SSEP/MEPs with precedex

[GaseousClay]

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I have seen sparse literature, mainly saying precedex does not lower amplitude of signals during monitoring but if anything lowering MEPs only. Anyone being told by NM folks not to use this drug during spine cases with neuromonitoring? I feel like the benefit of lower pain scores post op make it an ideal choice for a TIVA or half mac gas paired with propofol.

Precedex has become a lot cheaper as well so prefer using it to remifentanil.

 

[deleted162650]

It has no significant effect.

 

[2010houston]

I use it in all my spine cases.

 

[MikeMerk-MtS]

I have seen sparse literature, mainly saying precedex does not lower amplitude of signals during monitoring but if anything lowering MEPs only. Anyone being told by NM folks not to use this drug during spine cases with neuromonitoring? I feel like the benefit of lower pain scores post op make it an ideal choice for a TIVA or half mac gas paired with propofol.

Precedex has become a lot cheaper as well so prefer using it to remifentanil.

Can slightly lower EPs (I believe both motor and sensory) but my neuromonitoring people are fine with it as long as they're aware of its use.

 

[dipriMAN]

Pretty sure the NM people are fine with anything but volatiles and NMB. Even if it does have an effect on monitoring, just try not to bolus or change the infusion too much during the monitoring.

 

[Urzuz]

Pretty sure the NM people are fine with anything but volatiles and NMB. Even if it does have an effect on monitoring, just try not to bolus or change the infusion too much during the monitoring.

Adding some volatile agent is fine in the vast majority of cases and NMBs can be used in certain circumstances as well (depending on what is being monitored). It is completely dependent on the individual patient, what the neuromonitoring folks are monitoring, the patient's pathology, baseline signals, etc.

For the original question, as people above me said, Precedex is fine.

 

[deleted697535]

Adding some volatile agent is fine in the vast majority of cases and NMBs can be used in certain circumstances as well (depending on what is being monitored). It is completely dependent on the individual patient, what the neuromonitoring folks are monitoring, the patient's pathology, baseline signals, etc.

For the original question, as people above me said, Precedex is fine.

Right on.
Ive done sux infusions during these cases. meps were fine

 

[Arch Guillotti]

Ive done sux infusions during these cases. meps were fine

 

[GaseousClay]

Just did a case where the surgeon totally forgot the NM was there. But yea ours give us heat all the time for using dex but I pretty much ignore them. I already succumb to their tiva only demands I’m not letting them dictate my whole anesthetic.

 

[deleted162650]

I already succumb to their tiva only demands

Just remind them that if they need TIVA for every case they really suck at their job.

 

[Urzuz]

I really encourage everyone (especially the residents) to learn a little bit about neuromonitoring. I feel like many anesthesiologists don’t understand the differences in monitoring (SSEPs/MEPs/EMG, etc) and how the anesthetics we use affect their signals, so they’re willing to just follow whatever the neuromonitoring person says blindly. If you understand a little bit about neuromonitoring and can have an intelligent conversation with them, you will be able to tune your anesthetic to achieve their goals. Imagine if you gave an NMB every time the surgeon asked for more relaxation? That’s the equivalent of just doing exactly what the neurophysiologist says.

Just remind them that if they need TIVA for every case they really suck at their job.

This is absolutely right. But remember to confidently call them on their BS you have to speak their language.

 

[MikeMerk-MtS]

What about throwing in a little Ketamine to offset the minimal decrease in signal from Precedex? Everyone's happy!

 

[deleted697535]

Jesus wept, the idea that one who has literally never even opened a bottle or sevo or a vial of propofol never to mind actually administering it to a patient can dictate an anesthetic plan is beyond belief.

I had a Neuro senior resident one day complain the etco2 was out of range during an awake crani. 0 sedation. It was out of control. I asked him did he want me to kick the patient in the guts to get him breath more

Another Neuro fellow tried to declare a dude brain dead about 25 mins after 100mg of roc. He was certain roc didn't affect the brain stem reflexes. And he was a fellow. Now a staff somewhere annoying someone else

Are these really the people we should be bowing down to. They know very little about anesthesia, just read a 1 page guide I'd imagine

 

[nimbus]

Jesus wept, the idea that one who has literally never even opened a bottle or sevo or a vial of propofol never to mind actually administering it to a patient can dictate an anesthetic plan is beyond belief.

I had a Neuro senior resident one day complain the etco2 was out of range during an awake crani. 0 sedation. It was out of control. I asked him did he want me to kick the patient in the guts to get him breath more

Another Neuro fellow tried to declare a dude brain dead about 25 mins after 100mg of roc. He was certain roc didn't affect the brain stem reflexes. And he was a fellow. Now a staff somewhere annoying someone else

Are these really the people we should be bowing down to. They know very little about anesthesia, just read a 1 page guide I'd imagine

You have neurologists? Audiologists do neuromonitering where I am.

 

[dipriMAN]

I really encourage everyone (especially the residents) to learn a little bit about neuromonitoring. I feel like many anesthesiologists don’t understand the differences in monitoring (SSEPs/MEPs/EMG, etc) and how the anesthetics we use affect their signals, so they’re willing to just follow whatever the neuromonitoring person says blindly. If you understand a little bit about neuromonitoring and can have an intelligent conversation with them, you will be able to tune your anesthetic to achieve their goals. Imagine if you gave an NMB every time the surgeon asked for more relaxation? That’s the equivalent of just doing exactly what the neurophysiologist says.




This is absolutely right. But remember to confidently call them on their BS you have to speak their language.

I am a resident, have read more about neuromonitoring than I should have. I don’t find it’s that meaningful for me to know. Frankly I frequently wonder if it’s meaningful for the surgeon most of the time.

Its easier to just do the GA with no volatile and no paralytics. Use dex, use opioids, use ketamine, or whatever you want with propofol.

 

[Urzuz]

I am a resident, have read more about neuromonitoring than I should have. I don’t find it’s that meaningful for me to know.

You don't have to be an expert on neuromonitoring to the point of you being able to do their job for them, but knowing what they are monitoring and how it relates to your anesthetics is very important for you to know. If neuromonitoring is a total blackbox to you, you will be one of those anesthesiologists that just does whatever the neuromonitoring person tells you to do because you don't know (or don't care to know) what they are trying to achieve. It doesn't sound like that is the case with you, but for others it may be.

Its easier to just do the GA with no volatile and no paralytics. Use dex, use opioids, use ketamine, or whatever you want with propofol.

Is it? If you blindly run a TIVA (or even worse, an "ivory tower" TIVA consisting of propofol, fentanyl, precedex, lidocaine, magnesium, ketamine, ????) out in practice every time you see a neuromonitoring person because you don't know what they are monitoring, you will be setting yourself up for failure. A simple example -- a one level spine case that will take <60 min skin to skin, and they are monitoring nothing but EMG. Your plan? Now imagine the same surgery, but they are monitoring nothing but SSEPs. How does that change what you will do? Or will you do a GA with no volatile and no paralytic for both cases?

 

[deleted162650]

Sometimes it’s fun to secretly turn on some nitrous. Do it like 3 or 4 times for 5-10mins a pop and watch their heads explode.

 

[dipriMAN]

You don't have to be an expert on neuromonitoring to the point of you being able to do their job for them, but knowing what they are monitoring and how it relates to your anesthetics is very important for you to know. If neuromonitoring is a total blackbox to you, you will be one of those anesthesiologists that just does whatever the neuromonitoring person tells you to do because you don't know (or don't care to know) what they are trying to achieve. It doesn't sound like that is the case with you, but for others it may be.



Is it? If you blindly run a TIVA (or even worse, an "ivory tower" TIVA consisting of propofol, fentanyl, precedex, lidocaine, magnesium, ketamine, ????) out in practice every time you see a neuromonitoring person because you don't know what they are monitoring, you will be setting yourself up for failure. A simple example -- a one level spine case that will take <60 min skin to skin, and they are monitoring nothing but EMG. Your plan? Now imagine the same surgery, but they are monitoring nothing but SSEPs. How does that change what you will do? Or will you do a GA with no volatile and no paralytic for both cases?

Tooshe

 

[drmwvr]

Have yet to see a surgeon change anything or do anything different when alerted to a change in ssep/mep monitoring. Merely a 'huh' and keep on going....

 

[dipriMAN]

Have yet to see a surgeon change anything or do anything different when alerted to a change in ssep/mep monitoring. Merely a 'huh' and keep on going....

Only case I’ve seen the surgeon adjust what he has been doing is during a cord tumor, while he was retracting things for access. Don’t frankly see the point with posterior fusions and thjngs

 

[dipriMAN]

You don't have to be an expert on neuromonitoring to the point of you being able to do their job for them, but knowing what they are monitoring and how it relates to your anesthetics is very important for you to know. If neuromonitoring is a total blackbox to you, you will be one of those anesthesiologists that just does whatever the neuromonitoring person tells you to do because you don't know (or don't care to know) what they are trying to achieve. It doesn't sound like that is the case with you, but for others it may be.



Is it? If you blindly run a TIVA (or even worse, an "ivory tower" TIVA consisting of propofol, fentanyl, precedex, lidocaine, magnesium, ketamine, ????)

An aside, do people really do this insane set up for a TIVA?

 

[Mman]

I had a Neuro senior resident one day complain the etco2 was out of range during an awake crani.

I would patiently ask them what the ETCO2 was since I had no way of monitoring it accurately.

 

[DocVapor]

An aside, do people really do this insane set up for a TIVA?

There are plenty of people out there that will mix the propofol, lidocaine, and ketamine in 1 syringe and run it +/- precedex. Bolus fentanyl/magnesium. It's not really that insane. Personally I don't like having the mixed drugs so generally I will run prop/precedex separately so I can titrate each individually and then bolus fentanyl/ketamine/magnesium.

 

[DocVapor]

Have yet to see a surgeon change anything or do anything different when alerted to a change in ssep/mep monitoring. Merely a 'huh' and keep on going....

Generally, yes, but we have one functional neurosurgeon that does a lot of the cutting-edge spinal cord stim stuff and will actively have discussions with neuromonitoring and make adjustments based on that. I don't know if his outcomes are any better but it at least is nice to see him actually getting something out of the increased cost to the patient.

 

[BLADEMDA]

The addition of dexmedetomidine to propofol-remifentanil regimen does not exert an adverse effect on MEP and SSEP monitoring in adult patients undergoing thoracic spinal cord tumor resection.

Effects of Dexmedetomidine on motor- and somatosensory-evoked potentials in patients with thoracic spinal cord tumor: a randomized controlled trial

We hypothesized that the addition of dexmedetomidine in a clinically relevant dose to propofol-remifentanil anesthesia regimen does not exert an adverse effect on motor-evoked potentials (MEP) and somatosensory-evoked potentials (SSEP) in adult patients ...

www.ncbi.nlm.nih.gov

 

[MoMoGesiologist]

I don’t care what you’re monitoring, just do a half mac gas +/- some narcotics and you’ll be fine. Just no paralytic for motors.

 

[Monty Python]

Only case I’ve seen the surgeon adjust what he has been doing is during a cord tumor, while he was retracting things for access. Don’t frankly see the point with posterior fusions and thjngs

My favorite neuro surgeon, in his mid-50s, scoffs at the younger ones who need/demand full monitoring for just about everything. This particular guy never uses it, and does a lot of backs and necks. He says the ones who use it are just CYA for medicolegal reasons and supposed standard of care.

 

[deleted171991]

My favorite neuro surgeon, in his mid-50s, scoffs at the younger ones who need/demand full monitoring for just about everything. This particular guy never uses it, and does a lot of backs and necks. He says the ones who use it are just CYA for medicolegal reasons and supposed standard of care.

VA hospitals do spines without any neuromonitoring regularly. If they had an increased rate of complications, the newspapers would be full of them. ("Veteran gets paralyzed because of lazy VA doctors.")

I think neuromonitoring is just a crutch for bad spine surgeons.

 

[CopaceticOne]

I think neuromonitoring is just a crotch for bad spine surgeons.

Crotch or crutch? With you I feel it could have been intentional or just a typo.

 

[dipriMAN]

VA hospitals do spines without any neuromonitoring regularly. If they had an increased rate of complications, the newspapers would be full of them. ("Veteran gets paralyzed because of lazy VA doctors.")

I think neuromonitoring is just a crotch for bad spine surgeons.

Definitely get the feeling it’s the result of some kickbacks to neurosurgeons from these private companies.

 

[drmwvr]

Definitely get the feeling it’s the result of some kickbacks to neurosurgeons from these private companies.

It's hospital based neuromonitoring with hospital employees where I am...pure overhead...but I'm sure a win-win arrangement as the hospital can charge insurance for more than the anesthesia bill using the most low tech equipment in the room next to the rongeurs.

 

[deleted171991]

Crotch or crutch? With you I feel it could have been intentional or just a typo.

Typo.

 

[deleted162650]

Typo.

Freudian slip.