Spinal doses

[anbuitachi]

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we mostly use bupi for spinals, unless very short case. i was taught to put max 3ml bupivicaine 0.5% which lasts about 3 hours. it's pretty much what everyone go by here. can add epi for a slightly longer effect. adding more increases risk of high spinal so was taught not to do it

just wondering for the other people do you go over 3ml iso bupivicaine? does anyone know of any study that determined this dosage for isobaric bupivicaine? isn't it supposed to be isobaric, would 4ml really increase high spinals by that much in a average height person?

 

[deleted162650]

I get 3 hours out of 1.5mL iso bupi. A full 3mL will go way longer. 3mL + fent 20mcg = 5-6 hours. I've done it multiple times for revisions.

 

[anbuitachi]

I get 3 hours out of 1.5mL iso bupi. A full 3mL will go way longer. 3mL + fent 20mcg = 5-6 hours. I've done it multiple times for revisions.

thats odd, i never have it go that long. usually 3-4 hours of surgical anesthesia.

 

[Arch Guillotti]

thats odd, i never have it go that long. usually 3-4 hours of surgical anesthesia.

Same here.

 

[AdmiralChz]

Adding an epi wash can usually buy you an extra hour or so. A trick I didn’t really know about until starting my current PP job

 

[deleted59964]

higher doses of plain bupivicaine do not go higher - i suggest the youtube glass spine video

i sometimes use 20mg for long procedure, once had an academic attending give 5ml of 0.5% plain - no high block, got 5 hours of surgical anaesthesia from it.

 

[anbuitachi]

higher doses of plain bupivicaine do not go higher - i suggest the youtube glass spine video

i sometimes use 20mg for long procedure, once had an academic attending give 5ml of 0.5% plain - no high block, got 5 hours of surgical anaesthesia from it.

thats what i assumed too! we have some surgeons that like to do vascular bypasses under spinal only, and sometimes they go way over the 3h mark and with the heavy heparin and all we dont put in epidurals, sometimes i want to just add more bupi!

 

[ethilo]

I took over a complex hysterectomy 3 hours in by a partner who did a spinal anesthetic (pt had MH risk). Dose was 1.6ml spinal bupi with 25mcg fentanyl and 150mcg epi. I redosed ancef at 4 hours, pt was off the table at 5.5 hours. I was pretty antsy for the last hour and a half. Legs were barely starting to wiggle on arrival to PACU. I've never put epi in my spinals before, that was pretty impressive! I think 150mcg was kind of a lot though from what I've read out there.

 

[anbuitachi]

I took over a complex hysterectomy 3 hours in by a partner who did a spinal anesthetic (pt had MH risk). Dose was 1.6ml spinal bupi with 25mcg fentanyl and 150mcg epi. I redosed ancef at 4 hours, pt was off the table at 5.5 hours. I was pretty antsy for the last hour and a half. Legs were barely starting to wiggle on arrival to PACU. I've never put epi in my spinals before, that was pretty impressive! I think 150mcg was kind of a lot though from what I've read out there.

we put in 200 mcg of epi so 150 isn't much to us.

1.6 of heavy bupi? thats a long time. from my experience, have had much better success with iso bupi than heavy bupi. some people ive worked with use heavy bupi for almost all the spinals cause its usually what's in the kit. others dont use the kit spinal and use iso. feels to me the iso block lasts longer and may be denser? heavy bupi has more variables with positioning and all. i put in 2ml heavy bupi for C sections, and not an insignificant # of them can move their legs after <2 hours. i dont often see that to the same extent with 3ml iso bupi

 

[ethilo]

Same here.

Yeah I routinely use 3mL bupi 0.5% + 25mcg fent for knees and hips. Toes frequently are able to wiggle throughout the procedure, spinal seems to last around 3 hours before it starts receding.

 

[anbuitachi]

so yea seems like 3ml is a popular choice. anyone know why 3 and not more?

Also in terms of baricity, do they make hyperbaric/hypobaric for other local anesthetics? or do you make your own by adding dextrose? ive never heard of anyone talk about hyperbaric mepivicaine or lidocaine

 

[2Fast2Des]

Adding an epi wash can usually buy you an extra hour or so. A trick I didn’t really know about until starting my current PP job

What do you do if your kit doesn't have epi?

 

[anbuitachi]

What do you do if your kit doesn't have epi?

get epi from the carts. some of our kits are drugless due to the shortage recently.. have to take everything from the carts/workroom

 

[ethilo]

so yea seems like 3ml is a popular choice. anyone know why 3 and not more?

Also in terms of baricity, do they make hyperbaric/hypobaric for other local anesthetics? or do you make your own by adding dextrose? ive never heard of anyone talk about hyperbaric mepivicaine or lidocaine

during the spinal bupi shortage my current group was mixing its own hyperbaric bupi with d50 and pain 0.75%. They had some formula to do it. I wasnt a part of it (it was before I was joined) but it seemed to have tided them over.

 

[AdmiralChz]

get epi from the carts. some of our kits are drugless due to the shortage recently.. have to take everything from the carts/workroom

Exactly, just use the 1mg code vial pull up and squirt back into vial - coats the walls of the syringe with epinephrine hence "epi wash". None of our current kits seem to have epinephrine, but we have so many different ones at our hospital thanks to the shortage...

During the hyperbaric shortage (sort of still going on with us intermittently) we were just using plain 0.5% bupi. I tried 2 mL but found it sometimes wasn't quite enough (didn't get a high enough level) for sections... 3 mL seems to be better. Thankfully I've only had to use it like twice.

 

[deleted59964]

thats what i assumed too! we have some surgeons that like to do vascular bypasses under spinal only, and sometimes they go way over the 3h mark and with the heavy heparin and all we dont put in epidurals, sometimes i want to just add more bupi!

the 5ml of 0.5% bupi was for a vascular case - worked well - used a low dose propofol tci after a while as it’s a long time for the patient to be on the table

 

[anbuitachi]

Exactly, just use the 1mg code vial pull up and squirt back into vial - coats the walls of the syringe with epinephrine hence "epi wash". None of our current kits seem to have epinephrine, but we have so many different ones at our hospital thanks to the shortage...

During the hyperbaric shortage (sort of still going on with us intermittently) we were just using plain 0.5% bupi. I tried 2 mL but found it sometimes wasn't quite enough (didn't get a high enough level) for sections... 3 mL seems to be better. Thankfully I've only had to use it like twice.

i prob wouldve just put in a CSE if no hyperbaric. i imagine would take a lottt of iso to consistently to get up to midthoracic level for a C section

 

[2Fast2Des]

get epi from the carts. some of our kits are drugless due to the shortage recently.. have to take everything from the carts/workroom

Hmm I'll have to find the glass vials epi, the ones we have in stock are the rubber tops so it would make it a bit of a hassle to draw up. Fortunately never been in the scenario in PP to have to worry about epi washouts yet since our surgeons aren't that slow for the cases we do spinals for (ortho/OB), but good idea for the vascular cases...

 

[anbuitachi]

Hmm I'll have to find the glass vials epi, the ones we have in stock are the rubber tops so it would make it a bit of a hassle to draw up. Fortunately never been in the scenario in PP to have to worry about epi washouts yet since our surgeons aren't that slow for the cases we do spinals for (ortho/OB), but good idea for the vascular cases...

we have both i dont really care which one i use . the glass ones are a bit easier to draw up after gloving up. but the vial ones i just open the kit, draw it up and squirt it in one of the containers. only need like .2ml anyway

 

[Arch Guillotti]

Adding an epi wash can usually buy you an extra hour or so. A trick I didn’t really know about until starting my current PP job

I never understood the epi wash thing. Just put 100 mcg in there and be done with it.

 

[2Fast2Des]

I never understood the epi wash thing. Just put 100 mcg in there and be done with it.

True, might be easier to use an insulin syringe and just put in .1 or .2 ml instead

 

[deleted162650]

Hmm I'll have to find the glass vials epi, the ones we have in stock are the rubber tops so it would make it a bit of a hassle to draw up. Fortunately never been in the scenario in PP to have to worry about epi washouts yet since our surgeons aren't that slow for the cases we do spinals for (ortho/OB), but good idea for the vascular cases...

Super easy to pry off the stoppers with a pair of Kellys. I do it all the time with fent and duramorph so I can draw straight outta the vials.

 

[deleted162650]

i prob wouldve just put in a CSE if no hyperbaric. i imagine would take a lottt of iso to consistently to get up to midthoracic level for a C section

So, I had this same concern back when we had to start using iso 0.5% bupi for sections due to the shortage. After reviewing the literature some people posted here, I settled on using 2mL + the usual fent and duramorph. I was amazed how well it worked. Gave a mid-thoracic level every time. If you blinded me I don’t think I could tell the difference between it and the heavy stuff for sections - except the BP drop is a tad mellower with the iso.

 

[anbuitachi]

So, I had this same concern back when we had to start using iso 0.5% bupi for sections due to the shortage. After reviewing the literature some people posted here, I settled on using 2mL + the usual fent and duramorph. I was amazed how well it worked. Gave a mid-thoracic level every time. If you blinded me I don’t think I could tell the difference between it and the heavy stuff for sections - except the BP drop is a tad mellower with the iso.

interesting. so the whole thing about iso not moving is FAKE?

 

[DM27]

Isobaric will definitely spread in the directions of the fluid level. If you have someone go from sitting to laying down it will get some degree of increased caudal and cephalad spread. The spread is just much less compared to a hyper or hypobaric solution. I would equate it more to a "layering out".

The video mentioned somewhat shows this:




This one is actually better but longer (oh yeah):

 

[anbuitachi]

Yea I saw both. Idk how much he gave but his iso didn't move much at all even supine. That's why I'm surprised it covered enough for a section up to T4

 

[deleted162650]

Yea I saw both. Idk how much he gave but his iso didn't move much at all even supine. That's why I'm surprised it covered enough for a section up to T4

Yeah, I was surprised too how well it worked. All I can say is that it definitely behaves differently in a term pregnant chick than it does in the total joint population. Goes higher, sets up quicker, and doesn’t last as long. There must be something to the whole epidural vein engorgement/decreased anesthetic requirement business of pregnancy.

 

[Simba1711]

Sorry to bump an old thread but curious about this question as well. Some of my surgeons are slow af. I usually give 3cc 0.5 % isobaric Bupivicaine for hip and knees but it might not last long enough if they struggle. If I give 4-5 cc will I get a high spinal? I understand that isobaric doesn’t spread that much compared to hyperbaric. I did a literature search but couldn’t really find anything.

 

[Teillard]

Sorry to bump an old thread but curious about this question as well. Some of my surgeons are slow af. I usually give 3cc 0.5 % isobaric Bupivicaine for hip and knees but it might not last long enough if they struggle. If I give 4-5 cc will I get a high spinal? I understand that isobaric doesn’t spread that much compared to hyperbaric. I did a literature search but couldn’t really find anything.

Can't finish with isobaric marcaine? Sheesh......Just punt and go combined spinal/epidural. Pull the catheter at the end.

 

[DesiredMemberName?]

Can't finish with isobaric marcaine? Sheesh......Just punt and go combined spinal/epidural. Pull the catheter at the end.

Better yet, just pop in an LMA if needed when the spinal wears off.

Bonus points if you announce loudly to the room that the surgery has taken so ridiculously long that you now have to convert to general.

We have completely moved away from bupiv because it lasts too long. Surgeons were complaining about patients not able to do same day PT. If your surgeons cant finish the case before 3cc of 0.5% bupiv wears off, that is a surgical issue.

 

[psychbender]

Can't finish with isobaric marcaine? Sheesh......Just punt and go combined spinal/epidural. Pull the catheter at the end.

Had a surgeon like this in a place where we did regional for everything. He wanted blocks and spinals for his knees, (and a flip room!) because the other guy had them. However, the other guy did a primary knee in under an hour, he regularly took 3-4+. I initially did the same spinal/ACB as I'd do for the other guy, but had to put an LMA in when he dragged on too long. I once took over a colleague's case where he did exactly what you suggest, and placed a CSE with the intention of dosing the epidural when the spinal wore off. I thought that was overkill just to placate the surgeon and avoid a GA.

 

[GassYous]

Wash with epi or add fentanyl/precedex
or a tetracaine spinal

 

[sevoflurane]

Wash with epi or add fentanyl/precedex
or a tetracaine spinal

I’m a pretty simple guy and thankfully we have fast ortho… ob can be a little slow if you get the short straw/slower surgeon.

I’ve always felt that fentanyl increases the density of the spinal but not duration.

Does precedex reliably increase duration to a significant amount? Just a wash out of a 200mcg vial?

I’ll do an epi wash to get some vasoconstriction if I’m concerned for time.

Curious about the precedex though.

 

[deleted1130227]

Wash with epi or add fentanyl/precedex
or a tetracaine spinal

isobaric tetracaine with epi or phenylephrine will give you six hours easy. Haven't done it for atlas 15 years.

 

[PpfSuxTube]

isobaric tetracaine with epi or phenylephrine will give you six hours easy. Haven't done it for atlas 15 years.

There shouldn't be any reason in 2025 for a 6 hour spinal is there? Epi or phenyl in a spinal, ive never seen anyone do in 12 years now...
I wouldn't be encouraging this type of old school practice to enable incompetent surgeons. If a surgeon is taking this long to do basically any procedure they need to be outed and know they are outliers.

Being slow is incompetence I don't care what anyone says

Our guys are doing 4 joints, even 5 in 7. 5 hours regularly.

We've even been blocked from using bupiv spinals in our surgical centre cause it lasts too long and delays discharges

 

[deleted1130227]

There shouldn't be any reason in 2025 for a 6 hour spinal is there? Epi or phenyl in a spinal, ive never seen anyone do in 12 years now...
I wouldn't be encouraging this type of old school practice to enable incompetent surgeons. If a surgeon is taking this long to do basically any procedure they need to be outed and know they are outliers

Our guys are doing 4 joints, even 5 in 7. 5 hours regularly.

We've even been blocked from using bupiv spinals in our surgical centre cause it lasts too long and delays discharges

99.9%+ agree. it is why my last one was so long ago. It was an elective LE revascularization on somebody whose airway I really, really, really didn't want to touch. Got away with it. Never say never.

 

[NukHopkins]

99.9%+ agree. it is why my last one was so long ago. It was an elective LE revascularization on somebody whose airway I really, really, really didn't want to touch. Got away with it. Never say never.

You did the case with a spinal? No heparin given for the revasc?

 

[deleted1130227]

You did the case with a spinal? No heparin given for the revasc?

a dose of IV heparin given after a spinal anesthetic in a non anticoagulated patient (non-bloody tap) was considered OK way back when. Haven’t done vascular for over a decade. Not sure about now.

 

[Teillard]

You did the case with a spinal? No heparin given for the revasc?

Do combined GA/epidural on open AAA's all the time.

 

[Katheudontas parateroumen]

I feel like a total newb asking this but I have to ask so then I’ll learn…. I never used isobaric bupivicaine before. Spinal bupivicaine 0.75 is composed with dextrose. Is isobaric bupivicaine just “plain” bupivicaine?

 

[Urzuz]

I feel like a total newb asking this but I have to ask so then I’ll learn…. I never used isobaric bupivicaine before. Spinal bupivicaine 0.75 is composed with dextrose. Is isobaric bupivicaine just “plain” bupivicaine?

Yes. Most people use the preservative free 0.5% bupivacaine that says "not for spinal anesthesia" on the bottle.

 

[pgg]

We used to reconstitute tetracaine in dextrose (think it was 10%?) for super long spinals for slow orthopods.

The problem is that even if the block lasts long enough, the patient has to lay there and put up with the surgery for all those hours. That's hard for them if they're lightly sedated, and if you're going to heavily sedate them you might as well just do GA from the start and save everyone the drama.

Anyway, those were the days we'd put art lines in elective total hips and run nitroprusside infusions to reduce blood loss with controlled hypotension. We did some dumb stuff.

 

[nimbus]

Do combined GA/epidural on open AAA's all the time.

We used to give spinal morphine for most of our pump cases.

 

[nimbus]

We used to reconstitute tetracaine in dextrose (think it was 10%?) for super long spinals for slow orthopods.

The problem is that even if the block lasts long enough, the patient has to lay there and put up with the surgery for all those hours. That's hard for them if they're lightly sedated, and if you're going to heavily sedate them you might as well just do GA from the start and save everyone the drama.

Anyway, those were the days we'd put art lines in elective total hips and run nitroprusside infusions to reduce blood loss with controlled hypotension. We did some dumb stuff.

Not as dumb as HSS in the 1990s. High epidural, swan, a-line, and epinephrine infusion for total hips. There’s dumb and there’s dumber.

Hypotensive epidural anesthesia for total hip arthroplasty: a review - PubMed

Hypotensive epidural anesthesia provides arterial hypotension to maintain a mean arterial pressure of 50 mmHg and it can be used to reduce blood loss during total hip replacement. The technique combines an extensive epidural blockade with an intravenous infusion of low-dose epinephrine. This...

pubmed.ncbi.nlm.nih.gov

 

[nimbus]

a dose of IV heparin given after a spinal anesthetic in a non anticoagulated patient (non-bloody tap) was considered OK way back when. Haven’t done vascular for over a decade. Not sure about now.

Still okay. We put lumbar drains in for TEVAR all the time. 14g Tuohy is a nice stout needle😉

 

[gasmd98]

We used to reconstitute tetracaine in dextrose (think it was 10%?) for super long spinals for slow orthopods.

The problem is that even if the block lasts long enough, the patient has to lay there and put up with the surgery for all those hours. That's hard for them if they're lightly sedated, and if you're going to heavily sedate them you might as well just do GA from the start and save everyone the drama.

Anyway, those were the days we'd put art lines in elective total hips and run nitroprusside infusions to reduce blood loss with controlled hypotension. We did some dumb stuff.

Hey, Sharrock and his team gots lots of papers out of that “technique.” Looking back I cringe when I think of all the fluid I used to dump into big long bowel cases. Of course when the case was over and the BP dropped during dressings the surgeon would demand more fluid. “What, you only gave 8 liters? He needs at least 10 for this case!” That third space was one big mutha.

Now, one old technique that is gold is a low dose hypobaric spinal for anal cases in prone jackknife. Roll them over, position and pop in the spinal. Sit back, minimal sedation and relax. Patient can roll themselves back onto stretcher at end of case.

 

[PpfSuxTube]

Not as dumb as HSS in the 1990s. High epidural, swan, a-line, and epinephrine infusion for total hips. There’s dumb and dumber.

Hypotensive epidural anesthesia for total hip arthroplasty: a review - PubMed

Hypotensive epidural anesthesia provides arterial hypotension to maintain a mean arterial pressure of 50 mmHg and it can be used to reduce blood loss during total hip replacement. The technique combines an extensive epidural blockade with an intravenous infusion of low-dose epinephrine. This...

pubmed.ncbi.nlm.nih.gov

Was it us being dumb or the surgeons/procedure/equipment/techniques of the time?

Now, one old technique that is gold is a low dose hypobaric spinal for anal cases in prone jackknife. Roll them over, position and pop in the spinal. Sit back, minimal sedation and relax. Patient can roll themselves back onto stretcher at end of case.

Spinal anything isn't better than GA anymore and that position for any surgery is almost extinct also

 

[Teillard]

Now, one old technique that is gold is a low dose hypobaric spinal for anal cases in prone jackknife. Roll them over, position and pop in the spinal. Sit back, minimal sedation and relax. Patient can roll themselves back onto stretcher at end of case.

Used to do isobaric lidocaine for 45 minute micro-lumbar discectomies just like that. Place SAB side lying, rolls onto table, rolls back to stretcher at the end. Do 7 or 8. Pretty nice day.

 

[nimbus]

Was it us being dumb or the surgeons/procedure/equipment/techniques of the time?

It was dumb. I was in training at the time. Nobody else was doing that. Total hips were straightforward cases even then. General or spinal, rarely an Aline if the patient was sick.

 

[lotsapain]

I took over a complex hysterectomy 3 hours in by a partner who did a spinal anesthetic (pt had MH risk). Dose was 1.6ml spinal bupi with 25mcg fentanyl and 150mcg epi. I redosed ancef at 4 hours, pt was off the table at 5.5 hours. I was pretty antsy for the last hour and a half. Legs were barely starting to wiggle on arrival to PACU. I've never put epi in my spinals before, that was pretty impressive! I think 150mcg was kind of a lot though from what I've read out there.

Epi wash for a longer lasting local anesthetic (ie Bupi) does not give you that much longer of a duration of action. Epi wash came from the time that lidocaine spinals were used. I still use it occasionally you can achieve 30-60 minutes of extra duration but your mileage may vary.

Dosing over 3ml will not lead to anything good - you wont get longer duration but may risk a higher level. Use 1.5-2 ml of hyperbaric bupi and have the patient sit 1-2minutes to avoid higher level. Alternatively add .2ml of Fent and/or .3ml of Duramorph to 1.5 of bupi..... There are multiple factors including patient's height / weight when you go into extremes as well as anatomy (ie plica )