Neuraxial recipes?

[CanGas]

Advertisement - Members don't see this ad

Ok, I’m trolling for some communal knowledge. I would like to see what are peoples favorite spinal recipes. What are your cocktails that you use for knee scopes (yes, I know the literature says highest satisfaction and fastest discharge from recovery with LMA/GA but what if they really want to watch the screen), TURBP’s, TURPs, C-Sections, ect. Ideally what drugs and what is your guestimate on duration of action.

In private practice I guess you are somewhat lucky vs a teaching hospital as no C/S should take 3 hrs and you can more perfectly tailor your spinal so the patient is wiggling her toes as the surgeon staples the skin.

What about intra-thecal opioids for outpatient procedures and the risk of delayed respiratory depression?

Also for those bloody long cases (3,4,5hr), where you want to sedate the pt for comfort I always hate when my staff force me to use Epimorph. I have had people break through 100mcg/kg/min of propofol to try and scratch their damn itchy nose.

Some staff always add 15-20 mcg of Fent, others 10-20mcg Sufent. Damn if I can see a difference.

Inquiring minds want to know.

Here are some of my Voodoo Recipes, all time durations are totally guestimates.

Stat C/S
Bup 0.75% 1.6cc
Fent 15 mcg (0.3 cc)
Epimorph 100 mcg (BMJ says just as effective as 200mcg but less late apnea)
Seems to wear off around the 2-2.5 hr mark without the incidence of higher blocks I saw with 1.8 cc (“I can’t breath, I can’t breath”, barf. Oh the joys of obstetrics). Epimorph for long term analgesia but does increase the nausea though my impression is the lower dose helps, fent for more acute and seems to deal with the discomfort with the eversion of the uterus + gives a little more sedation to keep the anxiety down.

TURBT
This is a hard one. I prefer LMA with TIVA but for those who want to be awake you are always trying to guess the size of the tumor and how much burning of the anterior wall they are going to do.
a)
One I picked up from one staff is:
Lido 2% 2cc
Bup 0.75% 0.8cc
Fent 20mcg (0.4cc)
Like I said, all voodoo. Lasts ~1.5hr. Not sure where I stand with the Lido and lithotomy with the risk of TRI in addition to the intrathecal Fentanyl in an outpatient.
b)
What else has worked and I am a little more comfortable with is:
Small tumor + fast surgeon = Bup 0.75% 1cc (~1h)
Average = Bup 0.75% 1.2cc (1-1.5hr)
Extensive tumor = Bup 0.75% 1.4-1.6cc (1.5-2.5hr depending on age of pt)

TURP
Again difficult to gauge based on size of prostate and whether you have the junior resident doing the plumbing or a staff man.
I’m not as concerned about having the early toe wiggling as they are all going to be admitted anyways but I also don’t want my 14:00 TURP to still be in recovery at 21:00.

Depends but somewhere around Bup 0.75% 1.6cc + Fent 20 mcg for fastish (<2hr), Bup 0.5 3cc for slowish (3-4hr).

Hip Arthroplasty
Depends on elective vs emergent. Decent shape vs frail.
Generally Bup 0.75% 1.6-1.8cc with OR side down for 5 min
Or
Bup 0.5% 2.5 if fastish - 3cc for a longer block (if really slow 0.2 Epi 1:1000). Isobaric seems to have less potential for initial hemodynamic impact. This is what I use for the little old lady broken hip cases. =/- Fent/Sufent (no real science).
P.S. For positioning the poor little old broken ladies/gents (assuming no contraindications) I pre-med them with Ketamine 15mg, Midaz 1 which gorks them perfectly, then roll them in the stretcher to a lateral position with broken hip down, fire in the spinal then transfer them to the table.

Knee Arthroplasty
Generally Bup 0.5% 2.5-3cc.

Knee Arthroscopy
If fast: Bup 0.75% 0.8cc and leave lateral operating side down for 5 min for a unilateral block that lasts ~1hr.


All right, I have exposed my ignorance. Please enlighten me oh wise ones in the ways of neuraxial techniques.

P.S. You can tell your lawyers that the above drug doses are for discussion only and should only be used by people who know that Bup 0.75% 1.8cc in Grampa with severe AS is a bad thing. No lawsuits allowed.

 

[jetproppilot]

Ok, I’m trolling for some communal knowledge. I would like to see what are peoples favorite spinal recipes. What are your cocktails that you use for knee scopes (yes, I know the literature says highest satisfaction and fastest discharge from recovery with LMA/GA but what if they really want to watch the screen), TURBP’s, TURPs, C-Sections, ect. Ideally what drugs and what is your guestimate on duration of action.

In private practice I guess you are somewhat lucky vs a teaching hospital as no C/S should take 3 hrs and you can more perfectly tailor your spinal so the patient is wiggling her toes as the surgeon staples the skin.

What about intra-thecal opioids for outpatient procedures and the risk of delayed respiratory depression?

Also for those bloody long cases (3,4,5hr), where you want to sedate the pt for comfort I always hate when my staff force me to use Epimorph. I have had people break through 100mcg/kg/min of propofol to try and scratch their damn itchy nose.

Some staff always add 15-20 mcg of Fent, others 10-20mcg Sufent. Damn if I can see a difference.

Inquiring minds want to know.

Here are some of my Voodoo Recipes, all time durations are totally guestimates.

Stat C/S
Bup 0.75% 1.6cc
Fent 15 mcg (0.3 cc)
Epimorph 100 mcg (BMJ says just as effective as 200mcg but less late apnea)
Seems to wear off around the 2-2.5 hr mark without the incidence of higher blocks I saw with 1.8 cc (“I can’t breath, I can’t breath”, barf. Oh the joys of obstetrics). Epimorph for long term analgesia but does increase the nausea though my impression is the lower dose helps, fent for more acute and seems to deal with the discomfort with the eversion of the uterus + gives a little more sedation to keep the anxiety down.

TURBT
This is a hard one. I prefer LMA with TIVA but for those who want to be awake you are always trying to guess the size of the tumor and how much burning of the anterior wall they are going to do.
a)
One I picked up from one staff is:
Lido 2% 2cc
Bup 0.75% 0.8cc
Fent 20mcg (0.4cc)
Like I said, all voodoo. Lasts ~1.5hr. Not sure where I stand with the Lido and lithotomy with the risk of TRI in addition to the intrathecal Fentanyl in an outpatient.
b)
What else has worked and I am a little more comfortable with is:
Small tumor + fast surgeon = Bup 0.75% 1cc (~1h)
Average = Bup 0.75% 1.2cc (1-1.5hr)
Extensive tumor = Bup 0.75% 1.4-1.6cc (1.5-2.5hr depending on age of pt)

TURP
Again difficult to gauge based on size of prostate and whether you have the junior resident doing the plumbing or a staff man.
I’m not as concerned about having the early toe wiggling as they are all going to be admitted anyways but I also don’t want my 14:00 TURP to still be in recovery at 21:00.

Depends but somewhere around Bup 0.75% 1.6cc + Fent 20 mcg for fastish (<2hr), Bup 0.5 3cc for slowish (3-4hr).

Hip Arthroplasty
Depends on elective vs emergent. Decent shape vs frail.
Generally Bup 0.75% 1.6-1.8cc with OR side down for 5 min
Or
Bup 0.5% 2.5 if fastish - 3cc for a longer block (if really slow 0.2 Epi 1:1000). Isobaric seems to have less potential for initial hemodynamic impact. This is what I use for the little old lady broken hip cases. =/- Fent/Sufent (no real science).
P.S. For positioning the poor little old broken ladies/gents (assuming no contraindications) I pre-med them with Ketamine 15mg, Midaz 1 which gorks them perfectly, then roll them in the stretcher to a lateral position with broken hip down, fire in the spinal then transfer them to the table.

Knee Arthroplasty
Generally Bup 0.5% 2.5-3cc.

Knee Arthroscopy
If fast: Bup 0.75% 0.8cc and leave lateral operating side down for 5 min for a unilateral block that lasts ~1hr.


All right, I have exposed my ignorance. Please enlighten me oh wise ones in the ways of neuraxial techniques.

P.S. You can tell your lawyers that the above drug doses are for discussion only and should only be used by people who know that Bup 0.75% 1.8cc in Grampa with severe AS is a bad thing. No lawsuits allowed.

WAY too much info.

I dont do spinals anymore on short cases on healthy patients (not referring to OB).

The 25 year old ASA 1 will be in the hospital for hours waiting for the block to wear off. And urinary retention is an issue.

Give a stick of propofol, 0-100 ug fentanyl, slip in a #4 LMA, crack some des/sevo, turn it off at the end, being 'em to PACU, and they're walking out of the hospital 30 min later.

If you're gonna do a spinal, use bupiv 15 mg hyperbaric unless they're really short, then back off to 12 mg. No need for opiods. Slow surgeon? .2mg epi with the bupiv.

When you lay them down, give 10 mg ephedrine IV prophylactically.

WAY too much mental masturbation in academia.

 

[stephend7799]

go up to .5 mg of duramorph in the intrathecal space for your c sections.. and you shoud be routinely adding duramorph to the spinals for csections. So much better pain relief for 24 hours... Much much better.. sometimes on pod number 1 you will have no pain at all if you use duramorph and nothing else...

 

[militarymd]

I try to keep it simple.....


12 mg marcaine + 0.3 mg of preservative free morphine for C-Sections (anything greater than 0.3 mg just increases side effects without improvement in pain scores)



15 mg of marcaine for everything else.....I've also started using isobaric marcaine a lot.....no need to worry about positioning.

 

[Noyac]

Totally agree with Jet and the others here. Too many recipes and guess work. If they are going to get a spinal , its: 15mg bupiv, 300mcg duramorph for TKA, C/S, and hips. If they are going home I don't do spinals unless the pt really wants one (ie: wants to watch) and then they get 12-15mg bupiv with 20-25 mcg fent, no duramorph. Also I do those old broken hips the same way: ketamine 10-20mg after about 2-4mg versed, roll them bad hip down and spinal. But I don't hold them there for more than a minute.

Now my only different spinal concoction is meperidine 75mg mixed 1cc to 1cc with D10. This is a awesome spinal that allows the pt to move their legs frequently throughout the case but they feel nothing for 1-1.5 hrs. I use it for TURP's , Turbt's, BTL's and those short cases.

 

[CanGas]

Mental masturbation is right. I'm just a tool at the beck and call of the staff man. I've got my PDA database full of this personalized crap for each of the 60 odd staffpeople I work with. So and so likes epidurals loaded with Lido 2% intra-op, so and so likes Bup 0.5, others Bup 0.25 and on and on.

On the good side you get to see how a ton of different people run a case differently and end up with similar outcomes. Take what works for you and leave the rest.

It's at the point now where when running a room independently I do it the way I want but when the staffman is there I do it their way as it just makes things easier. Keep the staffman happy and you will be happy. No need to rock the boat unless I feel very strongly about something or if I feel it is in the patients best interest to do it differently.

As for Duramorph, sounds great but I am pretty sure it is not licensed for Canada yet. Just like Dexmeditomidine. Sure wish I could play with those though, sounds useful.

 

[jetproppilot]

go up to .5 mg of duramorph in the intrathecal space for your c sections.. and you shoud be routinely adding duramorph to the spinals for csections. So much better pain relief for 24 hours... Much much better.. sometimes on pod number 1 you will have no pain at all if you use duramorph and nothing else...

I'm personally not a fan of Duramorph. Too many side effects, judging from patients and, uhhh my boss (wife).

Baby #1 boss had duramorph.

The itching was significant. And subsequent epidural duramorph gave her alotta sedation.

Baby #2 she had a spinal with HB bupiv 15mg + fentanyl 25ug.

And for the doubters of the team approach out there, heres one for ya.

I've got a diamond-in-the-ruff CRNA in my group. David K. Dude places epidural/spinal better than most MDs. He worked as a neurosurgeon's assistant B4 CRNA school for many years, so he's got a 3 D picture in his mind when it comes to parturient's backs.

My wife and I had another doodie on Mar 15, 2006. Beautiful baby boy!

I signed my wife's C section chart.

David K CRNA put the spinal in, while I was in front of my wife. She's a former L&D RN so she needed no help with positioning.

David K did the spinal in less than a minute (not counting setting-up time).

Minimal itching. Had a dilaudid pca post op which she pushed several times in the 1st 24hrs. Worked great, with no side effects.

After that ketorolac/occasional percocet worked fine.

 

[Noyac]

I'm personally not a fan of Duramorph. Too many side effects, judging from patients and, uhhh my boss (wife).

Baby #1 boss had duramorph.

The itching was significant. And subsequent epidural duramorph gave her alotta sedation.

Baby #2 she had a spinal with HB bupiv 15mg + fentanyl 25ug.

And for the doubters of the team approach out there, heres one for ya.

I've got a diamond-in-the-ruff CRNA in my group. David K. Dude places epidural/spinal better than most MDs. He worked as a neurosurgeon's assistant B4 CRNA school for many years, so he's got a 3 D picture in his mind when it comes to parturient's backs.

My wife and I had another doodie on Mar 15, 2006. Beautiful baby boy!

I signed my wife's C section chart.

David K CRNA put the spinal in, while I was in front of my wife. She's a former L&D RN so she needed no help with positioning.

David K did the spinal in less than a minute (not counting setting-up time).

Minimal itching. Had a dilaudid pca post op which she pushed several times in the 1st 24hrs. Worked great, with no side effects.

After that ketorolac/occasional percocet worked fine.

Dude, I recall your distaste for the duramorph spinal but I just don't see the SE's. The pts almost never touched their PCA's and therefore the OB's stopped writing for PCA's post-op. They get some p.o. pain meds the next day and are ready to go home but OB keeps them for 2 days for some reason.

 

[jetproppilot]

Dude, I recall your distaste for the duramorph spinal but I just don't see the SE's. The pts almost never touched their PCA's and therefore the OB's stopped writing for PCA's post-op. They get some p.o. pain meds the next day and are ready to go home but OB keeps them for 2 days for some reason.

Alright Noy, friend, persistent motherfu kker, ( ).

I respect your opinion/experience to the point that, for the next 10 C Sections , Jets doin' a study, and I'm gonna follow these baby mommas post op.

If they've gotta lotta side effects, I'm jumpin' on my snowboard and faky'in my way to your house to kick your a s s.

 

[Noyac]

Alright Noy, friend, persistent motherfu kker, ( ).

I respect your opinion/experience to the point that, for the next 10 C Sections , Jets doin' a study, and I'm gonna follow these baby mommas post op.

If they've gotta lotta side effects, I'm jumpin' on my snowboard and faky'in my way to your house to kick your a s s.

Just do one thing:

Don't ask about itching and they won't be itching.

BTW, your bigger than me I'm sure since you live in La. ( ) but my 6'0" 185lbs frame will take you down, that is, if you can catch me on my snowboard. We got about 2 ft of pow the last 2 days and I'm rippen like a madman possessed. My wife and I spent 3 hours snowboarding this am and are back for the final 4. Then off to the slopes again tomorrow.




Want a job?

 

[jetproppilot]

Just do one thing:

Don't ask about itching and they won't be itching.

BTW, your bigger than me I'm sure since you live in La. ( ) but my 6'0" 185lbs frame will take you down, that is, if you can catch me on my snowboard. We got about 2 ft of pow the last 2 days and I'm rippen like a madman possessed. My wife and I spent 3 hours snowboarding this am and are back for the final 4. Then off to the slopes again tomorrow.




Want a job?

Man, thats tempting, bro.

I'm the kinda dude that can be happy anywhere as long as the extracurriculars around my crib are cool.

And your crib is hard to beat, bro.

Just need to convince my y'aat boss ( 😡 ).

Heres some info for ya.

Had never been on a snowboard before our last ski trip...after a three hour lesson I caught on quick...liked it so much I turned in my skis...

was boardin' blues the next day...

put me at your crib and I'll be sprayin' your as s with a powder-rooster-tail, gunnin' for the olympic snow board team.

P.S....I'm a legend in my own...uhhh...mind....

I'm a l

 

[Noyac]

Man, thats tempting, bro.

I'm the kinda dude that can be happy anywhere as long as the extracurriculars around my crib are cool.

And your crib is hard to beat, bro.

Just need to convince my y'aat boss ( 😡 ).

Heres some info for ya.

Had never been on a snowboard before our last ski trip...after a three hour lesson I caught on quick...liked it so much I turned in my skis...

was boardin' blues the next day...

put me at your crib and I'll be sprayin' your as s with a powder-rooster-tail, gunnin' for the olympic snow board team.

P.S....I'm a legend in my own...uhhh...mind....

I'm a l

Bring your wife and I'll show her that coona*ses can live and thrive here (my wife for example). She will love it and you will too. I'd love to get you in my group, seriously. And I'll let you spray me while your here.

 

[stephend7799]

duramorph is the way to go....
0.5 mg intrathecal..

dont worry about the ses.. mostly pruritis.. write for nalbuphine 10 mg iv every 4 hours as needed...

something for nausea..
they have a foley...
write for pain prn.. doesnt matter what it is.. if you like a narcotic. go for it.. the incidence of delayed resp depression with intrathecal morphine is really really low.. amazing how much people talk about it..

a friend of mine called me today told me he used 0.7mg of duramorph..

 

[Noyac]

duramorph is the way to go....
0.5 mg intrathecal..

dont worry about the ses.. mostly pruritis.. write for nalbuphine 10 mg iv every 4 hours as needed...

something for nausea..
they have a foley...
write for pain prn.. doesnt matter what it is.. if you like a narcotic. go for it.. the incidence of delayed resp depression with intrathecal morphine is really really low.. amazing how much people talk about it..

a friend of mine called me today told me he used 0.7mg of duramorph..

Dude, you are right on with the Nubain. I use it routinely and I make sure the RN's don't use benadryl (it doesn't work at all). If they do, I ask them "where in these orders do you see benadryl"? "DO NOT USE IT, please."
But, 700mcg is way to much in my opinion. Many studies show no further benefit beyond 300-400mcg. Just SE's. I used "1.0MG" in training for rad. prostates, those guys never touched their PCA and they never complained of pruritis either. I can't explain it, but I am not about to do it today.

 

[apma77]

is there any literature that benedryl doesnt work for pruritus after duramorph??

 

[Noyac]

is there any literature that benedryl doesnt work for pruritus after duramorph??

Not sure but after seeing the nurses give it and then giving nubain, I kind no reason to use benadryl.

 

[ThinkFast007]

Eur J Anaesthesiol. 2006 May;23(5):418-21. Epub 2006 Feb 10. Related Articles, Links


The impact of intraoperative propofol administration in the prevention of postoperative pruritus induced by epidural morphine.

Kostopanagiotou G, Pandazi A, Matiatou S, Kontogiannopoulou S, Matsota P, Niokou D, Kitsou M, Crepi E, Christodoulaki K, Grigoropoulou I.

University of Athens, Attikon Hospital, School of Medicine, 2nd Clinic of Anaesthesiology, Athens, Greece.

SummaryBackground and objective: We examined the efficacy of intraoperative propofol administration to prevent pruritus induced by epidural morphine. Methods: Seventy patients ASA I-II undergoing combined epidural and general anaesthesia for hysterectomy were randomly assigned to two groups, Group P where anaesthesia was induced with propofol and fentanyl and maintained with propofol-nitrous oxide and Group S in which anaesthesia was induced with thiopental and fentanyl and maintained with sevoflurane-nitrous oxide. All patients received a ropivacaine epidural bolus with 3 mg morphine 1 h before the end of surgery. The incidence and severity of pruritus were evaluated every 4 h for the first 12 h postoperatively by blinded observers. Results: The total incidence of pruritus was significantly higher (P = 0.024) in Group S (65.6%) compared to Group P (29%) between 4 and 8 h postoperatively. There were also significantly more patients (P = 0.03) reporting severe pruritus in Group S (22%) compared to Group P (0). Conclusion: Propofol-based general anaesthesia compared to thiopental-sevoflurane-based anaesthesia reduces the incidence and severity of pruritus induced by a single injection of 3 mg epidural morphine with ropivacaine.

👍 or 👎

 

[MTGas2B]

Chloroprocaine spinals, anyone?

I've been enjoying the first month of the rest of my professional life. Lucked out with an anesthesiology elective as the last month of my intern year before starting my CA-1 year.

I was able to give my first spinal today, for a knee arthroscopy case. It was also probably the last time I'll use chloroprocaine to do it, not really at hit at UW I've heard. Worked great, didn't hang around too long, no trouble with urinary retention.

Think it will ever come back into style?
(Anesth Analg 2004;99:553–8)

 

[jetproppilot]

Chloroprocaine spinals, anyone?

I've been enjoying the first month of the rest of my professional life. Lucked out with an anesthesiology elective as the last month of my intern year before starting my CA-1 year.

I was able to give my first spinal today, for a knee arthroscopy case. It was also probably the last time I'll use chloroprocaine to do it, not really at hit at UW I've heard. Worked great, didn't hang around too long, no trouble with urinary retention.

Think it will ever come back into style?
(Anesth Analg 2004;99:553–8)

Very interesting post.

Sounds like a good idea for practices that have OB dudes doing quick C sections.

Out of, oh, about 12 OBs I work with, I could use it on.....

TWO.

and, continually, there is no pressure on private practice clinicians that routinely take 75 minutes for an operation that should be between 20-40 minutes long.

What would your anesthesia partner say to you if you routinely took 20 minutes to put in a central line???