DISCLOSURE: I have no disclosures to report regarding financial incentives or gains from pharmaceutical companies or manufacturers. INTRODUCTION Beyond “Marcaine Spinals” vs GA Perioperative physicians/providers Patient’s perceptions and preferences (Shevde, 1991, 800 pts) 70% General anesthesia 20% Local 10% “Spinal”/Epidural Patient Satisfaction > 90% after CNB Significant Benefits with Reg Anes REGIONAL ANALGESIA- IMPROVEMENT IN OUTCOME Decreased- GA side effects/ complications Opiate Side Effects Blood Loss, DVT LOS, Hosp Cost Ileus, constipation, N/V Stress Response Chronic Pain MI, ischemia Pulmonary Complications POCD, POD? Improved- OR Efficiency PACU Recovery and rehab Post-op Analgesia Patient Satisfaction Surgeon Satisfaction High Efficiency Intraop and Postop High Success Rates Low Complication Rates Intraop and Postop High Patient / Surgeon Satisfaction GOALS FOR CNB IN AMBULATORY PATIENTS I. HIGH EFFICIENCY Intraoperative Efficiency Postoperative Recovery Local Anesthetic and Dose Spinal Epidural Anesthesia Technique GA vs CNB Spinal vs Epidural Malchow, Randall, MD Outpatient Spinals and Epidurals
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DISCLOSURE:
I have no disclosures to report regarding financial incentives or gains from pharmaceutical companies or manufacturers.
INTRODUCTION
Beyond “Marcaine Spinals” vs GAPerioperative physicians/providersPatient’s perceptions and preferences (Shevde, 1991, 800
pts)70% General anesthesia20% Local10% “Spinal”/Epidural
Patient Satisfaction > 90% after CNBSignificant Benefits with Reg Anes
REGIONAL ANALGESIA-IMPROVEMENT IN
OUTCOME Decreased-GA side effects/ complicationsOpiate Side EffectsBlood Loss, DVTLOS, Hosp CostIleus, constipation, N/VStress Response Chronic PainMI, ischemiaPulmonary ComplicationsPOCD, POD?
Improved-OR Efficiency PACU Recovery and rehabPost-op Analgesia Patient SatisfactionSurgeon Satisfaction
High EfficiencyIntraop and Postop
High Success Rates
Low Complication RatesIntraop and Postop
High Patient / Surgeon Satisfaction
GOALS FOR CNB IN AMBULATORY PATIENTS
I. HIGH EFFICIENCY
Intraoperative EfficiencyPostoperative RecoveryLocal Anesthetic and DoseSpinal EpiduralAnesthesia TechniqueGA vs CNB Spinal vs Epidural
Malchow, Randall, MD Outpatient Spinals and Epidurals
ACT (Anesthesia Controlled Time) I: In OR – Turn Over To
Surgeon (TOTS)preoxygenation/ Induction/
Airway Management II: Dressing On – Out of ORemergence/ Extubation/ LMA
Removal
Spinals - quick block time (ave 7min) and
onset time can be comparable to GA (ACT I)
Epidurals - placement of catheter in block room
(initiate low dosing in block room) consider alkalinize solution consider fast onset agent CP: sets up 8min faster than Lido
consider CSE (if in OR and/or uncertain surgical duration) consider dose thru needle technique
(if in OR)
Both techniques eliminate emergence/extubation time (ACTII)
EFFICIENCY INTRAOPSPINAL RECOVERY
DOSE-RESPONSE
Surg Type
Drug Dose
mg
Baricity Motor Blk
Time Disch
Author
Knee Scope
Bupiv 5 Hyper 181* Lui
19967.5 202
10 260
15 471
Knee
Scope
Lido 40 Iso 93 178 Urmey
199560 128 216
80 142 214
DURATION WITH HYPERBARIC BUPIVACAINE
LIU, 1996
Measurement: Duration:
Duration of Surgical Anesthesia
Umbilicus 5 min/mg
Knee 13 min/mg
Ankle 15 min/mg
Achievement of Discharge Criteria 21 min/mg
SPINAL CHLOROPROCAINE-IDEAL AGENT?
History:1951: 1st SAB w/ chloroprocaine; 214 pt series in 19521980: Neurotoxicity case series (8): due to sod bisulfite/low pH1987: Low back pain concerns. Due to EDTA.
1996: New PF/antioxidant free CP:No known neurotoxicity not FDA approved for SAB use; “off-label”(nor is isobaric bupiv or lidocaine, fentanyl)Use only preparations in “brown vials”:Bedford Labs, generic CPAstra Zeneca, “Nesacaine-MPF”; pH= 2.7-4.0(Avoid Abbott, clear vial, with sodium bisulfate)
SPINAL CHLOROPROCAINE
30-60mg dose range (40mg most common)40-50mg: 45-70min60mg: 60-90min< duration compared to lidocaine
<< duration comp to bupivacaine
Casati, 2007 CP- 50mg Lidocaine-50mg
Motor (min) 60 100
Sensory (min) 95 120
Ambulation (min) 103 152
Lacassee, 2011 CP- 40mg Bupivacaine- 7.5
Motor (min) 76 119
Sensory (min) 146 329
Discharge (min) 76 min faster for CP
SPINALS:CP 40MG
LIDO 40MG BUPIV 7.5MG
(ALL ISOBARIC)
CP
CP
< duration CP vs lidocaine. 104 vs 134min for d/c criteria
<< duration CP vs Bup113 vs 191min for d/c criteria
Kouri, 2004; Yoos, 2005; Casati, 2007
Lido
Bupiv
Malchow, Randall, MD Outpatient Spinals and Epidurals
ADJUNCTS (NON-OPIOID) WITH SPINALS/EPIDURALS
E P I N E P H R I N E :
20-50% > in duration (esplido and tetracaine)Greater effect on Time to
Discharge than blk durationPoor Recovery Profile
(Urmey, 1996)added 81 min to Time to
Ambulationadded 106 min to Time to
DischargeRecommendation: Avoid
C L O N I D I N E :
Dose: 15-30ugEven 15ug > motor/sens
durationHigh Cost in U.S.10ml SD vial (1000ug)Europe has low dose vialsHigh dose (1-2mcg/kg):
Rapidly Metabolized t1/2 = 25sec“no significant plasma concentration”More “titratable” due to short durationRapid RecoveryReady for discharge one hour earlier compared to lido (Neal)Lidocaine may double discharge time comp to CP< time to void
interventions, and unplanned admissionsConsider spinals early in day
Wong, 2001; Williams, 2005
Consider entering OR 5 min sooner if possible for possibly difficult pts
COMBINED SPINAL EPIDURAL
Capitalize advantages from eachFast onset< hemodynamic changes TitratableMinimize disadvantages from eachSlow onset w/ epiduralsAvoid sacral sparing/patchy blk from epiduralSlow recovery from lg spinal dose
Malchow, Randall, MD Outpatient Spinals and Epidurals
Malchow, Randall, MD Outpatient Spinals and Epidurals
BARICITY CHOICE
Hyperbaric: sacral roots or extensive spread importantIsobaric: > duration; LE/groin/GU surgeryHypobaric: jack-knife posn (lido 20-40)Spread: also depend on dose and direction of orifice
Urmey, ‘03
PERI-RECTAL CASES- “SADDLE” BLOCKS
For Jack-Knife Cases: - Use Reverse T-burg for needle placement, then use T-burg for hypobaric LA (Lido 20-40mg)(or sitting pos’n for placement with hyperbaric, then wait 10 min)
For Lithotomy- Perirectal cases:- Consider Saddle block hyperbaric, low dose LA (Lido 20-30mg or Bupiv 3-
5mg)
MEPIVACAINE SPINAL FOR OUTPTKNEE SURGERY
(60) ACL ptsIsobaric mepiv 1.5%60 vs 80mgPros, RCT, DBEpidural
Supplementation: 12% in 60mg grp 3% in 80mg grp
L1 Regression: 146 min vs 159 min
Knee Scopes:M-30mg + F10 vs M-40mg
Other Estimates: Other: 40-50mg = 90-120min
surgical anesthesia 45mg = 220min for discharge
readiness
Pawlowski, 2000; YaDeau, 2005; O’Donnell, 2010
M30 + F10 M40
Sensory (min): 118 170
Ambulation (min): 176 206
Ropivacaine 50% spinal potency
compared to bupiv or levobupiv same recovery profile as
bupivacaine (> 3hr dischtimes) (1 study of volunteers
demonstrated 14min/mg for Time of Discharge)No advantage over bupiv
Levobupivacaine similar potency to bupiv same recovery profile as
bupivacaine (> 3 hr dischtimes) (1 study w/ hypobaric LB-4
or 5mg w/ Fent 10ug = 90 and 132min Time of Discharge for knee scopes)No advantage over bupiv
OTHER SPINAL LOCAL ANESTHETICSMcDonald, 1999, Capelleri, 2005, O’Donnell, 2008; DeSantiago, 2009; DeSantiago, 2011
ProcaineOlder drug, short actinghigh failure rate (17%)10% solution; 60-
Campanovo et al. A Prospective Double Blinded RCT Comparing the Efficacy of 40mg and 60mg Hyperbaric and Isobaric 2% Prilocaine for Intrathecal Anesthesia in the Ambulatory Surg. A&A. 2010; 111: 568-72.
Choi et al. Neuraxial anesthesia and Bladder Dysfunction in the Perioperative Period: A Systematic Review. CJA. 2012; 59;681-703.
Casati et al. Spinal Anesthesia with Lidocaine or Prev Free 2-Chloroprocaine for Outpatient Knee Arthroscopy. A&A. 2007; 104:959-64.
Forster. Revival of Old Local Anesthetics for Spinal Anesthesia in Ambulatory Surgery. Curr Opn Anes. 2011; 24:633-7.
Forster. Short-acting Spinal Anesthesia in the Ambulatory Setting. Curr Opn Anes; 2014; 27:597-604.
Goldblum et al. The use of 2-Chloroprocaine for Spinal Anesthesia: A Review. Acta Anaesth Scand. 2013; 57: 545-552.
Korkonen et al. A Comparison of Selective Spinal Anesthesia with Hyperbaric Bupivacaine and General Anesthesia with Desflurane for Outpatient Knee Arthroscopy. A&A. 2004; 99: 1668-73.
Lacasse M. Comparison of Bupivacaine and 2-Chloroprocaine for Spinal Anesthesia for Outpatient Surgery. C Jnl Anesth. 2011; 58:384-391.
Mulroy et al. Managemetn of Bladder Volumes When Using Neuraxial Anesthesia. Intl Anes Clin. 2012; 50: 101-110.
O’Donnell et al. Reg Anes Techniques for Ambulatory Orthopedic Surg. Curr Opn Anes. 2008; 21: 723-8.
Santiago et al. Low Dose Low Concentration Levobupivacaine Plus Fentanyl Selective Spinal Anesthesia for Knee Arthroscopy: A Dose Finding Study. A&A 2011; 112: 477-80.
Williams et al. Reg Anes Procedures for Ambulatory Knee Surgery: Effects on In-Hosp Outcomes. Intl Anes Clin. 2005.
Malchow, Randall, MD Outpatient Spinals and Epidurals