Your input on spinal dose for TAH please

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leaverus

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Have a 60-something patient coming for TAH-BSO (usual duration for this surgeon approx. 2hrs barring any complications) and absolutely does not want GA and is requesting that I give her a spinal. Never done that for a TAH before and she's quite short: approx. 4'8" maybe 4'10" tops and weighs probably 100lb. I'm planning to do a CSE, but not sure how to dose up the spinal. i'm afraid with a full 2cc of 0.75% bupiv she'll get a high spinal. Suggestions please? Isobaric?

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Consent for possible conversion to GA, in light of Her height, and the fact that TAH can be uncomfortable even with neuraxial

Epidural. Titrate to effect during surgery. Then leave in for postop pain. Or CSE.
 
Have a 60-something patient coming for TAH-BSO (usual duration for this surgeon approx. 2hrs barring any complications) and absolutely does not want GA and is requesting that I give her a spinal. Never done that for a TAH before and she's quite short: approx. 4'8" maybe 4'10" tops and weighs probably 100lb. I'm planning to do a CSE, but not sure how to dose up the spinal. i'm afraid with a full 2cc of 0.75% bupiv she'll get a high spinal. Suggestions please? Isobaric?

edit: i was clearly wrong because nobody else suggested isobaric bupiv for this. i could still see myself using it but i wont lump everyone else in.
 
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I did a few TAH oversees using spinal technique. The thing is the procedure could take anywhere from 2 - 4 hours, therefore I gave my patients a good dose using hyperbaric bupivicaine 15mg and never had a problem with high spinal, Again this was oversees....
 
I did a few TAH oversees using spinal technique. The thing is the procedure could take anywhere from 2 - 4 hours, therefore I gave my patients a good dose using hyperbaric bupivicaine 15mg and never had a problem with high spinal, Again this was oversees....

2-4 hours for a 45 minute private practice procedure - yikes!
 
Have a 60-something patient coming for TAH-BSO (usual duration for this surgeon approx. 2hrs barring any complications) and absolutely does not want GA and is requesting that I give her a spinal. Never done that for a TAH before and she's quite short: approx. 4'8" maybe 4'10" tops and weighs probably 100lb. I'm planning to do a CSE, but not sure how to dose up the spinal. i'm afraid with a full 2cc of 0.75% bupiv she'll get a high spinal. Suggestions please? Isobaric?



Just give the 2 mL heavy Boop and when she feels like she can't breathe she will quickly change her mind and put the LMA in herself. :smuggrin:
 
Tetracaine anyone? With some epi in there it should last 2 hours minimum.
 
Have a 60-something patient coming for TAH-BSO (usual duration for this surgeon approx. 2hrs barring any complications) and absolutely does not want GA and is requesting that I give her a spinal. Never done that for a TAH before and she's quite short: approx. 4'8" maybe 4'10" tops and weighs probably 100lb. I'm planning to do a CSE, but not sure how to dose up the spinal. i'm afraid with a full 2cc of 0.75% bupiv she'll get a high spinal. Suggestions please? Isobaric?

Your choice of CSE is excellent.

I'd give TWELVE MILLIGRAMS of hyperbaric bupivicaine intrathecal.

I'd also have a syringe of .5% bupivicaine connected to the epidural catheter for potentially needed Re Dose

since

two hours for a TAH-BSO is unusually long so you may need to reinject intraoperatively.

Actually,

at the ninety minute mark I'd inject 5mL of .5% bupiv prophylactically

for good measure.
 
I've actually done this before.....1.6mg of 0.75mg bupi for a normal sized pt. adjust your dose down prn. I'd also recommend running a propofol GTT for "sedation"
 
I've actually done this before.....1.6mg of 0.75mg bupi for a normal sized pt. adjust your dose down prn. I'd also recommend running a propofol GTT for "sedation"

Did you mean 1.6ml or 1.6mg of 0.75%?

I am a proponent of low dose spinals, but even I would give a tiny bit more.

Also, it is a lot easier to say "cc's" than "ml's". We used to say "cc's" all time. I forget the reason we switched years back.
 
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Also, it is a lot easier to say "cc's" than "ml's". We used to say "cc's" all time. I forget the reason we switched years back.

Because JCAHO (now known simply as TJC) declared someone may mistake cc for 00 in an order. JCAHO...do I really need to say any more?
 
appreciate the input so far. absolutely i'm going to tell her that conversion to GA is always a possibility. tetracaine unfortunately is not on the formulary (actually my understanding is that it's been taken completely off the market??). i guess i'll try 1.6cc 0.75% bupiv. with some extra inline on the epidural cath. or would the 0.5% be a better choice for this surgery? if so, how much - 3cc?
 
appreciate the input so far. absolutely i'm going to tell her that conversion to GA is always a possibility. tetracaine unfortunately is not on the formulary (actually my understanding is that it's been taken completely off the market??). i guess i'll try 1.6cc 0.75% bupiv. with some extra inline on the epidural cath. or would the 0.5% be a better choice for this surgery? if so, how much - 3cc?

Is your 0.5% hyperbaric? If not, I personally would stick with the 0.75% which we know is hyperbaric. You are going to want a T4 block to allow the patient to tolerate the peritoneal manipulation. Most of the stimulation is going to be if the surgeon starts messing around with bowel.

You say she refuses general anesthesia. Inquire about her reasons -- maybe she has concerns that you can address. This way if you do have to convert her to GA it is not necessarily a psychologically traumatic experience for her.

Why a TAH-BSO? If it's going to be a gyn-onc case, I would make a stronger argument for putting her to sleep so she tolerates staging -- can add to length of case if you are waiting on pathology.

Just some thoughts for you to consider. I hope all goes well.
 
Is your 0.5% hyperbaric? If not, I personally would stick with the 0.75% which we know is hyperbaric. You are going to want a T4 block to allow the patient to tolerate the peritoneal manipulation. Most of the stimulation is going to be if the surgeon starts messing around with bowel.

You say she refuses general anesthesia. Inquire about her reasons -- maybe she has concerns that you can address. This way if you do have to convert her to GA it is not necessarily a psychologically traumatic experience for her.

.

no, it's isobaric. believe me, i tried to convince her for GA. She's scared of going to sleep and never waking up - oddly enough, she's been an OR nurse for many years so she's sees how safe it is and yet she still doesn't want GA. i have to admit, on academic reasons i'm curious to see how it goes under neuraxial. she's an easy airway and i'll have access at all times, so...
 
Did you mean 1.6ml or 1.6mg of 0.75%?

I am a proponent of low dose spinals, but even I would give a tiny bit more.

Also, it is a lot easier to say "cc's" than "ml's". We used to say "cc's" all time. I forget the reason we switched years back.

Yea meant 1.6cc of 0.75% thanks for picking that up, typing on an iPhone sucks. I would def recommend against isobaric bupi, you really wanna make sure to get a high level
 
She's a nurse? Bad things always happen to nurses. Be ready for a subdural injection, or a total spinal, or your syringe to spinal needle connection is weak and the syringe explodes off the needle when you inject and most of the marcaine is in but not all of it. Eek

Also, why not 2% lido boluses for a CSE to extend the duration? It'll kick in faster and go away faster after surgery.
 
She's a nurse? Bad things always happen to nurses. Be ready for a subdural injection, or a total spinal, or your syringe to spinal needle connection is weak and the syringe explodes off the needle when you inject and most of the marcaine is in but not all of it. Eek

:laugh: don't i know it, man - that was my first thought. i didn't want to be the one, but she's requesting me. 2% lido is not a bad idea, but if the spinal goes fine there's no reason for it.
 
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