Spinal Anesthesia and normal lumbar lordosis

[DrAmir0078]

Happy Thanksgiving my fellows here, I wish you are having a wonderful Thanksgiving lunch and dinner with your family and friends.

A quick question :
We know we have that normal lumbar lordosis, and when it comes to using Hyperbaric Bupivacaine in spinals, how important to you to flex the hips and knees of your patient after laying supine, especially for procedure like inguinal hernia, lower abdominal surgeries?
I meant hyperbaric Bupivacaine, so for how long would you recommend to keep the patient in flexing status, beside would you recommend reverse trendelenburg position too (just a little bit)? If yes, when, I mean while flexing or after flexing time is over!

I was about to write another case - to address my successful dealing with Mr. Lordosis in a patient who had bilateral inguinal hernia repair, but definitely will be presented during the comments if any.

Love to hear your perspective.

Amir

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[deleted875186]

I personally have never flexed the hips, I’m curious to hear if other people have done it and found it to do anything??

I do reverse trendelenberg, but I personally have found that the hyperbaric bupi can give a patchy block in non pregnant patients. I tend to usually always use isobaric bupi, it’s a shorter time for the block to set up and anecdotally less hypotension. But in the United States, we hardly ever do abdominal procedures under spinal outside of C sections.

 

[deleted162650]

Approximately 0 seconds.

 

[DrAmir0078]

Approximately 0 seconds.

I believe without your Glass Spine video, I won't be able to 3D the hyperbaric vs Isobaric in my mind.

Then by digging this horizon, I found in Hadzic's Textbook of Regional Anesthesia and Acute Pain Management.
"Flexion of the supine patient’s hips and knees flattens lumbar lordosis and decreases sacral pooling of local anesthetic. Combined with Trendelenburg positioning, this may help cephalad spread"

Again "Following the injection of a hyperbaric solution at the level of L3/L4 in a supine subject, this solution travels predominantly by bulk flow under the influence of gravity “downward” along the curvature of the spine. It naturally moves to the concavity of the thoracic curve, exposing the neuraxial tissue to local anesthetic. If, however, the level of injection is more caudal, the hyperbaric solution may be descend below the lumbar lordosis and fail to spread more cephalad, particularly if the injection is performed while sitting and the patient is not quickly placed supine."

So, personally what I am trying to conclude between the lines!

So, I had in my own experience vs seeing other Attendings some failure rate in young adult (not pregnant, not obese - concluding that intra abdominal pressure could be a reason for reshaping the lordosis), and I thought of lordosis after reading Hadicz, so minimizing lordosis with hyperbaric plus Glass Spine understanding, I believe personally will get better outcomes.

 

[DrAmir0078]

I personally have never flexed the hips, I’m curious to hear if other people have done it and found it to do anything??

I do reverse trendelenberg, but I personally have found that the hyperbaric bupi can give a patchy block in non pregnant patients. I tend to usually always use isobaric bupi, it’s a shorter time for the block to set up and anecdotally less hypotension. But in the United States, we hardly ever do abdominal procedures under spinal outside of C sections.

I have explained my understanding with Glass Spine video that @SaltyDog sent me weeks ago.

I truly want to use isobaric and would love to, but not always available, same as preservative free Lidocaine - Damn I want to learn, even I asked to buy it from the market, still no answer!

I don't think, by flexing while using isobaric will make a difference like hyperbaric ones!

Lower abdominal surgeries like appendectomies we sometimes use spinals!

The other day, left hemicolectomy, done with spinal for an old patient, our only problem was hypotension and Bradycardia and was managed well beside narcotics preloading!

 

[2Fast2Des]

Why preload

I have explained my understanding with Glass Spine video that @SaltyDog sent me weeks ago.

I truly want to use isobaric and would love to, but not always available, same as preservative free Lidocaine - Damn I want to learn, even I asked to buy it from the market, still no answer!

I don't think, by flexing while using isobaric will make a difference like hyperbaric ones!

Lower abdominal surgeries like appendectomies we sometimes use spinals!

The other day, left hemicolectomy, done with spinal for an old patient, our only problem was hypotension and Bradycardia and was managed well beside narcotics preloading!

Why preload with narcotics if you're doing straight spinal?

 

[DrAmir0078]

Why preload


Why preload with narcotics if you're doing straight spinal?

Attending gave 50 mcg Fentanyl and Midazolam (The patient was uncooperative - difficult to maintain a position, beside it was painful to bend - he was like 75 + years old with a history of osteoarthritis), we planned to do combined spinal epidural but weren't successful at all, with our measures, so only spinal was done with 3 ml Heavy marcaine.

 

[Psai]

Are you doing it sitting or laying down

 

[DrAmir0078]

Are you doing it sitting or laying down

Sitting like on a chair on the theater table - the regular position or only semi setting with knees extended...

 

[bellevueperson]

We do a decent number of hips, knees, and urologic procedures with hyperbaric bupi spinals and don't flex the hips or knees once supine.

 

[DrAmir0078]

We do a decent number of hips, knees, and urologic procedures with hyperbaric bupi spinals and don't flex the hips or knees once supine.

Can you get your randomized data for an X number of patients your practice performed looking at age, gender, weight, procedures, dose of hyperbaric, table flat or not (means position either reversed vs not Trendelenburg) and any event encountered!

I am like you and others, I had decent number - unfortunately without data during my SHO period, but I have 25 handy on my logbook and got around 5 probably out of 25 unsuccessful blocks (mostly young male, skinny not overweight with marked lordosis - last two of them very marked).

I am trying to link my understanding with Glass Spine!

 

[bellevueperson]

Can you get your randomized data for an X number of patients your practice performed looking at age, gender, weight, procedures, dose of hyperbaric, table flat or not (means position either reversed vs not Trendelenburg) and any event encountered!

I am like you and others, I had decent number - unfortunately without data during my SHO period, but I have 25 handy on my logbook and got around 5 probably out of 25 unsuccessful blocks (mostly young male, skinny not overweight with marked lordosis - last two of them very marked).

I am trying to link my understanding with Glass Spine!

Would probably be difficult to get de-identified data, but our population is on the older (50-90 years old) and heavier side (mostly BMI 30-40, up to 50s-60). Total and uni knees and hip arthroplasties with fair number of hip fractures. We keep the table flat and usually dose 1.2-1.4 mL (some go a little higher based on height) of 0.75% bupi.

 

[nimbus]

Would probably be difficult to get de-identified data, but our population is on the older (50-90 years old) and heavier side (mostly BMI 30-40, up to 50s-60). Total and uni knees and hip arthroplasties with fair number of hip fractures. We keep the table flat and usually dose 1.2-1.4 mL (some go a little higher based on height) of 0.75% bupi.

Wow you have some big patients. Thankfully our surgeons are not yet desperate enough to do total joints on BMI 50+.

 

[DrAmir0078]

Would probably be difficult to get de-identified data, but our population is on the older (50-90 years old) and heavier side (mostly BMI 30-40, up to 50s-60). Total and uni knees and hip arthroplasties with fair number of hip fractures. We keep the table flat and usually dose 1.2-1.4 mL (some go a little higher based on height) of 0.75% bupi.

Thanks for the reply,
Such age and BMI, for me at least - rarely experienced failed Spinals in comparison to young age normal weight vs athletes vs skinny
Although lordosis in obese is another + (plus) compared to non obese ones, but hadn't experienced problems with them when change their position supine.
I thought wrongly if obesity would reshape lordosis on supine and still trying to convince myself there is an issue or mystery, but glass spine proved that lordosis is an issue we should never ignore beside Hadicz.
Moreover 1.2 - 1.4 ml only 0.75 % bupivacaine is enough for such major procedures, I take off my hat impressed, because we give 3 ml hyperbaric bupivacaine 0.5%- but I believe you have enough resources like narcotics and I am not sure if you do regionals with the procedure as an extra.

 

[getdown]

I don't mean to thread hijack but I thought this was somewhat related to this thread:

U.S. woman dies after botched nose job in Mexico

I particular love this quote "Doctors allegedly began the operation on Oct. 30 by administering Avila anesthesia via her spine. The anesthesia reportedly travelled to her brain, instead of downward throughout her body. Avila soon went into cardiac arrest and hospital officials put her into a medically induced coma to prevent further brain damage. The rhinoplasty was never performed."

What the hell are you doing a spinal for a nose job? Unless surgeons were injecting local inside the nose and ended up doing an intravascular injection but this makes absolutely zero sense.

 

[DrAmir0078]

I don't mean to thread hijack but I thought this was somewhat related to this thread:

U.S. woman dies after botched nose job in Mexico

I particular love this quote "Doctors allegedly began the operation on Oct. 30 by administering Avila anesthesia via her spine. The anesthesia reportedly travelled to her brain, instead of downward throughout her body. Avila soon went into cardiac arrest and hospital officials put her into a medically induced coma to prevent further brain damage. The rhinoplasty was never performed."

What the hell are you doing a spinal for a nose job? Unless surgeons were injecting local inside the nose and ended up doing an intravascular injection but this makes absolutely zero sense.

It could be a media translation error !