Phenylephrine in Spinal

[heartICU]

Do any of you guys have any experience with adding phenylephrine to a spinal? I have heard that adding up to 5mg phenylephrine with local will significantly prolong the length of the block, but am unable to find many references to support it. I did find one that stated there was a slightly longer block when combined with lidocaine, but I am just looking to see if anyone has personal experience with this technique.

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[jetproppilot]

Do any of you guys have any experience with adding phenylephrine to a spinal? I have heard that adding up to 5mg phenylephrine with local will significantly prolong the length of the block, but am unable to find many references to support it. I did find one that stated there was a slightly longer block when combined with lidocaine, but I am just looking to see if anyone has personal experience with this technique.

never heard of it. adding a small amount of epi supposedly prolongs certain local anesthetics.

and you meant 5 ug, huh? or 50 ug? 5 milligrams would blow your carotid arteries out of your neck.

 

[militarymd]

I have used epi....as high as 0.2 mg.....whopping dose.

 

[heartICU]

never heard of it. adding a small amount of epi supposedly prolongs certain local anesthetics.

and you meant 5 ug, huh? or 50 ug? 5 milligrams would blow your carotid arteries out of your neck.

Nope, I really meant 5 milligrams. I found one article that documented it in a RCT, but I was looking to see if anyone had ever done it with anything other than lidocaine. The article is below.

Acta Anaesthesiol Scand. 1999 May;43(5):556-62. Related Articles, Links


Enhancement of intrathecal lidocaine by addition of local and systemic clonidine.

Dobrydnjov I, Samarutel J.

Department of Anaesthesiology and Intensive Care, Kohtla-Jarve Hospital, Estonia.

BACKGROUND: Enhancement of local anesthetic-produced regional blocks by clonidine seems well established. There are insufficient data about dose-effect relationship of combinations of clonidine with individual agents, efficiency of local versus systemic administration of clonidine, and comparative evaluation of clonidine with vasoconstrictors. Because of unavailability of long-acting local anaesthetics at the time of study, our aim was to evaluate augmentation of lidocaine spinal block with local or systemic clonidine and to compare the results with the efficacy of intrathecal phenylephrine. METHODS: Ninety pts of age 50-72 yrs with ASA 1-4 physical status, scheduled for open prostatectomies, hysterectomies or ostheosynthesis of fractured hip were randomized to one of 6 treatment groups, 15 pts in each. Patients received intrathecally (L3-L4) either 100 mg of plain lidocaine (group L100); or a mixture of lidocaine 40 and 80 mg with clonidine 100 micrograms (groups L40-C100 and L80-C100); or a combination of lidocaine 40 and 80 mg with clonidine 300 micrograms orally 60 min before spinal puncture (L40-C300 and L80-C300). Addition of intrathecal phenylephrine 5 mg to 80 mg of lidocaine was also investigated (L80-P5). RESULTS: There were no significant intergroup differences concerning demographic data or type of surgery. All operations (duration up to 150 min) were completed without need for analgesic supplementation. The addition of clonidine resulted in a significant reduction of the onset time of spinal block and prolongation of the duration of sensory and motor blocks compared to plain lidocaine or lidocaine with phenylephrine. In spite of the well-known hypotensive action of alpha 2-agonists, haemodynamic depression only in group L80-C300 was significantly more pronounced than in L100 and L80-P5 groups. The least decrease of BP and minimal need of rescue ephedrine among all patients studied were recorded in the group receiving low dosage of lidocaine with intrathecal clonidine (L40-C100). Sedation occurred in most patients receiving clonidine. CONCLUSION: Our results indicate that addition of clonidine to lidocaine, irrespective of the route of administration, prolongs the duration of spinal block and permits a reduction of the lidocaine dose needed for a given duration of block. Addition of phenylephrine results in a less pronounced statistically significant prolongation of anaesthesia. The regression of sensory block before restoration of motor function seems to be a specific (and unfortunate) effect of both clonidine and phenylephrine.

Publication Types:
Clinical Trial
Randomized Controlled Trial

PMID: 10342005 [PubMed - indexed for MEDLINE]

 

[heartICU]

I have used epi....as high as 0.2 mg.....whopping dose.

We routinely use 0.2 mg epi in all of our spinals, too.

 

[ultraconsrvativ]

Look in your Mass General book and it will confirm that 5 mg is utilized. I've used this many times and it works very well.

 

[jetproppilot]

Look in your Mass General book and it will confirm that 5 mg is utilized. I've used this many times and it works very well.

wow. seems like alotta phenylephrine, even for the intrathecal space.

Think it works better than epi?

 

[redstorm]

HOw long do you want your spinals to last? days? tetracaine will give you a good 5-6 hours if you mix in the right amount of additives// I cant see why anyone would want more of a block.. go general if more is needed..

 

[jetproppilot]

HOw long do you want your spinals to last? days? tetracaine will give you a good 5-6 hours if you mix in the right amount of additives// I cant see why anyone would want more of a block.. go general if more is needed..

I don't know if we had bad luck or what, but we eventually stopped using tetracaine because of more-than-acceptable failed blocks. Seemed like the tetracaine was degrading in the spinal kit or something....we stopped using it, went exclusively with bupivicaine, and the failed blocks stopped.

Anybody else experienced this? Does tetracaine degrade quicker than other local anesthetics while on the shelf?

 

[militarymd]

I don't know if we had bad luck or what, but we eventually stopped using tetracaine because of more-than-acceptable failed blocks. Seemed like the tetracaine was degrading in the spinal kit or something....we stopped using it, went exclusively with bupivicaine, and the failed blocks stopped.

Anybody else experienced this? Does tetracaine degrade quicker than other local anesthetics while on the shelf?

I have found tetracaine to be fairly unreliable...variable set-up time, variable reliability.

marcaine and lidocaine are much more reliable....although lidocaine has its problems

 

[jwk]

wow. seems like alotta phenylephrine, even for the intrathecal space.

Think it works better than epi?

Same here - that's 1/2cc of Neo - a significant part of the total volume of your injectate.

.1-.2 of epi has always worked fine for me. PLUS, it's included in a lot of SAB kits. Adding Neo just adds additional drug cost.

Virtually all our spinals are now done with bupivicaine. Tetracaine, and now lido, seem to be a thing of the past.

 

[UTSouthwestern]

A lot of the kits had tetracaine premixed and those seem to be the ones that had the most problem with degradation. Some others have the tetracaine in the unmixed, powdered form which seems to preserve its activity.

On a side note, I used one kit at one of the hospitals I am now covering and it had 3 different types of needles and 8 different agents. I wanted to save the rest of the stuff because of the big freaking waste it is to use just one needle and one agent and throw the rest of the stuff away.

 

[heartICU]

HOw long do you want your spinals to last? days? tetracaine will give you a good 5-6 hours if you mix in the right amount of additives// I cant see why anyone would want more of a block.. go general if more is needed..

I had a patient for a hip revision that I really didn't want to put to sleep. EF 15%, valvular disease, COPD, etc. The marcaine with epi spinal I used worked just fine, but as I was talking about the case later, someone mentioned that you can add phenylephrine to prolong it further. I just thought it would be good for patients who are high risk for general anesthesia (if they are having a longer procedure).

 

[militarymd]

If you put 10 to 20 mg of tetracaine crystals into 15 mg of standard bupivicaine solution, and you inject into the sab space....you will get 6 to 8 hours of surgical time. I did that a few times when I was a resident with the anesthesioloigst who anesthetized Bill Clinton for his knee surgery in 1997.

I personally feel that general anesthesia is more appropriate for higher acuity patients undergoing intermediate to high risk surgeries. Their marginal physical status are more likely to decompensate during surgical procedures that involve blood loss and fluid shifts.....I would hate to convert to a GA during a 5 hour hip redo when the patient develops hypoxemia or hypotension...at this point you would subject the patient both the risks of a GA and SAB.

 

[Tenesma]

just out of experience i would NEVER use a spinal for a patient w/ an EF of 15% with valvular porblems.... much safer to put in an epidural and dose it up slowly so they don't completely decompensate on you

 

[UTSouthwestern]

I had a patient for a hip revision that I really didn't want to put to sleep. EF 15%, valvular disease, COPD, etc. The marcaine with epi spinal I used worked just fine, but as I was talking about the case later, someone mentioned that you can add phenylephrine to prolong it further. I just thought it would be good for patients who are high risk for general anesthesia (if they are having a longer procedure).

That's a very risky choice. With an EF of 15%, that patient is precariously dependent on what afterload that can be generated by SVR to maintain his/her coronary perfusion pressure. Drop this patient's afterload with a spinal would, as Tenesma has stated, make your day miserable. Didn't happen which is a good thing. Also, if the even a little of the injectate went intravascular, that epi kick to a failing heart would also make the day a miserable one.

 

[Justin4563]

If you put 10 to 20 mg of tetracaine crystals into 15 mg of standard bupivicaine solution, and you inject into the sab space....you will get 6 to 8 hours of surgical time. I did that a few times when I was a resident with the anesthesioloigst who anesthetized Bill Clinton for his knee surgery in 1997.

I personally feel that general anesthesia is more appropriate for higher acuity patients undergoing intermediate to high risk surgeries. Their marginal physical status are more likely to decompensate during surgical procedures that involve blood loss and fluid shifts.....I would hate to convert to a GA during a 5 hour hip redo when the patient develops hypoxemia or hypotension...at this point you would subject the patient both the risks of a GA and SAB.

a 5 hour hip redo gets a general from me with invasive lines... minimum aline and twist my arm will get a cvp so when the emboli get to her heart i can suck it out with a syringe..

 

[Justin4563]

That's a very risky choice. With an EF of 15%, that patient is precariously dependent on what afterload that can be generated by SVR to maintain his/her coronary perfusion pressure. Drop this patient's afterload with a spinal would, as Tenesma has stated, make your day miserable. Didn't happen which is a good thing. Also, if the even a little of the injectate went intravascular, that epi kick to a failing heart would also make the day a miserable one.

supposedly.. as an older attending told me.. use isobaric marcaine and you shouldnt drop the afterload.. in fact I insist on doing a spinal for chf when indicated.. and dropping afterload is not a problem unless its aortic stenosis with a high gradient across the valve.. you definitely dont wanna be dropping afterloads there

 

[militarymd]

I use isobaric marcaine quite frequently....I love the way it sets up....most of the time.

 

[Tenesma]

don't get me wrong... after load reduction via sympathectomy is great for a bad heart.... but why not do it smoothly via epidural... especially if it may be a long case and you don't want to worry about a spinal wearing off...

 

[heartICU]

That's a very risky choice. With an EF of 15%, that patient is precariously dependent on what afterload that can be generated by SVR to maintain his/her coronary perfusion pressure. Drop this patient's afterload with a spinal would, as Tenesma has stated, make your day miserable. Didn't happen which is a good thing. Also, if the even a little of the injectate went intravascular, that epi kick to a failing heart would also make the day a miserable one.

Wouldn't afterload reduction in a failing heart be a good thing? This patient also had several spinals in the past, at our institution, for cystos and such, and therefore we felt comfortable doing it again. Also, with isobaric marcaine, which is what we used, that huge sympathectomy isn't as pronounced. This guy's normal BP was 90s/60s, and he never varied from that. In fact, throughout the entire case, his BP never wavered between 110 and 120 systolic.

We did insert an aline and CVP, along with two IVs, and also had an extremely low tolerance for giving blood...total blood loss for the hip was 300 (it was staff doing it, not a resident - this particular surgeon is known for minimizing blood loss in high risk cases), which he got back as a unit of PRBCs.

 

[heartICU]

don't get me wrong... after load reduction via sympathectomy is great for a bad heart.... but why not do it smoothly via epidural... especially if it may be a long case and you don't want to worry about a spinal wearing off...

I agree - that would have been a great option. I actually prefer doing cases under epidural to spinal - I find a 2% mepivacaine epidural is extremely predictable. My attending, however, felt the spinal would be sufficient, and safe for the patient, and since this guy had had spinals in the past without incident, that's what we went for.

 

[Tenesma]

yeah.... everybody can do things differently in anesthesia...

UT's point about SVR is that there is a fine line between afterload reduction and hypoperfusion of the coronaries....

why did you need an a-line or a CVP? I would have done that case w/ epidural, regular IV and a BP cuff.... but that is my personal view on things

 

[UTSouthwestern]

Wouldn't afterload reduction in a failing heart be a good thing? This patient also had several spinals in the past, at our institution, for cystos and such, and therefore we felt comfortable doing it again. Also, with isobaric marcaine, which is what we used, that huge sympathectomy isn't as pronounced. This guy's normal BP was 90s/60s, and he never varied from that. In fact, throughout the entire case, his BP never wavered between 110 and 120 systolic.

We did insert an aline and CVP, along with two IVs, and also had an extremely low tolerance for giving blood...total blood loss for the hip was 300 (it was staff doing it, not a resident - this particular surgeon is known for minimizing blood loss in high risk cases), which he got back as a unit of PRBCs.

Missed the part about the spinal being isobaric. Still I'd probably be more inclined to use an epidural and have the added benefit of being able to use less local, more narcotic epidurally, and have the catheter available for post op pain control

 

[coccygodynia]

I agree - that would have been a great option. I actually prefer doing cases under epidural to spinal - I find a 2% mepivacaine epidural is extremely predictable. My attending, however, felt the spinal would be sufficient, and safe for the patient, and since this guy had had spinals in the past without incident, that's what we went for.

heartICU - where are you doing your residency?

 

[coccygodynia]

I agree - that would have been a great option. I actually prefer doing cases under epidural to spinal - I find a 2% mepivacaine epidural is extremely predictable. My attending, however, felt the spinal would be sufficient, and safe for the patient, and since this guy had had spinals in the past without incident, that's what we went for.

heartICU - where are you in residency?

 

[heartICU]

heartICU - where are you doing your residency?

Actually, I am not a resident - I am a SRNA at the Cleveland Clinic. You?

 

[jetproppilot]

Actually, I am not a resident - I am a SRNA at the Cleveland Clinic. You?

you're a stud, dude.

 

[heartICU]

you're a stud, dude.

Actually, dudette

 

[jetproppilot]

Actually, dudette

my apologies. You're on the top of your game. Keep it up.

 

[s204367]

I just finished residency and joined a group in CT....they all use .5% bupivicaine isobaric, 3cc plus 3mg..yes mg.....of Neo. They claim they get 4-5 hours easily with that dose. I routinely use isobaric bupivicaine with 25mcg of fentanyl, and find you get 3-4 hours with that. Occ I add clonidine, but if the case is longer than 4 hours I use a CSE. Unfortunately, the group I joined are older grads, and don't care for CSE's. The surg attendings can do a virgin hip in one hour to 2 hours depending on the surgeon. Occ under an hour if the att is using a cementless hip.

I have searched the literature for Neo and spinals, and there is not a lot of info on it.

 

[jetproppilot]

I just finished residency and joined a group in CT....they all use .5% bupivicaine isobaric, 3cc plus 3mg..yes mg.....of Neo. They claim they get 4-5 hours easily with that dose. I routinely use isobaric bupivicaine with 25mcg of fentanyl, and find you get 3-4 hours with that. Occ I add clonidine, but if the case is longer than 4 hours I use a CSE. Unfortunately, the group I joined are older grads, and don't care for CSE's. The surg attendings can do a virgin hip in one hour to 2 hours depending on the surgeon. Occ under an hour if the att is using a cementless hip.

I have searched the literature for Neo and spinals, and there is not a lot of info on it.

pretty cool. Thanx for the post.