prone cases/paralytics

[donaldfaison]

Hello all,

CA-1 here have a question about paralytics in the prone position. Have an attending who will keep patient paralyzed no matter what in any sort of prone surgery. His/her justification is you don't want the patient bucking and possibly losing an airway in the prone position.

This kind of confuses me. Lets say for a spine case with SSEP monitoring with patient on 0.5 MAC + remi/sufenta infusion, are additional paralytics really needed for this if not requested by surgeon? Prone anal surgery or lithotripsy, are paralytics really needed?

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[Psai]

For lithotripsy, paralysis is nice because the targets are small and stones can be very painful, causing tachypnea which makes it even more difficult to work. But needed? No.

 

[Urzuz]

Hello all,

CA-1 here have a question about paralytics in the prone position. Have an attending who will keep patient paralyzed no matter what in any sort of prone surgery. His/her justification is you don't want the patient bucking and possibly losing an airway in the prone position, or the possibility of masking awareness.

This kind of confuses me. Lets say for a spine case with SSEP monitoring with patient on 0.5 MAC + remi/sufenta infusion, are additional paralytics really needed for this if not requested by surgeon? Prone anal surgery or lithotripsy, are paralytics really needed?

No and no. I never keep a patient paralyzed for any of the surgeries you listed (except for perhaps during exposure on certain spine cases if a surgeon wants it).

Your attending shouldn't be having you run a patient so light during surgery that you live in fear that they may buck on the tube at any moment. Even if they do start breathing on their own, give them a little opioid and your problem is solved.

 

[anbuitachi]

Hello all,

CA-1 here have a question about paralytics in the prone position. Have an attending who will keep patient paralyzed no matter what in any sort of prone surgery. His/her justification is you don't want the patient bucking and possibly losing an airway in the prone position.

This kind of confuses me. Lets say for a spine case with SSEP monitoring with patient on 0.5 MAC + remi/sufenta infusion, are additional paralytics really needed for this if not requested by surgeon? Prone anal surgery or lithotripsy, are paralytics really needed?

Your attending is weird as hell. How does it work when they are running MEPs? We dont paralyze 95% of our spine cases except sometimes for exposure. Just put in the tube and secure it well. It's VERY rare to have it fall out.

 

[Noyac]

Remi/sufenta infusion?
Are yo7 really running both? Or is it one or the other?

 

[donaldfaison]

Your attending is weird as hell. How does it work when they are running MEPs? We dont paralyze 95% of our spine cases except sometimes for exposure. Just put in the tube and secure it well. It's VERY rare to have it fall out.

MEPs are the exception, he/she does not paralyze obviously for that.

Remi/sufenta infusion?
Are yo7 really running both? Or is it one or the other?

Meant one or the other.

 

[jeesapeesa]

small dose of paralytic for exposure. i don't usually paralyze for spines (prone). prop infusion +/- remi and they do just fine. as a CA-1 be sure to learn how to properly secure your airway and your attending should teach you this. i tape and usually put small tegaderms on each side.

 

[gasblaster]

small dose of paralytic for exposure. i don't usually paralyze for spines (prone). prop infusion +/- remi and they do just fine. as a CA-1 be sure to learn how to properly secure your airway and your attending should teach you this. i tape and usually put small tegaderms on each side.

I also add some benzoin/mastisol for good measure for long spine cases, oily patients, men (or women) with facial hair, MEPs... ok well a lot of the time.

 

[deleted126335]

I like paralysis right after induction for the turn. Other than that...don’t care much.

 

[The Physician Philosopher]

Small doses of paralytics can clean up SSEPs but I am talking small amounts 5mg roc every hour or so) over an entire case.

That said, unless your patient is on a huge amount of opioids... sufenta should keep everyone akinetic if run at an appropriate infusion rate. With low dose volatile (1/2 Mac), nitrous (if SSEPs tolerate), and sufenta... Your patient shouldn't be moving anyway. For the opioid tolerant patient (high dose methadone, 100mg oxycodne daily, etc) I add ketamine infusions on top of this when needed to keep them akinetic. Ketamine also helps with SSEP signals.

I only use paralytic for tube and turn and then maybe at end of case if I want to get sufenta off early for a quick exam.

TPP

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[Noyac]

TPP, nitrous is one of the worst things we can run in spine cases due to neuromonitoring. I’m surprised you can get away with it.

For the record, I’m in the camp of zero paralytic for spine unless requested by surgeon.

 

[The Physician Philosopher]

TPP, nitrous is one of the worst things we can run in spine cases due to neuromonitoring. I’m surprised you can get away with it.

For the record, I’m in the camp of zero paralytic for spine unless requested by surgeon.

I hear ya. We are a rare breed when it comes to nitrous for Neuro cases. It's the first thing we dump if the baseline signals are not as good as we want. That said, you can run it at low doses (50% or less).

That said, we rely heavily on opioid infusions to get immediate Neuro exams in the operating room. Our neurosurgeons and Ortho spine docs love it.

TPP

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[Noyac]

I hear ya. We are a rare breed when it comes to nitrous for Neuro cases. It's the first thing we dump if the baseline signals are not as good as we want. That said, you can run it at low doses (50% or less).

That said, we rely heavily on opioid infusions to get immediate Neuro exams in the operating room. Our neurosurgeons and Ortho spine docs love it.

TPP

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Same here for PACU exams. Our guys literally want the pt doing calisthenics the minute they hit the PACU.
Salty, here is another one for your “Noy’s list of dislikes”. I rarely use remi. I prefer sufenta for these case except for cervicals. Those don’t matter as much since the post op pain isn’t as much.
IMo, the remi pts take longer to get comfy in PACU therefore, longer PACU stays.

 

[deleted162650]

Same here for PACU exams. Our guys literally want the pt doing calisthenics the minute they hit the PACU.
Salty, here is another one for your “Noy’s list of dislikes”. I rarely use remi. I prefer sufenta for these case except for cervicals. Those don’t matter as much since the post op pain isn’t as much.
IMo, the remi pts take longer to get comfy in PACU therefore, longer PACU stays.

I’m with you on the remi. I think it’s a pants-on-head ******ed choice for spine cases (really for damn near any case, but that’s another topic). I loved Sufenta gtts in residency, but haven’t had it on formulary since.

I’ll add it to the list.

 

[anbuitachi]

what's wrong with fentanyl? You guys dont like it? It's my go to opioid for spines, except cervical which I will use remi for

 

[IlDestriero]

I rarely paralyze for anything. An exception is Neuro in pins, unless they’re doing Neuro monitoring. I came in to help several years ago when a guy moved in pins and popped out. It was a scary couple minutes. There was a lot of blood and one of the pins was near the eye. All was well, but it could have been a tragedy. I don’t know if they were doing monitoring or electively didn’t paralyze.


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Il Destriero

 

[Noyac]

what's wrong with fentanyl? You guys dont like it? It's my go to opioid for spines, except cervical which I will use remi for

Nothing wrong.

 

[deleted875186]

I’m with you on the remi. I think it’s a pants-on-head ******ed choice for spine cases (really for damn near any case, but that’s another topic). I loved Sufenta gtts in residency, but haven’t had it on formulary since.

I’ll add it to the list.

Only a resident, but my opinion is I would not want a Remi infusion for myself for surgery, only so the neurosurgery team could get a neuro exam 15 minutes earlier in the OR instead of th PACU, at the expense of my post op pain control.

Honestly, is there any real advantage to getting a neuro exam more quickly, other than simply satisfying the surgeon. I think it’s the most ridiculous notion, and several of my attendings put such emphasis on a quick wake up as if nothing else mattered.

 

[The Physician Philosopher]

Only a resident, but my opinion is I would not want a Remi infusion for myself for surgery, only so the neurosurgery team could get a neuro exam 15 minutes earlier in the OR instead of th PACU, at the expense of my post op pain control.

Honestly, is there any real advantage to getting a neuro exam more quickly, other than simply satisfying the surgeon. I think it’s the most ridiculous notion, and several of my attendings put such emphasis on a quick wake up as if nothing else mattered.

Being an acute pain attending... I can definitely attest to this. They care much much more about the wake up than post op pain control. In fact, it often feels like they focus on a wake up test at the cost of post op pain control.

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[Noyac]

Honestly, is there any real advantage to getting a neuro exam more quickly, other than simply satisfying the surgeon. I think it’s the most ridiculous notion, and several of my attendings put such emphasis on a quick wake up as if nothing else mattered.

Yeah I see your point but think of it this way. Let’s say the wake up is delayed and the surgeon has another long case to follow. S/He now can’t get a good neuro exam and scrubs into the next case. Then the PACU RN calls and says the exam isn’t ideal. Now what?
So if possible, it is better to have the pts awake ASAP. And if it’s the last case of the day, I want to go home. So you can be damn sure that pt will do calisthenics in the PACU the minute they arrive.

But as a resident, I would focus on the intraoperative anesthetic for now. And then as you are approaching graduation you can start to fine tune your wake ups. There’s a lot to learn and you will not be expected to wake up your pts on a dime when you get out as much as you will be expected to be safe.

 

[deleted162650]

Only a resident, but my opinion is I would not want a Remi infusion for myself for surgery, only so the neurosurgery team could get a neuro exam 15 minutes earlier in the OR instead of th PACU, at the expense of my post op pain control.

The 2 are not mutually exclusive. You can have a very heavily narc'd patient that is still able to follow commands. The key is getting rid of all the other crap that keeps them asleep.

 

[Noyac]

The 2 are not mutually exclusive. You can have a very heavily narc'd patient that is still able to follow commands. The key is getting rid of all the other crap that keeps them asleep.

So true and the opposite of a heavily narcotized is one that can’t follow commands either.

 

[anbuitachi]

I dont know about yours but the neuro exam done here right afterwards is not a rigorous neuro exam done by neurologists. It's literally move your 4 extremities.... They dont even have to be very awake for it. If they are bucking on the tube and flailing their arms and legs, they pass

 

[coffeebythelake]

The 2 are not mutually exclusive. You can have a very heavily narc'd patient that is still able to follow commands. The key is getting rid of all the other crap that keeps them asleep.

Opioids can mess up your neuro exam. I've seen it personally, and it's well supported by literature.

Recovery and neurological examination after remifentanil-desflurane or fentanyl-desflurane anaesthesia for carotid artery surgery (PDF Download Available)

 

[Noyac]

I dont know about yours but the neuro exam done here right afterwards is not a rigorous neuro exam done by neurologists. It's literally move your 4 extremities.... They dont even have to be very awake for it. If they are bucking on the tube and flailing their arms and legs, they pass

Not my guys. I’m not joking when I say they are doing calisthenics. They just are in bed when doing them. Move this, move that, push, pull, squeeze, hold this leg in the air, now this one, look at me I’m talking to you.

 

[Noyac]

Opioids can mess up your neuro exam. I've seen it personally, and it's well supported by literature.

Recovery and neurological examination after remifentanil-desflurane or fentanyl-desflurane anaesthesia for carotid artery surgery (PDF Download Available)

I would not put a CEA pt in the same boat as a lumbar spine pt. Hugely different surgeries with hugely different pain requirements.

Plus your study was done at an academic center. I don’t give much credence in emergence times to studies done in academic centers. One can achieve impressive results with many different forms of an anesthetic. As an anesthesiologist you must be capable of achieving the same outcome with more than one approach. Then, I would argue that you are a master at your domain.

 

[deleted162650]

Took the words right outta my mouth @Noyac

 

[anbuitachi]

I would not put a CEA pt in the same boat as a lumbar spine pt. Hugely different surgeries with hugely different pain requirements.

Plus your study was done at an academic center. I don’t give much credence in emergence times to studies done in academic centers. One can achieve impressive results with many different forms of an anesthetic. As an anesthesiologist you must be capable of achieving the same outcome with more than one approach. Then, I would argue that you are a master at your domain.

How does it differ that much. I never been to PP so i dont know. At least here a lot of the academic guys used to be in PP, and people leave for PP as well.

 

[projectpat]

you can work in longer acting narcs while on remi infusion. Remi is great for a reliably smooth emergence.

 

[pgg]

Remifentanil is great for stimulating procedures that won't have a lot of postop pain and where rapid emergence is desirable.

I really don't like it for cases that might have significant postop pain. Sure, you can work in something longer acting before you turn it off, but opioid induced hyperalgesia is a real thing and remi is one of the worst offenders. I think it's the wrong drug for most spine cases.

 

[The Physician Philosopher]

Remifentanil is great for stimulating procedures that won't have a lot of postop pain and where rapid emergence is desirable.

I really don't like it for cases that might have significant postop pain. Sure, you can work in something longer acting before you turn it off, but opioid induced hyperalgesia is a real thing and remi is one of the worst offenders. I think it's the wrong drug for most spine cases.

Completely agree.

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[GaseousClay]

With the magic of sugammadex who cares anymore. Paralyze away

 

[coffeebythelake]

With the magic of sugammadex who cares anymore. Paralyze away

they might care if they want motor evoked potentials

 

[narcusprince]

I could see an argument about paralyzing prones spines when only seps or no neuromonitoring. Likely your attending is afraid of an air embolism with open bone exposed.

 

[GaseousClay]

they might care if they want motor evoked potentials

i thought it was safe to assume everyone knows you don't paralyze for MEP

 

[Urzuz]

Remifentanil is great for stimulating procedures that won't have a lot of postop pain and where rapid emergence is desirable.

I really don't like it for cases that might have significant postop pain. Sure, you can work in something longer acting before you turn it off, but opioid induced hyperalgesia is a real thing and remi is one of the worst offenders. I think it's the wrong drug for most spine cases.

Can I like this 100x over? I have never ever understood why people run it for spines. It makes no sense, is a waste of money, and is cruel to the patient. Their recovery doesn't end after their "smooth wake up."

 

[Psai]

Can I like this 100x over? I have never ever understood why people run it for spines. It makes no sense, is a waste of money, and is cruel to the patient. Their recovery doesn't end after their "smooth wake up."

I had a patient that took a truckload of dilaudid after a long spine and they were still in agony. I couldn't believe they were still breathing with the doses we gave. Not opioid naive but enough to knock out a horse.

 

[deleted697127]

I had a patient that took a truckload of dilaudid after a long spine and they were still in agony. I couldn't believe they were still breathing with the doses we gave. Not opioid naive but enough to knock out a horse.

Annnnnnd now I’ve spent half an hour unsuccessfully googling how much dilaudid it would take to knock out a horse.

 

[Psai]

Annnnnnd now I’ve spent half an hour unsuccessfully googling how much dilaudid it would take to knock out a horse.

We were well into double digits very quickly