Minimum duration 15 mg iso bupiv with epi

[caligas]

Oral board type case: Knee removal of antibiotic spacer, placement of new implant. Obese, COPD/asthma, MH susceptible, on Coumadin (held) INR 1.2.

Prefer to do spinal MAC, AWARE I COULD do CSE but seems like a pain in her and INR 1.2.

So... a big boy dose of iso bupiv 12-15 mg with epi and narcotic should be VERY likely to last 4 hours, yes? (Haven’t used tetracaine in 20 years)

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[chocomorsel]

Oral board type case: Knee removal of antibiotic spacer, placement of new implant. Obese, COPD/asthma, MH susceptible, on Coumadin (held) INR 1.2.

Prefer to do spinal MAC, AWARE I COULD do CSE but seems like a pain in her and INR 1.2.

So... a big boy dose of iso bupiv 12-15 mg with epi and narcotic should be VERY likely to last 4 hours, yes? (Haven’t used tetracaine in 20 years)

Yes. If I remember correctly, even plain iso lasts a long time. But for sure four hours because we used it on bilateral knees. It’s been a while though.

 

[Iso4ane]

INR of 1.2 is essential normal. What is your concern with this?

 

[caligas]

INR of 1.2 is essential normal. What is your concern with this?

What is your concern with my concern?

It’s slightly above the standard normal range, but obviously I’m willing to do a spinal. I could also do a CSE, but somewhat prefer not to do the epidural, mainly because she is huge and it’s more of a hassle but debatably more of a risk due to larger needle size.

 

[Southpaw]

So... a big boy dose of iso bupiv 12-15 mg with epi and narcotic should be VERY likely to last 4 hours, yes? (Haven’t used tetracaine in 20 years)

Yes

 

[Iso4ane]

What is your concern with my concern?

It’s slightly above the standard normal range, but obviously I’m willing to do a spinal. I could also do a CSE, but somewhat prefer not to do the epidural, mainly because she is huge and it’s more of a hassle but debatably more of a risk due to larger needle size.

Maybe concern wasn’t the right word. Was curious if the INR of 1.2 was in the for or against column.

 

[DocVapor]

How obese is she? Sometimes you need the touhy just to function as the introducer if you aren't going to use a fatter spinal needle.

 

[caligas]

How obese is she? Sometimes you need the touhy just to function as the introducer if you aren't going to use a fatter spinal needle.

good point. Big enough to probably go for the 22g W needle after I bend two or three 25g needles

 

[UscGhost]

Oral board type case: Knee removal of antibiotic spacer, placement of new implant. Obese, COPD/asthma, MH susceptible, on Coumadin (held) INR 1.2.

Prefer to do spinal MAC, AWARE I COULD do CSE but seems like a pain in her and INR 1.2.

So... a big boy dose of iso bupiv 12-15 mg with epi and narcotic should be VERY likely to last 4 hours, yes? (Haven’t used tetracaine in 20 years)

I have done revisions under iso 15mg spinal + duramorph and managed to get 6-7 hours. Although that last 1-2 hours can require additional IV meds to support. If it's a younger, larger patient then its closer to 4-5 hour range before you start needing additional IV meds.

You can always convert to LMA or nitrous via a tight face mask if you just need another 30 mins

 

[deleted162650]

I have done revisions under iso 15mg spinal + duramorph and managed to get 6-7 hours.

This.

You’ll get 4 hours with just the 15mg bupi without the adjuvants.

 

[DocMcCoy]

Similar recipe for a slow surgeon and feel I reliably get 3 hrs of surgical anesthetic. Most leave PACU still dead from the waist down but I have had a couple achy and moving everything before they head upstairs around hour 4.

 

[anbuitachi]

4 hour def doable in a lot of patients but the longer it is the less reliable. ive had patients start complaining of pain before 4 hr mark and start moving with 15mg bupi + epi

 

[deleted697535]

I think I've gotten 7 hours with 15mg iso and 20 fentanyl for a 70 yo knee. It was heavy propofol after 4 hours. For me too

 

[Hoya11]

Oral board type case: Knee removal of antibiotic spacer, placement of new implant. Obese, COPD/asthma, MH susceptible, on Coumadin (held) INR 1.2.

Prefer to do spinal MAC, AWARE I COULD do CSE but seems like a pain in her and INR 1.2.

So... a big boy dose of iso bupiv 12-15 mg with epi and narcotic should be VERY likely to last 4 hours, yes? (Haven’t used tetracaine in 20 years)

If I know its really going to be >2hrs Im not going to do a spinal and MAC, spinal yes but ill throw an LMA in at least in addition

 

[PainDrain]

I have had two cases recently where a 15mg dose of iso bupi lasted 5 hours. More than enough for the surgeon to attempt to exsanguinate the patients of every last drop.

 

[deleted162650]

If I know its really going to be >2hrs Im not going to do a spinal and MAC, spinal yes but ill throw an LMA in at least in addition

Sooooooo unnecessary.

 

[Lidolover]

for knee cases (arthroplasties and other cases) we usually do preop dual adductor canal and IpAck block with spinal. Interestingly, our data show its faster to do it under general tho.

 

[DrOwnage]

Senior resident here. In the shop I train in, isobaric is kind of rare thing, however I've convinced attendings many times to do it when it sounds clinical necessary. In my 8-10 or so isobaric spinals with 12.5-15mg I stalked the patient's charts. Many of them were first start cases and they were usually not able to move their legs until around 2:30 in the afternoon. I didn't do it if it was an afternoon case because the ortho resident had to stay until the patient could move their legs. Based on my experience those patients spinals lasted at least around 5 hours for complete pain relief and possible surgical anesthesia. FYI I've found the hemodynamic stability of isobaric to be kind of awesome compared to hyperbaric.

 

[deleted59964]

Big boy dose is 20 to 25 mg

 

[caligas]

Big boy dose is 20 to 25 mg

Interesting! Always assumed that 15 was max to avoid high spinal.

 

[Arch Guillotti]

Interesting! Always assumed that 15 was max to avoid high spinal.

17.5 works ok. If I felt the need to give 20 I might think of doing something else.

 

[BLADEMDA]

Imho, 20 mg of isobaric is the maximum dose.

I’ve used isobaric Bup 15 mg with 0.1 Mg of epi hundreds of times and that dosage reliably lasts for 3.5-4.0 hours of surgical level block. Typically, that dosage lasts for 5 hours.

Ymmv, but isobaric Bup 20 mg with epi will typically exceed 6 hours of surgical quality anesthesia.

 

[dhb]

Chlorexidine spinals last forever

 

[Arch Guillotti]

Chlorexidine spinals last forever

What's that mean?

 

[PainDrain]

What's that mean?

There are case reports of accidental clorhexidine intrathecal injection causing catastrophic neurological damage.

 

[Arch Guillotti]

There are case reports of accidental clorhexidine intrathecal injection causing catastrophic neurological damage.

How do you inject a sponge in the spine? The only form I have ever seen is on the sponge stick.

 

[PainDrain]

How do you inject a sponge in the spine? The only form I have ever seen is on the sponge stick.

One of the case reports I read said there was an accidental injection because the chlorhexidine was in a glass ampule similar to spinal bupi. It’s crazy but true.

 

[MirrorTodd]

How do you inject a sponge in the spine? The only form I have ever seen is on the sponge stick.

Not intrathecal but epidural. Overseas. https://patientsafe.files.wordpress.com/2015/11/chlorhexidine-mental-block.pdf

The accident was the result of mistaken identification of the clear fluids in two identical metal containers which were used in the procedure of inserting a needle into the patient’sepidural space external to the spinal cord. In this case the two solutions were an antiseptic(chlorhexidine in alcohol, both highly neurotoxic) and saline, which is used in a syringe attached tothe end of the Tuohy’s needle to detect loss of resistance when the epidural space is entered. Instead ofthese two solutions being checked by the anaesthetist from labelled packs or ampoules, the nursingstaff had decanted the solutions into two identical metal “galley pots”. The colour of the antisepticsolution had recently been made lighter because the concentration of the chlorhexidine had beenincreased to improve bacterial antisepsis. The first entry into the epidural space resulted in aspirationof blood and so the needle was withdrawn. During a second pass of the needle, light pink fluid wasobtained on aspiration. This was wrongly interpreted as blood contamination and the full 8 ml of fluid(now known to be chlorhexidine in alcohol) was erroneously injected into the epidural space.

 

[deleted59964]

Chlorexidine spinals last forever

chlorox too

 

[deleted59964]

How do you inject a sponge in the spine? The only form I have ever seen is on the sponge stick.

this happened in a sydney hospital about 10 years ago. prep used to be poured into a pot. it was coloured pink so you wouldn’t mix up your pot with your local ... despite this somehow it still got mixed up - someone thought it had been blood tinged from a prior attempt

edit - was epidural (makes more sense)

https://patientsafe.files.wordpress.com/2015/11/chlorhexidine-mental-block.pdf

 

[deleted59964]

Imho, 20 mg of isobaric is the maximum dose.

I’ve used isobaric Bup 15 mg with 0.1 Mg of epi hundreds of times and that dosage reliably lasts for 3.5-4.0 hours of surgical level block. Typically, that dosage lasts for 5 hours.

Ymmv, but isobaric Bup 20 mg with epi will typically exceed 6 hours of surgical quality anesthesia.

i can’t be bothered with CSEs often.
20mg reliably give 4-5 hours

i have given 25mg a few times ... i do get uncomfortable with that dose but nothing much happened except a very long block.

height of block from iso is mostly position and rate of injection dependant duration is dose dependant

 

[nimbus]

Chlorexidine spinals last forever

Digoxin too.

 

[deleted162650]

Digoxin too.

And TXA

 

[dhb]

And TXA

I've seen one of those...: ugly

 

[Planktonmd]

Oral board type case: Knee removal of antibiotic spacer, placement of new implant. Obese, COPD/asthma, MH susceptible, on Coumadin (held) INR 1.2.

Prefer to do spinal MAC, AWARE I COULD do CSE but seems like a pain in her and INR 1.2.

So... a big boy dose of iso bupiv 12-15 mg with epi and narcotic should be VERY likely to last 4 hours, yes? (Haven’t used tetracaine in 20 years)

You don't need Epi with Bupivacaine.
And that spinal dose of Isobaric Bupivacaine should be enough, but if this is an oral board question then your spinal is either not going to work or just quits working in the middle of the surgery, you need to be prepared to do GA and likely have problems with airway management.

 

[Planktonmd]

Chlorexidine spinals last forever

Formalin is more reliable

 

[BLADEMDA]

The addition of Epi to Bupivacaine will likely extend the duration of the block by about 45 minutes. So, IMHO, the use of isobaric Bupivacaine with epi 0.1 mg should reliably give you 3.5-4.0 hours of surgical anesthesia. For older patients I expect that duration to be in the 4.5 range. I also like to add a little Fentanyl to the spinal most of the time in the range of 15-20 micrograms to increase the quality of the block.

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[BLADEMDA]

https://www.ijcmr.com/uploads/7/7/4/6/77464738/ijcmr_1394_may_13.pdf

 

[BLADEMDA]

Total hip arthroplasty (THA) is frequently performed under spinal anesthesia using either isobaric or hypobaric anesthetic solution. However, these two solutions have never been compared under similar surgical conditions. In the present study, we compared the anesthetic and hemodynamic effects of isobaric and hypobaric bupivacaine in 40 ASA physical status I–II patients undergoing THA in the lateral decubitus position under spinal anesthesia. With operative side up, patients randomly received, in a double-blinded manner, a spinal injection of 3.5 mL (17.5 mg) of plain bupivacaine mixed with either 1.5 mL of normal saline (isobaric group) or 1.5 mL of distilled water (hypobaric group). Sensory level and degree of motor block were evaluated on the nondependent and dependent sides until regression to L2 and total motor recovery. Hemodynamic changes during the first 45 min after spinal injection, and the time between spinal administration and first analgesic for a pain score >3 (on a 0–10 scale) were noted. Demographic characteristics of both groups were comparable. Upper sensory level and maximal degree of motor block were comparable between the operative and nonoperative sides in each group and between corresponding sides in both groups. Compared with the isobaric group, in the hypobaric group there was a prolonged time to sensory regression to L2 on the operative side (287 ± 51 versus 242 ± 36 min, P < 0.004) and a prolonged time to first analgesic (290 ± 46 versus 237 ± 39 min, P < 0.001). No difference in quality of motor block was noted at the end of surgery. Hemodynamic changes were comparable. We conclude that for THA in the lateral position, spinal hypobaric bupivacaine seems to be superior to isobaric in that it prolongs the sensory block on the operative side and delays the use of analgesics after surgery without further compromising hemodynamic stability.

Isobaric Versus Hypobaric Spinal Bupivacaine for Total Hip... : Anesthesia & Analgesia

isobaric and hypobaric bupivacaine in 40 ASA physical status I–II patients undergoing THA in the lateral decubitus position under spinal anesthesia. With operative side up, patients randomly received, in a double-blinded manner, a spinal injection of 3.5 mL (17.5 mg) of plain bupivacaine mixed...

journals.lww.com

 

[BLADEMDA]

 

[kmurp]

for knee cases (arthroplasties and other cases) we usually do preop dual adductor canal and IpAck block with spinal. Interestingly, our data show its faster to do it under general tho.

Faster recovery you mean? What are you using for your spinal?

 

[Velefunt]

Yes: 15mg isobaric

Yes: 22G whitacre

 

[Southpaw]

Yes: 22G whitacre

rarely if ever a need for that