Scoliosis post op pain control

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apma77

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Anyone asking the surgeon to place epidural in before closing??
or are most people doing pca...there is ALOT of pain if patient had thoracotomy for anterior repair as well

im wondering what you all are doing for post op pain??
 
Do people use epidurals for these at all? For the repairs Ive seen the epidural space is likely non functional after the operation plus the levels needed to cover would be considerable.
 
yes there is literature on good pain control from placing epidural after scoliosis surgery. some people put lumbar and thoracic (2 catheters) for full coverage. Mostly ive seen tho just pca afterwards which is poor at best for pain control for this surgery
 
I always had good results with epidurals and using whatever local (usually bupiv) and PFMS. 12 hrs b/4 pulling the epidural you slap a fentanyl patch on them and then pull the epidural. They do fine.
 
thats what I love about this forum. Always learn something new.
 
I do about 2-5 of these a week, both pediatric and adult in Plano at this superbusy scoliosis hospital:
http://www.consultingorthopedists.com

There would be holy heck raised if an epidural catheter is not placed. The epidural space IS functional, especially this close to the surgery. Later, some patients may form epidural adhesions that block good flow and post surgical accessing of the epidural space might be difficult with the hardware in place if you are a wide lateral approach individual, but even then it is not impossible. The hardware does not cross the midline.

I would caution against using strong local anesthetic infusions in the epidural as this can mask nerve irritation caused by incorrectly placed or migrating hardware. A narcotic based basal infusion with demand PCEA of 2-3 cc/15 min does the trick and our patients are usually out of the hospital in 3-5 days because their pain is so well controlled with the PCEA.
 
UTSouthwestern said:
I do about 2-5 of these a week, both pediatric and adult in Plano at this superbusy scoliosis hospital:
http://www.consultingorthopedists.com

There would be holy heck raised if an epidural catheter is not placed. The epidural space IS functional, especially this close to the surgery. Later, some patients may form epidural adhesions that block good flow and post surgical accessing of the epidural space might be difficult with the hardware in place if you are a wide lateral approach individual, but even then it is not impossible. The hardware does not cross the midline.

I would caution against using strong local anesthetic infusions in the epidural as this can mask nerve irritation caused by incorrectly placed or migrating hardware. A narcotic based basal infusion with demand PCEA of 2-3 cc/15 min does the trick and our patients are usually out of the hospital in 3-5 days because their pain is so well controlled with the PCEA.
Click to expand...

What's your narcotic, MS, fent, Demerol, hydromorphone?
 
UT Southwestern...are you placing these epidurals post op (awake or asleep) or is the surgeon putting them in for you before he closes the wound???
and how long do you keep the catheters in for ??
 
UT...how long do you keep the catheters in and are they placing 2 catheters (at what level for full backs???)
 
i have an adult scoliosis case will be done staged over 2 days..1st day anterior approach t8-L3 (thoracotomy), next day t3-s1 posterior approach
pt to be on vent overnight between the case days. Im thinking of keeping the patient on remi and propofol overnight.
I will ask surgeon to place epidural at T8 level and run 0.125%bupi + 2mcg/cc fentanyl at 5cc/hr on 2nd day after patient is extubated...

any input??? or ideas
 
First piece of advice: Tell him to send the patient here. Shouldn't have to be staged unless an unexpected complication or severe bleeding occurs anteriorly.

We routinely do anterior thoracolumbar fixation followed by 10+ segmental posterior fusions and do them in less than 6 hours, usually less than 5 hours. Keeping a patient asleep, intubated, and vented overnight indicates to me that this surgeon is likely going to take 12+ hours to do both procedures, which is too long.

Aside from the obvious stuff (A line, central line), I'd run Precedex for the posterior portion/2nd day in anticipation of a quick wake up after the procedure for a thorough neuro assessment.

Are your surgeons utilizing full neuro montoring?
 
We would have our surgeons place the epidural. Some of them worked pretty good but seemed like a lot of them were not 100% satisfactory. We would end up running it at a high rate w/no demand dose and using a PCA as well. Usually 1/8th or 1/4% bupi plus dilaudid.
 
we will do full neuro monitoring so i will run TIVA with propofol/remi for the whole case (yes i know i could try 0.5mac gas)....i will stay away from precedex because he most likely cause high EBL and i'll have to transfuse like crazy...i will put on a BIS so i dont have to run anesthetic at god-aweful levels....

my concern is how to manage post-op pain...this patient will cry bloody murder if her pain isnt manged well
 
Post op I would keep the patient on Precedex for the first 24 hours, use the epidural, and write for IV Dilaudid boluses for breakthrough. You personally can give a 2-5 mg hit of ketamine after the neurochecks are done and that will usually keep them very settled for the next several hours, enough for the other medications to kick in.

As for TIVA, I'm not a fan of 12+ hours of TIVA, especially with hypersensitizing remifentanil. Since the first day is already going to be a wash in terms of waking the patient up, you may as well load them on IV Dilaudid or IV Methadone, then just use propofol for your TIVA.

On your second day, I'd still avoid remi and use boluses of narcotic du jour, get them breathing as they are closing SQ tissue (propofol already off and gas on), titrate narcotic or ketamine, gas off, flip, extubate, and head to ICU.
 
UT..what typa EBL (range) do you run into?

im sure yours are less cause your surgeons do this all the time..my orthopod s expecting significant bleeding so i dont think we will extubate on 2nd day...

also..do you run precedex after extubation??? and at what doses?
 
300-800 cc typically. I can't remember the last time I had to transfuse. Even with the outliers, I've still extubated at the end of the case. I run the precedex at .3-.5 through the case then turn it down one hour before extubation to 0-.2 wake them up test them then turn the precedex back up to .4-.7 to rest them afterwards.
 
UT ..

we will be putting in 2 epidural catheters (this is talked about in literature) ; one at t6 and one at L 3-4 so we can get broad coverage...plan is to infuse bupi 0.0625% with 2mcg/cc fentanyl (5cc/hr for thoracic and 5cc for lumbar)

any thoughts or ideas???
 
I would stop all IV narcs 1 hour prior to skin closure and bolts both ED catheters 15-20 mine with 5 cc each of your mix or 1 mcg/cc sufenta.
 
patient will be on vent overnight after day 2 of surgery (posterior repair).
plan is to start epidural shortly before patients sedation is turned off in the morning.

have you done intercostal blocks for post-op pain also in addition to epidural??
 
apma77 said:
patient will be on vent overnight after day 2 of surgery (posterior repair).
plan is to start epidural shortly before patients sedation is turned off in the morning.

have you done intercostal blocks for post-op pain also in addition to epidural??
Click to expand...
Why do you think that you need intercostal blocks if you have 2 epidurals?
 
UTSouthwestern said:
Post op I would keep the patient on Precedex for the first 24 hours, use the epidural, and write for IV Dilaudid boluses for breakthrough. You personally can give a 2-5 mg hit of ketamine after the neurochecks are done and that will usually keep them very settled for the next several hours, enough for the other medications to kick in.

As for TIVA, I'm not a fan of 12+ hours of TIVA, especially with hypersensitizing remifentanil. Since the first day is already going to be a wash in terms of waking the patient up, you may as well load them on IV Dilaudid or IV Methadone, then just use propofol for your TIVA.

On your second day, I'd still avoid remi and use boluses of narcotic du jour, get them breathing as they are closing SQ tissue (propofol already off and gas on), titrate narcotic or ketamine, gas off, flip, extubate, and head to ICU.
Click to expand...


Dude, I couldn't add one thing to this. That is exactly how I would do it. I totally agree with avoiding remi. And I would never consider running remi over night in a pt like this. She would be nearly impossible to get comfortable after turning it off after running for over 24 hrs.
 
apma77 said:
patient will be on vent overnight after day 2 of surgery (posterior repair).
plan is to start epidural shortly before patients sedation is turned off in the morning.

have you done intercostal blocks for post-op pain also in addition to epidural??
Click to expand...

Wow. So the patient will be essentially under 48 hours of general anesthesia/deep sedation. Just wow.

Intercostal blocks are superfluous with two epidurals in place, plus the fact that the the greatest area of pain (two foot midline posterior incision) will not be covered by intercostal nerve blocks. The thoracotomy scar should fall well within the range of the epidurals and would provide much superior analgesia than intercostal blocks.

Again, since the patient is going to be intubated and vented post anterior and post posterior repair, I would just load the patient with Dilaudid or Methadone, preferably the latter given its 12-15 hour duration of action.
 
This spine surgeon does NOT do scoliosis surgery on a regular basis so this is a new venture. My plan is to run sufenta drip and propofol drip overnight and back on remi for the case since he wants to do wakeup tests (yes even with MEPs). After the posterior repair and final neuro exam its back on sufenta and to the ICU for overnight vent. In the morning turn off propofol , sufenta and extubate. Dose epidural catheters prior to extubation...

He is expecting a couple liters of EBL (which in my book is probably 5-6 liters) so im bracing for a blood bath and massive fluid shifts....

any thoughts??
 
apma77 said:
This spine surgeon does NOT do scoliosis surgery on a regular basis so this is a new venture. My plan is to run sufenta drip and propofol drip overnight and back on remi for the case since he wants to do wakeup tests (yes even with MEPs). After the posterior repair and final neuro exam its back on sufenta and to the ICU for overnight vent. In the morning turn off propofol , sufenta and extubate. Dose epidural catheters prior to extubation...

He is expecting a couple liters of EBL (which in my book is probably 5-6 liters) so im bracing for a blood bath and massive fluid shifts....

any thoughts??
Click to expand...

Would not use the remi on day 2. Aside from chasing the BP, you will still be subjecting them to a long hypersensitizing time frame. Methadone or Dilaudid for day one and overnight with versed or propofol infusions to keep them sedated (although I think it would be better to wake them up after the anterior part).

Second day you can use the sufenta infusion with or without Precedex but I would get them breathing during SQ closure, propfol off at least one hour prior to planned wakeup with gas to cover, sufenta off, small hit (2-5 mg of ketamine 30 min prior to wakeup), gas off flip extubate, should wake up very quickly.
 
Plankton.............................regardless of your moderator role.

anyways...UT...thats a good thought..however with the massive bloodloss i will keep her intubated overnight since there is no intensivist at my hospital
 
Last edited by a moderator:
Understandable. During the case, I'm assuming you will have cellsaver going. Make sure that your scrub techs don't discard blood soaked laps. Have them squeeze them out and use the cellsaver to salvage the blood. If the case does take as long as I am thinking it will, you should have plenty of cellsaver to give. Remember that each unit of donor product you give will increase M&M for this patient. Don't run them superdry; saw another anesthesiologist do that and nearly killed the patient.

Keep track of the coags at least every 4 hours, TEG if you have it, keep the UOP up, use small doses of mannitol as needed.

Do you have IV methadone there? It would really simplify pain control for the first 24 hours. Otherwise scheduled doses of Dilaudid (.02-.05 mg/kg q 4-6 hours) after part 1 with BP control parameters in place.
 
Almost forgot: use an antifibrinolytic infusion. Amicar should be sufficient. Tranexamic acid is stronger but has a theoretical risk of affecting color vision. Desmopressin if the patient has been on platelet inhibitors and/or TEG/platelet mapping shows inhibition.
 
apma77 said:
Plankton........................................................... regardless of your moderator role.

anyways...UT...thats a good thought..however with the massive bloodloss i will keep her intubated overnight since there is no intensivist at my hospital
Click to expand...

I have to say that I am a little bit surprised by your unprovoked reaction and I also think that it is absolutely inapropriate.
I was trying to say to you that you are overdoing everything in this case and that the next thing I am affraid you might say is that you decided to do this case under hypothermic cardiac arrest to lower blood loss.
You are saying that there is no intensivist at your hospital so this makes me think that you are not a resident, so what are you? a CRNA?
 
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I'm going to ask that this disagreement stop at the last post. These cases are a particular favorite of mine and I would rather the thread remain focused on the interesting topic at hand.
 
UTSouthwestern said:
I'm going to ask that this disagreement stop at the last post. These cases are a particular favorite of mine and I would rather the thread remain focused on the interesting topic at hand.
Click to expand...

I agree, and I think this is a great case but sometimes overdoing things leads to complications and unnecessary interventions.
This is my opinion and I think it is important for the new anesthesiologists to realize that it is actually possible to do a case like this one in a simple straight forward manner.
When someone posts a case for discussion it is assumed that he is open to hear all the points of view especially from people with a little more experience.
 
ut...

are you using amicar on all scoliosis cases or just selectively?

also would it be prudent to run it on both days if the case is staged?

thanks
 
I use antifibrinolytics selectively and rarely, if ever in pedi patients.

Plank, DDAVP does not reverse platelet inhibitors. It does increase expression of von Willebrand's factor to help promote platelet adhesion with platelets not inhibited by Plavix et al. If a patient is 100% inhibited on a platelet inhibitor, the case should be cancelled unless you want to start transfusing platelets before skin incision.
 
would you suggest using amicar on my 27 yr old patient (possible blood bath) for both days?
 
what is your dosing for the amicar? shall i bolus on both days?
 
I would load on both days. 5-10 grams then 200 mg/kg for the rest of each part.

Understand that these suggestions are for high risk patients or surgeons.
 
what toxic or potential downsides of amicar shall i look out for??
 
The usual stuff: anaphylactic reactions (very rare), complications of hypercoagualability, etc. They are unlikely in the situation you are likely going to be in, wherein much of this patient's coagulation factors are likely to be in use if, as you say, your surgeon is not as attentive to hemostasis as is desirable.

Would like to know how everything turns out.
 
It's not that strange. A lot of times you will see some surgeon doing a major whack that for the patient's benefit, he/she should refer to an experienced surgeon. What could take the latter 4-6 hours to complete takes the former 12-24 surgical hours to do with all of the consequences of superlong GETA, massive blood loss, prone positioning greater than 10 hours, etc.

This is why my first and foremost piece of advice was to recommend to the surgeon that he refer the patient to the guys that do 250-300/year (www.consultingorthopedists.com).

Barring that, what Apma is doing is no different than a local guy or former resident classmate calling someone with experience doing an unusual case for advice.

He could just as easily e-mailed me but this post allows everyone to chime in with their thoughts on how to manage a complicated case for the patient's benefit. First and foremost Apma does not want a 29 year old to suffer from both the surgeon and anesthesiologist's lack of knowledge and experience on the patient's case type and its perioperative management.
 
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