Neuraxial for C-Scope?

[ZA_Gasman]

So... first case tomorrow is a colonoscope. No problem, right. Uh Uh. 59y old female patient, otherwise well. 2x previous GA for open chole and a hysterectomy. Both occasions had what sounds like bronchospasm post op. Now absolutely terrified of anesthesia.... Point blank refuses to be sedated for the scope (I do fairly heavy sedation with Midaz 1-2mg, propofol and alfentanil titration against response)

She has previously had a spinal for a pyelogram, thinks spinal is the best thing since sliced cheese, and is demanding a spinal for her scope. I should mention that this is a day care facility, which looks a lot like closing at around 14h00, and the surgeon is **** hot, takes 10-11min for a full colonoscope.

Thoughts? I have concerns.
1. Can't guarantee that spinal will cover peritoneal afferents for the insufflation.
2. Prolonged weakness in a day care facility - basically she has to be street ready in <5hrs.
3. Should I subject her to the risks of a spinal on her demand? I wasn't planning to go anywhere near the airway anyway, so should I try harder to convince her to have her (un)conscious sedation?

Would love to have some opinions... Anyone with any experience in spinals for C-scope?

---

Members don't see this ad.

 

[Laurel123]

Ketamine and propofol and nothing else. They are asleep, comfortable, breathing, stable and the drugs are even bronchdilators!

 

[Planktonmd]

So... first case tomorrow is a colonoscope. No problem, right. Uh Uh. 59y old female patient, otherwise well. 2x previous GA for open chole and a hysterectomy. Both occasions had what sounds like bronchospasm post op. Now absolutely terrified of anesthesia.... Point blank refuses to be sedated for the scope (I do fairly heavy sedation with Midaz 1-2mg, propofol and alfentanil titration against response)

She has previously had a spinal for a pyelogram, thinks spinal is the best thing since sliced cheese, and is demanding a spinal for her scope. I should mention that this is a day care facility, which looks a lot like closing at around 14h00, and the surgeon is **** hot, takes 10-11min for a full colonoscope.

Thoughts? I have concerns.
1. Can't guarantee that spinal will cover peritoneal afferents for the insufflation.
2. Prolonged weakness in a day care facility - basically she has to be street ready in <5hrs.
3. Should I subject her to the risks of a spinal on her demand? I wasn't planning to go anywhere near the airway anyway, so should I try harder to convince her to have her (un)conscious sedation?

Would love to have some opinions... Anyone with any experience in spinals for C-scope?

If she wants a spinal give her a straight fenatnyl spinal.

 

[urge]

Do the spinal with chloroprocaine and write case report.
Or
Do spinal with demerol.
Or
Tell her all she need is lidocaine jelly up her a**.

 

[jwk]

We'd never consider a spinal for even a second in this patient - or anyone else. This from a practice that does probably 125 GI cases a week and thousands of epidurals and spinals each year as well. Sedation or nada. After all, it CAN and IS done with no sedation in many places. She's the one that will end up with inadequate pain relief and a prolonged block (you know, the 1:100 or 1:1000 risks you talk about) and then she'll really be pissed.

The patient doesn't get to make all the choices. They can make requests - and you have the right to refuse unreasonable requests, which this is.

On a different note - 10-11 minutes for a colonoscopy is too fast - at that speed, they're gonna be missing something. That's the kind where they claim they can see the ileo-cecal valve from the turn at the hepatic flexure.

 

[dhb]

5mg bupivacaine

 

[ZA_Gasman]

Thanks for the input...

Did the case, under spinal. All attempts to talk her into anything else were fruitless. In private practice in this town, NO-ONE is prepared to have an awake colonoscope.

I read up Ben-David's stuff on low dose spinals for arthroscopy, looked like something I could do, did an even better than usual informed consent session, and poked her in the back - 20/20 lido/fentanyl, 4ml total volume, worked like a charm. Slight discomfort only, ambulated herself out of the facility 2h30 post injection, passing urine, mild pruritis only, no PONV (gave her ondansetron) - 1X happy patient, 1X relieved anaesthetist.

Just glad she had a negative scope - imagine the headache involved in doping her for a hemicolectomy

 

[dhb]

poked her in the back - 20/20 lido/fentanyl, 4ml total volume, worked like a charm. Slight discomfort only, ambulated herself out of the facility 2h30 post injection, passing urine, mild pruritis only, no PONV (gave her ondansetron) - 1X happy patient, 1X relieved anaesthetist.

Why did you chose that for your spinal? for a short procedure it seems like not a lot of benefit vs side effects of both drugs.

Just glad she had a negative scope - imagine the headache involved in doping her for a hemicolectomy

Easy: strait epidural... if she's showing you the money why not give her what she wants?

 

[ZA_Gasman]

Why did you chose that for your spinal? for a short procedure it seems like not a lot of benefit vs side effects of both drugs.

I'm hearing you.... Guess I really wanted her up and about real quick. Was concerned that 5mg Bupiv wasn't gonna cut it for analgesia, I just don't have much low dose spinal experience, and with this particular patient, didn't want to take a chance. Was and still am concerned about TNS with Lido. 20mcg Fentanyl.... I'm not worried. There are guys here doin spinals with morphine. Now that scares me. Pruritis , I can deal with. Resp depression, I'd rather not. 20mcg Fentanyl... I've never had resp depression, and I put that much into most of my spinals..

Just goes to show, that if there are 1001 ways of doing something, we probably don't really know which is the right one.... Yet!