Mixing local anesthetics for epidural

[kmurp]

So let’s say I’ve got an epidural in with lidocaine and it’s 90min in. I’m starting to think I better reinject, but I don’t want the block to last forever in PACU. Could my rebolus be chloroprocaine instead, or would that produce an unexpected result?

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[Ezekiel2517]

Yes, go wild

 

[Hoya11]

So let’s say I’ve got an epidural in with lidocaine and it’s 90min in. I’m starting to think I better reinject, but I don’t want the block to last forever in PACU. Could my rebolus be chloroprocaine instead, or would that produce an unexpected result?

i wouldnt bother with cpc

i would just redose with lido 2% 5cc at a time

even if you overshoot by 10ml, not a huge delay in recovery, and also think why is it bad? as long as there is no hypotension i would think being numb for an hour or so longer is a good thing, and actually i will give a "tail" of 0.25% bupi when i know things are near done and im going to pull the catheter, for prolonged analgesia after the lido wears off...

 

[deleted697535]

procedure? Day case or no? patient?
what is your goal?
is it a section?
Why is it taking 90 mins?
Cant do anything without context

 

[fakin' the funk]

So let’s say I’ve got an epidural in with lidocaine and it’s 90min in. I’m starting to think I better reinject, but I don’t want the block to last forever in PACU. Could my rebolus be chloroprocaine instead, or would that produce an unexpected result?

No reason you can't mix, assuming you know what the crap you're doing

 

[kmurp]

procedure? Day case or no? patient?
what is your goal?
is it a section?
Why is it taking 90 mins?
Cant do anything without context

Sorry. Day case, let’s say it’s a young, healthy ACL, and for whatever reason the surgeon is struggling.

 

[deleted162650]

Sorry. Day case, let’s say it’s a young, healthy ACL, and for whatever reason the surgeon is struggling.

In that case I'd ask why in the hell you did an epidural in the first place.

 

[deleted697535]

Yep you can get stung with day case neuraxial. Id be very selective on them.
A young healthy acl is LMA 99 times out of 100
So that makes it a very hard question to answer

 

[deleted171991]

In that case I'd ask why in the hell you did an epidural in the first place.

Because regional is the new mania. Gods forbid one suggests GA and/or opiates, what incompetence!

 

[deleted162650]

Because regional is the new mania.

In that case, in an effort to remain on the cutting edge, I will now transition to doing all my thyroids under cervical epidurals.

 

[deleted171991]

In that case, in an effort to remain on the cutting edge, I will now transition to doing all my thyroids under cervical epidurals.

Weak sauce. This is the real deal: Heart patient stays awake for bypass surgery

 

[kmurp]

Yep you can get stung with day case neuraxial. Id be very selective on them.
A young healthy acl is LMA 99 times out of 100
So that makes it a very hard question to answer

Stung? As in PDPHA or urinary retention?

 

[deleted697535]

Stung? As in PDPHA or urinary retention?

All of the above, but usually delayed motor recovery requiring admission and too much paperwork. No bother if youre in a big centre with lots of beds, but what if its a day hospital... Just a pain

 

[fakin' the funk]

Sorry. Day case, let’s say it’s a young, healthy ACL, and for whatever reason the surgeon is struggling.

As I implied, you don't know what the crap you're doing

 

[kmurp]

All of the above, but usually delayed motor recovery requiring admission and too much paperwork. No bother if youre in a big centre with lots of beds, but what if its a day hospital... Just a pain

Understood. The delayed motor recovery is why I was asking if I could rebolus with nesacaine

 

[kmurp]

As I implied, you don't know what the crap you're doing

Could you expand on that? Are you referring to using neuraxial for outpatient surgery or something else?

 

[Plead the Fifth]

At my place, neuraxial for outpatient surgery is used sparingly. Once in a while we might use an epidural or spinal for a COPDer coming in for a urological procedure so we don’t have to intubate and play the weaning game in PACU. Seems like overkill for a healthy ACL.

 

[mikey014]

Well if I could chime in. I had a navy corpsman with a recent URI about a week before surgery a knee scope for an ACL tear. I was thinking about canceling. But the patient said it was really hard to schedule surgery dates with his navy schedule. His URI he felt was because he recently went on a dive in close quarters with other corpsman. Healthy ASA 1. I originally wanted to do the case under regional. But the surgeon didn't want to try that. I decided to do the case with an LMA. He got really sick. Couldn't stop vomiting, 102 fever, chills, cold seat. Ended up coming back to the ED needing IV antibiotics and anti emetics. Although the patient did fine ... I felt like it was completely avoidable if I used a regional technique.

A week later a 68 year old came in with the same thing. Knee scope. 1 wk old URI. I gave the surgeon the option. Regional or cancel. His choice. I did the case with an epidural with lidocaine. Patient did really well but I think next time I'd do chloroprocaine. The onset of lidocaine (12 cc's 2% without bicarb [on shortage so it's frowned upon to use unless we really need it]) took a while. And the case was really fast. So the patient was really numb in pacu for 2.5 hours before ready for discharge. I think chloroprocaine would have been more suitable for outpatient surgery and what I'll be doing in the future.

Seems like everyone likes to skin his car a different way. But I'm agreeing with the OP. I think epidural is a good option in certain cases.

 

[deleted162650]

Well if I could chime in. I had a navy corpsman with a recent URI about a week before surgery a knee scope for an ACL tear. I was thinking about canceling. But the patient said it was really hard to schedule surgery dates with his navy schedule. His URI he felt was because he recently went on a dive in close quarters with other corpsman. Healthy ASA 1. I originally wanted to do the case under regional. But the surgeon didn't want to try that. I decided to do the case with an LMA. He got really sick. Couldn't stop vomiting, 102 fever, chills, cold seat. Ended up coming back to the ED needing IV antibiotics and anti emetics. Although the patient did fine ... I felt like it was completely avoidable if I used a regional technique.

A week later a 68 year old came in with the same thing. Knee scope. 1 wk old URI. I gave the surgeon the option. Regional or cancel. His choice. I did the case with an epidural with lidocaine. Patient did really well but I think next time I'd do chloroprocaine. The onset of lidocaine (12 cc's 2% without bicarb [on shortage so it's frowned upon to use unless we really need it]) took a while. And the case was really fast. So the patient was really numb in pacu for 2.5 hours before ready for discharge. I think chloroprocaine would have been more suitable for outpatient surgery and what I'll be doing in the future.

Seems like everyone likes to skin his car a different way. But I'm agreeing with the OP. I think epidural is a good option in certain cases.

A) I don’t think your anesthetic choice had anything to do with the guy getting sicker

B) Even if you convince yourself that regional is superior, why an epidural??? What’s wrong with a spinal?

 

[kmurp]

A) I don’t think your anesthetic choice had anything to do with the guy getting sicker

B) Even if you convince yourself that regional is superior, why an epidural??? What’s wrong with a spinal?

Certainly a spinal is fine as well. HSS and, I think, Virginia Mason do it that way. It would be nice to have the rapid onset block like a spinal if working alone. If with a crna, I think the epidural looks more attractive. The other potential issue is PDPHA , of course.
As to some questions posted above, we too currently do knees with an LMA. I’m quite sure that’s the mainstream approach. Our surgeons have asked us to change this practice to regional to matchup to what has become standard practice in our region with a different group that has been doing it this way for over 15 years running 10 rooms of outpatient ortho per day.
Given that my personal experience is LMA, I was hoping for comments from others’ experience on following lidocaine or mepivacaine with chloroprocaine. I’ve not done that.

 

[dhb]

I have never done an epidural for a LE procedure.
0.25% bupivacaine and the patient is out in 3h max.

 

[fakin' the funk]

Could you expand on that? Are you referring to using neuraxial for outpatient surgery or something else?

I'm referring to your extremely insane original question, "Is it ok to use multiple local anesthetics to dose an epidural that I put in for an outpatient ACL reconstruction"

 

[kmurp]

I'm referring to your extremely insane original question, "Is it ok to use multiple local anesthetics to dose an epidural that I put in for an outpatient ACL reconstruction"

Ok. Like I asked originally, is there a problem with it.?
I’ve not personally done it as we haven’t had OB in our practice in years and back when I did OB a fair amount, we didn’t have chloroprocaine. I’m guessing, maybe, you think it’s a dumb question because these days chloroprocaine is often used in OB to rapidly extend an epidural for a cesarean .? I know it can be done, just wondering if maybe the duration is alterered which isn’t a problem in OB but would potentially be in an outpatient.

 

[deleted162650]

There's no problem with mixing.

Why is it that your surgeons feel this is a superior technique. If you ask me, the other practice should be converting to your method (LMA +/- block).

 

[kmurp]

There's no problem with mixing.

Why is it that your surgeons feel this is a superior technique. If you ask me, the other practice should be converting to your method (LMA +/- block).

I agree and wish it was so. But these surgeons will own the ASC so I feel I need to take their very strong preference into account. For them, it’s about having zero time for induction/emergence with the epidural. Don’t really feel I’ll be able to convince them otherwise given the conversations I’ve had.
Thanks for your response.

 

[Hoya11]

I agree and wish it was so. But these surgeons will own the ASC so I feel I need to take their very strong preference into account. For them, it’s about having zero time for induction/emergence with the epidural. Don’t really feel I’ll be able to convince them otherwise given the conversations I’ve had.
Thanks for your response.

But arent they concerned about the long discharge time and PACU backing up ? I sometimes do neuraxial in an ASC and I have the patient ambulate and urinate before going home. If its one or two cases of neuraxial then ok, but if you are doing 10 cases with an epidural there will be very long dc times as it abates and inevitably complications like wet taps

 

[pgg]

So let’s say I’ve got an epidural in with lidocaine and it’s 90min in. I’m starting to think I better reinject, but I don’t want the block to last forever in PACU. Could my rebolus be chloroprocaine instead, or would that produce an unexpected result?

It's fine.

As you're probably aware, using chloroprocaine may reduce the efficacy of any neuraxial opioid you give. This is one disadvantage of using it to augment epidurals for c-sections.

I think neuraxial anything for outpatient surgery is usually the wrong answer, unless you're working in the 3rd world and there's a meaningful economic difference between a $3 needle & bupivacaine anesthetic and a $30 propofol & gas & tube anesthetic.

 

[nimbus]

But arent they concerned about the long discharge time and PACU backing up ? I sometimes do neuraxial in an ASC and I have the patient ambulate and urinate before going home. If its one or two cases of neuraxial then ok, but if you are doing 10 cases with an epidural there will be very long dc times as it abates and inevitably complications like wet taps

I’ve never tried it myself but it seems like a good situation for epidural saline washout of local.

 

[kmurp]

Replying to above questions:
1. epidural saline washout: might be a nice idea. Hadn’t heard of it before having a conversation with one of the guys from Vanderbilt who also suggested it. I don’t know why but for some reason it makes me uncomfortable. But so did blood patches when I first was introduced to them.

2. Regarding PACU backup: evidently it’s not a problem at the hospital owned ASC the surgeons now work in, but it certainly worries me. There will certainly be days with ten or more knees. It seems pretty clear to me from speaking to anesthesiologists who work in centers that do a lot of regional, that I’ll need to be using primarily nesacaine to facilitate discharge. That is, if we can get it. My hospital is currently out of any local that would be appropriate for neuraxial at an ASC.

3. Providing I can get local anesthetics, I’ve written a protocol for the PACU nurses regarding voiding. Basically, we won’t require it and will follow the algorithm used by Mulroy in his voiding study from 15 years ago or the POUR review in anesthesiology from a few years back or Dr. An Teunkens‘ study in RAPM FROM 2016. The authors were kind enough to answer my emails regarding their protocols currently as was HSS’ outpatient surgery centers’ director. Basically, if no risk factors for POUR, and not voided, bladder scan and discharge with instructions if volume is less than 400 ml. Those with larger volumes get to spend more time enjoying our company. This, of course, assumes we can get the short acting local that these studies are based on. I haven’t decided what we will use when we start doing joints. There seem to be many variations depending on who you talk to that all work. Patient selection seems to be more important than what I will do, but this large ortho group does have a protocol that’s works in another location which we will start out following. Those folks will, of course, be required to void among other things.

4. PDPHA: yes it’s also on my list of worries (which is wayyy longer than this list of things). I know we will have it happen. I’ve even got discharge instructions for a blood patch ready to go as I’m thinking we will do those at the ASC. In my discusssion with the the ASC director at HSS and the author of a study on PDPHA incidence at HSS, their incidence of PDPHA requiring EBP is very low using 27ga whitacres which mirrors my now old experience from when I was doing OB and routinely using CSE for labor. That said, HSS does a lot of people from out of town that they lose to follow up like the teenager who had a spinal there that we did a blood patch on not too long ago. The question becomes, do you want to take the somewhat higher incidence of PDPHA which is less severe with the spinal or the lower incidence of severe PDPHA with the epidural? There are, of course, other considerations in this choice like risk of LAST and flexibility on the timing of placement of the block.
Anyway, thanks to (most) of you for your helpful thoughts.

 

[nimbus]

Replying to above questions:
1. epidural saline washout: might be a nice idea. Hadn’t heard of it before having a conversation with one of the guys from Vanderbilt who also suggested it. I don’t know why but for some reason it makes me uncomfortable. But so did blood patches when I first was introduced to them.

2. Regarding PACU backup: evidently it’s not a problem at the hospital owned ASC the surgeons now work in, but it certainly worries me. There will certainly be days with ten or more knees. It seems pretty clear to me from speaking to anesthesiologists who work in centers that do a lot of regional, that I’ll need to be using primarily nesacaine to facilitate discharge. That is, if we can get it. My hospital is currently out of any local that would be appropriate for neuraxial at an ASC.

3. Providing I can get local anesthetics, I’ve written a protocol for the PACU nurses regarding voiding. Basically, we won’t require it and will follow the algorithm used by Mulroy in his voiding study from 15 years ago or the POUR review in anesthesiology from a few years back or Dr. An Teunkens‘ study in RAPM FROM 2016. The authors were kind enough to answer my emails regarding their protocols currently as was HSS’ outpatient surgery centers’ director. Basically, if no risk factors for POUR, and not voided, bladder scan and discharge with instructions if volume is less than 400 ml. Those with larger volumes get to spend more time enjoying our company. This, of course, assumes we can get the short acting local that these studies are based on. I haven’t decided what we will use when we start doing joints. There seem to be many variations depending on who you talk to that all work. Patient selection seems to be more important than what I will do, but this large ortho group does have a protocol that’s works in another location which we will start out following. Those folks will, of course, be required to void among other things.

4. PDPHA: yes it’s also on my list of worries (which is wayyy longer than this list of things). I know we will have it happen. I’ve even got discharge instructions for a blood patch ready to go as I’m thinking we will do those at the ASC. In my discusssion with the the ASC director at HSS and the author of a study on PDPHA incidence at HSS, their incidence of PDPHA requiring EBP is very low using 27ga whitacres which mirrors my now old experience from when I was doing OB and routinely using CSE for labor. That said, HSS does a lot of people from out of town that they lose to follow up like the teenager who had a spinal there that we did a blood patch on not too long ago. The question becomes, do you want to take the somewhat higher incidence of PDPHA which is less severe with the spinal or the lower incidence of severe PDPHA with the epidural? There are, of course, other considerations in this choice like risk of LAST and flexibility on the timing of placement of the block.
Anyway, thanks to (most) of you for your helpful thoughts.

You could avoid all these problems by doing GA/LMA for knee scopes like 99% of the rest of America. Take your patients to PACU with the LMA in and you will have zero emergence time in the OR.