for anything else. It's odd to me that the adult ortho (and other) surgeons keep asking for more relaxation when the patient has zero twitches and physically cannot be any more relaxed!

I get asked for "relaxation" all the time. Inguinal hernias, mastectomies, etc. I then proceed to place my LMA and start dense relaxation with sevo. I ignore >95% of what surgeons say. It's either idiotic nonsense, blatant lie, or irrelevant.

 

[pgg]

Don't agree with this. You're telling me a difficult hip exposure doesn't require paralysis? They'll have to compensate with bigger incisions, more distraction/tension, and more soft tissue trauma. How hard is it to paralyze an intubated patient? No one needs zero twitches til the end but if you really want them to hurry the hell up, it might help to give them good operating conditions.

Yeah, agreed.

I don't really understand the reluctance to just give these patients some rocuronium.

I mean surgeons ask for silly stuff all the time. Table up, table down. Maybe an inch of difference in table height makes their job marginally easier. I don't have to stretch my brain to imagine how zero twitches makes an orthopod's job marginally easier too.

Giving roc doesn't make my job any harder.

 

[ProwlerturnGas]

I think in the days pre-sugammadex I was more resistant to “need more relaxation ”. Now, 20-30 more no problem

 

[pgg]

Sugammadex changed my practice.

Giving more roc usually makes my job easier. I often keep people paralyzed, no twitches, until the last stitch goes in. Sevo down to 0.5-0.6% or so. Sugammadex in, sevo off, flows up. They open their eyes and are ready to extubate about the time the dressing goes on.

I don't see much point in getting people breathing or titrating opioid to RR/ETCO2. Not hard to estimate how much opioid patients will need, to within a reasonable margin. People will breathe when they're awake, if they don't get too much opioid. They can always get more if they wake up asking for it.

 

[deleted1183938]

Yeah, agreed.

I don't really understand the reluctance to just give these patients some rocuronium.

I mean surgeons ask for silly stuff all the time. Table up, table down. Maybe an inch of difference in table height makes their job marginally easier. I don't have to stretch my brain to imagine how zero twitches makes an orthopod's job marginally easier too.

Giving roc doesn't make my job any harder.

There are some people in this field who just have too much ego or just like drama. I have met them on my travels and they literally get off on fighting w surgeons over some silly things. Makes no sense to me. One literally told me when I asked him why he loves screwing with the surgeons, refusing to give them simple things they ask for and responding with “well Dr So and So doesn’t need any of this why do you??” and he said it was because he grew up with a bunch of boys and he’s used to the back and forth and actually enjoys it. I just shook my head.

I just want to go to work, do my job safely, be drama free as possible unless it’s going to harm the patient. Then we can tussle.

Of course he told me I don’t know how to own the room. Well if owning the room means constantly fighting w surgeons and pushing their buttons, I would rather stay the wallflower and mind my business quietly on my IPad.

 

[Lookingforlolz]

ortho surgeons here all have chosen their “preferred cocktail” full of redundencies.

spinal MAC, spinal LMA, spinal ETT with full relaxation.

knees are even worse, one guy wants spinal +adductor + GA with full relaxation. I agree with most here in that while I probably think their requests are kind of silly, but as long as it’s not completely idiotic i’m happy to be flexible. As long as the patient is well taken care of I’ll do whatever they request within reason. I think the whole “standing up to the surgeon” mentality isn’t worth the squeeze. These dudes are my coworkers, and we’re all just trying to do right by the patient and do a good job. They probably trained with a particular sort of anesthesia technique, and if it worked then they want it always out in practice. it’s whatever

 

[vector2]

, spinal ETT with full relaxation.

No.

 

[ans2021]

ortho surgeons here all have chosen their “preferred cocktail” full of redundencies.

spinal MAC, spinal LMA, spinal ETT with full relaxation.

knees are even worse, one guy wants spinal +adductor + GA with full relaxation. I agree with most here in that while I probably think their requests are kind of silly, but as long as it’s not completely idiotic i’m happy to be flexible. As long as the patient is well taken care of I’ll do whatever they request within reason. I think the whole “standing up to the surgeon” mentality isn’t worth the squeeze. These dudes are my coworkers, and we’re all just trying to do right by the patient and do a good job. They probably trained with a particular sort of anesthesia technique, and if it worked then they want it always out in practice. it’s whatever

Just curious. If a surgeon trained with anesthesia that all cases get blocked, including ulnar nerve transposition, patients with exisiting nerve palsies, are you doing the blocks because the surgeon asked and thats how he trained? I'm not sure doing a spinal plus a full GA is taking care of the patient IMO.

 

[circleK]

Had one ortho way back during residency that required epidural and GA (LMA) for every total bc a pt once talked during a min of one of his cases once while sedated (or at least the story goes). He also had a microphone under his hood so everyone in the OR could hear his god complex at full volume.

 

[GassYous]

Yeah, agreed.

I don't really understand the reluctance to just give these patients some rocuronium.

I mean surgeons ask for silly stuff all the time. Table up, table down. Maybe an inch of difference in table height makes their job marginally easier. I don't have to stretch my brain to imagine how zero twitches makes an orthopod's job marginally easier too.

Giving roc doesn't make my job any harder.

It's just annoying when the patient has just gotten 50 of roc and the surgeon says they aren't paralyzed enough.

 

[deleted1183938]

ortho surgeons here all have chosen their “preferred cocktail” full of redundencies.

spinal MAC, spinal LMA, spinal ETT with full relaxation.

knees are even worse, one guy wants spinal +adductor + GA with full relaxation. I agree with most here in that while I probably think their requests are kind of silly, but as long as it’s not completely idiotic i’m happy to be flexible. As long as the patient is well taken care of I’ll do whatever they request within reason. I think the whole “standing up to the surgeon” mentality isn’t worth the squeeze. These dudes are my coworkers, and we’re all just trying to do right by the patient and do a good job. They probably trained with a particular sort of anesthesia technique, and if it worked then they want it always out in practice. it’s whatever

Honestly though, what is the point of a spinal with a GA?? Are you guys doing spinal Morphine or something? What’s the point of the redundancy? Have you asked? And then the Adductor Canal on top of it? Jesus.
I am curious by nature and would for sure ask the reasoning.

 

[deleted1183938]

Just curious. If a surgeon trained with anesthesia that all cases get blocked, including ulnar nerve transposition, patients with exisiting nerve palsies, are you doing the blocks because the surgeon asked and thats how he trained? I'm not sure doing a spinal plus a full GA is taking care of the patient IMO.

💯. Adding more stress on the patient for what?

 

[deleted1183938]

It's just annoying when the patient has just gotten 50 of roc and the surgeon says they aren't paralyzed enough.

You know, lots of these Roc batches ain’t worth **** these days.

 

[sevo00]

I mean I’m All about making the surgeons job easier and could give two ****s as long as patient is safe and the surgeon is fast. But wth is the point of spinal with general? I would def stand by ground on that one and straight out refuse. Just added risk to the patient with zero benefit. Who cares if the patient talked once? As long as the patient didn’t move why does the surgeon care if the patient did talk. Give a few more mls of prop and up your infusion and wallah they dont talk anymore

 

[abolt18]

I mean I’m All about making the surgeons job easier and could give two ****s as long as patient is safe and the surgeon is fast. But wth is the point of spinal with general? I would def stand by ground on that one and straight out refuse. Just added risk to the patient with zero benefit. Who cares if the patient talked once? As long as the patient didn’t move why does the surgeon care if the patient did talk. Give a few more mls of prop and up your infusion and wallah they dont talk anymore

Or just GA all of his patients.

 

[dumbmedstudent]

At my shop most patients get both. But our surgeons are slow

 

[abolt18]

At my shop most patients get both. But our surgeons are slow

Why both? If they're too slow for a spinal, straight GA alone will do the job.
Why not just start putting in an LMA and ETT together in every patient? I guess redundancy is best

 

[dumbmedstudent]

Why both? If they're too slow for a spinal, straight GA alone will do the job.
Why not just start putting in an LMA and ETT together in every patient? I guess redundancy is best

I thought it was dumb at first too. But a low dose spinal actually works great for post op pain. Almost always there is no need for IV narcs. Makes the PT/discharge process much smoother

 

[GassYous]

Why both? If they're too slow for a spinal, straight GA alone will do the job.
Why not just start putting in an LMA and ETT together in every patient? I guess redundancy is best

Low dose dilaudid spinal bill for postop pain

 

[nimbus]

I thought it was dumb at first too. But a low dose spinal actually works great for post op pain. Almost always there is no need for IV narcs. Makes the PT/discharge process much smoother

Is this for outpatient joint replacement? What’s in the low dose spinal? Any urinary retention issues?

 

[MalloryWeiss]

Here's a contrarian view: Neuraxial + GA w/ ETT (0.5 MAC) +/- regional (adductor, PENG, etc.) = great technique.

Benefits:
- neuraxial narcotic = postop pain control, minimal postop narcotics
- neuraxial bupi = intraop pain control, minimal intraop narcotics
- supplemental regional block = post-op pain control, minimal postop narcotics
- paralysis = satisfies surgeon's preference for "optimal operating conditions" aka relaxation
- fast wakeup since not a lot of inhalational on board
- presumably less PONV and POCD due to less inhalational
- no need for jaw thrusts, oral airways, or adjusting malpositioned LMA's
- minimal hemodynamic issues when patient's hydrate and you're running 0.5 MAC
- zero intra-op narcotic use therefore less PONV compared w/ straight GA
- if slow surgeon, no problem because you're already prepared to extend the anesthetic via inhalational or additional LA (if you have an epidural)

Disadvantages:
- More work for the anesthesiologist = no debate there.
- Time = minimal. A well prepared anesthesiologist knows how to parallel process and get this done safely and with rapid efficiency.
---- step 1) spinal/epidural
---- step 2) induction + tube (Have induction drugs and airway ready to go so right when you lay them down. Empirically give a little pre-induction pressor, minimal IV narcotic on induction because the sympathetic drive from ETT stimulation helps maintain BP)
---- step 3) operate
---- step 4) regional drugs and needle and ultrasound ready to go prior to extubation
---- step 5) extubate to mask, continue monitoring EtCO2 while you're doing your. block
---- result: block is usually complete before the gurney even gets to the room, not to mention patient is wide awake by then
- "increased risk" = I call BS on this all day.
---- Airway? We have video laryngoscopes everywhere. Prefer an ETT over an LMA or oral airway any day.
---- Hemodynamics? Dude, don't run a full MAC of gas, obviously.

 

[sevo00]

Here's a contrarian view: Neuraxial + GA w/ ETT (0.5 MAC) +/- regional (adductor, PENG, etc.) = great technique.

Benefits:
- neuraxial narcotic = postop pain control, minimal postop narcotics
- neuraxial bupi = intraop pain control, minimal intraop narcotics
- supplemental regional block = post-op pain control, minimal postop narcotics
- paralysis = satisfies surgeon's preference for "optimal operating conditions" aka relaxation
- fast wakeup since not a lot of inhalational on board
- presumably less PONV and POCD due to less inhalational
- no need for jaw thrusts, oral airways, or adjusting malpositioned LMA's
- minimal hemodynamic issues when patient's hydrate and you're running 0.5 MAC
- zero intra-op narcotic use therefore less PONV compared w/ straight GA
- if slow surgeon, no problem because you're already prepared to extend the anesthetic via inhalational or additional LA (if you have an epidural)

Disadvantages:
- More work for the anesthesiologist = no debate there.
- Time = minimal. A well prepared anesthesiologist knows how to parallel process and get this done safely and with rapid efficiency.
---- step 1) spinal/epidural
---- step 2) induction + tube (Have induction drugs and airway ready to go so right when you lay them down. Empirically give a little pre-induction pressor, minimal IV narcotic on induction because the sympathetic drive from ETT stimulation helps maintain BP)
---- step 3) operate
---- step 4) regional drugs and needle and ultrasound ready to go prior to extubation
---- step 5) extubate to mask, continue monitoring EtCO2 while you're doing your. block
---- result: block is usually complete before the gurney even gets to the room, not to mention patient is wide awake by then
- "increased risk" = I call BS on this all day.
---- Airway? We have video laryngoscopes everywhere. Prefer an ETT over an LMA or oral airway any day.
---- Hemodynamics? Dude, don't run a full MAC of gas, obviously.

0.5 Mac does not reliable prevent awareness. Need atleast 0.7 Mac. With more gas now and a Spinal on board now you have a hypotensive patient and have to start pressors. Very complicated anesthetic whereas spinal with just prop at 50 mcg/kg/min with a simple mask on would have just been efficient

 

[MalloryWeiss]

0.5 Mac does not reliable prevent awareness. Need atleast 0.7 Mac. With more gas now and a Spinal on board now you have a hypotensive patient and have to start pressors. Very complicated anesthetic whereas spinal with just prop at 50 mcg/kg/min with a simple mask on would have just been efficient

Awareness is relative to the stimulation you’re receiving.

0.5 MAC with zero supplemental analgesic while you’re receiving a large abdominal surgery - then, yes I would agree with you that you would need to up the inhalational.

However, in this scenario 0.5 MAC is administered to eliminate awareness of ETT stimulation. Surgical stimulation does not contribute here because there is also a neuraxial anesthetic on board.

In short, this results in minimal to no hemodynamic issues.