Single Shot Spinal Narcotics

[VentdependenT]

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Have any of you used a single shot spinal duramorph for any large abdominal/sternotomy heart case?

Is it worth anything?

 

[BLADEMDA]

Have any of you used a single shot spinal duramorph for any large abdominal/sternotomy heart case?

Is it worth anything?

Venty,

I have used this technique about 100-150 times but never for hearts. I used it for AAA, thoracotomies, nephrectomy, TAH, etc.

Yes, it does work well in the PACU but the duration of action is from 12-18 hours. This means those thoracotomies are really going to be hurting at night. I like the single shot duramorph for the "healthy" AAA who can get by on PCA at night. It seemed adequate for nephrectomies and open radical prostatectomies as well.

Blade

 

[UTSouthwestern]

Have any of you used a single shot spinal duramorph for any large abdominal/sternotomy heart case?

Is it worth anything?

I have done it quite a few times, but only in patients who are not chronically anticoagulated and/or have been off anticoagulation for enough time for a normal TEG and coags.

In the patients I have used it in, it has worked very well (5 mcg/kg Duramorph, max 400 mcg). Occasionally I have had to chase the pressure, but usually not a significant amount, especially if I stick with the 5 mcg/kg dosing erring on the lower side if necessary.

 

[Noyac]

I use it quite often as well. But never for hearts. I don't do it for urology cases however. I don't want any urinary retention that may confuse the postop course. These pts get straight general.

I also add some local even if they are going to sleep. If I'm in there I might as well block them for a short time as well.

UT is absolutely right with the 400 mcg max dose as well. I'm usually down aroud 250 - 300 mcg's.

I don't find that they are very uncomfortable that evening, however. It seems to benefit the pts into the next day in my experience.

 

[UTSouthwestern]

I use it quite often as well. But never for hearts. I don't do it for urology cases however. I don't want any urinary retention that may confuse the postop course. These pts get straight general.

I also add some local even if they are going to sleep. If I'm in there I might as well block them for a short time as well.

UT is absolutely right with the 400 mcg max dose as well. I'm usually down aroud 250 - 300 mcg's.

I don't find that they are very uncomfortable that evening, however. It seems to benefit the pts into the next day in my experience.

Before our cardiologists and CT surgeons adopted more aggressive anticoagulation protocols, I would routinely use this technique and I found that the majority of my patients had great, and sometimes total pain relief for the first 12-16 hours, then had minimal IV narcotics for the next 12 hours (average of 3-5 mg of morphine IV over those 12 hours). Unfortunately, now I rarely use it for the hearts because of the protocols.

However, last week, I used it for two Ivor Lewis Esophagogastrectomies and those patients get a full laparatomy and huge right thoracotomy and both patients were awake and smiling 6 hours postop with only one of them getting 25 mg of Demerrol for shivering only.

 

[VentdependenT]

I use it quite often as well. But never for hearts. I don't do it for urology cases however. I don't want any urinary retention that may confuse the postop course. These pts get straight general.

I also add some local even if they are going to sleep. If I'm in there I might as well block them for a short time as well.

UT is absolutely right with the 400 mcg max dose as well. I'm usually down aroud 250 - 300 mcg's.

I don't find that they are very uncomfortable that evening, however. It seems to benefit the pts into the next day in my experience.

Fellas, what cases would you use them for? Better yet, when do you perceive this as an advantage to add to your anesthetic plan?

Does it really cut down on the systemic side effects of narcotics as compared to the traditional IV PCA for first 12-18 hours (I know the respiratory depression bit)?

I'm just more curious about this technique. I always hit my SSS C-Sections with duramorph but I have never gone ahead and given someone a blast o' narcotics intrathecally.

 

[UTSouthwestern]

Hearts not on anticoagulants preop, major thoracotomies, Ivor Lewis, lung transplants, exploratory laps, open Roux N Y, Nissen's, etc.

Most of the respiratory depressive effects occur in the first three to four hours so if the case is going to be a long one, that is less of a concern for me.

 

[Noyac]

Hearts not on anticoagulants preop, major thoracotomies, Ivor Lewis, lung transplants, exploratory laps, open Roux N Y, Nissen's, etc.

Most of the respiratory depressive effects occur in the first three to four hours so if the case is going to be a long one, that is less of a concern for me.

Yeah, all those but I do it in ortho cases (totals), and any abdominal cases that fit the bill. they must be staying over night. Thats all I require. I rarely place epidurals any longer.

 

[epidural man]

I would routinely use this technique and I found that the majority of my patients had great, and sometimes total pain relief for the first 12-16 hours, then had minimal IV narcotics for the next 12 hours (average of 3-5 mg of morphine IV over those 12 hours). Unfortunately, now I rarely use it for the hearts because of the protocols.

I have used intrathecal morphine many times for hearts at a private practice hospital in town. I think the reason the attendings do it is for billing purposes, because if I recall correctly (correct me if I am wrong), it was the Standford guys that showed that it does nothing for ICU discharge times and all that Jazz. However, when these guys that do it routinely at this hospital are asked about this, they all agreed with what UT is saying - that is that ICU nurses can always tell when it was given because they hurt less and require less IV stuff.

The guys at this place all claim they have never seen a spinal hematoma from this yet. They use a 27 gauge pencil point. I have seen them jump ship quickly when I couldn't get it on the 1rst or second attempt however.

I guess you got a figure it is usually at least 2 hrs after the spinal when the heparin goes in, and then it is reversed at the end, so it seems reasonable. I would not do it on my liscense however - but may change my mind if I actually looked at how much more money I can get for the attempt🙂

 

[UTSouthwestern]

I have used intrathecal morphine many times for hearts at a private practice hospital in town. I think the reason the attendings do it is for billing purposes, because if I recall correctly (correct me if I am wrong), it was the Standford guys that showed that it does nothing for ICU discharge times and all that Jazz. However, when these guys that do it routinely at this hospital are asked about this, they all agreed with what UT is saying - that is that ICU nurses can always tell when it was given because they hurt less and require less IV stuff.

The guys at this place all claim they have never seen a spinal hematoma from this yet. They use a 27 gauge pencil point. I have seen them jump ship quickly when I couldn't get it on the 1rst or second attempt however.

I guess you got a figure it is usually at least 2 hrs after the spinal when the heparin goes in, and then it is reversed at the end, so it seems reasonable. I would not do it on my liscense however - but may change my mind if I actually looked at how much more money I can get for the attempt🙂

If I'm not mistaken, it's another 5 points for billing as a procedure for post op pain control. Been awhile since I last did one.

The ICU nurses at one of our heart hospitals where I did it the most used to love seeing those patients because they would be stunned to learn that everything was done and they weren't screaming in pain. The patients tended to remain in the ICU to a usual length of time, but primarily for non pain related issues (mediastinal drainage, air leaks, etc.).

If I had to have heart surgery, I demand a Duramorph spinal or if possible an epidural placed the day before the surgery.

 

[coprolalia]

In the patients I have used it in, it has worked very well (5 mcg/kg Duramorph, max 400 mcg). Occasionally I have had to chase the pressure, but usually not a significant amount, especially if I stick with the 5 mcg/kg dosing erring on the lower side if necessary.

Have you seen a lot of itching at the 0.4 mg dose? We use Duramorph for c-sections (in addition to the bupivicaine, of course), but at much lower doses - like 100-200 mcg - and it seems to work fine and minimize the itching. Most of our patients with big belly procedures just get a straight forward thoracic epidural with constant infusion. When they are ready to ambulate (after 3-4 days), the Fragmin is stopped for 24 hours and the thing is pulled the next day. Haven't heard of anyone throwing a big PE yet while the anti-coag is held, and we haven't had any epidural hematomas. I'd say we're well into the low thousands (for various procedures) using this technique over the past couple of years.

-copro, CA-2

 

[UTSouthwestern]

Have you seen a lot of itching at the 0.4 mg dose? We use Duramorph for c-sections (in addition to the bupivicaine, of course), but at much lower doses - like 100-200 mcg - and it seems to work fine and minimize the itching. Most of our patients with big belly procedures just get a straight forward thoracic epidural with constant infusion. When they are ready to ambulate (after 3-4 days), the Fragmin is stopped for 24 hours and the thing is pulled the next day. Haven't heard of anyone throwing a big PE yet while the anti-coag is held, and we haven't had any epidural hematomas. I'd say we're well into the low thousands (for various procedures) using this technique over the past couple of years.

-copro, CA-2

I haven't seen a lot of itching, but I have standing orders to treat it. However, when I see my patients the day after, I always ask and they say no or they don't remember itching.

 

[coprolalia]

If I had to have heart surgery, I demand a Duramorph spinal or if possible an epidural placed the day before the surgery.

I haven't done a lot of hearts yet, but we never use an epidural in these patients. I'm not exactly sure why (seems reasonable - sternotomy, post-op pain, minimizing native sympathetic outflow, etc.). Why is this not considered a reasonable option by some? Is it just because of the big heparin dose when you go on-pump?

-copro

 

[coprolalia]

I haven't seen a lot of itching, but I have standing orders to treat it. However, when I see my patients the day after, I always ask and they say no or they don't remember itching.

What's your anti-itch order?

We start with diphenhydramine (12.5 mg IV), but this never seems to be adequate and a lot of women get pretty sedated even at this dose. We also use very low dose naloxone (40mcg), but this seems to take away some of the anti-pain benefit of the Duramorph. Some prescribe nalbuphine, but this isn't commonly done. I've actually had quite a few women complain of itching even at relatively low doses of Duramorph, but it never seems to be terribly disconcerting to them.

-copro

 

[VentdependenT]

I haven't done a lot of hearts yet, but we never use an epidural in these patients. I'm not exactly sure why (seems reasonable - sternotomy, post-op pain, minimizing native sympathetic outflow, etc.). Why is this not considered a reasonable option by some? Is it just because of the big heparin dose when you go on-pump?

-copro

This has been discussed before but I'm too lazy to find the link right now. Search for Thoracic Epidural or something like that.

WHat if you get a big old fat bloody tap before the heart? Thats the problem.

Why is that a problem you ask? Well if you get a epidural hematoma that develops during the case your window of therapy is 6-8 hours or so. Complicated heart? There goes your window.

Other problem is that if you ain't fast tracking a heart and you keep the pt down how are you gonna do a neuro check?

If you do get a funky neuro check (by funky I mean focal deficits) how do you know the source of the problem? Was it your bloody tap OR was it a shard of atherosclerosis dislodged by the aortic canula OR was it cerebral hypoxia from air-emboli OR etc...? Get my point? That stupid bloody tap will friggen keep your ass up all night long.

Other problem is the possibility of systemic anticoagulation after surgery for PE.

Otherwise it sounds like a damn fine idea.

UT?

 

[Planktonmd]

I haven't done a lot of hearts yet, but we never use an epidural in these patients. I'm not exactly sure why (seems reasonable - sternotomy, post-op pain, minimizing native sympathetic outflow, etc.). Why is this not considered a reasonable option by some? Is it just because of the big heparin dose when you go on-pump?

-copro

A big needle and an indwelling catheter increase the risk of bleeding, and since many of these patients become coagulopathic later this makes it even less attractive to have a catheter in the epidural space.

 

[jetproppilot]

Have any of you used a single shot spinal duramorph for any large abdominal/sternotomy heart case?

Is it worth anything?

One of my colleagues is a dude in his late sixties who works part time.....beloved dude, looks like he's 55....had MV repair at Oschner....had the duramorph single shot....had minimal pain.

I've never done it.

 

[Noyac]

Have you seen a lot of itching at the 0.4 mg dose? We use Duramorph for c-sections (in addition to the bupivicaine, of course), but at much lower doses - like 100-200 mcg - and it seems to work fine and minimize the itching. Most of our patients with big belly procedures just get a straight forward thoracic epidural with constant infusion. When they are ready to ambulate (after 3-4 days), the Fragmin is stopped for 24 hours and the thing is pulled the next day. Haven't heard of anyone throwing a big PE yet while the anti-coag is held, and we haven't had any epidural hematomas. I'd say we're well into the low thousands (for various procedures) using this technique over the past couple of years.

-copro, CA-2

There was a study back when I was a resident showing only more SE's with greater than 400mcg and no more analgesia. This is why most folks stop at 400 mcg. I am not interested in looking it up right now but its there.

As far as walking after a big belly case, our pts are walking the next day. 3-4 days is way to long. They had better be looking at going home soon after 3-4 days.

Your fragmin technique is fine. If you are on the once daily dose (40 mg) otherwise, all you need to wait is 12 hrs with the BID dose.

 

[coprolalia]

Ah, thanks. Good responses.

So, what's everyone's anti-itch cocktail(s)? Anyone try Vistaril?

Your fragmin technique is fine. If you are on the once daily dose (40 mg) otherwise, all you need to wait is 12 hrs with the BID dose.

We still wait 24 hours even with BID dosing if they've received more than 1 dose. I think this is the standard of care based on current recs (?). For example, if they've been on Fragmin BID, and their last dose was 9:00 AM, then we wait until after 9:00 AM the next day to pull the catheter.

-copro

 

[Noyac]

I haven't done a lot of hearts yet, but we never use an epidural in these patients. I'm not exactly sure why (seems reasonable - sternotomy, post-op pain, minimizing native sympathetic outflow, etc.). Why is this not considered a reasonable option by some? Is it just because of the big heparin dose when you go on-pump?

-copro

Most pts don't have extreme pain with sternotomy, the chest is wired shut and therefore pretty stable. Not like a thoracotomy or even a big belly case. So I feel an epidural is over kill with additional complications like what to do if you get a bloody tap, are on anticoagulants, etc. I know these scenarios are well worked out, but why go there? Plus there are more than a few times that these pts need support for the sympathectomy they get. Why confuse the issue. By the time the duramorph of the spinal wears off the pt is ready to transfer to the floor half the time. They are eating, walking, and overall doing well in most cases.

So its not the big heparin dose in my opinion. Its just not necessary and duramorph seems like a much better approach.

 

[Noyac]

Ah, thanks. Good responses.

So, what's everyone's anti-itch cocktail(s)? Anyone try Vistaril?

-copro

I would say to do a search because its been discussed adnauseum.

Nubain 5 mg prn

 

[jetproppilot]

Ah, thanks. Good responses.

So, what's everyone's anti-itch cocktail(s)?



-copro

Prophylactic narcan 400 ug in each bag of IVF at maintenance rate.