Lidocaine Spinals

[Laurel123]

Now that I am out in private practice world, things are a little different from residency so I was wondering how all you private practice guys do things:

Anyone use lidocaine spinals for C/S? We did in residency, but no one does it here.

How much 0.75% bupiva do you use for C/S? We used to use 2ml but that seemed to shock people here.

Lastly, what sort of NPO guidelines do you use for C/S since everyone is technically full stomach anyway.

Thanks ahead for the input.

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[UTSouthwestern]

Now that I am out in private practice world, things are a little different from residency so I was wondering how all you private practice guys do things:

Anyone use lidocaine spinals for C/S? We did in residency, but no one does it here.

How much 0.75% bupiva do you use for C/S? We used to use 2ml but that seemed to shock people here.

Lastly, what sort of NPO guidelines do you use for C/S since everyone is technically full stomach anyway.

Thanks ahead for the input.

So what are your partners using for their spinals if not lido/bupi/ropiv, etc?

 

[Laurel123]

So what are your partners using for their spinals if not lido/bupi/ropiv, etc?

They do use bupiva, but just a much lower dose. Like about 1.3 ml of bupiva

 

[Laryngospasm]

They do use bupiva, but just a much lower dose. Like about 1.3 ml of bupiva

The problem in residency is that it takes 1.5 hours for the resident to do the case

 

[soon2bdoc2003]

Now that I am out in private practice world, things are a little different from residency so I was wondering how all you private practice guys do things:

Anyone use lidocaine spinals for C/S? We did in residency, but no one does it here.

How much 0.75% bupiva do you use for C/S? We used to use 2ml but that seemed to shock people here.

Lastly, what sort of NPO guidelines do you use for C/S since everyone is technically full stomach anyway.

Thanks ahead for the input.

We use 1.3-1.6 + 15ug fent + epi for our c/s spinals. I'd cut that to 1.2 if it was a rescue spinal or a tiny patient. I only have ~100 sections under my belt but i remember more than a few times patients getting weak enough to need a nonrebreather. If I drew up 2ml for any kind of spinal a good 50% of my attendings would crap their pants. I usually get good levels and solid 2-3 hrs of anesthesia with those doses and unless there is a good reason not to i usually put in cse's so I can always dose the catheter to raise my level.. sometimes adding 100ug fent in the epidural makes for a very smooth case and a very comfortable patient. The catheter also helps alot when the 3am dream team is working diligently on a 2 hour closing.

 

[VolatileAgent]

might as well just inject the fentanyl in the i.v. you get the same effect. use 150-200mcg of preservative-free morphine, or in my humble opinion you're just wasting your time mixing the fentanyl into the spinal solution.

and, when we say 1.2 ml or 1.3 ml of bupiv, i'm assuming we're all talking about 0.75% bupivicaine in 8.75% dextrose, a hyperbaric mix that comes standard in a lot of kits (like braun's). there actually are, believe it or not, different doses and combinations of spinal anesthetics out there. give isobaric procaine a try one time, if you haven't. i've used it for short uro procedures. good results.

lastly, the whole lido induced "cauda equina syndrome" is way oversold. of course, people are chicken**** to use it because of the lawyers. this is the same reason why droperidol isn't used anymore, a perfectly good - maybe the best - antiemetic, especially if the patient is going to stay in house. the whole concept of neuroleptanesthesia, a great technique, has fallen by the wayside. guess that speaks to how good we've gotten with our cookie-cutter mentality. no wonder crna's think they can do the same job.

 

[Lizard1]

for c/s - i use 1.4 to 1.6ml of .75% marcaine, less if they are really tiny which doesn't seem to happen much anymore

for hip or knee replacements - i use 1.6 to 2ml of .75% marcaine with a whiff of epi for peace of mind

i also just started doing SAB's for hip fx's but am in the process of figuring out a good concoction. the pt can't lay on their fx side so ideally i'd like to make the sol'n hypobaric....but of course i never got a chance to do this is residency unfortunately and don't have any clinical experience with this - just know what the books say. tried straight up .5% marcaine(no additive - isobaric) last week and got an excellent sens block but hardly much of a motor. had to supplement the case with a little propofol here & there just because the not-so-intelligent pt wouldn't stop talking or moving around.

so what's a good mixture for these cases?

 

[pmichaelmd]

Now that I am out in private practice world, things are a little different from residency so I was wondering how all you private practice guys do things:

Anyone use lidocaine spinals for C/S? We did in residency, but no one does it here.

How much 0.75% bupiva do you use for C/S? We used to use 2ml but that seemed to shock people here.

Lastly, what sort of NPO guidelines do you use for C/S since everyone is technically full stomach anyway.

Thanks ahead for the input.

We use 1.4-1.6 mL 0.75% heavy bupiv with 150 mcg PF morphine and 25 mcg fentanyl with good result. Seems to provide enough time for the OB to do his or her thing.

 

[frotteurism]

for c/s - i use 1.4 to 1.6ml of .75% marcaine, less if they are really tiny which doesn't seem to happen much anymore

for hip or knee replacements - i use 1.6 to 2ml of .75% marcaine with a whiff of epi for peace of mind

i also just started doing SAB's for hip fx's but am in the process of figuring out a good concoction. the pt can't lay on their fx side so ideally i'd like to make the sol'n hypobaric....but of course i never got a chance to do this is residency unfortunately and don't have any clinical experience with this - just know what the books say. tried straight up .5% marcaine(no additive - isobaric) last week and got an excellent sens block but hardly much of a motor. had to supplement the case with a little propofol here & there just because the not-so-intelligent pt wouldn't stop talking or moving around.

so what's a good mixture for these cases?

I've not done many of these yet, but two views from two of my attendings...

One uses 17mg of isobaric bupivacaine (3.4cc of 0.5%)

One uses ketamine IV to allow them to lie fracture side down, does a hyperbaric bupivacaine spinal, then leaves the bed in reverse t-berg and fracture down tilt for five minutes or so.