short acting spinal options

[deleted875186]

curious what people do for shorter acting spinal, especially since we almost always do high dose bupi for spinals, since I’m in trainin and here the surgeries take so long.

Does low dose bupi wear off significantly faster? Any other options for very short surgeries?

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[BLADEMDA]

Chloroprocaine 40 mg produces shorter spinal block than articaine 40 mg in day-case knee arthroscopy patients. - PubMed - NCBI

 

[BLADEMDA]

Reg Anesth Pain Med. 2016 Sep-Oct;41(5):576-83. doi: 10.1097/AAP.0000000000000420.
Comparison of 2-Chloroprocaine, Bupivacaine, and Lidocaine for Spinal Anesthesia in Patients Undergoing Knee Arthroscopy in an Outpatient Setting: A Double-Blind Randomized Controlled Trial.
Teunkens A1, Vermeulen K, Van Gerven E, Fieuws S, Van de Velde M, Rex S.
Author information

Abstract
BACKGROUND AND OBJECTIVES:
Knee arthroscopy is a well-established procedure in day-case surgery, which is frequently performed under spinal anesthesia. It is, however, controversial whether the choice for a specific local anesthetic translates into relevant outcomes. We hypothesized that the use of 2-chloroprocaine would be associated with a faster recovery from sensorimotor block.

METHODS:
Ninety-nine patients were included in this prospective, double-blind, randomized controlled trial and randomly allocated to receive either 40 mg 2-chloroprocaine, 40 mg lidocaine, or 7.5 mg bupivacaine. The primary endpoint was the time until complete recovery of sensory block. Secondary endpoints included time to recovery from motor block, failure rates, incidence of hypotension/bradycardia, postoperative pain, first mobilization, voiding and discharge times, and the incidence of transient neurologic symptoms. This clinical trial was registered prior to patient enrollment (EudraCT 2011-003675-11).

RESULTS:
Patients in the chloroprocaine group had a significantly shorter time until recovery from sensory block (median, 2.6 hours; interquartile range [IQR], 2.2-2.9 hours) than patients in the lidocaine group (3.1 hours; IQR, 2.7-3.6 hours; P < 0.006) and in the bupivacaine group (6.1 hours; IQR, 5.5 hours to undefined hours; P < 0.0001). Chloroprocaine was associated with a significantly faster recovery from motor block than lidocaine and bupivacaine. Times to first mobilization, voiding, and discharge were significantly shorter for chloroprocaine when compared with bupivacaine, but not with lidocaine. In the bupivacaine group, patients needed significantly less rescue medication for postoperative pain when compared with lidocaine and chloroprocaine. Groups did not differ with respect to patient satisfaction, incidence of bradycardia/hypotension, and transient neurologic symptom rate.

CONCLUSIONS:
For spinal anesthesia in patients undergoing ambulatory knee arthroscopy, chloroprocaine has the shortest time to complete recovery of sensory and motor block compared with bupivacaine and lidocaine.

 

[Aether2000]

Meperidine PF, motor block 20 min, sensory 45min. Ropivacaine motor 45-60 min, sensory 60-90 min in most

 

[BLADEMDA]

Curr Opin Anaesthesiol. 2011 Dec;24(6):633-7. doi: 10.1097/ACO.0b013e32834aca1b.
Revival of old local anesthetics for spinal anesthesia in ambulatory surgery.
Förster JG1, Rosenberg PH.
Author information

Abstract
PURPOSE OF REVIEW:
In recent years, several older (first intrathecal use in the 1950s, 1960s, and 1970s) local anesthetics have been investigated as spinal anesthetics in ambulatory surgery because these drugs are claimed to cause less transient neurologic symptoms (TNS) than lidocaine which was the main spinal anesthetic for surgery of short-duration for decades. The review covers the current literature.

RECENT FINDINGS:
Several recent reports have dealt with the short-acting chloroprocaine and articaine and the intermediate-duration-acting prilocaine. Mepivacaine, another intermediate-acting drug, was applied in one trial only. Various dosages of these drugs either alone or with a small dose of fentanyl were compared with each other, with lidocaine, or with the currently most commonly used low-dose bupivacaine technique. The recovery from both motor and sensory block was usually reasonably fast. However, occasionally recovery after mepivacaine and prilocaine was prolonged which fits ill in a fast-flow ambulatory setting. TNS cases were very rarely reported.

SUMMARY:
The newest results corroborate (at least for chloroprocaine, articaine, and prilocaine) previous data that these drugs provide reliable and mostly well tolerated spinal blocks associated with an apparently smaller risk for postanesthesic TNS as compared with lidocaine. Further studies are warranted regarding broader indications, possible usefulness of adjuvants, and for the exploration of the side-effect profiles in detail. To what extent the observed revival of these older, rather well characterized local anesthetics leads to a wider use of spinal anesthesia in the ambulatory setting remains to be seen. This is also dependent on various organizational and local traditional factors.

 

[vector2]

2.5-3cc of mepivacaine 1.5% for knee scopes does the trick

 

[BLADEMDA]

I recommend you read this article below:

https://watermark.silverchair.com/a...guTItHMBhYg6jPlNuZzJR28iU8I_5hk0MaEuaYXJ-DUbA

The bottom line is that low dose hyperbaric Bupivacaine, 5 mg, can be utilized for unilateral anesthesia of a lower extremity or saddle block but one must allow enough time for the block to set up. Otherwise, the dosage will need to be increased to around 7.5 mg (if the patient is immediately turned supine).

 

[BLADEMDA]

Now, what would I actually do in clinical practice? I'd prefer a TIVA over a spinal anesthetic for outpatient knee scopes. For a saddle block, I'd use 5 mg of hyperbaric bupivacaine. If pressed to do a spinal for an outpatient, non rectal/non gynecological procedure, then I'd use isobaric ropivacaine (PF). Ropivacaine is much shorter acting than Bupivacaine and is typically dosed in a 1.5-2:1 ratio so that means 10-12.5 mg for a short case.


Intrathecal ropivacaine 5 mg/ml for outpatient knee arthroscopy: a comparison with lidocaine 10 mg/ml. - PubMed - NCBI

 

[lakersbaby]

KP uses 2-3% chloroprocaine spinals for all same day total hips and knees. Get a pretty consistent 1-1.5 hour duration.

 

[dhb]

0.25% bupivacaine give you a good hour of sensory block

 

[kmurp]

I’d be a little concerned about PDPHA in many of these younger knee scope patients.

 

[BLADEMDA]

I’d be a little concerned about PDPHA in many of these younger knee scope patients.

I seriously doubt most Anesthesiologists are doing spinals in young ASA 1 and 2 patients for knee scopes especially in private practice. It's a rare bird especially with the invention of the LMA, Sevo/Des or Propofol TIVA (with BIS).

 

[deleted875186]

Thanks for all the replies. I’ve yet to have an attending let me do less than 1.5 mL of hyperbaric bupi for a case since they are typically longer. Do you think I should start pressing to do these cases with lower doses and the other locals mentioned here tj get experience before graduating residency, or is it something easily picked up after in practice?

 

[nimbus]

Thanks for all the replies. I’ve yet to have an attending let me do less than 1.5 mL of hyperbaric bupi for a case since they are typically longer. Do you think I should start pressing to do these cases with lower doses and the other locals mentioned here tj get experience before graduating residency, or is it something easily picked up after in practice?

More than likely you won’t be doing spinals for short cases so there’s no point.

 

[deleted162650]

The best short acting spinal is an LMA.

 

[vector2]

Thanks for all the replies. I’ve yet to have an attending let me do less than 1.5 mL of hyperbaric bupi for a case since they are typically longer. Do you think I should start pressing to do these cases with lower doses and the other locals mentioned here tj get experience before graduating residency, or is it something easily picked up after in practice?

Yes. Because even in the real world when you're doing 99% LMA you'll occasionally get a short case on some respiratory or cardiac cripple where a saddle/LE neuraxial block is your best.

 

[Aether2000]

Sometimes I wonder about the ostensible enhanced safety with a spinal block given that we routinely do US endoscopy or bronchoscopy on those with 20% EF or severe pulmonary compromise....

 

[kmurp]

I seriously doubt most Anesthesiologists are doing spinals in young ASA 1 and 2 patients for knee scopes especially in private practice. It's a rare bird especially with the invention of the LMA, Sevo/Des or Propofol TIVA (with BIS).

Doesn’t HSS do all spinals for their knee scopes? A local group by me does all epidurals.

 

[Shimmy8]

Epidural or spinal for knee scopes??? WTF

 

[kmurp]

Epidural or spinal for knee scopes??? WTF

Yes, I know. It seems quite out of the mainstream and not what our group currently does.
I spoke with an anesthesiologist at HSS who did a study there on PDPHA with 27 Whitacre. The overall incidence down to age 20 was 1-2% depending on age and sex. None of the patients required EBP. I’ve never used a 27 Whitaker but I imagine that they could be a challenge. I suppose, based on her study of 300 patients, one could conclude that the risk of a severe PDPHA is similar to that of an epidural, and maybe lower depending on your personal we’re tap rate.
Anyway, it seems as if at HSS, that’s what they are doing.
The epidurals being done by the group in my area are done primarily with the idea of eliminating induction and emergence times to allow for an extra scope being scheduled each day.

 

[Psai]

Yes, I know. It seems quite out of the mainstream and not what our group currently does.
I spoke with an anesthesiologist at HSS who did a study there on PDPHA with 27 Whitacre. The overall incidence down to age 20 was 1-2% depending on age and sex. None of the patients required EBP. I’ve never used a 27 Whitaker but I imagine that they could be a challenge. I suppose, based on her study of 300 patients, one could conclude that the risk of a severe PDPHA is similar to that of an epidural, and maybe lower depending on your personal we’re tap rate.
Anyway, it seems as if at HSS, that’s what they are doing.
The epidurals being done by the group in my area are done primarily with the idea of eliminating induction and emergence times to allow for an extra scope being scheduled each day.

How does it take longer to place an lma and pull deep than putting in an epidural and checking to make sure it's in the right place etc

 

[nimbus]

How does it take longer to place an lma and pull deep than putting in an epidural and checking to make sure it's in the right place etc

If you’re supervising you can dose up the next patient in preop while the previous case is going. Still I would think the time savings is minimal.

 

[kmurp]

How does it take longer to place an lma and pull deep than putting in an epidural and checking to make sure it's in the right place etc

Well if you save five minutes per case, with seven turnovers, you could get in one more scope I guess. Or finish by 3:30. And, yes, this only works when working with crnas.