Post operative epidural monitoring

[jetproppilot]

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Our total joints have the epidural for 24 hours postoperatively. Our post op orders (that I plagiarized from previous gig) I think are too obtrusive...vital signs taken so much I don't think the patient can get any sleep.

If some of you private practice studs could post how often vitals are taken on your postoperative epidural infusion patients I'd be forever grateful.

Also we're probably gonna make a move to femoral catheters and would be interested in how your patients like them. Several of our orthopedists like the pt to get up in the afternoon of the case...what concentration LA do you use so quadricep weakness isn't "too" much?

Our epidural infusion is very weak (.0625% bupiv fent 2ug/mL epi 1ug/mL) but surprisingly keeps most pts pretty comfortable, and allows them to stand later in the day.

Thanks in advance.

 

[aredoubleyou]

fem cath with 0.2% ropiv had great results, +/- single shot sciatic. none of our bone heads like epidurals

 

[Bertelman]

Our total joints have the epidural for 24 hours postoperatively. Our post op orders (that I plagiarized from previous gig) I think are too obtrusive...vital signs taken so much I don't think the patient can get any sleep.

If some of you private practice studs could post how often vitals are taken on your postoperative epidural infusion patients I'd be forever grateful.

Also we're probably gonna make a move to femoral catheters and would be interested in how your patients like them. Several of our orthopedists like the pt to get up in the afternoon of the case...what concentration LA do you use so quadricep weakness isn't "too" much?

Our epidural infusion is very weak (.0625% bupiv fent 2ug/mL epi 1ug/mL) but surprisingly keeps most pts pretty comfortable, and allows them to stand later in the day.

Thanks in advance.

If you're only shooting for 24 hr of relief, why don't you go with a single shot femoral? No orders to worry about.

 

[lord_jeebus]

For knees we use femoral catheters with 0.2% ropi, and leave them in for 2-3 days. Sometimes ortho will clamp the pumps for a couple of hours prior to physical therapy, but this is not always an issue. The patients love them.

 

[Frank Rizzo]

fem cath with 0.2% ropiv had great results, +/- single shot sciatic. none of our bone heads like epidurals

+1

For our epi's, vitals are q4H

 

[sevoflurane]

Fem, sciatic for TKA's. Lumbar plexus or spinal with duramorph for hips. All single shots.

For open bellies that need epidurals we have oximeter q1hrs. for 24hrs (patients sleep with this). B.P's q2hrs. for 4 hours then q4hrs for the following 20 hrs.

If you are using CRNA's in your practice you can get them to chart vitals/evaluate your patients and get some additional units.. so long as they don't keep your patients up all night. 🙄

 

[Idiopathic]

dont do epidurals for total joints. single shot fem +/- catheter, single shot sciatic...they dont get to walk until catheter is out if thats the plan

 

[pgg]

As a resident we used 0.2% ropivacaine @4-6 mL/hr for our femoral catheters, usually removed POD 2, and patients loved them. In rare cases we'd also do sciatic catheters, but usually just single shot sciatics. We didn't get complaints about quad weakness; the orthopods and physical therapists just expected it and dealt with it.

I am embarrassed to admit that my current batch of PP orthopods essentially dictate our TKA anesthetics by forbidding peripheral nerve blocks. They have convinced themselves that short of Silence-of-the-Lambs-style patient restraints, a femoral block will inevitably result in persistent quad weakness, someone will get out of bed, fall, and fracture a hip. They haven't actually had such an event occur; one of them apparently read a case report in a comic book or whatever it is they read. I give intrathecal morphine (which they grumble about because "it always wears off at midnight and I get called"), they write for Demerol PCAs, and I wash my hands of the whole mess. It's a very unsatisfying arrangement because we could do so much better, but they bring the patients ...


For patients who get neuraxial opioids, our protocol is vitals q1h for the first 8h, then q4h. Usually this means by bedtime, the q1h hassling is done. Honestly, nothing short of continuous ICU-level monitoring would catch a respiratory event in time anyway. I don't see the point of pretending to monitor for delayed respiratory depression with hourly vitals 15 hours after injection in the first place.

For epidural infusions (pure LA or LA+fentanyl), vitals are q1h for the first 4h, then q4h. If a pump is adjusted upward, the q1h period starts over.

 

[Idiopathic]

As a resident we used 0.2% ropivacaine @4-6 mL/hr for our femoral catheters, usually removed POD 2, and patients loved them. In rare cases we'd also do sciatic catheters, but usually just single shot sciatics. We didn't get complaints about quad weakness; the orthopods and physical therapists just expected it and dealt with it.

I am embarrassed to admit that my current batch of PP orthopods essentially dictate our TKA anesthetics by forbidding peripheral nerve blocks. They have convinced themselves that short of Silence-of-the-Lambs-style patient restraints, a femoral block will inevitably result in persistent quad weakness, someone will get out of bed, fall, and fracture a hip. They haven't actually had such an event occur; one of them apparently read a case report in a comic book or whatever it is they read. I give intrathecal morphine (which they grumble about because "it always wears off at midnight and I get called"), they write for Demerol PCAs, and I wash my hands of the whole mess. It's a very unsatisfying arrangement because we could do so much better, but they bring the patients ...


For patients who get neuraxial opioids, our protocol is vitals q1h for the first 8h, then q4h. Usually this means by bedtime, the q1h hassling is done. Honestly, nothing short of continuous ICU-level monitoring would catch a respiratory event in time anyway. I don't see the point of pretending to monitor for delayed respiratory depression with hourly vitals 15 hours after injection in the first place.

For epidural infusions (pure LA or LA+fentanyl), vitals are q1h for the first 4h, then q4h. If a pump is adjusted upward, the q1h period starts over.

jesus christ

 

[pgg]

jesus christ

Amen.

The dosing is absurd, too. I think one of them does 15 mg with a 10 minute lockout. Older guy, been practicing for 30+ years now. I think he just thinks pain is normal and OK.

 

[hoyden]

fem cath with 0.2% ropiv had great results, +/- single shot sciatic. none of our bone heads like epidurals

same here, except we utilize epidurals for bl knees. low comcentration of bupiv with 3 mcg/ml of fentanyl for epidurals

 

[BISof60]

Fem nerve catheters for knees: 0.2% ropiv.

For a well-placed catheter, 4mL/hr is usually very sufficient to treat pain while allowing folks to do their PT. Higher than that, the PT's often but not always tell us the knees buckle during PT.

When I first started placing cathers, I sometimes had to run them 8-10mL/hr. Now my technique is better and the lower dose works well.

 

[sevoflurane]

Amen.

The dosing is absurd, too. I think one of them does 15 mg with a 10 minute lockout. Older guy, been practicing for 30+ years now. I think he just thinks pain is normal and OK.

I hear you PGG. That sounds like an awfully frustrating situation. May I humbly suggest you consider having a formal physician meeting with the orthopedic department? Block out a time in the board room and present your case to the best of your abilities. Think about what their objections are going to be and have preemptive solutions for their concerns. Most people listen to reason, and if you have good evidence to bring to the table it really helps your case.

If you decided to pursue this route don’t make it a “us against them” meeting. Although the orthopds are the people responsible for bringing in the patients, they are also your patients and if you can make their experience and outcomes better then it’s a win win situation.

I’ve been in that situation in regards to high volume local infiltration anesthesia which seems to be gaining popularity among orthopedic surgeons:

http://www.medscape.com/viewarticle/732743

http://www.orthosupersite.com/view.aspx?rid=80859

We had some objections to this technique. We all packed into a conference room and hashed things out in a constructive way. I believe that the end result was better for our patients. 🙄

 

[Oggg]

Fem nerve catheters for knees: 0.2% ropiv.

For a well-placed catheter, 4mL/hr is usually very sufficient to treat pain while allowing folks to do their PT. Higher than that, the PT's often but not always tell us the knees buckle during PT.

When I first started placing cathers, I sometimes had to run them 8-10mL/hr. Now my technique is better and the lower dose works well.

Does a CFNB with 0.2%ropivicaine give you quadriceps weakness and leg buckling with PT? One hospital protocol I have heard is partial weight bearing (chair only) while catheter is in, whereas if the patient gets a single shot, the PTs just keep checking the patient for leg buckling until the block fades, usually by POD1 afternoon.

 

[epidural man]

Does a CFNB with 0.2%ropivicaine give you quadriceps weakness and leg buckling with PT? One hospital protocol I have heard is partial weight bearing (chair only) while catheter is in, whereas if the patient gets a single shot, the PTs just keep checking the patient for leg buckling until the block fades, usually by POD1 afternoon.

We have had some falls with 0.2% ropiv. One kid broke his ankle. So yes, weakness is a possibility.

I put in a fem catheter and ran 0.1% ropiv a few days ago (for an ACL). The guy was very happy and had no trouble walking. However, I think that this would probably only work 50% of the time. I bet in some, it wouldn't be enough.

 

[silvester78]

We usualy place epidural for 48h. ropivacaine 2 or 3 mg/ml with morphine or Fentanyl depending on personal preference plus paracetamol IV. Vital signs every one to two hours until 21:00 and if stable then every three to four hours.The problem we have sometimes is that every hypotensive event is attributed by the orthopedics to epidural even if the drains are full of blood!!! So they just close the infusion instead of giving volume or blood!! Beside this, patients and orthopedics are most times very satisfy.