Mepivacaine spinal

[Fastrach]

Anyone used/using mepivacaine for spinals for short/intermediate duration procedures? If not, why not?

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[Planktonmd]

Anyone used/using mepivacaine for spinals for short/intermediate duration procedures? If not, why not?

To my knowledge there is no FDA approved spinal mepivacaine.

 

[rsgillmd]

To my knowledge there is no FDA approved spinal mepivacaine.

But that doesn't mean much. The Bupivacaine 0.5%-MPF (isobaric) in our hospital says not for spinal use, but I've used it many times (along with many attendings I know) without a problem. This was something we picked up from an attending that came from another institution. I find it causes less hypotension than the hyperbaric 0.75% bupivacaine when given for orthopedic procedures (usually done on old people who will questionably have any quality of life improvement from the procedure).

I think I read somewhere that the motor block can last longer than the sensory block with mepivacaine, which is probably why it is not used as commonly.

 

[Fastrach]

To my knowledge there is no FDA approved spinal mepivacaine.

Well ditto with 2-chlorprocaine and there are folks who use it in spinals without reservation...

 

[IceDoc]

Anyone used/using mepivacaine for spinals for short/intermediate duration procedures? If not, why not?

HSS uses mepivicaine for spinals in most of their ambulatory lower extremity procedures. They have not had any problems that I've heard of. Gets the patients out of PACU pretty quickly, and there is very little urinary retention.

And if you're truly looking at FDA indications, you'll find that most medicines are used outside of official FDA indications. Think about the last time you met FDA indications for blood and FFP transfusions. Last time I checked (admittedly a while ago), recombinent factor VIIa was only indicated for hemophilia. Not Trauma. Not subarachnoid hemorrhage.

 

[Planktonmd]

HSS uses mepivicaine for spinals in most of their ambulatory lower extremity procedures. They have not had any problems that I've heard of. Gets the patients out of PACU pretty quickly, and there is very little urinary retention.

And if you're truly looking at FDA indications, you'll find that most medicines are used outside of official FDA indications. Think about the last time you met FDA indications for blood and FFP transfusions. Last time I checked (admittedly a while ago), recombinent factor VIIa was only indicated for hemophilia. Not Trauma. Not subarachnoid hemorrhage.

In order to be able to use a drug for off label indication in the real world (not academia), you need to have good literature supporting it's use and good safety information, you also need to have an indication where the benefit of the drug outweighs the risk, this is not the case for intrathecal mepivacaine.
And this is why you will not see people in the real world trying exotic things like that until sufficient safety data had accumulated.

 

[2ndyear]

Well ditto with 2-chlorprocaine and there are folks who use it in spinals without reservation...

I use a lot of 2% chloprocaine for short spinals (knee scopes, cystos primarily, sometimes hernias and gyn stuff), and I use 13.5-15 mg of plain bupivicaine for total hips and most hip fractures (hyperbaric gets a higher block with faster regression).

My current thinking based on what I've read places chloroprocaine as being a better drug than lidocaine for a short spinal as far as TNS. In regards to mepivicaine spinals, I've never done one. One case series that I read showed 1000 patients, 33% incidence of back pain, 7% incidence of TNS. Admittedly this is one study, but large enough to convince me that, for a short spinal I'll use chloroprocaine, if I need a longer one then either use less bupivacaine or bite it and wait for the block to wear off, or just don't do a spinal.

 

[Jeff05]

i am at a major academic center and we routinely use mepiv 1.5% for GU procedures.

for exampe TURP, seed implants, etc - procedures that are a max of about 90 min. about 2.2-2.6ml of local with about 10-25mcg fent. perfect, dense spinal. exceptional hemodynamic stability, predictable offset - patients are moving legs by end and out of pacu within 1-2 hours.

 

[Planktonmd]

i am at a major academic center and we routinely use mepiv 1.5% for GU procedures.

for exampe TURP, seed implants, etc - procedures that are a max of about 90 min. about 2.2-2.6ml of local with about 10-25mcg fent. perfect, dense spinal. exceptional hemodynamic stability, predictable offset - patients are moving legs by end and out of pacu within 1-2 hours.

You can do exactly the same thing with 7.5 mg hyperbaric Bupivacaine + 15mcg Fentanyl.

 

[sbmed100]

During my regional fellowship I must have done over 600 mepivicaine spinals (1.5% mepiv)...rare TNS, but less urinary retention and shorter duration than bupivicaine. We used mepivicaine for all our ambulatory spinals, and for some of the lower extremity joint replacements done by the faster surgeons. At HSS over the last decade or so they must have performed well over 50,000 of these mepivicaine spinals/combined spinal epidurals...I continue to use isobaric mepivicaine and bupivicaine in private practice now for my spinals. There is a large body of literature supporting the use of isobaric local anesthetics. Specifically look at many of the studies using neuraxial techniques that get published in Regional Anesthesia and Pain Medicine.

I don't quite understand the FDA argument. Are fentanyl, clonidine, epinephrine FDA approved as spinal additives? (I honestly don't know.) What I do know is that I don't have to crack open a any glass vials when I do my neuraxial blocks.

 

[rsgillmd]

You can do exactly the same thing with 7.5 mg hyperbaric Bupivacaine + 15mcg Fentanyl.

I second Plank's comment. Have done it many times.

 

[huktonfonix]

been looking for a good "outpatient spinal" alternative. What level are you guys getting with 7.5 mg hyperbaric bupivicaine + fentanyl? Im basically looking for something to last for a 30 -60 min procedure with a T10 level. What about demerol spinals? Does anyone know if there is any increased post op resp depression risk?

 

[thegasman]

You can do exactly the same thing with 7.5 mg hyperbaric Bupivacaine + 15mcg Fentanyl.

I believe using fentanyl in a spinal is also off-label use since there is not an fda indication for this (example why this doesn't mean anything)

 

[rsgillmd]

been looking for a good "outpatient spinal" alternative. What level are you guys getting with 7.5 mg hyperbaric bupivicaine + fentanyl? Im basically looking for something to last for a 30 -60 min procedure with a T10 level. What about demerol spinals? Does anyone know if there is any increased post op resp depression risk?

Last time I used the bupivacaine 7.5 mg/fentanyl concoction, I got a T8 level (pregnant woman). In the TURP cases (the level is about T10 on the nose. In my experience the duration is closer towards 75 minutes (mainly) to 90 minutes (less so) before you get return of motor function (occasional patients in the 60 minute range). If you are looking for something less than 60 minutes, this is probably not the way to go, unless you want to go lower on the bupivacaine.

Never tried a Demerol spinal. From an attending who has used them in the past, there is a relatively high incidence of N/V, in addition to being more expensive. Also we would have to go the main pharmacy in person (at least in my hospital) to pick up preservative free Demerol. She did not report any experiences of respiratory depression.

 

[rsgillmd]

been looking for a good "outpatient spinal" alternative. What level are you guys getting with 7.5 mg hyperbaric bupivicaine + fentanyl? Im basically looking for something to last for a 30 -60 min procedure with a T10 level. What about demerol spinals? Does anyone know if there is any increased post op resp depression risk?

Last time I used the bupivacaine 7.5 mg/fentanyl concoction, I got a T8 level (pregnant woman). In the TURP cases (I would only use this with the quicker surgeons) the level is about T10 on the nose. In my experience the duration is closer towards 75 minutes (mainly) to 90 minutes (less so) before you get return of motor function (occasional patients in the 60 minute range). If you are looking for something less than 60 minutes, this is probably not the way to go, unless you want to go lower on the bupivacaine.

Never tried a Demerol spinal. From an attending who has used them in the past, there is a relatively high incidence of N/V, in addition to being more expensive. Also we would have to go the main pharmacy in person (at least in my hospital) to pick up preservative free Demerol. She did not report any experiences of respiratory depression.

 

[Planktonmd]

I believe using fentanyl in a spinal is also off-label use since there is not an fda indication for this (example why this doesn't mean anything)

Intrathecal Fentanyl is widely used and has never been connected to any complications over the years (except maybe increased uterine tone in late labor), the same can not be said for Mepivacaine.
Every drug you can think of has been tried intrathecally and /or epidurally but when you are in the trenches of private practice you don't have the advantage of trying experimental things because you will be crucified if any complication happens.

 

[dhb]

If you are looking for something less than 60 minutes, this is probably not the way to go, unless you want to go lower on the bupivacaine.

Yup i've done the 5mg bupivacaine mixed with equal volume of CSF no motor block +- 45min analgesia

 

[lobelsteve]

Intrathecal Fentanyl is widely used and has never been connected to any complications over the years (except maybe increased uterine tone in late labor), the same can not be said for Mepivacaine.
Every drug you can think of has been tried intrathecally and /or epidurally but when you are in the trenches of private practice you don't have the advantage of trying experimental things because you will be crucified if any complication happens.

We have FDA approval for 3 spinal meds (albeit for chronic infusion and not surgery). Morphine, Baclofen, and Prialt.
Current consensus paper also lists clonidine, bupivacaine, fentanyl, hydromorphone as options. But this is all for implanted infusion pumps with indwelling spinal catheters. We do not see hemodynamic changes, but you don't face cath tip granulomas. The literature shows that most anything can get dumped into the spine: methadone, demerol, gabapentin.