[Qwiigley]

Experienced CRNAs;
Lets look at positioning, needles, doses for spinals for total hip replacements.
What are your likes, dislikes. Drug choice, doses. What is your favorite position for placing?

Spinals for total hips in our hospital needs to last around 1 hr but with some surgeons it needs to last a little longer. Many times I will use Tetracaine 1mL with Dextrose 1mL with Fentanyl 25mcg and between .2-.3 mg of duramorph. I lay the pt on the effected side (starting a light propofol gtt and giving them some versed before hand). I position them in a semi-fetal position and quickly place the spinal using midline technique. (We don't have anyone to help us with airway, sedation or holding the pt soemtimes). Of course, I have them on a pulse ox so if I have to, I break sterile and deal with the airway/oxygenation. Usually if I'm fast enough, I can throw it in before anyone has a chance to desat.
I find that for the really elderly, I need to use paramedium technique. I am not real great at that yet. Os, Os, Os with the old guys!
Whittacre needles are in our kit 25g. Occasionally a 22g without an introducer has to be used, but I try to avoid.
How young of a person do you give spinals to? I had a 22 yo male with a kidney stone that needed ESWL and I wanted to give a sufenta spinal to him, but my peers thought he was too young. What do you think?
(I'm tired of reading about questions that have nothing to do with practicing anesthesia, maybe we can use this blog for what it is intended for: bettering our practice).

[JoeCRNA]

I tend to do things quite similarly; however, I use a little ketamine 10-20 mg (typically 10mg) in addition to some versed and occasionally propofol for premedication. I have found this combination has minimal respiratory depression and is tolerated well by patients.

I have not done much with the paramedian approach, but have been talking to colleagues and reading more about it. It is my intent to give it a try the next time an opportunity presents itself.

With regards to age limits for spinals, I don't really see an issue so long as the patient can tolerate the procedure, and a small gauge pencil point is used. What specifically are your colleagues concerned about? PDPH? Have you ever worried about the age of a Parturient undergoing a c/s...

[snowboarderRN]

I use tetracaine or hypobaric marcaine which I really like - I can position the patient quickly after I place the spinal and the patient doesn't have to stay affected side down as the block doesn't move around much. I put the spinal in affected side down or sitting if they can tolerate it. I then put them on a propofol gtt for comfort....

[stonecrna]

Total hip-Position patient lateral, affected hip up. O2 via simple mask, Versed 2mg, Fent 50mcg. Pulse-ox, bp cuff on. Bup. 1/2% preservative free, no dextrose 12.5mg + 0.25mg duramorph 0.5mg/ml (3ml total). 22ga quincke for the old folks (when is the last time you had to patch an old bird for a HA? I never have.) Tell the circulator to start prepping the hip. Propofol gtt 50mcg/kg/min- titrate as needed.
Spinals work just as well on young folks- just make sure to use the 25ga whitacre.
I used to do sufenta spinals for my ESWLs, but found deep sedation with propofol +/- LMA saves time and is just as effective.

[Qwiigley]

....nice!!.....

[jwk]

Originally Posted by Qwiigley

I position them in a semi-fetal position and quickly place the spinal using midline technique. (We don't have anyone to help us with airway, sedation or holding the pt soemtimes). Of course, I have them on a pulse ox so if I have to, I break sterile and deal with the airway/oxygenation. Usually if I'm fast enough, I can throw it in before anyone has a chance to desat.

How young of a person do you give spinals to? I had a 22 yo male with a kidney stone that needed ESWL and I wanted to give a sufenta spinal to him, but my peers thought he was too young. What do you think?
(I'm tired of reading about questions that have nothing to do with practicing anesthesia, maybe we can use this blog for what it is intended for: bettering our practice).

I'm not a fan of deep sedation for spinals or epidurals, and definitely wouldn't be in the situation you describe with limited or no real help. No argument with a little versed and/or fentanyl, but I want a responsive patient if possible, and certainly don't want them so snowed I have to worry about their airway.

I see no problem at all with a spinal in younger patients. Why not? If you're worried about a headache, use a 27ga needle. Works great.

[stanman1968]

sitting preferred, lateral for hips. usually 15 mg bupivicaine with epi 20mcg fentanyl and if going to ob or ICU some duramorph. For hips CSE epidural for post op pain with a strait local running no narcotics to avoid dumb ass concerns over resp depression.
When placing 2mg at most of versed.

[paindoc]

I haven't done these for years, but used to use hypobaric tetracaine (powder mixed in sterile water) with the affected hip up, 22ga Quincke tip needle, with fentanyl 12mcg. We had post op nausea when using duramorph. Marcaine is isobaric, not hypobaric.

[Qwiigley]

hey guys!
I had a student with me all day today, whew! I'm tired of talking! But, he had this study concerning the change of Isobaric marcaine to hypobaric when warmed to body temp. Anyone see that study? I'd like to read more; I forgot to ask him for a copy.

[stanman1968]

Just a reminder to check lab values. Had a 72 fx hip with bad CAD miX2 and CABGX4, with EF 35%, ortho wanted a spinal CBC from yesterday showed platelets at 98, I thought that was a bit low and also thinking are we trending a bad way here? Ordered another cbc platelets back at 65, no spinal. Ortho finally did it with a general but that is another story.
Remember if I had done the spinal without checking or had under pressure from ortho and it had gone bad it would have been my A$$ on the line in a big fat lawsuit and I would have been responsible for screwing up the remaining part of this mans life.