Outpatient Hips

[GassYous]

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How are you guys doing total hips and scopes outpatient? Spinal with mepiv? Lma? Peng/fi?

It seems like the hip scopes are really painful and have had some trouble with managing it in pacu without a lot of opioids before discharge.

 

[staple]

scope recipe

ponv prevention + lots of opioids + PRN rescue block.

if Really worried about ponv, tiva + antiemetics + 300-500 mcg fentanyl

narcotics are really just unavoidable in scopes.

 

[GassYous]

I've been trying to keep my opioids to below 100 of fent or 1-2 of dilaudid for outpatients to minimize pacu time but I figured I was underdosing for hip scopes since they look really uncomfortable in pacu. I do ett. Shoulders do really nicely with interscalenes +/- something for the biceps with no opioids and knees (without acl) seem to be happy with just 50-100 of fent. Thanks for the reply.

 

[Urzuz]

Hip scope - ETT with paralysis (while on traction). PRN fentanyl/hydromorphone. IV ketorolac. Surgeon injects intraarticular local+morphine. PO acetaminophen and PRN hydromorphone in PACU. The vast majority of patients do fine. Maybe 5-10% require a rescue fascia iliaca block (dilute local anesthetic so you don’t give them quad weakness and buy them an admission).

THA - PO multimodals of choice (acetaminophen, Celebrex, etc etc). Dilute fascia iliaca preop optional. Spinal with 1.2-1.4 ml hyperbaric bupivacaine + 10-20 mcg of fentanyl. Propofol sedation. Patients get their PT sessions in PACU and discharged.

 

[staple]

I've been trying to keep my opioids to below 100 of fent or 1-2 of dilaudid for outpatients to minimize pacu time but I figured I was underdosing for hip scopes since they look really uncomfortable in pacu. I do lma. Shoulders do really nicely with interscalenes +/- something for the biceps with no opioids and knees (without acl) seem to be happy with just 50-100 of fent. Thanks for the reply

A lot of my partners don’t use as high of narcotics doses as me. Our pacu nurses brought It up to me one day. They asked why my hip scope patients rarely needed a rescue block, while my partners were >50% requiring a rescue block. The answer is simple. I give lots of narcotics. I’m not naive to the fact narcotics have nasty side effects. But I believe we often times under dose narcotics in the OR. This is one procedure that unfortunately can’t be avoided.

I also agree with urzuz... love multimodal approach. After paralysis is no longer needed, I’ll titration narcotic to spontaneous respiratory rate of 8 on 0.7 MAC of gas.

 

[staple]

One final thought of the day. If you go to the PACU to evaluate a hip scope patient’s pain, if the pain score > respiratory rate, Tylenol. If the RR > pain score, consider narcotic or block.

 

[kmurp]

I’ve had some luck using a PENG. Block for hips scopes. Have only done a few so far.

 

[Hoya11]

How are you guys doing total hips and scopes outpatient? Spinal with mepiv? Lma? Peng/fi?

It seems like the hip scopes are really painful and have had some trouble with managing it in pacu without a lot of opioids before discharge.

we start out with geta and titrated fent/dilauded. tylenol and toradol and surgeon local. usually 200mcg and 1-2mg in total. rarely a femoral block in recovery room if needed - like less than 10 percent of the time