probably stupid OR question

[amyl]

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I am a third year med student on surgery rotation but it is the closest thing to anes i am going to get this year. i wanted to ask a question but the anes. was not approachable at all. she was trying to do an intrathecal block for a colon resection...the guys spine was all fused and he couldn't bend at all. plus he screamed and jumped and complained everytime she poked him despite lidocaine and sometimes jumped even at her finger. so her is my question, why couldn't he be induced put in lateral recumbent and then try to get the into the theca... why did she sit him up, fully awake and try like 5 times and then give up? I am sure there is a good reason but I couldn't think of any and I was sure she would be upset if i asked her (surgeon was getting mad, etc.) thanks as always, amy

 

[militarymd]

Medical legal reason not to stick a needle into an anesthetized person's spine and inject medication....although it is likely safe.

 

[Noyac]

Medical legal reason not to stick a needle into an anesthetized person's spine and inject medication....although it is likely safe.

However, we do it in kids all the time.

 

[VolatileAgent]

she was trying to do an intrathecal block for a colon resection...the guys spine was all fused and he couldn't bend at all.

sure it was an intrathecal and not an epidural? were they originally planning on doing this case awake?

 

[amyl]

anes wanted the epidural and the patient denied for whatever reason so they were going intrathecally. no, not planning on doing it awake ever (do they do colon resections awake?) but for some reason were concerned about post-op pain. patient was NOT stoic.

 

[zippy2u]

Amy, perhaps the take home message is that if you're contemplating having surgery, don't put an academic teaching center high on your list of places to go, especially during the months of July-December. Regards, ----Zippy

 

[2ndyear]

I suspect they were attempting to place some form of morphine intrathecal right? Either preservative free morphine or Depo-Dur, both for post op pain. As to why sitting up, this can also be done laterally as you mention. But some people have little experience with this myself included. I've done many epidural/spinals sitting but only about 5 lateral. I know I need to work on this in the next year.

 

[dr_bigmac]

30 mg of propofol makes all the difference

 

[VolatileAgent]

anes wanted the epidural and the patient denied for whatever reason so they were going intrathecally. no, not planning on doing it awake ever (do they do colon resections awake?) but for some reason were concerned about post-op pain. patient was NOT stoic.

first, no, as far as i'm aware no one ever does colon resections awake... unless accidentally (ie., my original sarcasm was apparently missed). the point is, there's no point in doing an "intrathecal" anesthetic on this type of patient. an epidural, sure. but, unless they are doing a continuous infusion spinal, something that is very uncommon and certainly not indicated for POP, intrathecal is not even on the radar screen as a planned anesthetic for this type of case.

in other words (and if you didn't mishear/misunderstand), zippy summed it up perfectly.

 

[VolatileAgent]

I suspect they were attempting to place some form of morphine intrathecal right? Either preservative free morphine or Depo-Dur, both for post op pain. As to why sitting up, this can also be done laterally as you mention. But some people have little experience with this myself included. I've done many epidural/spinals sitting but only about 5 lateral. I know I need to work on this in the next year.

very, VERY soft indication for this, especially since you can put duramorph in the epidural space with the same effect. depo-dur only goes in the epidural space and is absolutely contraindicated intrathecally.

 

[nimbus]

very, VERY soft indication for this, especially since you can put duramorph in the epidural space with the same effect. depo-dur only goes in the epidural space and is absolutely contraindicated intrathecally.

You are correct about depodur.

Indications for intrathecal opioids:
1. 8 units for injection+2 units for POD#1 visit==>$200-$600 depending on payer.
2. MRB in academic setting.
3. Increase demand for Zofran.

 

[militarymd]

first, no, as far as i'm aware no one ever does colon resections awake... unless accidentally (ie., my original sarcasm was apparently missed). the point is, there's no point in doing an "intrathecal" anesthetic on this type of patient. an epidural, sure. but, unless they are doing a continuous infusion spinal, something that is very uncommon and certainly not indicated for POP, intrathecal is not even on the radar screen as a planned anesthetic for this type of case.

in other words (and if you didn't mishear/misunderstand), zippy summed it up perfectly.

When I was training at Bethesday Naval Hospital, I anesthetized more than one U.S. Senator/other VIPs who wanted to be awake for their colon resections.

And with a deft surgeon, it was not a problem.

Intrathecal injections of narcotic is a common method of post-op pain management for various thoracoabdominal procedures....per nimbus post.

 

[Noyac]

first, no, as far as i'm aware no one ever does colon resections awake... unless accidentally (ie., my original sarcasm was apparently missed). the point is, there's no point in doing an "intrathecal" anesthetic on this type of patient. an epidural, sure. but, unless they are doing a continuous infusion spinal, something that is very uncommon and certainly not indicated for POP, intrathecal is not even on the radar screen as a planned anesthetic for this type of case.

in other words (and if you didn't mishear/misunderstand), zippy summed it up perfectly.

I've done more than a few colon resections with the pt awake (intentionally).

And I do intrathecal injections on many abdominal cases with PFMS or Dilaudid. I just did 3 TAH's 2 days ago. One awake with 200 mcg Dialuadid in the spinal, the other 2 were straight GA b/c they refused the intrathecal. The one with dilaudid left the next day and never, not once, needed any additional pain meds (or nausea meds for that matter). The other 2 were still in house today.

 

[Pilot Doc]

awake for their colon resections.

Not really relevant, but interesting ... one of the throwaway journals had an article a couple years back by a surgeon in an isolated hospital who did sigmoid colectomy/end colostomy for bad diverticulitis under local with a LLQ mcburney type incision. !!

 

[VolatileAgent]

When I was training at Bethesday Naval Hospital, I anesthetized more than one U.S. Senator/other VIPs who wanted to be awake for their colon resections.

And with a deft surgeon, it was not a problem.

Intrathecal injections of narcotic is a common method of post-op pain management for various thoracoabdominal procedures....per nimbus post.

brave politicians... now, there's an interesting concept. and, deft surgeons. guess we don't have either around here.

we definitely go to sleep for all of our colon resections. our surgeons like 'em nice and relaxed, and spontaneous breathing is kinda hard after 8-10mg of vecuronium.

we also do a lot of epidurals for these folks. it's a nice technique for both intra-op and post-op pain control. toss it in at about T9-T10 and use 1/2 percent bupiv during the case and bupiv/fent post-op. but, i've got no problems with intrathecal morphine... if you're doing a c-section, that is. if you're going to go through the trouble of doing a neuraxial, might as well put in an epidural.

awake colon resections... mmmm... okay. whatever floats your boat. i'll leave those to you. 😉

 

[VolatileAgent]

You are correct about depodur.

Indications for intrathecal opioids:
1. 8 units for injection+2 units for POD#1 visit==>$200-$600 depending on payer.
2. MRB in academic setting.
3. Increase demand for Zofran.

we do a lot of major regionals here, and we do put in epidurals for these folks. we follow them longer, and i don't believe (admit i don't know for sure) the billing is different. they are followed post-op by our acute pain service.

how do you effectively deal with itching, a real problem with intrathecal mso4? nubain? naloxone? i'll tell you what are "standard orders" here... and it rarely works. but, if you start ordering nubain, all you seem to get are phone calls from the nurses.

 

[VolatileAgent]

I've done more than a few colon resections with the pt awake (intentionally).

really?!!? resections? not exams under anesthesia? not prone-jacknife "butt-ectomies" for things like condyloma? we do spinal/neuraxials for a lotta that kinda stuff. i admit, i haven't been in the butt room in a while (typically more junior level-type cases). so, you gotta tell me more about this, what indications, what section of colon, etc. this just seems like a colossally bad idea on the face of it, and must have a very narrow range of indication (ie., distal descending for divertics, etc.).

And I do intrathecal injections on many abdominal cases with PFMS or Dilaudid. I just did 3 TAH's 2 days ago. One awake with 200 mcg Dialuadid in the spinal, the other 2 were straight GA b/c they refused the intrathecal. The one with dilaudid left the next day and never, not once, needed any additional pain meds (or nausea meds for that matter). The other 2 were still in house today.

not disagreeing at all that it seems to be used a lot with gynie. have seen a lot of post-delivery BTLs done under spinal.

a colon resection... maybe your guys are fast, but chances are if they get deep into the **** (pun intended) and the thing is going to get more complex, you're going to sleep anyway (which, if you recall, is why amyl started this thread in the first place). besides, intrathecal morphine alone ain't going to get you a surgical anesthesia level. maybe we're just doing more complex cases, or maybe our surgeons just suck. with one of our surgeons, if the patient so much as moves a hair follicle during the case, he starts screaming wanting to know why the patient isn't fully relaxed.

iow, just hope no one is suggesting spinal anesthesia is the preferred technique for a colon resection... or even a good idea, for that matter.

 

[Noyac]

really?!!? resections? not exams under anesthesia? not prone-jacknife "butt-ectomies" for things like condyloma? we do spinal/neuraxials for a lotta that kinda stuff. i admit, i haven't been in the butt room in a while (typically more junior level-type cases). so, you gotta tell me more about this, what indications, what section of colon, etc. this just seems like a colossally bad idea on the face of it, and must have a very narrow range of indication (ie., distal descending for divertics, etc.).



not disagreeing at all that it seems to be used a lot with gynie. have seen a lot of post-delivery BTLs done under spinal.

a colon resection... maybe your guys are fast, but chances are if they get deep into the **** (pun intended) and the thing is going to get more complex, you're going to sleep anyway (which, if you recall, is why amyl started this thread in the first place). besides, intrathecal morphine alone ain't going to get you a surgical anesthesia level. maybe we're just doing more complex cases, or maybe our surgeons just suck. with one of our surgeons, if the patient so much as moves a hair follicle during the case, he starts screaming wanting to know why the patient isn't fully relaxed.

iow, just hope no one is suggesting spinal anesthesia is the preferred technique for a colon resection... or even a good idea, for that matter.

My bad, I forgot, you know it all.

 

[jnax]

Epidurals are preferably placed in awake patients, because it is generally regarded as being the safest way in terms of preventing possible nerve/spine damage. An awake patient can report parasthesias and other symptoms of trouble. Also some of the earlier signs of intravascular injection of local anesthetics, eg rinning in the ears will can be obtained from awake pts.

Epidurals are placed in children while asleep due to the weighted risk/benefit ratio of potential nerve/spine damage versus the much higher likely hood of damage/failed epidural placement/wet-tap when the children squirm, jump, shake, scream, and gyrate as you attemp to find the epidural space.

Also in terms of why did they anesthesiologist not attempt an epidural. It sounds as if the patient had some sort of spinal fusion which would have likely obliterated the epidural space at those levels and made attempting epidural placement rather impossible.

Peace,
Jnax

 

[VolatileAgent]

My bad, I forgot, you know it all.

😕

why the hate?

tell me about your experience doing awake colectomies. i'm interested in hearing about this. do i think it's a good idea? no. but, i'm open to hearing about what you did.

i know a hell of a lot, but i'll be the first to admit i don't know everything.

 

[VolatileAgent]

Epidurals are preferably placed in awake patients, because it is generally regarded as being the safest way in terms of preventing possible nerve/spine damage. An awake patient can report parasthesias and other symptoms of trouble. Also some of the earlier signs of intravascular injection of local anesthetics, eg rinning in the ears will can be obtained from awake pts.

Epidurals are placed in children while asleep due to the weighted risk/benefit ratio of potential nerve/spine damage versus the much higher likely hood of damage/failed epidural placement/wet-tap when the children squirm, jump, shake, scream, and gyrate as you attemp to find the epidural space.

Also in terms of why did they anesthesiologist not attempt an epidural. It sounds as if the patient had some sort of spinal fusion which would have likely obliterated the epidural space at those levels and made attempting epidural placement rather impossible.

Peace,
Jnax

good post. typically, though, the lidocaine in the test dose placed in an epidural will be insufficient to elicit tinnitus or peri-oral numbness, metallic taste, etc. so, unless you start to bolus it with anesthetic while they are still awake, you may not see these signs. the reason why you do a test dose is to look for tachycardia/bp changes first or profound numbess below the dermatome at the insertion point, both signs of misplacment (ie., intravascular catheter and accidental intrathecal, respectively).

 

[amyl]

thanks for all the responses... it was an intrathecal attempt at morphine, failed. the case went perfectly, small part of colon with ca resected... and the patient never once complained of pain post op... so i guess it didn't matter that she couldn't get it. i guess i should have prefaced this by explaining that this was at the VA hospital. I have only been in a handful of hospitals, this is my first VA experience....and they seem to do everything differently 😉