spinal anesthesia in the ASC

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Mman said:
Thanks for recognizing my hard work with diet and exercise.

I'm still waiting to hear what benefit a pregnant patient gets from an LMA compared to an ETT....
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A case from today:

34 year white female approximately 21 weeks Estimated Gestational age presents for a cerclage. Normal weight. No Gerd. Healthy. Patient requests GA. OB requests SAB with no sedation whatsoever. After discussion with the anxious patient she agrees to a Propofol sedative for the SAB instead of GA. OB likes the idea of just a little propofol. Chlorprocaine was used for the SAB (bottle says not for spinal use right on the front). Propofol 50 mg IV x 1 followed by another 50 mg IV x 1 then SAB placed without difficulty. Case took 17 minutes. Patient was in PACU for 52 minutes then went home.

Both patient and OB doctor are happy with the anesthetic.
 
Anesth Analg. 2005 Feb;100(2):566-72.

Spinal 2-chloroprocaine: a comparison with small-dose bupivacaine in volunteers.

Yoos JR, Kopacz DJ.


Source

Department of Anesthesiology, Virginia Mason Clinic, 1100 Ninth Avenue, Seattle, WA 98111, USA.


Abstract


Ambulatory surgery continues to increase nationwide. Because spinal lidocaine is associated with transient neurologic symptoms, many clinicians have switched to small-dose bupivacaine for outpatient spinal anesthesia. However, bupivacaine often produces inadequate surgical anesthesia and has an unpredictable duration. Preservative-free 2-chloroprocaine (2-CP) has reemerged as an alternative for outpatient spinal anesthesia. We designed this double-blind, randomized, crossover, volunteer study to compare 40 mg of 2-CP with small-dose (7.5 mg) bupivacaine with measures of pinprick anesthesia, motor strength, tolerance to tourniquet and electrical stimulation, and simulated discharge criteria. Peak block height (2-CP average T7 [range T3-10]; bupivacaine average T9 [range T4-L1]), regression to L1 (2-CP 64 +/- 10 versus bupivacaine 87 +/- 41 min), and tourniquet tolerance (2-CP 52 +/- 11 versus bupivacaine 60 +/- 27 min) did not differ between drugs (P = 0.15, 0.12, and 0.40, respectively). However, time to simulated discharge (including time to complete block regression, ambulation, and spontaneous voiding) was significantly longer with bupivacaine (2-CP 113 +/- 14, bupivacaine 191 +/- 30 min, P = 0.0009). No subjects reported transient neurologic symptoms or other side effects. We conclude that spinal 2-CP provides adequate duration and density of block for ambulatory surgical procedures, and has significantly faster resolution of block and return to ambulation compared with 7.5 mg of bupivacaine.
 
Anesth Analg. 2004 Jan;98(1):75-80, table of contents.

Spinal 2-chloroprocaine: a comparison with lidocaine in volunteers.

Kouri ME, Kopacz DJ.


Source

Department of Anesthesiology, Virginia Mason Medical Center, 1100 Ninth Avenue, B2-AN, Seattle, WA 98111, USA.


Abstract


Subarachnoid lidocaine has been the anesthetic of choice for outpatient spinal anesthesia. However, its use is associated with transient neurologic symptoms (TNS). Preservative-free formulations of 2-chloroprocaine are now available and may compare favorably with lidocaine for spinal anesthesia. In this double-blinded, randomized, crossover study, we compared spinal chloroprocaine and lidocaine in 8 volunteers, each receiving 2 spinal anesthetics: 1 with 40 mg 2% lidocaine and the other with 40 mg 2% preservative-free 2-chloroprocaine. Pinprick anesthesia, tolerance to transcutaneous electrical stimulation and thigh tourniquet, motor strength, and a simulated discharge pathway were assessed. Chloroprocaine produced anesthetic efficacy similar to lidocaine, including peak block height (T8 [T5-11] versus T8 [T6-12], P = 0.8183) and tourniquet tolerance (46 +/- 6 min versus 38 +/- 24 min, P = 0.4897). Chloroprocaine anesthesia resulted in faster resolution of sensory (103 +/- 13 min versus 126 +/- 16 min, P = 0.0045) and more rapid attainment of simulated discharge criteria (104 +/- 12 min versus 134 +/- 14 min, P = 0.0007). Lidocaine was associated with mild to moderate TNS in 7 of 8 subjects; no subject complained of TNS with chloroprocaine (P = 0.0004). We conclude that the anesthetic profile of chloroprocaine compares favorably with lidocaine. Reliable sensory and motor blockade with predictable duration and minimal side effects make chloroprocaine an attractive choice for outpatient spinal anesthesia.

IMPLICATIONS:

The spinal anesthetic profile of chloroprocaine (40 mg) compares favorably with the same dose of spinal lidocaine. Reliable sensory and motor blockade with predictable duration and minimal side effects and without signs of transient neurological symptoms make chloroprocaine an attractive choice for outpatient spinal anesthesia
 
Nesacaine_MPF_A2011_lg.jpg


Evidence based Medicine shows this can be used safely for a spinal anesthetic; yet, read the bottle itself. This is just like using an LMA in the second trimester. An LMA is perfectly safe up to 18-20 weeks estimated Gestational age (Non obese, No Gerd) for short procedures.
 
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LMA vs ETT with Sux for 17 min case:

1. LMA has a lower incidence of sore throat
2. LMA has no risk of Myalgias
3. LMA is associated with a faster room turnover
4. LMA less stimulating than an ETT so lower SEVO/DES anesthetic requirements
5. Lower frequency of coughing during emergence
6. Lower incidence of desaturations during emergence
 
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BLADEMDA said:
LMA vs ETT with Sux for 17 min case:

1. LMA has a lower incidence of sore throat
2. LMA has no risk of Myalgias
3. LMA is associated with a faster room turnover
4. LMA less stimulating than an ETT so lower SEVO/DES anesthetic requirements
5. Lower frequency of coughing during emergence
6. Lower incidence of desaturations during emergence
Click to expand...

You know that you don't have to paralyze to intubate, right?
 
BLADEMDA said:
LMA vs ETT with Sux for 17 min case:

1. LMA has a lower incidence of sore throat
2. LMA has no risk of Myalgias
3. LMA is associated with a faster room turnover
4. LMA less stimulating than an ETT so lower SEVO/DES anesthetic requirements
5. Lower frequency of coughing during emergence
6. Lower incidence of desaturations during emergence
Click to expand...

😴
 
BLADEMDA said:
LMA vs ETT with Sux for 17 min case:

1. LMA has a lower incidence of sore throat sure but in a pregnant woman near term has an increased incidence of malpractice attorneys coming after you
2. LMA has no risk of Myalgias But has increased incidence of aspiration and law suits
3. LMA is associated with a faster room turnover in your hands maybe if you don't know how to time your anersthetic
4. LMA less stimulating than an ETT so lower SEVO/DES anesthetic requirements So to save 2 dollars on anesthesia you would expose your patient to aspiration and yourself to litigation?
5. Lower frequency of coughing during emergenceNot a significant problem if you know what you are doing
6. Lower incidence of desaturations during emergenceReally???
Click to expand...
You really need to rethink a few things in the way you practice I think.
 
Ad hominem attacks. That's all you ever post. No facts. No studies. I have provided Journal articles and textbook references. I've also posted a recent case and how I handled it. I consider the subject matter closed and will no longer respond to your posts.
 
BLADEMDA said:
So, your plan for a pregnant woman is to give mega doses of propofol upfront and hope she doesn't get vocal cord dysfunction? You do realize that adults are much more prone to vocal cord trauma than children?
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No, I would just do prop, sux, tube, sudoku. They're pregnant, they get an RSI or a spinal. Hoping that your expert trumps their expert at trial if there is a disaster strikes me as a stupid way to practice medicine.
 
IlDestriero said:
No, I would just do prop, sux, tube, sudoku. They're pregnant, they get an RSI or a spinal. Hoping that your expert trumps their expert at trial if there is a disaster strikes me as a stupid way to practice medicine.
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I do pregnant patients all the time including today. Most get an LMA for an incomplete abortion. Today's patient was 14 weeks.

Our "N" is well into the thousands without an aspiration for pregnant patients. I understand your fear of a lawsuit. But, fear isn't a good way to make medical decisions.

Lack of experience clearly shows and the reaction to that lack of experience is Ad hominem attacks without any factual evidence whatsoever.

It doesn't matter how many studies I post or textbooks I reference or personal cases I've done with this technique as you have made up your mind on this dogma. My group is careful with pregnant patients when selecting Them for an LMA which is why we have never had even one aspiration.

I really don't care that most of you RSI a woman who is 12 weeks pregnant for a 17 minute procedure.
I will continue to practice based on best available published evidence.
 
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It's funny how the weeks of pregnancy this good doctor is willing to LMA keeps shrinking... now he is down to 12 weeks 😛
If you guys keep giving him hard time he most likely would drop it to just around conception.
 
Planktonmd said:
It's funny how the weeks of pregnancy this good doctor is willing to LMA keeps shrinking... now he is down to 12 weeks 😛
If you guys keep giving him hard time he most likely would drop it to just around conception.
Click to expand...

There is disagreement over the exact time in pregnancy when an LMA should not be the first selection for airway management. At some point in pregnancy the risk of regurgitation may outweigh any potential benefits. Some use 12 weeks gestational age while many others use 16 weeks. My threshold is higher at around 18-20 weeks (no obesity, no Gerd) and I prefer the supreme LMA if available.

I don't know why we can't have a civil discussion about why we choose a certain gestational age like 16 weeks over 18 weeks. The evidence seems to support the higher gestational age. Over the past decade my group has moved up the gestational age to 16 weeks with no increase in complications. Recently, I have moved to 18 weeks.
 
Tables 1 and 2 show some clinical applications of the LMA. Patients should ordinarily be fasted and free from increased risk of regurgitation / aspiration (e.g., not a "full stomach", not more than 14-16 weeks pregnant, no symptoms of esophageal reflux, etc). The LMA is particularly useful where a mask fit is difficult, e.g., in bearded or edentulous patients or where both hands of the anaesthetist need to be free. Patients do not necessarily need be breathing spontaneously for the LMA to be of use. Provided the patient has normal lungs and normal laryngeal anatomy, positive pressure ventilation (PPV) can usually be used successfully. However, when peak airway pressures exceed 20 cm H2O, gas leaks around the cuff are more likely.

University of Toronto Canada
 
BLADEMDA said:
There is disagreement over the exact time in pregnancy when an LMA should not be the first selection for airway management. At some point in pregnancy the risk of regurgitation may outweigh any potential benefits. Some use 12 weeks gestational age while many others use 16 weeks. My threshold is higher at around 18-20 weeks (no obesity, no Gerd) and I prefer the supreme LMA if available.

I don't know why we can't have a civil discussion about why we choose a certain gestational age like 16 weeks over 18 weeks. The evidence seems to support the higher gestational age. Over the past decade my group has moved up the gestational age to 16 weeks with no increase in complications. Recently, I have moved to 18 weeks.
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Sure, we can be civil... as long as you don't paste 25 entire studies as a response :naughty:
There are places in the world where doing a C section with LMA GA is a very common practice and even here in this country, a while back, C sections used to be done with a mask!
There was a study in Japan I think a few years ago that showed zero incidence of aspiration in C sections done with an LMA.
All that is unfortunately irrelevant because here in the USA you will be crucified if you are the unlucky one who puts an LMA in a pregnant woman and have a complication.
The gestational age is debatable and 12 weeks is probably OK but there is no agreement as you said, and for that reason there will be plenty of "experts" who would testify against you at any gestational age.
Why risk it?
 
So University of Toronto, several textbooks and numerous publications aren't enough to show standard of care was met with the use of the LMA at 14 weeks gestational age?

Again, why risk it just isn't a scientific answer when the evidence shows that an LMA (supreme LMA) is perfectly safe at 14 weeks gestational age.

No matter. You can tube them all but I prefer to use a LMA over an ETT provided safety can be maintained for the patient.

FYI, we have had more aspirations on non pregnant patients than pregnant ones (zero) because obesity is a risk factor.


http://forums.studentdoctor.net/archive/index.php/t-393413.html
 
BLADEMDA said:
I've used 5 mg before with good results (0.25 percent Bup, 2mls) with about the same pacu stay.
Click to expand...

That's my point but who wants to a study showing equivalency and not superiority...
Nordic Pharma is marketing 2-chloroprocaine in europe for spinal use (Ampres) : 10 x 5 ml 10mg / ml (1%).[€104] vs hb bupivacaine: 5 x 20mg / 4ml (0,5%) €27 so roughly double the cost albeit modest...
 
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