Spines

[DrRobert]

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How are ya'll doing spines, especially in private practice?

Depending on the surgeon we usually do:

TIVA with Fentanyl gtt, Propofol gtt, Rocuronium gtt, A-line, 2 PIVs

or

0.5 MAC Desflurane, 50% N2O, Fentanyl gtt, Rocuronium gtt, A-line, 2 PIVs


We might put in a central line if the patient is sick and might require vasoactive drips.

 

[UTSouthwestern]

How are ya'll doing spines, especially in private practice?

Depending on the surgeon we usually do:

TIVA with Fentanyl gtt, Propofol gtt, Rocuronium gtt, A-line, 2 PIVs

or

0.5 MAC Desflurane, 50% N2O, Fentanyl gtt, Rocuronium gtt, A-line, 2 PIVs


We might put in a central line if the patient is sick and might require vasoactive drips.

Largely depends on what kind of spines. Scoliosis? 360's? Lami's? Cervical's?

Not sure why you would run TIVA + roc gtt since presumably the TIVA is to facilitate neuro monitoring including motors/MEP's.

 

[DrRobert]

Largely depends on what kind of spines. Scoliosis? 360's? Lami's? Cervical's?

Not sure why you would run TIVA + roc gtt since presumably the TIVA is to facilitate neuro monitoring including motors/MEP's.

I meant for the big spine cases like PSF, tumor resections, etc.

A couple surgeons request the Rocuronium gtt because they don't want the patient moving at all during the neuro monitoring. They want "zero twitches".

 

[UTSouthwestern]

I meant for the big spine cases like PSF, tumor resections, etc.

A couple surgeons request the Rocuronium gtt because they don't want the patient moving at all during the neuro monitoring. They want "zero twitches".

Wow. Those two could just do without monitoring if they are manipulating the spine without motors.

GETA. A line. CVP if scoli repair or needs central access due to poor peripheral access. Precedex. Cellsaver. Sed Line primarily for EEG visualization as opposed to its "number." Paralysis for exposure only. 1/3 - 1/2 MAC gas of choice.

 

[DrRobert]

Wow. Those two could just do without monitoring if they are manipulating the spine without motors.

GETA. A line. CVP if scoli repair or needs central access due to poor peripheral access. Precedex. Cellsaver. Sed Line primarily for EEG visualization as opposed to its "number." Paralysis for exposure only. 1/3 - 1/2 MAC gas of choice.

No narcotics?

 

[Jeff05]

TIVA with propofol and remi. maybe a touch of gas in the background. the dose of fentanyl to make them not move during certain very stimulating parts (provided i can't use paralysis when they're monitoring MEPs) would be too huge so remi is great here. if you're running remi/prop and a bit of gas they will NOT move. i think dilaudid makes them happiest after wakeup.

 

[UTSouthwestern]

No narcotics?

Whatever is available.

 

[Mista Suprane]

TIVA with propofol and remi. maybe a touch of gas in the background. the dose of fentanyl to make them not move during certain very stimulating parts (provided i can't use paralysis when they're monitoring MEPs) would be too huge so remi is great here. if you're running remi/prop and a bit of gas they will NOT move. i think dilaudid makes them happiest after wakeup.

i'm just a CA-1, but our neuro monitoring people are ok for either MEPs or continuous EMGs with neuromuscular blockade PROVIDED they have 2 twitches. to try our best to acheive this steady state, we run vec gtt, and titrate up and down based on their twitch amplitude data. just did a case like this today. as far as sedation, usually iso/N20 (<1 MAC) with fentanyl or remifentanil gtt.

as you said, the paralysis is probably unnecessary given adequate sedation/opioid, but i guess having that extra layer of protection with the vec gtt is something i need to make me feel comfortable with such a case since i'm a junior resident.

but interesting that the neuro monitoring people in your hospital require complete lack of paralysis. i wonder what the difference is?

 

[UTSouthwestern]

Finished an 8 hour L2 - S1 ALIF, T2 - Ilium posterior fusion on a 63 y/o with 150 degree scoli. No paralysis except during initial exposures. Patient adequately controlled with narc during superstimulating portions of case. Extubated within 5 minutes of end of case.

No paralysis gives the techs the ability to run a baseline and continuosly compare full motor function throughout the case. In these cases, "unbending"/derotating the thoracic spine can cause instant partial or total paralysis. That is why I keep the patient paralysis free.

Smaller degenerative spine fusion cases usually do not require this unless there is a significant amount of distraction planned.

 

[coprolalia]

No paralysis gives the techs the ability to run a baseline and continuosly compare full motor function throughout the case. In these cases, "unbending"/derotating the thoracic spine can cause instant partial or total paralysis. That is why I keep the patient paralysis free.

Same at our institution.

I've done these a variety of different ways. Propofol, 1/2 MAC volatile, Precedex, remifentanil, fentanyl, etc., etc.

The easiest (and cheapest) is just propofol plus fentanyl infusion. After bolusing, run the propofol at 200 mcg/kg/min and the fentanyl at 2mcg/kg/hr for at least the first 2 hours. Then, you can start to titrate down. I haven't seen much advantage to adding Precedex, other than it may provide you a slight insurance policy and slightly better hemodynamic control. We usually use rocuronium up front, and our surgeons like full relaxation while they are getting exposure. After that, no more NMBs.

Definitely hook-up the CellSaver, especially in a multi-level (e.g., T6 to L2, etc.) case. You're going to lose a lot of blood.

-copro

 

[Noyac]

No paralysis except for exposure portion. TIVA (usually Propofol sometimes Dex) mix in some ketamine on occasions. Sufenta or Fentanyl gtts. I run no gas but others use up to 1/2 MAC.

 

[Dejavu]

I was going to ask this yesterday, but I didn't want to hijack the thread so early. Even now I hope that doesn't happen.

My question: In your discussion of risks and complications, do you discuss postop permanent blindness? How about death?

Just curious, because I talk about these two items with all my pts, but few of my colleagues do. Lawyers tell you to talk about things that are "material" to making a decision. Dr Kaplan from Closed Claims Project once said to talk about things that happen more than 1/10,000 and "the really big ones". It seems to me that death and blindness qualify as both "really big" and as "material" to decision making.

 

[Noyac]

I was going to ask this yesterday, but I didn't want to hijack the thread so early. Even now I hope that doesn't happen.

My question: In your discussion of risks and complications, do you discuss postop permanent blindness? How about death?

Just curious, because I talk about these two items with all my pts, but few of my colleagues do. Lawyers tell you to talk about things that are "material" to making a decision. Dr Kaplan from Closed Claims Project once said to talk about things that happen more than 1/10,000 and "the really big ones". It seems to me that death and blindness qualify as both "really big" and as "material" to decision making.

I do and it is on our consent. I underline right in front of the pt.

 

[NeuroPhysGuy]

i'm just a CA-1, but our neuro monitoring people are ok for either MEPs or continuous EMGs with neuromuscular blockade PROVIDED they have 2 twitches. to try our best to acheive this steady state, we run vec gtt, and titrate up and down based on their twitch amplitude data. just did a case like this today. as far as sedation, usually iso/N20 (<1 MAC) with fentanyl or remifentanil gtt.

as you said, the paralysis is probably unnecessary given adequate sedation/opioid, but i guess having that extra layer of protection with the vec gtt is something i need to make me feel comfortable with such a case since i'm a junior resident.

but interesting that the neuro monitoring people in your hospital require complete lack of paralysis. i wonder what the difference is?

Sorry for the delay, I just got your message. Two twitches should be ok for shorter cases. The main difference is that the amplitude of MEPs will be severely diminished under these circumstances. With gas there is a formula (I can't remember it off the top of my head) about amplitude loss every hour. This means that techs will have to increase stimulation by X volts per hour (I think it's around 15-20), and stimulation can only go so high. This is why I stated only to use that technique on short cases (if using gas). Once that threshold is reached, the tech will be unable to stim high enough and responses will not be obtained. This would be much more difficult when responses are 1/2-1/3 of normal amplitude due to an NMB drip.