Spinal doses

[lotsapain]

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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

They still do it, part of that decision process is $$$$$ - that is 20 units to start the case you do the calculation.

 

[lotsapain]

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

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

That is absolute nonsense, well placed spinal for sicker patients is often the correct answer. Looks like you are a relatively recent grad, and yes many people still use prone jacknife for appropriate access to hemorrhoids.

 

[deleted87051]

They still do it, part of that decision process is $$$$$ - that is 20 units to start the case you do the calculation.

Figured it was money and/or MRB. “Let’s make a simple case as complicated as possible.”

 

[PpfSuxTube]

That is absolute nonsense, well placed spinal for sicker patients is often the correct answer. Looks like you are a relatively recent grad, and yes many people still use prone jacknife for appropriate access to hemorrhoids.

They couldn't even prove spinal was better for hip# so I absolutely doubt you have anything to back up your grandstanding. Thanks

What does that even mean? The correct answer.

 

[Dantrolene FC]

They couldn't even prove spinal was better for hip# so I absolutely doubt you have anything to back up your grandstanding. Thanks

What does that even mean? The correct answer.

So according to what you’ve written, a spinal anesthetic is never better than general anesthesia…

So I’m assuming you’re going GETA on OB...

I’m assuming if you have a patient with a known difficult airway, then you’re going to opt for a general anesthetic rather than a spinal anesthetic…

 

[deleted87051]

So according to what you’ve written, a spinal anesthetic is never better than general anesthesia…

So I’m assuming you’re going GETA on OB...

I’m assuming if you have a patient with a known difficult airway, then you’re going to opt for a general anesthetic rather than a spinal anesthetic…

Of course it depends on the circumstances but sometimes it is prudent to secure a know difficult airway from the get go.

 

[PpfSuxTube]

So according to what you’ve written, a spinal anesthetic is never better than general anesthesia…

So I’m assuming you’re going GETA on OB...

I’m assuming if you have a patient with a known difficult airway, then you’re going to opt for a general anesthetic rather than a spinal anesthetic…

Buddy I do complex cardiac all day every day. We don't have difficult airways

 

[UscGhost]

They couldn't even prove spinal was better for hip# so I absolutely doubt you have anything to back up your grandstanding. Thanks

What does that even mean? The correct answer.

It often can be difficult to prove, as many variables.

And much depends on the skill and comfort of the doc with each modality.

1cc of 0.5 isobaric bupiv and 50mcg of pro is extremely stable for sick elderly.

Can you do LMA or geta well, sure, but I find it's much more prone to hypotension. Maybe others do things to mitigate that..pre induction neo, ephedrine or use etomidate or ketamine, etc

Hard to mess up 1cc of bupiv spinal. Not that hard to get significant hypotension if you overdo the induction for GA. But pros and cons to each approach and of course, different ways to counter the cons of each

Ga is less hassle

 

[PpfSuxTube]

It often can be difficult to prove, as many variables.

And much depends on the skill and comfort of the doc with each modality.

1cc of 0.5 isobaric bupiv and 50mcg of pro is extremely stable for sick elderly.

Can you do LMA or geta well, sure, but I find it's much more prone to hypotension. Maybe others do things to mitigate that..pre induction neo, ephedrine or use etomidate or ketamine, etc

Hard to mess up 1cc of bupiv spinal. Not that hard to get significant hypotension if you overdo the induction for GA. But pros and cons to each approach and of course, different ways to counter the cons of each

Ga is less hassle

Look i agree so many ways to skin a cat... 1 agree spinal is equal. Pros cons. Not better

I just don't understand why the regional and spinal crowd can't see it that way... they want to save someone from a GA...

Yesterday I did 4 Mitraclip. Combined EF maybe 55%. Average age 90. All extubated a minute after probe came out. Most going home today. Some could even have gone home last night.

No one on planet earth can tell me my way isn't safe. I don't care

What is this guy saying about correct answer? Dude couldn't do any cases i do, never even seen it

 

[sevoflurane]

Look i agree so many ways to skin a cat... 1 agree spinal is equal. Pros cons. Not better

I just don't understand why the regional and spinal crowd can't see it that way... they want to save someone from a GA...

Yesterday I did 4 Mitraclip. Combined EF maybe 55%. Average age 90. All extubated a minute after probe came out. Most going home today. Some could even have gone home last night.

No one on planet earth can tell me my way isn't safe. I don't care

What is this guy saying about correct answer? Dude couldn't do any cases i do, never even seen it

I fully agree. There are many ways to do an anesthetic. To claim one is better than another is just not there unless we are talking about shoulder scopes or TSA’s mainly attributable to post op pain control or spinal for c-sections, etc. I might do a FIB for an 80 y/o hip/femur fx… but rarely, if ever, do I do these guys under spinal. A gentle GA in these patients is not difficult.

Our TAVR GA rate is much higher than national norms, yet our OR WIWO are super fast. 4-5 TAVRs by 3pm. Our post deployment assessment of significant PVL’s that require further intervention intra-op is probably better as well. We find ourselves asking for a few more cc’s after deployment if the leak is more than we are comfortable with based on TEE.

Lots of people claiming GA is overkill yet TEE imaging is >>> TTE at evaluating leaks in certain patients. You address any issues in the OR and not a few months later when they get their follow-up echo. .5 mac anesthesia under paralytics for these cases = quick wake-ups.

 

[UscGhost]

Look i agree so many ways to skin a cat... 1 agree spinal is equal. Pros cons. Not better

I just don't understand why the regional and spinal crowd can't see it that way... they want to save someone from a GA...

Yesterday I did 4 Mitraclip. Combined EF maybe 55%. Average age 90. All extubated a minute after probe came out. Most going home today. Some could even have gone home last night.

No one on planet earth can tell me my way isn't safe. I don't care

What is this guy saying about correct answer? Dude couldn't do any cases i do, never even seen it

I agree.

We have an annoying surgeon who promises Mac to all of his patients when LMA is generally safer and he tells them it's because general is dangerous.

Just caused hassle

 

[PpfSuxTube]

I fully agree. There are many ways to do an anesthetic. To claim one is better than another is just not there unless we are talking about shoulder scopes or TSA’s mainly attributable to post op pain control or spinal for c-sections, etc. I might do a FIB for an 80 y/o hip/femur fx… but rarely, if ever, do I do these guys under spinal. A gentle GA in these patients is not difficult.

Our TAVR GA rate is much higher than national norms, yet our OR WIWO are super fast. 4-5 TAVRs by 3pm. Our post deployment assessment of significant PVL’s that require further intervention intra-op is probably better as well. We find ourselves asking for a few more cc’s after deployment if the leak is more than we are comfortable with based on TEE.

Lots of people claiming GA is overkill yet TEE imaging is >>> TTE at evaluating leaks in certain patients. You address any issues in the OR and not a few months later when they get their follow-up echo. .5 mac anesthesia under paralytics for these cases = quick wake-ups.

Interesting. We never do trans fem tavi under GA but we do have really excellent echo techs who get good tte images. I dont see many coming back for any new pvl issue inside a few yrs but I haven't really checked... were doing 4 by 2pm start 8am

 

[sevoflurane]

Personally, I find it easier to paralyze and tube the 40+ bmi, copd’er that tends to abdominal breathe and has a higher likelihood of poor TTE windows. TEE, has the added benefit of easily assessing coronary flows with low coronary heights. On poor CT imaging, we can easily measure aortic valve area in 3d and give guidance btw 26 and 29 sapiens. I’ve picked up on coronary occlusions we had to stent over the years, a few effusions, etc.
Image quality while X-planing the Ao short axis in color I feel is better and super quick.
But that is what this discussion is about. A lot of different ways to carry out an anesthetic. 👍🏽

 

[cchoukal]

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

Length of surgery aside, I am of the mind that we shouldn’t be randomly putting weird **** into people’s intrathecal space. I do fentanyl and Duramorph up on OB because the culture strongly favors it, but I even think that is a little weird.

 

[UscGhost]

Length of surgery aside, I am of the mind that we shouldn’t be randomly putting weird **** into people’s intrathecal space. I do fentanyl and Duramorph up on OB because the culture strongly favors it, but I even think that is a little weird.

Why is it weird?

Fentanyl makes the spinal more effective in the short term and duramorph for postop

 

[pgg]

Figured it was money and/or MRB. “Let’s make a simple case as complicated as possible.”

Will any insurance company actually pay for a PA catheter or the rest of this fluff in a hip these days?

 

[pgg]

Why is it weird?

Fentanyl makes the spinal more effective in the short term and duramorph for postop

I find that about 15 mcg fentanyl in OB spinals has two great benefits

1) it lets you get away with 1.4 or even 1.2 mL of the hyperbaric bupi for the very fast surgeons

2) it is much, much better than plain bupi at covering the visceral pain of having the uterus yanked out of the body and flopped on her abdomen

Morphine's onset isn't really fast enough to help with either of those things, but of course it's great for the next 12-24h.

So I put 15 mcg fentanyl and 200 mcg morphine in every OB spinal. If I take over a case where the starter didn't use fentanyl, I can usually tell the difference if a uterus-yanker is operating.

 

[Simba1711]

I just did spinal for hip replacement with isobaric bupi 0.5 % 4 cc since surgeon slow af. Probably easier to do geta at this point.

 

[cchoukal]

Why is it weird?

Fentanyl makes the spinal more effective in the short term and duramorph for postop

All of that is true, I just think it's kind of... icky. Like, I don't add things to my nerve blocks, either.

 

[UscGhost]

All of that is true, I just think it's kind of... icky. Like, I don't add things to my nerve blocks, either.

I se. I probably wouldn't jump on the precedex ketamine spinals

But opioids in spinals have been around for probably as long as spinals themselves. If they cause an issue, it's never risen above the noise

 

[deleted87051]

Will any insurance company actually pay for a PA catheter or the rest of this fluff in a hip these days?

Good question. But I have noticed insurance companies don’t notice or take action on odd or rare practices. Things (like nerve blocks) don’t appear on their radar until they they become widespread and affect their bottom line. At that point they develop strategies to restrict payments. If HSS is the only place doing it, they may not notice.

Another consideration is that HSS had and maybe still has a higher than usual number of “cash only” surgeons who don’t take insurance. I don’t know if their patients pay cash for everything or if they use insurance for other parts of their care.

 

[abolt18]

I find that about 15 mcg fentanyl in OB spinals has two great benefits

1) it lets you get away with 1.4 or even 1.2 mL of the hyperbaric bupi for the very fast surgeons

2) it is much, much better than plain bupi at covering the visceral pain of having the uterus yanked out of the body and flopped on her abdomen

Morphine's onset isn't really fast enough to help with either of those things, but of course it's great for the next 12-24h.

So I put 15 mcg fentanyl and 200 mcg morphine in every OB spinal. If I take over a case where the starter didn't use fentanyl, I can usually tell the difference if a uterus-yanker is operating.

I do 15 fentanyl and 150 of PF morphine. I tried without fentanyl for a while and found that the faster onset of the fentanyl seemed to have a pretty significant positive benefit, especially with our fast OBs.

 

[sevoflurane]

15 mcg fent + 100 mcg pf Morphine camp