Spinal dose for morbidly obese

[drlee]

I'm doing a TAH/BSO under spinal for a 5'3" 112kg patient with severe asthma and severe OSA. Not to mention history of old CVA and GERD. I usually give 1.5 mL of hyperbaric bupivicaine + fentanyl 25 mcg. However, because this patient is fat as hell, I gave a reduced dose of 1.3mL. To my dismay she felt pain while the surgeon was manipulating her uterus. How much would anyone give in this patient in order to get a T5 level?

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[Bertelman]

I fail to see how decreasing the dose for a spinal could help here.

Why do you think the dose should be decreased for increased BMI?

 

[MTGas2B]

Other than c-sections, I haven't done any open (or laparoscopic) abdominal surgery under spinal. I think that's for a reason, a lot of the visceral sensation that comes with uterine manipulation is unavoidable, even with worlds best spinal. Even with a T4 or T5 level they would probably feel uterine manipulation. I presume incision was fine. What level did you get when you checked the block?

My OB experience was in two parts, our big academic medical center, and a private hospital. At the academic hospital they always externalized the unterus with c-sections, and sure enough almost every patient got sick and/or felt significant discomfort. At the private hospital virtually no one externalized the uterus, and sure enough a lot fewer patients got sick. But some still did.

Spinals in abdominal surgery are really to be avoid, I think. OB is an exception, mom sees baby, mom and dad chat, everyone is happy most of the time. (Don't fear the GA c-section) The other exception is medically underserved countries, where spinals are a lot cheaper than GA. They require less drugs, less monitoring, etc. Then its a resource issue.

Its a nice idea to avoid tubing a patient with asthma, but the case you presented I would argue she has risk factors that would make me want to secure the airway up front (GERD, OSA, obesity), rather than after the spinal wears off while they're calling urology to fix the ureter.
How did her airway look, if MP 3 and no chin, all the more reason to secure her airway upfront.

 

[RabbMD]

At the very least I would have done a combined spinal epidural. If you are so worried about GA that you are doing regional here, then wouldn't you want to have an epidural to bolus if the spinal started to wear off. Additionally, often you need to use an epidural needle to stent for the long spinal needle in the morbidly obese as well so that you don't bend the spinal needle all over the place manipulating through os.

 

[Noyac]

Other than c-sections, I haven't done any open (or laparoscopic) abdominal surgery under spinal. I think that's for a reason, a lot of the visceral sensation that comes with uterine manipulation is unavoidable, even with worlds best spinal. Even with a T4 or T5 level they would probably feel uterine manipulation. I presume incision was fine. What level did you get when you checked the block?

My OB experience was in two parts, our big academic medical center, and a private hospital. At the academic hospital they always externalized the unterus with c-sections, and sure enough almost every patient got sick and/or felt significant discomfort. At the private hospital virtually no one externalized the uterus, and sure enough a lot fewer patients got sick. But some still did.

Spinals in abdominal surgery are really to be avoid, I think. OB is an exception, mom sees baby, mom and dad chat, everyone is happy most of the time. (Don't fear the GA c-section) The other exception is medically underserved countries, where spinals are a lot cheaper than GA. They require less drugs, less monitoring, etc. Then its a resource issue.

Its a nice idea to avoid tubing a patient with asthma, but the case you presented I would argue she has risk factors that would make me want to secure the airway up front (GERD, OSA, obesity), rather than after the spinal wears off while they're calling urology to fix the ureter.
How did her airway look, if MP 3 and no chin, all the more reason to secure her airway upfront.

I have done many TAH's under spinal and they work great. I will disagree with you here.

 

[Planktonmd]

I have done many TAH's under spinal and they work great. I will disagree with you here.

I have to strongly disagree as well.
I have done all kinds of abdominal surgery under spinal/epidural anesthesia with excellent results.
You need to carefully select the right patient, the right procedure and the right surgeon though.

 

[drlee]

I didn't bother checking a level since I did end up doing a combined spinal epidural. This patient was so nervous, it didn't matter if the spinal really worked or not. I had to sedate her because of her nerves but then her airway would obstruct. There was a Catch-22. To keep her quiet, I had to make her deep but she would subsequently obstruct. If I kept her awake, she would move and annoy the living hell out of the surgeon. So I just put her to sleep and ended the misery.
So going back to my original question, how much local anesthetic would you give for a TAH for a 5'3" 112kg patient assuming you wanted a T5 level??

 

[Planktonmd]

So going back to my original question, how much local anesthetic would you give for a TAH for a 5'3" 112kg patient assuming you wanted a T5 level??

15 mg Hyperbaric Bupivacaine with 25 mcg Fentanyl (regardless of her weight).

 

[drlee]

So that would be 2 mL plus the volume of the fentanyl added. That seems like a high amount to me. I believe Barash recommended 1.5 mL total of local anesthetic regardless of height except for extreme heights (i.e., over 6 feet tall and under 5 feet tall). Is that the volume you use in clinical practice? Have you ever experienced a high spinal??

 

[Planktonmd]

So that would be 2 mL plus the volume of the fentanyl added. That seems like a high amount to me. I believe Barash recommended 1.5 mL total of local anesthetic regardless of height except for extreme heights (i.e., over 6 feet tall and under 5 feet tall). Is that the volume you use in clinical practice? Have you ever experienced a high spinal??

I use 15 mg almost all the time and that can be 2 cc of 0.75% hyperbaric or 3 cc of 0.5% isobaric and almost always with Fentanyl.
I also give Ephedrine or Neo before starting.
Occasionally you will see a block a little bit higher than you wanted but that is easy to treat, but with this dose you almost never see an inadequate block.
Never had a total spinal.

 

[Bertelman]

I didn't bother checking a level since I did end up doing a combined spinal epidural. This patient was so nervous, it didn't matter if the spinal really worked or not. I had to sedate her because of her nerves but then her airway would obstruct. There was a Catch-22. To keep her quiet, I had to make her deep but she would subsequently obstruct. If I kept her awake, she would move and annoy the living hell out of the surgeon. So I just put her to sleep and ended the misery.
So going back to my original question, how much local anesthetic would you give for a TAH for a 5'3" 112kg patient assuming you wanted a T5 level??

That may have been your indication for a GA to begin with.

 

[Monty Python]

I use 15 mg almost all the time and that can be 2 cc of 0.75% hyperbaric or 3 cc of 0.5% isobaric and almost always with Fentanyl.
I also give Ephedrine or Neo before starting.
Occasionally you will see a block a little bit higher than you wanted but that is easy to treat, but with this dose you almost never see an inadequate block.
Never had a total spinal.

Ever use preservative-free morphine in lieu of (or with) the fentanyl? Pros / cons in your opinion?

 

[huktonfonix]

Ever use preservative-free morphine in lieu of (or with) the fentanyl? Pros / cons in your opinion?

pros: more stable pain control vs PCA, get to charge for "pain management"

cons:you get called if breakthrough pain, nausea, pruritis, etc.. if not covered by ordered meds, possible respiratory depression (never seen it at the doses we use 0.1-0.3 mg) , no proven benefit in most lower abdominal surgeries vs PCA (no study Ive seen anyway).

 

[jwk]

I have done many TAH's under spinal and they work great. I will disagree with you here.

We used to do a ton of them under epidural and have all but abandoned them. GA, even in the OP's case, is so much easier all around. And although the patient does fit the morbidly obese criteria, I can tell you that's not far from being an average sized patient down here in the South.

 

[Planktonmd]

Ever use preservative-free morphine in lieu of (or with) the fentanyl? Pros / cons in your opinion?

I add intrathecal morphine 0.3 mg to the Bupivacaine/Fentanyl mixture in all C section patients but not in other abdominal surgeries done under regional because in these cases I usually use a CSE and the post op pain will be managed by the epidural.
By the way in a patient that resembles the OP's patient (extreme anxiety) the best plan could be epidural anesthesia + LMA and Propofol drip.
This could give you an excellent intraop and post op analgesia while avoiding any systemic narcotics and inhaled agents.

 

[narcusprince]

I didn't bother checking a level since I did end up doing a combined spinal epidural. This patient was so nervous, it didn't matter if the spinal really worked or not. I had to sedate her because of her nerves but then her airway would obstruct. There was a Catch-22. To keep her quiet, I had to make her deep but she would subsequently obstruct. If I kept her awake, she would move and annoy the living hell out of the surgeon. So I just put her to sleep and ended the misery.
So going back to my original question, how much local anesthetic would you give for a TAH for a 5'3" 112kg patient assuming you wanted a T5 level??

Dr Lee
Had a pt last week same condition TAH under spinal. Kept freaking desating when I had the propofol going at 35ml/hr.Pt would obstruct and move her arms and sats would drop in between her pulling the pulse ox of herself. So what we decided was to put a nasal trumpet in. Take a MAC safe NC and place the O2 end deeper into the nasal trumpet and place the CO2 sensor at the proximal end. Turn the propofol up to 45ml/hr pt was sleeping, not obstructing and we had perfectly good ETCO2 and no hand movement.

 

[ecCA1]

" a MAC safe NC"

Never heard of such a thing. What's the trade name?

 

[jwk]

" a MAC safe NC"

Never heard of such a thing. What's the trade name?

That's a nasal cannula with a separate sampling lumen for EtCO2.

 

[huktonfonix]

" a MAC safe NC"

Never heard of such a thing. What's the trade name?

aka "Salter" cannula. You can make your own with an angio and any nc also

 

[DreamLover]

I have to strongly disagree as well.
I have done all kinds of abdominal surgery under spinal/epidural anesthesia with excellent results.
You need to carefully select the right patient, the right procedure and the right surgeon though.

I have to agree with this...have you rotated through the VA? Regional anesthesia is your friend with a lot of those folks....if not contraindicated...I'd rather not put my 80+ yo male with a 100 pack yr hx, CAD s/p 3 MIs, CHF and CRI to sleep for a 30 min right sided inguinal hernia repair....but like mentioned...it's to be determined on a case by case basis

 

[huktonfonix]

I have to agree with this...have you rotated through the VA? Regional anesthesia is your friend with a lot of those folks....if not contraindicated...I'd rather not put my 80+ yo male with a 100 pack yr hx, CAD s/p 3 MIs, CHF and CRI to sleep for a 30 min right sided inguinal hernia repair....but like mentioned...it's to be determined on a case by case basis

for a hernia? MAC/block/local. Dont even need neuraxial

 

[DreamLover]

for a hernia? MAC/block/local. Dont even need neuraxial

True...but lets just say that the length of these cases are a lot longer than you'd ideally expect them to be....i.e. surgery interns do a lot of these at the VA and they can be painstakingly long....thus...my spinals tend to turn into MACs as they wear off intraoperatively anyway

BUT if they are finished in a relatively decent time, the spinal offers good pain management in the PACU and tend to wear off at just about the right time for PACU discharge....I find they work pretty well for our situations

 

[Noyac]

True...but lets just say that the length of these cases are a lot longer than you'd ideally expect them to be....i.e. surgery interns do a lot of these at the VA and they can be painstakingly long....thus...my spinals tend to turn into MACs as they wear off intraoperatively anyway

BUT if they are finished in a relatively decent time, the spinal offers good pain management in the PACU and tend to wear off at just about the right time for PACU discharge....I find they work pretty well for our situations

Yes, everything is different at the VA.

 

[Mofeen]

With surgery residents at my place, greater than 95% of inguinal hernias are done under a true MAC. Ie. a touch of versed and remi or straight remi.

 

[Noyac]

With surgery residents at my place, greater than 95% of inguinal hernias are done under a true MAC. Ie. a touch of versed and remi or straight remi.

And what are you running the remi at for a MAC?

 

[jetproppilot]

15 mg Hyperbaric Bupivacaine with 25 mcg Fentanyl (regardless of her weight).

Yep.

Concur with Plankster.

I know Noy's a big fan of GIVING IT ALL too.

 

[Noyac]

Yep.

Concur with Plankster.

I know Noy's a big fan of GIVING IT ALL too.

Yep.

But I have cut back to 10mg in the ones that have had an epidural running.

Everyone else gets 15mg.