Regional benefits

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Big stupid question. Sorry
Is regional/neuraxial of any consistently proven benefits other than same day discharge for elective joints.

It seems like every 3 to 6 months there is a new study out that conflicts with what the last says.

Which to believe?

When I started everyone had to have a spinal for fractured hip, now there's no difference from a big uk trial.

And if I read a us journal (written by biased regionalists) everyone has to have a spinal. I don't get it

Please enlighten me?
 
Fake news.
I believe outcomes are pt and just as importantly, provider specific.
I also believe that some of the benefits are less amendable to studies.
 
Newtwo said:
Big stupid question. Sorry
Is regional/neuraxial of any consistently proven benefits other than same day discharge for elective joints.

It seems like every 3 to 6 months there is a new study out that conflicts with what the last says.

Which to believe?

When I started everyone had to have a spinal for fractured hip, now there's no difference from a big uk trial.

And if I read a us journal (written by biased regionalists) everyone has to have a spinal. I don't get it

Please enlighten me?
Click to expand...

no difference in what? which trial are you referring to
 
Newtwo said:
Big stupid question. Sorry
Is regional/neuraxial of any consistently proven benefits other than same day discharge for elective joints.

It seems like every 3 to 6 months there is a new study out that conflicts with what the last says.

Which to believe?

When I started everyone had to have a spinal for fractured hip, now there's no difference from a big uk trial.

And if I read a us journal (written by biased regionalists) everyone has to have a spinal. I don't get it

Please enlighten me?
Click to expand...
Evidence for elective total joints is overwhelming in favor of regional.

Hip fracture goes back and forth, but especially got the demented folk, I feel regional is the way to go, but there is evidence in both directions.
 
Newtwo said:
Big stupid question. Sorry
Is regional/neuraxial of any consistently proven benefits other than same day discharge for elective joints.

It seems like every 3 to 6 months there is a new study out that conflicts with what the last says.

Which to believe?

When I started everyone had to have a spinal for fractured hip, now there's no difference from a big uk trial.

And if I read a us journal (written by biased regionalists) everyone has to have a spinal. I don't get it

Please enlighten me?
Click to expand...

If regional/neuraxial has proven benefit for same day discharge joints, then why doesn't it stand to reason those benefits exist for other patients? Not even going to discuss potentially biased studies, but patients getting SAB for elective joints consume considerably less opioid during their stay (my hospital tracks this) which comes with it's own benefit. Surgeons state, in the OR, there's less blood loss and a cleaner field of vision with SAB. With SAB, the anesthetic is considerably 'cleaner' and more pleasant for patients. It's what I'd want for joint replacement. Beyond controversial endpoints such as quicker recovery/EBL/transfusion/DVT/PE/mortality, it's just an elegant, simple way to do a joint.
 
Increasingly our surgeons want no foley and ambulation on the day of surgery so we’ve been moving away from spinals and definitely away from spinal opioids. Would love to hear how others are doing it.
 
nimbus said:
Increasingly our surgeons want no foley and ambulation on the day of surgery so we’ve been moving away from spinals and definitely away from spinal opioids. Would love to hear how others are doing it.
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No spinal opioid, no Foley. Plain spinal (mepi or bupi). PT day of surgery. Patients who get SAB end up with about 1/2 the opioid of patients who get GA, day of surgery. I think all that opioid can slow you down....
 
nimbus said:
Increasingly our surgeons want no foley and ambulation on the day of surgery so we’ve been moving away from spinals and definitely away from spinal opioids. Would love to hear how others are doing it.
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Currently doing spinal without opioid because that's what people were doing at new gig, but at my old gig did LOTS of total joints with SAB with 0.1 mg duramorph. No Foley's. Limited fluid to 1.5 L. Had no urinary retention issues.
 
facted said:
Evidence for elective total joints is overwhelming in favor of regional.

Hip fracture goes back and forth, but especially got the demented folk, I feel regional is the way to go, but there is evidence in both directions.
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personally, i never understood doing a spinal for these demented old hip fractures.. the operation is quick, not super painful, and you dont have to deal with the demented person under an LMA.. plus with the spinal you get the arthritic spine with scoliosis and then the joy of sedating grandma with the same or more meds than needed for the straight GA.. i do an LMA

For total joints we are locked in on spinals for most people but GA and a block also work great and is underutilized. I dont believe EBL is really less with a spinal
 
Hoya11 said:
personally, i never understood doing a spinal for these demented old hip fractures.. the operation is quick, not super painful, and you dont have to deal with the demented person under an LMA.. plus with the spinal you get the arthritic spine with scoliosis and then the joy of sedating grandma with the same or more meds than needed for the straight GA.. i do an LMA

For total joints we are locked in on spinals for most people but GA and a block also work great and is underutilized. I dont believe EBL is really less with a spinal
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I give 0.5 of midaz and about 20 of ketamine for spinal sedation and can usually get through the case with just that. Works great and patient is back to baseline in pacu. As for the spinal itself, yes, it may be tricky, but with a 22g needle, I can usually get it within less than 5 minutes. If I can't get it, I'll just pop the LMA in but personally always go for the spinal first if there are no contradictions.

As for less EBL, why you may feel that it's not different, there are quite a few studies (for elective total joints) which not only show that EBL in the OR is less, but also that there is less post--op EBL and fewer transfusions.

There is also evidence for this with epidurals for abdominal surgery.
 
I used to do spinals on all these cases now I almost never do one.
They all get GA and some sort of block, and they all do well. The very old with a fractured hip is actually a very easy anesthetic, simply GA with LMA just stay light, and if you don't want much post-op delirium use a Propofol infusion instead of inhaled agents.
 
Planktonmd said:
I used to do spinals on all these cases now I almost never do one.
They all get GA and some sort of block, and they all do well. The very old with a fractured hip is actually a very easy anesthetic, simply GA with LMA just stay light, and if you don't want much post-op delirium use a Propofol infusion instead of inhaled agents.
Click to expand...

I prefer GA for the old demented hip. When using gas I minimize narcs and just work in 20-30 mcg of precedex near the end and they wake up like a dream.
 
facted said:
I give 0.5 of midaz and about 20 of ketamine for spinal sedation and can usually get through the case with just that. Works great and patient is back to baseline in pacu. As for the spinal itself, yes, it may be tricky, but with a 22g needle, I can usually get it within less than 5 minutes. If I can't get it, I'll just pop the LMA in but personally always go for the spinal first if there are no contradictions.

As for less EBL, why you may feel that it's not different, there are quite a few studies (for elective total joints) which not only show that EBL in the OR is less, but also that there is less post--op EBL and fewer transfusions.

There is also evidence for this with epidurals for abdominal surgery.
Click to expand...

what do you believe to be the mechanism of reduced EBL under neuraxial vs GA ?
 
Hoya11 said:
what do you believe to be the mechanism of reduced EBL under neuraxial vs GA ?
Click to expand...
Lower arterial and peripheral venous blood pressure.

Lower EBL with regional has been shown in a ton of studies if you run a quick pubmed.
 
Planktonmd said:
I used to do spinals on all these cases now I almost never do one.
They all get GA and some sort of block, and they all do well. The very old with a fractured hip is actually a very easy anesthetic, simply GA with LMA just stay light, and if you don't want much post-op delirium use a Propofol infusion instead of inhaled agents.
Click to expand...

This. Less is more with these old folks
 
facted said:
GA is less than a spinal?
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If we're talking a 1 hr hip pinning then yeah, a spinal is wasting mine and the surgeons time and the patient does just as fine with an LMA and propofol infusion.

Edit: I also don't like awake patients. Even with a spinal, most still sedate the patient. I just take the spinal out of the picture and crank the sedation. Also these old folks usually don't need much post-op opioid. A THR is probably a different story but I honestly don't do many of those.
 
facted said:
Currently doing spinal without opioid because that's what people were doing at new gig, but at my old gig did LOTS of total joints with SAB with 0.1 mg duramorph. No Foley's. Limited fluid to 1.5 L. Had no urinary retention issues.
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Do you have an age limit for spinal duromorph? At my previous place, we do spinal + block+ sedation. Now one orthopod likes duromorph. I am concerned about the delayed respiratory suppression of the 70+.
 
narcotics999 said:
Do you have an age limit for spinal duromorph? At my previous place, we do spinal + block+ sedation. Now one orthopod likes duromorph. I am concerned about the delayed respiratory suppression of the 70+.
Click to expand...
Use 50 mcg.
 
facted said:
GA is less than a spinal?
Click to expand...
Yes! A spinal causes hypotension that you need to treat and you still need to give sedation, sometimes heavy sedation to prevent these patients from jumping of the table when they hear the hammers and chisels.
 
I wonder if anybody has done a study where the GA and regional groups were maintained exactly at the same BP levels. I have a feeling many of those EBL benefits are simply due to anesthesiologists feeling way more comfortable with a (relatively) low BP during a MAC versus GA.

When you have a hypertensive 70-80 year-old with God knows what brain vessels, you'll feel just fine with 100/60 while he's snoring away on propofol, but you'll want a MAP "within 20% of his resting MAP" (i.e. higher) during GA.
 
FFP said:
I wonder if anybody has done a study where the GA and regional groups were maintained exactly at the same BP levels. I have a feeling many of those EBL benefits are simply due to anesthesiologists feeling way more comfortable with a (relatively) low BP during a MAC versus GA.

When you have a hypertensive 70-80 year-old with God knows what brain vessels, you'll feel just fine with 100/60 while he's snoring away on propofol, but you'll want a MAP "within 20% of his resting MAP" (i.e. higher) during GA.
Click to expand...
The amount of sedation you need to give to these patients so they don't move or strike a conversation with the surgeon is pretty much equivalent to GA, but some people just don't want to admit it.
 
And who cares about blood loss. It’s only significant if there is a surgical misadventure, and if that happens you’re gonna wish you did a GA with ETT.

Also EBL estimates are mostly fiction. I’ve often wondered how they estimate EBL in the literature.
 
Planktonmd said:
The amount of sedation you need to give to these patients so they don't move or strike a conversation with the surgeon is pretty much equivalent to GA, but some people just don't want to admit it.
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I routinely do prop at 50mcg for the younger crowd and down to 25-35 for the 70+ crowd. That's GA in your book?
 
nimbus said:
And who cares about blood loss. It’s only significant if there is a surgical misadventure, and if that happens you’re gonna wish you did a GA with ETT.
Click to expand...
Who cares about EBL? You don't see it because you rarely transfuse in the OR an elective total joint, but they do tend bleed post-op and avoiding intra-op EBL can help avoid a transfusion.

I've done prob close to a thousand elective hips and knees, mostly with spinal and maybe 50-100 of them with GA. The post-op pain and mental status outcomes alone in PACU and the floor make the spinal well worth it, not to mention EBL, PE risk, etc ..

Why people are so adverse to spinal for total joints in the face of the literature is just beyond me. What do you gain by avoiding the spinal?
 
Planktonmd said:
Yes! A spinal causes hypotension that you need to treat and you still need to give sedation, sometimes heavy sedation to prevent these patients from jumping of the table when they hear the hammers and chisels.
Click to expand...
What are you putting in your spinal? I use isobaric and rarely have to treat the BP. Mean often hovers around 60 which I'm happy with. I use 35-50mcg of prop usually for sedation. On occasion higher in the sub 50 crowd.

And your acting as if GA doesn't affect BP (or neurons!)

Show of hands: who's patients are more combative waking up in PACU after a spinal with sedation than a GA?
 
Hip fractures being a separate argument, I don’t get doing GA for elective joint arthroplasty unless your surgeon is horrendous and/or super slow. It’s pretty clear patients do better with SAB.
 
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facted said:
What are you putting in your spinal? I use isobaric and rarely have to treat the BP. Mean often hovers around 60 which I'm happy with. I use 35-50mcg of prop usually for sedation. On occasion higher in the sub 50 crowd.

And your acting as if GA doesn't affect BP (or neurons!)

Show of hands: who's patients are more combative waking up in PACU after a spinal with sedation than a GA?
Click to expand...
Isobaric Bupivacaine is not really what you want to do if you are planning to discharge the patient from PACU to home.
 
facted said:
Who cares about EBL? You don't see it because you rarely transfuse in the OR an elective total joint, but they do tend bleed post-op and avoiding intra-op EBL can help avoid a transfusion.

I've done prob close to a thousand elective hips and knees, mostly with spinal and maybe 50-100 of them with GA. The post-op pain and mental status outcomes alone in PACU and the floor make the spinal well worth it, not to mention EBL, PE risk, etc ..

Why people are so adverse to spinal for total joints in the face of the literature is just beyond me. What do you gain by avoiding the spinal?
Click to expand...


We rarely transfuse any primary total joints, intraop or postop. When they get transfused, it’s not because of anesthesia. There are other more significant and obvious factors.

With rare exception, my GAs wake up as clear headed as my spinals. Multimodal pain control, minimizing narcotics, and no benzos has made a big impact. I’ve done it every which way, did essentially 100% spinals for 10+ years, and my current GAs are as good as anything I’ve done.
 
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Planktonmd said:
Isobaric Bupivacaine is not really what you want to do if you are planning to discharge the patient from PACU to home.
Click to expand...
1.3-1.5 ml of 0.5% bupi is wearing off by the time I hit PACU with a relatively fast surgeon (1-1.5 hr TKR).

With that being said, we don't do ambulatory total joints.
 
nimbus said:
I’ve said this before. If there is a clear advantage of one technique over another, we wouldn’t be having this debate. The fact that debate has been going on for decades indicates to mean that there isn’t much difference. Both techniques are incredibly safe and have their unique set of problems.

Does regional anaesthesia improve outcome after total hip arthroplasty? A systematic review | BJA: British Journal of Anaesthesia | Oxford Academic
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Review is 9 yrs old and discusses more regional blocks than SAB. Even that analysis acknowledges the benefits of regional though, and their ‘limitations of regional’ are pretty weak sauce.
 
Southpaw said:
Review is 9 yrs old and discusses more regional blocks than SAB. Even that analysis acknowledges the benefits of regional though, and their ‘limitations of regional’ are pretty weak sauce.
Click to expand...


I’d love to see a more recent review.
 
facted said:
1.3-1.5 ml of 0.5% bupi is wearing off by the time I hit PACU with a relatively fast surgeon (1-1.5 hr TKR).

With that being said, we don't do ambulatory total joints.
Click to expand...
At the end of the day, in this business there are always multiple ways to achieve the right outcome, non of them is wrong and non of them is the only choice. It remains a question of style and preference.
 
facted said:
What are you putting in your spinal? I use isobaric and rarely have to treat the BP. Mean often hovers around 60 which I'm happy with. I use 35-50mcg of prop usually for sedation. On occasion higher in the sub 50 crowd.

And your acting as if GA doesn't affect BP (or neurons!)

Show of hands: who's patients are more combative waking up in PACU after a spinal with sedation than a GA?
Click to expand...

never had a combative patient after spinal before. at least they can't move their lower half!
 
FFP said:
I wonder if anybody has done a study where the GA and regional groups were maintained exactly at the same BP levels. I have a feeling many of those EBL benefits are simply due to anesthesiologists feeling way more comfortable with a (relatively) low BP during a MAC versus GA.
Click to expand...


My assumption is the decrease in EBL during spinal/epidural joints is because the neuraxial anesthetic causes arterial vasodilation below the level of the block. So the BP in their leg (which is impacting the bleeding) is lower than where you are measuring it in the arm. Under GA, the BP in the arm and the leg are basically identical.
 
Current Strategies in Anesthesia and Analgesia for Total Knee Arthroplasty. - PubMed - NCBI

Anesthesia and Analgesia Practice Pathway Options for Total Knee Arthroplasty: An Evidence-Based Review by the American and European Societies of R... - PubMed - NCBI

Honestly, my choice of technique for Total Joints is based upon surgeon preference. While I do think Neuraxial is "better" the benefits are subtle and surgeon dependent. There are a few cases where the patient is better served with a spinal but those are few number.
 
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