Kypho/vertebroplasty anesthesia options

[hyperalgesia]

I have an osteoporotic patient in her 60's who is an excellent kyphoplasty candidate except for the fact that she has severe, end-stage COPD. Pulmonology has documented there is "almost zero chance she could come off of a ventilator" in the event that she requires intubation. She has failed conservative options; meds, bracing, etc and wants to go ahead with a kyphoplasty (T7,8, L1). Does anyone have experience doing kypho/vertebroplasty using local only, without sedation?

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[pars]

I've been doing them under local/MAC for the last 2 years. They're usually awake enough to talk while I'm working and want to know what that pounding that sounds like a hammer is... A few times I've done local without any sedation because they've messed up their NPO status and it's gone ok. Lidocaine/marcaine down to bone. I prefer a bit of sedation though...

If you're just doing straight local I personally would pick the one area that hurts the most and do that first (either T7 and 8, or L1). 3 levels under straight local sounds like a beating for everyone in the room...

 

[hellothane]

If you do not want to perform under local try single shot epidural or if body habitus allows prone and place LMA for a real light general. I use both of these techniqes for kyphoplsty as the surgeon does not want a MAC.

 

[lobelsteve]

I do v-plasty under local. I will on occasion use fentanyl and versed, but not more than 2/2 for v-plasty so far.

Use a 25g 3.5 quincke and infiltrate the periosteum with 1% lido with epi.
No pain after that.

 

[facetguy]

Have you guys come across any reimbursement problems for vertebroplasty since some unfavorable studies were released of late?

 

[hyperalgesia]

Thanks guys, great to hear about your experiences.

On the reimbursement question, I haven't seen any change at my institution and I doubt there will be any (other than the usual slow death of all reimbursement). The recent studies aren't enough to undo the vast amount of supportive literature out there. At least IMHO.

 

[SleepIsGood]

Thanks guys, great to hear about your experiences.

On the reimbursement question, I haven't seen any change at my institution and I doubt there will be any (other than the usual slow death of all reimbursement). The recent studies aren't enough to undo the vast amount of supportive literature out there. At least IMHO.

For our stims and Vplasty...we use .25% bupi with epi....it'll stay longer. LIdo as you know just wears off after a bit.

 

[Pain_doc]

V-plasty can be done comfortably with just local. The procedure itself is not the issue with the pulmonary cripples (no blood loss, no fluid shifts, no fluid overload, etc.), its the position. Although you can place the bed in some reverse t-berg, its that prone position that they find most bothersome. Of course, if the patient is uncomfortable, they move. Then it takes longer, they become more restless, they move more......

Sometimes, a little sedation goes a long way. When in doubt, I get an anesthesiologist involved & let them provide me the motionless field.

 

[Tenesma]

also, god forbid you emblize some of that cement into their lungs - that can cause some wicked desats