Patient with MH that you can't paralyze

[jetproppilot]

36 y/o healthy, skinny female coming in for a lumbar fusion because of a bad car wreck.

Has a job, shuns opiods,

got dealt a bad life hand, got in a wreck, has this bad back issue that needs fixing. she's FO REAL. Not drug seeking, not looking for a workmans comp/disability ride, she wants to have this surgery so her quality of life will improve so she can get back to work and caring for her family.(for you new dudes out there, for people having back surgery, this is rare.)

HERE'S THE ISSUE.

Back when she was seven, she had an operation and malignant hyperthermia ensued.

The incident was quelled, she reports that she almost died; subsequent muscle biopsy proved what was suspected.

SHE'S THE REAL DEAL. Not a cousin, not her aunt. Not her brother.

HER. I mean SHE...uhhhh....whatever...SHE REALLY HAS MALIGNANT HYPERTHERMIA! She, her, we, it....SHE'S GOT IT.

How would you proceed? PREOP, INTRAOP, POSTOP???

Lumbar fusion, several levels, with a rokkstarr surgeon.

The rokkstarr surgeon says its gonna take four hours (so it'll be four hours...not 6...not 10...not even 5. It'll be FOUR, with a standard deviation of fifteen minutes.)

SSEPs will be utilized so long term utilization of non depolarizing neuromuscular blockers can't happen.

Nor can nitrous, really.

WOULD LIKE TO HEAR FROM THE RESIDENTS/med students with some anesthesia SWAGGER out there FIRST....ATTENDINGS PLEASE PUT A 12 HOUR HOLD ON YOUR POST if you don't I'm gonna pull you over, full lights and siren, demand you exit your vehicle, demand you interlace your fingers behind your head, and walk BACKWARDS towards me, ever so slowly...any breach and it's a NINE TO DA DOME, after which you'll MEET LUCIFER.

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[ssmallz]

Propfol, Ketamine, Opioid infusion. Start the opiods early, get em real deep w/propfol, intubate w/out muscle relaxant or just use minimal muscle relaxant for intubation. Maintain the infusion for a case, slap on a bis for documentation purposes, replace blood loss, yada yada yada.

 

[NotAMD]

36 y/o healthy, skinny female coming in for a lumbar fusion because of a bad car wreck.

Has a job, shuns opiods,

got dealt a bad life hand, got in a wreck, has this bad back issue that needs fixing. she's FO REAL. Not drug seeking, not looking for a workmans comp/disability ride, she wants to have this surgery so her quality of life will improve so she can get back to work and caring for her family.(for you new dudes out there, for people having back surgery, this is rare.)

HERE'S THE ISSUE.

Back when she was seven, she had an operation and malignant hyperthermia ensued.

The incident was quelled, she reports that she almost died; subsequent muscle biopsy proved what was suspected.

SHE'S THE REAL DEAL. Not a cousin, not her aunt. Not her brother.

HER. I mean SHE...uhhhh....whatever...SHE REALLY HAS MALIGNANT HYPERTHERMIA! She, her, we, it....SHE'S GOT IT.

How would you proceed?

Lumbar fusion, several levels, with a rokkstarr surgeon.

The rokkstarr surgeon says its gonna take four hours (so it'll be four hours...not 6...not 10...)

SSEPs will be utilized so long term utilization of non depolarizing neuromuscular blockers can't happen.

Nor can nitrous, really.

WOULD LIKE TO HEAR FROM THE RESIDENTS FIRST....ATTENDINGS PLEASE PUT A 12 HOUR HOLD ON YOUR POST if you don't I'm gonna pull you over, full lights and siren, and demand you exit your vehicle, interlace your fingers behind your head, and walk BACKWARDS towards me, ever so slowly...any breach and it's a NINE TO DA DOME, after which you'll MEET LUCIFER.

deep general tiva with propofol (~150) and remi (~.25-.5) plus minus a little dex or ketamine background and a 1mg dilaudid load after induction - propofol bolus syringe for putting down any intermittent movement

 

[proman]

SSEPs will be utilized so long term utilization of non depolarizing neuromuscular blockers can't happen.
[/B]

SSEPs, being purely sensory signals, are unaffected by neuromuscular blockers. The baseline EMG signals of an unrelaxed patient makes it harder to monitor SSEPs. Our neuromonitoring guys would always ask for full relaxation. For this patient, I would use propofol/ketamine TIVA with a vecuronium infusion and a touch of hydromorphone at the end.

 

[jetproppilot]

SSEPs, being purely sensory signals, are unaffected by neuromuscular blockers. The baseline EMG signals of an unrelaxed patient makes it harder to monitor SSEPs. Our neuromonitoring guys would always ask for full relaxation. For this patient, I would use propofol/ketamine TIVA with a vecuronium infusion and a touch of hydromorphone at the end.

Not implying NMBs affect SSEPs.

Surgeon doesnt want them paralyzed.

 

[proman]

Not implying NMBs affect SSEPs.

Surgeon doesnt want them paralyzed.

Sorry I must have misunderstood. She'd be a good person for my favorite pre-med:

4mg tizanidine
900mg gabapentin
1000mg acetaminophen

Methadone as the only opioid would be a good choice too. I like to use 0.1mg/kg dose. 2/3 at induction, 1/3 when closing. A lot of ways to skin this cat.

 

[BobBarker]

Induction with versed, fentanyl, and propofol. Intubate without relaxant. Run them on a precedex infusion along with propofol on a syringe pump. Bolus fentanyl intermittently throughout the case.

 

[amyl]

flush the machine, etc. tiva prop and remi and one of the times i want a bis... i did a MH liver transplant last month.... 14 hour case... i feel like i gave a liter of propofol

 

[Bertelman]

I'm not understanding the need for a BIS in a pt. that is not paralyzed.

 

[fakin' the funk]

36 y/o healthy, skinny female coming in for a lumbar fusion because of a bad car wreck.

Mine might be unimaginative, but here goes.

Setup: Flush machine w/ high flow O2 x30minutes, remove the vaporizers from the machine and room, succinylcholine outta the room, make sure the chart etc has listed in BIG LETTERS "allergies" to all the -fluranes and succinylcholine. Like, in a font way bigger than "Codeine causes N/V" . For effect you could make sure the "reaction" as listed is "DEATH". Depending on your surgeon, A-line, some albumin, some hetastarch in the room, 0.5-1 L of each. At least one 18g PIV or bigger on a warmer. Upper and lower body forced air warming blankets.

Induction: propofol, roc, fent. If you REALLY have to do this case with zero NDMB, then induction with propofol and 30-40 mcg/kg alfentanil. But since you're gonna prone this person, SSEP setup time, yadda yadda, you probably have time to sneak in 20-30mg roc and still be OK by the time they're through fascia. Dexamethasone 4mg.

Maintenance: Propofol 150-250mcg/kg/min, fentanyl 1-3 mcg/kg/hr. I'd be heavier on prop than fent. See if the neurophysiologist will setup EEG for you. Otherwise, BIS would be nice but not necessary. 80% oxygen in air. When they're done with monitoring and are thinking about starting to close, 70% nitrous, propofol off, fentanyl off, see when she starts breathing, 10-20mg propofol boluses as needed. Spontaneously ventilating or with PSV that you can trust, fentanyl 50mcg at a time until etCO2 is above 45. Ondansetron 4mg, 100% oxygen just before the flip. Should be a pretty wakeup.

I don't see what ketamine or dexmedetomidine gets you here other than messing up your wakeup (and I'm too lazy to look up its effects on SSEPs)

 

[Gimlet]

Surgeon doesnt want them paralyzed.

Can I ask about that? A couple of the spine guys here (and now the spine fellow) have gotten in the habit of asking us to let the NMB wear off. I think their logic is that they theorize they'll see muscle groups react if they're irritating the nerve roots too much. I'm guessing the sensitivity of that is piss-poor.

If they're that concerned about it, why not monitor MEPs? I'm sick of getting grilled every 15 minutes about "how many twitches" we have, and sick of going through all my predrawn sticks of phenylephrine and ephedrine to keep their MAPs appropriate while having them deep enough to not move with no NMB on board.

 

[lord_jeebus]

I had a very similar case. The pt was older, but otherwise the story was the same (biopsy-confirmed MH; spine surgery with MEPs, etc.)

MH cart inventoried and moved to the room. Surgeons and nursing staff reminded of the significance of MH. Sux hidden. 1-800-MH-HYPER phone number prominently posted. Machine flushed; vaporizers removed.

Induction with propofol + fentanyl. Airway was easy without relaxant. Maintenance with propofol, remi, maybe ketamine. Neo gtt. When neurophysiologist was done with MEPs, propofol off and N2O on, a little dilaudid, and a mg or two of vec just in case.

Smooth wake-up.

 

[fakin' the funk]

I'm guessing the sensitivity of that is piss-poor.

If they're that concerned about it, why not monitor MEPs? I'm sick of getting grilled every 15 minutes about "how many twitches" we have, and sick of going through all my predrawn sticks of phenylephrine and ephedrine to keep their MAPs appropriate while having them deep enough to not move with no NMB on board.

Re: adequate MAPs, just run a phenylephrine drip. No biggie.

 

[IlDestriero]

Re: adequate MAPs, just run a phenylephrine drip. No biggie.

Not usually an issue if you maximize the dope and minimize the propofol with some ketamine. I'll refrain from commenting further at this time.
Though I don't really understand the need to give Vec at the end of the case report above. She might be light, paralyze her? I'm also not so sure of the need to have MHAUS on speed dial if you use a non triggering anesthetic, or a 30 min machine prep. We use some fancy device now, takes about 5 minutes. I do support removing the sux and vaporizers, I have a paranoid fear of a small volatile leak, or a really bad resident.

 

[lord_jeebus]

Not usually an issue if you maximize the dope and minimize the propofol with some ketamine. I'll refrain from commenting further at this time.
Though I don't really understand the need to give Vec at the end of the case report above. She might be light, paralyze her? I'm also not so sure of the need to have MHAUS on speed dial if you use a non triggering anesthetic, or a 30 min machine prep. We use some fancy device now, takes about 5 minutes. I do support removing the sux and vaporizers, I have a paranoid fear of a small volatile leak, or a really bad resident.

My paranoid fear (not based on something that happened to me personally, but someone else) involves patient movement on 60-70% N2O in the prone position. I agree that after a long propofol TIVA, and with remi still on, it's unlikely to be an issue.

I agree that I'm very unlikely to actually call MHAUS, but I don't want to look stupid trying to Google their number in the event that I need them.

 

[jwk]

Can I ask about that? A couple of the spine guys here (and now the spine fellow) have gotten in the habit of asking us to let the NMB wear off. I think their logic is that they theorize they'll see muscle groups react if they're irritating the nerve roots too much. I'm guessing the sensitivity of that is piss-poor.

If they're that concerned about it, why not monitor MEPs? I'm sick of getting grilled every 15 minutes about "how many twitches" we have, and sick of going through all my predrawn sticks of phenylephrine and ephedrine to keep their MAPs appropriate while having them deep enough to not move with no NMB on board.

I don't play the "how many twitches" game. They're either going to be fully relaxed, or not relaxed at all. Roc at induction, and nothing else, OR, roc all the way through.

 

[sevoflurane]

....ATTENDINGS PLEASE PUT A 12 HOUR HOLD ON YOUR POST if you don't I'm gonna pull you over, full lights and siren, demand you exit your vehicle, demand you interlace your fingers behind your head, and walk BACKWARDS towards me, ever so slowly...any breach and it's a NINE TO DA DOME, after which you'll MEET LUCIFER.[/B]

Air traffic control.... we're still in a holding pattern at 250 knots.

 

[rsgillmd]

Not usually an issue if you maximize the dope and minimize the propofol with some ketamine. I'll refrain from commenting further at this time.
Though I don't really understand the need to give Vec at the end of the case report above. She might be light, paralyze her? I'm also not so sure of the need to have MHAUS on speed dial if you use a non triggering anesthetic, or a 30 min machine prep. We use some fancy device now, takes about 5 minutes. I do support removing the sux and vaporizers, I have a paranoid fear of a small volatile leak, or a really bad resident.

 

[Idiopathic]

with the exception of the prep to the room (vaporizers/sux locked down) this is no different than the 30+ cases I did during residency where MEPs were monitored. TIVA with prop + remi AT LEAST add in lidocaine/precedex/ketamine infusions if you wish.

pretty typically my cocktail is propofol/remi/lidocaine/ketamine intraop with sufentanil for the end, +/- BIS, i can see the utility for following BIS trends but by the time it hits 80 you better have done something to fix it, so probably you dont gain much unless you are watching it like a hawk.

Lidocaine off 15 minutes before flip, continue low dose ketamine into PACU at 6-10mg/hour based on weight...the lidocaine will significantly reduce your propofol requirements and allow you to wake up quicker and more comfortably, based on personal experience.

 

[jetproppilot]

Air traffic control.... we're still in a holding pattern at 250 knots.

Sevo thirty-nine-twenty-seven, turn right heading two seven zero, maintain 3500 until established, cleared ILS runway two eight approach.

 

[rsgillmd]

with the exception of the prep to the room (vaporizers/sux locked down) this is no different than the 30+ cases I did during residency where MEPs were monitored. TIVA with prop + remi AT LEAST add in lidocaine/precedex/ketamine infusions if you wish.

pretty typically my cocktail is propofol/remi/lidocaine/ketamine intraop with sufentanil for the end, +/- BIS, i can see the utility for following BIS trends but by the time it hits 80 you better have done something to fix it, so probably you dont gain much unless you are watching it like a hawk.

Lidocaine off 15 minutes before flip, continue low dose ketamine into PACU at 6-10mg/hour based on weight...the lidocaine will significantly reduce your propofol requirements and allow you to wake up quicker and more comfortably, based on personal experience.

Idio, what rate did you run your lidocaine at?

 

[drccw]

geez that's a lot of complicated anesthetics...
A healthy dose of fentany infusion (probably start at 4 mcg/kg/hr)
and propofol...

I don't really like remi bc
a) it's expensive
b) I do believe in a "wind up" phenomenon
c) I think back wacks hurt
d) we don't have it

dexmedotomidine
a) it's expensive
b) it's a pain for me to get

drccw

 

[Idiopathic]

Idio, what rate did you run your lidocaine at?

2mg/minute, regardless of the case (crani, spine, thyroid, belly...)

 

[somedumbDO]

this isnt really rocket science here:
2 PIV, aline. 2PIV one for gtts other for volume.
machine prep, vaporizors taped off, sux out of the room.
Induction: if good airway, lido, fent, propofol, roc 0.6mg/kg ( it will wear off by the time you flip and position anyways, always a good idea to flip a paralyzed pt) bad airway -> AFOI
the bair hugger sandwich (our spine surgeon room is frigid)
nerve stim test so the police knows minimal paralytic
Maintence: prop plus sufenta +/- ketamine. Remi has an hyperanalgesic effect and they need narcs post op its a bad ideal. sufenta hard to overdose and with the ketamine may have an opiod sparing effect.
Colloids to replace blood loss
robaxin 1hr before wake up, IV tylenol if you got it
Wake up: cut the prop @ 50-100mcg/kg/m sufenta minimal titrate to breathing via PS Pro to RR @ 8
gtts off while dressings on
flip
yank the tube
get lunch

 

[rsgillmd]

This is unusual for you Jet. Where is the punch line?

 

[jetproppilot]

This is unusual for you Jet. Where is the punch line?

LOL!!

No punchline doc. Had a busy day today at the Taj Mahal so not much computer playing.

I like all the responses!

We all do things slightly different which is the interesting part of this business. I'll comment on some of the posts just at random:

1)I'm not a big fan of intubating without relaxant, nor do I think it necessary in this case. As many of you mentioned, an appropriate dose of rocuronium (or vec, or whatever nondepolarizer you like) can be utilized to facilitate intubation and get thru the flip...dose it right and it won't be an issue for monitoring/surgeon preference. For those of you in favor of intubating without relaxant, have you intubated alotta patients without relaxant? And no, I'm not referring to the feeble, 80 y/o COPDer in the ICU you've been called to intubate cuz they're on death's door where you give twenty milligrams of 2-6-diisopropylphenol laugh...or maybe nothing at all for laryngoscopy...I'm talking about a pretty healthy dude/dudette...

you might get lucky, slam a stikka white stuff, they might hold still, but probably not. Thirty bucking bronco seconds later after you've wrestled with the Miller two, sweat beginning to form on your brow, this situation eating up WAYYYYYY too many of your brain cells just to get the godd a m tube in...

it ain't worth it in my opinion.

Give a judicious dose of nondepolarizer. Make your life easy. We don't like to sweat unnecessarily in this anesthesia biz.

2) I like the attention to detail alotta you spoke of, like vaporizers actually taken off the machine.

Succinylcholine outta the room.

Yeah, we all know the triggers of MH and not to use them...but...know how easily it is to get distracted?

All of a sudden something unforeseen happens...the patient's blood pressure falls precipitously on induction for some unknown reason so you're searching for the phenylephrine/ephedrine syringe.... or the fire alarm goes off...or the circulator faints to the floor because she banged some dude she met at The Cat's Meow on a one night stand six weeks ago and now she's pregnant but doesn't know it yet and being nauseated for the last week all she's eaten in the last 72 hours is one Ritz cracker so she gets dizzy in the operating room and faints, hitting her head on the terazzo putting off the sound of a bowling ball thrown off a third floor balcony hitting the street..now the surgeon is huddled around her, the scrub tech is hitting the code button, thirty people now rush into the room saying collectively "WTF???"

point being, ANYTHING CAN HAPPEN THAT CAN DISTRACT YOU OR A COLLEAGUE TO FORGET NOT TO PUSH SUX OR TURN THE VAPORIZER...

I like that. The removal of the triggers so you can't make a mistake. And turn it on. Or push it.

4) Not sold on remifent. Big sufentanil fan for cases like this. Fentanyl I'm sure is ok but if I'm gonna do a case that needs an opioid infusion I'm using sufent.

BIG precedex fan. We have it. We use it.

5) Some of you dudes with SWAG out there brush this case off as not a big deal. I hear ya! I agree with you! I agree...you're saying BRING IT DUDE, CUZ I GOT IT. I respect that. Laud that....with a caveat being

UHHHHHH, DUDES, this IS a big deal.

This case is frought with peril even before you get started.

Your whole routine has been changed for this case...the setup is different...your intraoperative interventions are different...the people around you aren't as educated as you are with this condition...something unexpected may happen that can distract you or a coworker...

So yeah, it's not a big deal, but then again it is.

This ain't no routine LMA #4 kneescope.

YA FEEL ME?

Nice discussion. Nice posts.

 

[sevoflurane]

LOL!!

... Cat's Meow

Loved that place when I was 19 y/o. Ahh the memories...

We don't see this everyday and it's good practice to go through the routine. Good for both jedi masters and young patawans climbing up. MH is ours and we need to respect it as such.

As for the case, many ways to skin this cat. I do like remi because with other opiods (dilaudid, sufent, methadone)/adjuvants as a background, it makes for quick wake ups. I like it’s metabolism. It’s very titratable with regards to apnea.

I’ll grab a 200mcg vial of precedex. Put it on a minidripper diluted in 100mls. Watch it drip, drip, drip slowly (good side effect profile). 1 vial is usually enough and it’s easily adjustable.

I don’t do the lidocaine thing. I don’t like the idea of a continuous infusion of LA into a vein. I would not want to run a longer (4-6 hour case) with a de-conditioned, NYHC III (god forbid IV) 65 y/o, 60 kg patient for a T12-S1 spinal fusion. I know... it’s not voodoo. Just something I don’t do.

Ketamine gtt’s or intermittent boluses. In the big whack with an opiod tolerant patient I might induce with 3-6mg of versed allowing it time to take effect, and then 1.5mg/kg of ketamine and .5 mg/kg of roc. Mostly though, it’s versed, sufent, ketamine (.5mg/kg), lido, prop, roc.... all coming together at laryngoscopy.

Magnesium 4-6mg for a 4-6 hour case. 4mg w/in 30 minutes. Minidripper. I like it’s sedative and neuromuscular blocking properties... the cardiac protection is nice to have as well.

I start my 2-6-diisopropylphenol at 80mcg/kg,min. I prefer the lower side of things and let the other adjuvants (titratable ones with short context sensitive half-lifes do a lot of the work.). I keep in mind that short context sensitive half-lifes may mean more pain in the long run. Which is why I LOVE KETAMINE!

In the healthy heart and lungs, I give colloid early and try to stay dry/run them below what I feel is 10% of their baseline. Not hypotensive anesthetic, but almost.

Honestly, this is a schematic of a “general patient” who is to undergo this case... We all know that it changes often depending on the situation. The truth of the matter is that spine cases (and anesthesia in general) are often not about what pharmacy you use, but how you use the pharmacy in the context of the patient....

In this case sux and sevo would have been bad... yes. But what if you didn’t know?

Nice post.

Keep 'em coming.

 

[Lightwand]

Nice thread. Writing this out more for my own educational benefit, because there isn't much to add to what's already been said.
Flush machine, vaporizers off, sux out of room, etc.
Brief circulators, scrubs, surgical team about MH precautions, get everyone aware.
PIVx2, a-line.
Induction with fent/lido/prop/roc, assuming favorable airway.
Roc will be gone by the time you get lined up, flip, prep, drape, cut (at least in our hospital!).
Maintain with prop, sufenta (.4ish), nitrous if the monitoring guys will let you (ours are 50/50, usually can get the response, but first thing to lose if having trouble with initial monitoring). Throw in some ketamine for good measure- I usually just give a few boluses to load and don't typically run an infusion.
Sufenta will do most of the heavy lifting and spare a good deal of propofol.
I hate BIS, but would consider in this case, just because of the TIVA.
Fluids/colloids as necessary. Blood available.
Sufenta off about 20 min before finish, can add back some paralytic if concerned about the patient moving. Ride the propofol until you're ready to flip.
Flip over, tell patient to wake up and breathe, pull the tube.
Remind patient to breathe on way to PACU.

Lots of ways to skin this cat.

 

[jetproppilot]

Nice thread. Writing this out more for my own educational benefit, because there isn't much to add to what's already been said.
Flush machine, vaporizers off, sux out of room, etc.
Brief circulators, scrubs, surgical team about MH precautions, get everyone aware.
PIVx2, a-line.
Induction with fent/lido/prop/roc, assuming favorable airway.
Roc will be gone by the time you get lined up, flip, prep, drape, cut (at least in our hospital!).
Maintain with prop, sufenta (.4ish), nitrous if the monitoring guys will let you (ours are 50/50, usually can get the response, but first thing to lose if having trouble with initial monitoring). Throw in some ketamine for good measure- I usually just give a few boluses to load and don't typically run an infusion.
Sufenta will do most of the heavy lifting and spare a good deal of propofol.
I hate BIS, but would consider in this case, just because of the TIVA.
Fluids/colloids as necessary. Blood available.
Sufenta off about 20 min before finish, can add back some paralytic if concerned about the patient moving. Ride the propofol until you're ready to flip.
Flip over, tell patient to wake up and breathe, pull the tube.
Remind patient to breathe on way to PACU.

Lots of ways to skin this cat.

Nicely done.

Humbly disagree with your opinion on the BIS, tho...

yeah the company f u kk ed up with all their claims initially of eliminating intraop recall...a claim that was later refuted, almost to the company's demise...

but they bounced back, and I'm glad they did.

I've always looked at the BIS as another guide to anesthetic depth..

and I gotta tell you as an aside...

YEAH, YOU MIGHT THINK THE WHOLE BIS VIBE THING IS VOODOO.

IT IS NOT VOODOO. IT WORKS, IF YOU KNOW HOW TO INTEGRATE IT INTO YOUR FLOW.

BIS, if you know how to use it, allows you to wake up patients like this:

BAM!

no, I'm not a paid BIS consultant. GEEZ...thinkin' about it...maybe I should be...

 

[periopdoc]

I would do it just like I did every spine I did in residency with the additional steps of taking all triggers out of the room, flushing the machine or preferably getting an ICU vent, ensuring the MH cart is in the room, and briefly running through the MH algorithm with the OR team (assigning roles).

When the patient rolls through the OR door, hook up and start Remi infusion. Monitors, preox, induce with propofol and intubate without relaxant. The Remi/propofol combination is sufficient and yes I intubate without relaxants frequently enough to be pretty comfortable with it even in fairly muscular dudes as long as the airway is favorable. My favorite trick is to slip the tube in and listen for breath sounds in the end of the tube for confirmation of placement, but you have to be pretty good at getting them quickly and safely to the right level of anesthesia for that to work.

Propofol/ Remi infusion for the case. I might throw on a random number generator BIS if one was in the room. Low dose Ketamine if this is a chronic pain patient, although I am using it more and more for all-comers to painful surgery. Towards the last 30-45 min of the case wean the drips and get the patient breathing spontaneously. 10-15 min before the flip turn the propofol off. After the flip the remi comes off. Load with hydromorphone titrated to EtCO2 as you are extubating. To PACU for further opiate loading.

I don't use much remi anymore, but this is a perfect case for it. Even with the chronic pain patients, it was rare that I couldn't get them acceptably comfortable after a prolonged remi infusion case. The hyperalgesia is probably real, but it is treatable.

- pod

 

[jetproppilot]

I would do it just like I did every spine I did in residency with the additional steps of taking all triggers out of the room, flushing the machine or preferably getting an ICU vent, ensuring the MH cart is in the room, and briefly running through the MH algorithm with the OR team (assigning roles).

When the patient rolls through the OR door, hook up and start Remi infusion. Monitors, preox, induce with propofol and intubate without relaxant. The Remi/propofol combination is sufficient and yes I intubate without relaxants frequently enough to be pretty comfortable with it even in fairly muscular dudes as long as the airway is favorable. My favorite trick is to slip the tube in and listen for breath sounds in the end of the tube for confirmation of placement, but you have to be pretty good at getting them quickly and safely to the right level of anesthesia for that to work.

Propofol/ Remi infusion for the case. I might throw on a random number generator BIS if one was in the room. Low dose Ketamine if this is a chronic pain patient, although I am using it more and more for all-comers to painful surgery. Towards the last 30-45 min of the case wean the drips and get the patient breathing spontaneously. 10-15 min before the flip turn the propofol off. After the flip the remi comes off. Load with hydromorphone titrated to EtCO2 as you are extubating. To PACU for further opiate loading.

I don't use much remi anymore, but this is a perfect case for it. Even with the chronic pain patients, it was rare that I couldn't get them acceptably comfortable after a prolonged remi infusion case. The hyperalgesia is probably real, but it is treatable.

- pod

NICE!

Nice management. I wouldn't do it that way, but that really doesn't matter!

 

[rsgillmd]

.......
Magnesium 4-6mg for a 4-6 hour case. 4mg w/in 30 minutes. Minidripper. I like it’s sedative and neuromuscular blocking properties... the cardiac protection is nice to have as well......

I'm assuming you mean grams (gm or g -- whichever you prefer), not milligrams (mg).

Just wanted to point it out for any CA-1's who may not have used Magnesium yet.

 

[Jeff05]

lyrica and tylenol.
glyco 0.2mg.

induce with prop, lido, and remi bomb.

methadone 0.2mg/kg up front. run on a remi/prop.

 

[sevoflurane]

I'm assuming you mean grams (gm or g -- whichever you prefer), not milligrams (mg).

Just wanted to point it out for any CA-1's who may not have used Magnesium yet.

Yep. typo... my bad.

 

[Idiopathic]

for those of you who wouldnt use remifentanyl, i understand your reasoning. however, there isnt a better short acting intraoperative muscle relaxant, in my opinion. you can substitute 150-200mcg of remifentanyl with your induction agent and facilitate intubation in most people, and a steady infusion rate during the case will significantly reduce the chance that the patient will move, regardless of the BIS. i use it for many cases specifically for this reason. Sufentanyl or fentanyl are much better choices for postoperative analgesia, but remifentanyl with the appropriate adjuncts (dex/lido/k) will effectively blunt the intraoperative pain response. you should obviously add something at the end for postop pain (although you would be surprised at how well the ketamine and residual lidocaine work for postoperative pain...see the ketamine thread)

 

[periopdoc]

NICE!

Nice management. I wouldn't do it that way, but that really doesn't matter!

Thats what I love about anaesthesia, many different ways to arrive at the same goal, and each with their own strengths and weaknesses.

I just wish everyone understood that (see my post in the private forum). Tell me your goals and I will get you there, just don't try to tell me how to get there.

- pod

 

[jennyboo]

1. Preop: Go look at wherever we keep the MH kit and make sure it's still there. When's the last time you looked at it? Also remove volatile agents and sux from the room, flush the machine with 10+ L/min O2 for 20 minutes with a circuit and an extra bag on the Y-piece (to read EtVolatile), then change to a new circuit again.

2. Access: PIVx2, a-line.

3. Monitors: Standard monitors, A-line.

4. Induction: propofol, single dose of cisatracurium or vecuronium (just tell the surgeon it'll be gone in 30 minutes or whatever).

5. Maintenance: propofol infusion, remifentanil infusion, ketamine infusion, air/O2.

6. Postop analgesia: Dose long-acting narcotic intraop (hydromorphone 1.5-2mg). Tylenol & hydromorphone PCA post-op. She's not opioid tolerant so adjuncts are nice but she should be fine with a normal-range PCA.

 

[BISof60]

I would do it just like I did every spine I did in residency with the additional steps of taking all triggers out of the room, flushing the machine or preferably getting an ICU vent, ensuring the MH cart is in the room, and briefly running through the MH algorithm with the OR team (assigning roles).

- pod

I know all the books say flush the machine/disconnect vaporizors, etc. But I agree with periop--USE AN ICU VENTILATOR! There's little chance of residual vapor in the machine but why risk it?

This lady's going to have a smooth perioperative course unless somebody (i.e. me) gives her a triggering agent. Take any chance of vapor out of the equation--use TIVA and the ICU ventilator.

 

[seamonkey]

Jet,
i love your posts. I lurk a lot, post very infrequently.

That being said, as a CA-2......the anesthestic for this case is very straightforward. Your great teaching points are really about how to avoid screwing up what should be a pretty simple TIVA.

Vaporizers OFF machine. SUX out of room. Then.........

well, nuts , just run some propofol and remi/sufenta/whatever you want and plan for post-op analgesia. Hell, I'll work in a bunch of dilaudid on top of the remi, and watch them wake up so damn happy (eventually). Not rocket science really, just good anesthesia.

we need more clinical stuff on here. Maybe I'll get off my ass and post some fun cases too. Thanks for doing what you do.

 

[Arch Guillotti]

I know all the books say flush the machine/disconnect vaporizors, etc. But I agree with periop--USE AN ICU VENTILATOR! There's little chance of residual vapor in the machine but why risk it?

This lady's going to have a smooth perioperative course unless somebody (i.e. me) gives her a triggering agent. Take any chance of vapor out of the equation--use TIVA and the ICU ventilator.

I think using an ICU ventilator is crazy.

 

[IlDestriero]

I like the standard vent because I thoroughly understand its function and how to trouble shoot problems.
I'm a fan of the NICU vent for complex babies, but I don't really understand it as well and I have to have the RT set it up and review it with me each time. If I was more comfortable with it, I might use it more. I don't see any risk with a properly prepped anesthesia machine. Most of my colleagues just put a strip of 2" tape across the vent dials with "MH. MH. MH" across it.
Having the ability to add N2O could come in handy one day.

 

[Idiopathic]

I know all the books say flush the machine/disconnect vaporizors, etc. But I agree with periop--USE AN ICU VENTILATOR! There's little chance of residual vapor in the machine but why risk it?

This lady's going to have a smooth perioperative course unless somebody (i.e. me) gives her a triggering agent. Take any chance of vapor out of the equation--use TIVA and the ICU ventilator.

I disagree wholeheartedly, and MHAUS is fairly clear on this topic.

Q: How should the anesthesia machine be prepared before surgery for an MHS patient?

A: Ensure that anesthesia vaporizers are disabled by removing or taping in the “OFF” position. Flow 10L/min 02 through circuit for at least 20 minutes. During this time a disposable, unused breathing bag should be attached to the Y-piece of the circle system and the ventilator set to inflate the bag periodically. Use a new or disposable breathing circuit. The expired gas analyzer will indicate absence of volatile agents in the anesthesia circuit. Changing the CO2 absorbent (soda lime or baralyme) is not recommended if these procedures are followed. However, newer anesthesia machines such as the Drager Fabius may require up to 60 minutes of preparation. Check with the manufacturer of the machine for suggested washout procedure.

 

[scudrunner]

Jet,
i love your posts. I lurk a lot, post very infrequently.

That being said, as a CA-2......the anesthestic for this case is very straightforward. Your great teaching points are really about how to avoid screwing up what should be a pretty simple TIVA.

Vaporizers OFF machine. SUX out of room. Then.........

well, nuts , just run some propofol and remi/sufenta/whatever you want and plan for post-op analgesia. Hell, I'll work in a bunch of dilaudid on top of the remi, and watch them wake up so damn happy (eventually). Not rocket science really, just good anesthesia.

we need more clinical stuff on here. Maybe I'll get off my ass and post some fun cases too. Thanks for doing what you do.

Agreed. Although I can't contribute anything to he discussion yet, I really enjoy reading these clinical threads... might even be learning a thing or two.

 

[jwk]

Jet,
i love your posts. I lurk a lot, post very infrequently.

That being said, as a CA-2......the anesthestic for this case is very straightforward. Your great teaching points are really about how to avoid screwing up what should be a pretty simple TIVA.

Vaporizers OFF machine. SUX out of room. Then.........

well, nuts , just run some propofol and remi/sufenta/whatever you want and plan for post-op analgesia. Hell, I'll work in a bunch of dilaudid on top of the remi, and watch them wake up so damn happy (eventually). Not rocket science really, just good anesthesia.

we need more clinical stuff on here. Maybe I'll get off my ass and post some fun cases too. Thanks for doing what you do.

These cases are really our bread and butter. We do dozens of spines a week with varying degrees of neuro monitoring - from none to 3 zillion wires with the full rainbow of colors. The only minor monkey wrench is the MH. As already noted, remove the triggers from the room, flush the machine per MHAUS recommendations, and proceed as usual. ICU vent is gross overkill, a pain to deal with, and a totally unnecessary expense.

We usually tailor our anesthetic requirements to the wants/needs of the neuro monitoring people, which frequently is no N2O, 1/2 MAC of volatile, and most of the time no NMB's. So, most of our spines are near-TIVA anyway, so simply dropping the agent for the rare MH patient is no big deal. The only thing we'd have on pumps would be propofol. The other pumps are a pain at our place, so we simply don't use them. We don't stock remi, so most of us use intermittent fentanyl and/or dilaudid. A few of us use ketamine intermittently (no ketafol - our pharmacy nazis go berserk). Nobody is using lidocaine infusions. We tube just about everyone on roc - it's gone in plenty of time for the monitoring guys to do their thing. And in the true private practice KISS mode, the bulk of these patients probably have a single 18ga IV and standard monitors. Relatively few get/need a 2nd IV or A-line.

I will say that I'm a BIS convert - spines with TIVA / near-TIVA are the perfect cases for BIS. If you have it, I can't imagine why you wouldn't use it - and I'm an old fart that hated Aspect Medical and everything they did.