Total Joints and the “fluid situation”

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lolnotacop

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Our institution has put pressure on our group to reduce our IVF usage. We are looking and total joints particularly, which usually get spinal + propofol. Our standard case usually gets 1-2 L IVF intra and 1-2 L postop in PACU.

We are discussing whether or not we want to change our current standard away from spinal while we sort out the IVF shortage (and yes surgeons are dramatically reducing their use too…)

Would like to hear opinions from those that do LE joints without spinals. Any protocols you regularly use?

Was thinking maybe GETA with PENG and LFCN.
 
When I was a resident we had a big OB anesthesia guy from Stanford come and talk to us. Our culture was c-sections would routinely get 3-4L of crystalloid. IIRC he was advocating for more liberal use of pressors and less fluid.

It made sense to me, so I don’t go crazy loading neuraxial patients up with fluids just bc I’m doing a spinal (or epidural).
 
I am failing to understand why GETA would require less IVF than a spinal plus sedation. Just continue doing what you're doing and try to limit to 1 L for the case and post op. Our orthopod has the patient drink gatorade prior to arrival. Consider adding pre op oral hydration.

Only give post op fluids if warranted.
 
Decrease spinal dose maybe?

I use 0.5% isobaric bupic with 20 mcg fentanyl. 6-8mg total dose. Use 1 L intraop generally
 
Why are your patients getting so much IVF? We try to aim for 500mls total during a total joint. Our surgeons rarely lose more than 200mls of blood and we plan on discharging roughly 25-40% of total joints the same day. Urine retention is a huge issue and a big headache for some of these patients who then get a catheter that they may have to go home with. We rarely see hypotension that can’t be managed with a little vasopresser. Also a short or intermediate acting isobaric spinal is all our guys need and it cuts down significantly on the incidence of hypotension.
 
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Maz777 said:
Why 2-4L for a THA/TKA? That's a crazy amount. Ours rarely get more than 1L and most leave same day from PACU. Just going to cause retention issues with that volume.
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Seriously at levels like that I’d be surprised if you weren’t causing outright harm to your patients or their outcomes.

3L crystalloid is many people’s absolute maximum for crystalloid resuscitstion before switching to blood and you’re giving it routinely to day surgery patients? How on earth are your 80 year old little old lady tkas not getting heart failure?
 
Gaseous Clay said:
I am failing to understand why GETA would require less IVF than a spinal plus sedation. Just continue doing what you're doing and try to limit to 1 L for the case and post op. Our orthopod has the patient drink gatorade prior to arrival. Consider adding pre op oral hydration.

Only give post op fluids if warranted.
Click to expand...

Agreed, should be doing aggressive pre-op oral hydration. There’s no Gatorade shortage
 
Agree with all of you. None of my total joints receive more than 1L intraop and I routinely use pressors with spinal placement (along with ondansetron). I think it’s ridiculous to give more than 2L TOTAL, especially with spinal since patient will be able to take PO relatively sooner post.

We have PACU nurses who give more fluid than they should. Our joints are 23hr stays so usual orders are also for maintenance IVF (yes I know, it’s all being looked at).

We discussed more and landed on mepiv spinals for the reasons others have mentioned (we were using heavy 0.75 bupiv usually).
 
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The problem with aggressive preop oral hydration is that you have to count on patients to do it.

lolnotacop said:
Would like to hear opinions from those that do LE joints without spinals. Any protocols you regularly use?
Click to expand...

I haven't done a spinal for a joint in years. TKAs get adductor and ipack blocks, then general anesthesia. Hips get general anesthesia. The patients do fine.

I don't miss doing spinals in crusty old backs at all. Sure 90%+ of them are chip shots but the rare bit of difficulty always had me thinking why the hell didn't I just give propofol through that perfectly good IV and put a tube in this person.

They don't need much IV fluid. I run phenylephrine infusions on all of them. It's rare to lose a significant amount of blood. Once the gas is gone, so is the hypotension.

After all these years there still isn't good data suggesting better outcomes with neuraxial vs general. It's perplexing to me why spinals for joints are still common, especially with same-day discharges becoming more common.

If you start doing generals for joints, you'll probably like it. The hard part is going to be going back to spinals when the shortage is over. 🙂
 
Peng block prop sux tube, phenylephrine, ambulate same day and home.
More trouble.with knees even surgeon LIA does not guarantee adequate post.op pain control for ambulation.
 
Adductor + spinal (mepi/bupi) + propofol infusion for TKAs. IVF < 1L, EBL < 1L. Pressors for hypotension. About the same for THA except no blocks. Our surgeons average 1.5 - 2 hours. Home same day.
 
medicine2wallstreet said:
Spinals for ortho is dumb. If patients got just a spinal and not 150mcg infusion of propofol I'd buy the benefits vs general.

4 L fluids for ortho is dumb

PENG and LFCN blocks for hips is dumb. Just be normal

That's about all I have to say.
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I agree, I always tried to convince people to stay awake and watch the surgery if they got a spinal since you’re losing a lot of the benefit if they were going to get propofol anyway. They don’t need pressors and fluid then either. C-sections are way more uncomfortable and we do them awake without question.
 
ambiturner said:
I agree, I always tried to convince people to stay awake and watch the surgery if they got a spinal since you’re losing a lot of the benefit if they were going to get propofol anyway. They don’t need pressors and fluid then either. C-sections are way more uncomfortable and we do them awake without question.
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Sincerely? I want them to sleep, not the other way around. Who wants to talk to them for 2 hours!
 
ambiturner said:
I agree, I always tried to convince people to stay awake and watch the surgery if they got a spinal since you’re losing a lot of the benefit if they were going to get propofol anyway. They don’t need pressors and fluid then either. C-sections are way more uncomfortable and we do them awake without question.
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Why keep them awake? If I wanted to talk to patients I could do IM, or family medicine.
 
pgg said:
The problem with aggressive preop oral hydration is that you have to count on patients to do it.



I haven't done a spinal for a joint in years. TKAs get adductor and ipack blocks, then general anesthesia. Hips get general anesthesia. The patients do fine.

I don't miss doing spinals in crusty old backs at all. Sure 90%+ of them are chip shots but the rare bit of difficulty always had me thinking why the hell didn't I just give propofol through that perfectly good IV and put a tube in this person.

They don't need much IV fluid. I run phenylephrine infusions on all of them. It's rare to lose a significant amount of blood. Once the gas is gone, so is the hypotension.

After all these years there still isn't good data suggesting better outcomes with neuraxial vs general. It's perplexing to me why spinals for joints are still common, especially with same-day discharges becoming more common.

If you start doing generals for joints, you'll probably like it. The hard part is going to be going back to spinals when the shortage is over. 🙂
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is anyone else not doing spinals for knees?

just doing adductor and ipack and ga? i havent heard of that being done a lot
 
Hoya11 said:
is anyone else not doing spinals for knees?

just doing adductor and ipack and ga? i havent heard of that being done a lot
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My old group didn't. My new group, has an Ortho ASC, so we are beholden to the surgeons...

My view on both is that of pgg's. Don't really see much benefit to spinal and some can really be a pain in the ass.
 
crash2500 said:
My old group didn't. My new group, has an Ortho ASC, so we are beholden to the surgeons...

My view on both is that of pgg's. Don't really see much benefit to spinal and some can really be a pain in the ass.
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And the studies that people use to justify spinal being better than geta are all flawed.
 
I do spinal depending on the surgeon unfortunately

If the surgeon is fast and competent I do spinal plus ipack and acb.

If the surgeon sucks. Ga plus ipack and acb. Plus two Ivs.
 
We do spinals for all totals.

Patients do well intraop and postop. Do better in pacu on terms of pain control and ponv than the average GA. Patients happy and wide awake rolling into pacu

Much less intraop opioids, less bleeding, etc.

Are the end outcomes the same 24hrs later? Maybe. But it certainly looks like patients do better under spinal on average
 
You guys cancelling cases yet? Our hospital policy is now to cancel any elective case with over 2L fluid used.

Sadly this probably impacts me as a urologist more than most. Hard to justify an elective TURP which will use 10-15 3L bags.
 
narcotics999 said:
Sincerely? I want them to sleep, not the other way around. Who wants to talk to them for 2 hours!
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I believe that this is one explanation why the GA versus neuraxial trials didn’t show more benefit - more often than not people have their spinal patients under GA without a airway, not even deep/mod sedation. If you seriously believe spinal is better for outcomes and they’re totally numb why sedate them? Give them headphones, tv to watch, etc.
 
DoctwoB said:
You guys cancelling cases yet? Our hospital policy is now to cancel any elective case with over 2L fluid used.

Sadly this probably impacts me as a urologist more than most. Hard to justify an elective TURP which will use 10-15 3L bags.
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Not yet but unless we get a shipment this week I don’t see how we avoid it going forward. Of the procedural areas OB is using the most and the medical floors and ICUs seem to just be ignoring the issue.
 
DoctwoB said:
You guys cancelling cases yet? Our hospital policy is now to cancel any elective case with over 2L fluid used.

Sadly this probably impacts me as a urologist more than most. Hard to justify an elective TURP which will use 10-15 3L bags.
Click to expand...


And ortho. Just last week I had to build a dam with blankets so I wouldn’t be standing in a lake of irrigation fluid during an arthroscopic rotator cuff repair.

Maybe dialysis too.
 
DoctwoB said:
You guys cancelling cases yet? Our hospital policy is now to cancel any elective case with over 2L fluid used.

Sadly this probably impacts me as a urologist more than most. Hard to justify an elective TURP which will use 10-15 3L bags.
Click to expand...

We cut back last week due to not securing the shipment we had expected. Currently at ~80% volume. Tenuous situation that we are playing by ear, things seem like they will be changing week to week.
 
ambiturner said:
I believe that this is one explanation why the GA versus neuraxial trials didn’t show more benefit - more often than not people have their spinal patients under GA without a airway, not even deep/mod sedation. If you seriously believe spinal is better for outcomes and they’re totally numb why sedate them? Give them headphones, tv to watch, etc.
Click to expand...
Because most want to remember nothing
 
UscGhost said:
We do spinals for all totals.

Patients do well intraop and postop. Do better in pacu on terms of pain control and ponv than the average GA. Patients happy and wide awake rolling into pacu

Much less intraop opioids, less bleeding, etc.

Are the end outcomes the same 24hrs later? Maybe. But it certainly looks like patients do better under spinal on average
Click to expand...

My issue is the posterior pain after TKA is real, and IPACK is not enough to control it without a spinal masking everything.

All my patients go home and I dont want to give them dilaudid for the pain and the discharge home. Seems to go smoother with a spinal ( we even use half the dose) but the delay in discharge for urination and ambulation is significant.

I truly wish I could do a GA plus femoral and sciatic and send them home pain free to walk the next day when the block wears off.. and get away from the spinal but also have good pain control. The idea of walking POD 0 is annoying to me..
 
Hoya11 said:
My issue is the posterior pain after TKA is real, and IPACK is not enough to control it without a spinal masking everything.

All my patients go home and I dont want to give them dilaudid for the pain and the discharge home. Seems to go smoother with a spinal ( we even use half the dose) but the delay in discharge for urination and ambulation is significant.

I truly wish I could do a GA plus femoral and sciatic and send them home pain free to walk the next day when the block wears off.. and get away from the spinal but also have good pain control. The idea of walking POD 0 is annoying to me..
Click to expand...
Posterior pain is an issue for sure. Ipacks work sometimes, not reliable.

We use a very light spinal, so it helps reduce discharge delays, but still happen sometimes.

Patients seem happier in pacu with spinals on average. Data is murky
 
More than 2L of fluid is way too much, something is wrong with how you’re doing totals. Most should go to pacu with the same bag. Don’t you get a lot of retention?

GA vs spinal: isn’t the literature less blood loss, risk of dvt? Realistically doesn’t matter, if the patient looks difficult (anatomy or not going to tolerate spinal) GA. Good ortho surgeons don’t care, what they do care about is ambulating if they’re going to discharge same day. I will say that for GA it’s a pretty painful procedure and you run a lot of gas and more opioids, the old ladies not able to do PT bc of nausea is real.

If your spinal dose is high bc they’re slow just do GA. I’ve done mepivacaine and 1cc of 0.75 for the fast guys (<90 min skin to skin) and they’re moving their legs in pacu. One thing I would suggest is use a lower dose of heavy and have them lie on their side for 3 minutes. Ortho rooms are busy, I announce this after placing the spinal, tell them when the clock strikes X o’clock they can position. It’s only 3 minutes but I’ve found you get a great spinal with a lower dose, trick I learned from a guy who worked at an ortho only asc. Have to command the rooms attention, gives the circulator some time to chart.

Posterior knee pain: this is all how the ortho surgeon injects into the posterior capsule. I asked one of the ortho guys I respect who only does hips and knees about this bc his patient were dramatically different with pain control than the other people in his group. He said most people are trained for four injections in four quadrants, he said he injects everywhere, he aims for 20 injections of his cocktail. Almost all of his patients went home the same day
 
UscGhost said:
Posterior pain is an issue for sure. Ipacks work sometimes, not reliable.

We use a very light spinal, so it helps reduce discharge delays, but still happen sometimes.

Patients seem happier in pacu with spinals on average. Data is murky
Click to expand...


What’s in a very light spinal? Genuinely interested.

And is this at a hospital outpatient department or an outpatient surgery center? I have an opportunity to do joints at an outpatient surgery center but I don’t want to do it if I have to wait 2 hours after the last case for the patients to be discharged.
 
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3cc of 2% mepivacaine gets you about 70 min…1-1.2cc of heavy bupi reliably gives you 90-120 min. I actually like the heavy with them lying of their side as I mentioned above. Dense short block. Mepi I’ve had to put in a few LMAs at the end, you need a surgeon who is like clockwork for it to work. One of my previous partners had to have a come to Jesus talk with an ortho surgeon who kept vocally complaining about GA, 4 hour total joints +/- 1-2 hours, sometimes >1L of blood loss. Total princess to the staff. You can be a princess when you’re doing >8 totals in two rooms or >5 in one room and done before 4pm.

For an outpatient asc do the last one GA, make sure to do blocks.

One other option, for a good surgeon in an ASC. 0.5-0.75cc of heavy, then GA +prop infusion. Need less GA/narcotic, spinal wears off quickly. You’re essentially doing two anesthetics so if you’re eat what you kill can only bill for one. Right patient, right surgeon it’s elegant, wrong patient wrong surgeon it’s an overkill mess. A lot of what makes a good total joint program work is familiar staff/surgeons.
 
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medicine2wallstreet said:
Spinals for ortho is dumb. If patients got just a spinal and not 150mcg infusion of propofol I'd buy the benefits vs general.

4 L fluids for ortho is dumb

PENG and LFCN blocks for hips is dumb. Just be normal

That's about all I have to say.
Click to expand...
Are you an attending yet? Good Lord, I hope so.
 
ambiturner said:
I agree, I always tried to convince people to stay awake and watch the surgery if they got a spinal since you’re losing a lot of the benefit if they were going to get propofol anyway. They don’t need pressors and fluid then either. C-sections are way more uncomfortable and we do them awake without question.
Click to expand...
Let me get this straight, you actually try to convince your patients to stay awake and talk to you during the surgery? That’s very impressive. You must have the compassion and patience of a saint.
 
nimbus said:
What’s in a very light spinal? Genuinely interested.

And is this at a hospital outpatient department or an outpatient surgery center? I have an opportunity to do joints at an outpatient surgery center but I don’t want to do it if I have to wait 2 hours after the last case for the patients to be discharged.
Click to expand...
Small or older patient, I'll use 5-6mg of 0.5% isobaric

Larger, younger patient, I'll use up to 7-7.5mg.

I add 20mcg of fent as that allows me to use less bupiv and still obtain a good spinal. Not uncommon for patients to move their feet during closure if I turn off the property gtt. No pain though.

Heavy prop gtt during case. Neither me or the surgeons wants patients moving and chatting.

I do the same protocol for outpatient ASC and inpatient.
 
Spinal + GETA (0.5 MAC) +/- adductor/PENG/ETC

Works great. MAC cases are truly annoying. I prefer a secured airway which also allows you to paralyze and uptitrate anesthetic should the case go longer. PONV from inhalational is also reduced when you use significantly lower concentrations of gas.
 
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