Combined-regional general technique?

[DreamweaverSRNA]

If anyone uses this method of anesthesia, like with hips, please tell me how this works. I am trying to expand my care plans from "just the basics", but I am not sure how this one is done. It makes sense that you would put in the epidural for post-op pain and early ambulation, but do you actually use it to decrease volatile agent amounts intra-op by dosing it pre-op? Thanks!

[TraumaNurse]

We usually give a dose on insertion of the Epidural. For short cases, we may not dose it anymore until post-op. For the bigger cases, however, we will dose it intermittently and/or start the CEA infusion during the case. For intermittent, I use Lidocaine 2% with Epi starting with 3mL. For CEA we use 0.125% Bupivacaine with 20 mcg/mL of Fentanyl in the bag (We usually start the infusion at 2-3 mL/hr). This does help to decrease the narcotic and volitile agent requirements. Hope this helps.

[gaspassah]

the technique is when you place the epidural needle and verify placement, inset a spinal needle through it, there are some epidural needles with a special "side port" specifically for this. once csf is present indicating the sub arach sp. inject the spinal med through the spinal needle. withdraw the spinal needle and thread the epidural cath. this can then be activated later.

d

[heartICU]

We usually don't use our epidurals to augment the anesthetic until the bloodletting is over...you don't want a sympathectomy and then run into some bleeding and not have your patient be able to respond with tachycardia, vasoconstriction, etc.

[gaslinq]

If anyone uses this method of anesthesia, like with hips, please tell me how this works. I am trying to expand my care plans from "just the basics", but I am not sure how this one is done. It makes sense that you would put in the epidural for post-op pain and early ambulation, but do you actually use it to decrease volatile agent amounts intra-op by dosing it pre-op? Thanks!

It seems a shame to already have the epidural in and not use it during the procedure. Yes, you can give anesthetic through the epidural catheter and thus decrease the need for volatile agents. The key word here is TITRATION. Since you already have a working epidural, you can use less concentration of the volatile agent and since you already have a volatile agent, you can also decrease the volume and/or concentration of the epidural agent . You can also use low concentrations of intravenous agents like Propofol without the corresponding need for high dose narcotics since analgesia (and muscle relaxation) is already provided for by the regional. For hip surgery, though, I would think that a purely regional technique should be enough unless the patient needs airway support for positions other than supine. Combined regional/general technique is more suitable for upper abdominal procedures wherein a purely regional technique may require such a high level as to compromise the patient's ventilation and cardiovascular function due to the sympathetic blockade while a purely general technique would deprive the patient of the pre-emptive analgesia and excellent post-operative pain control provided by an epidural catheter.A combined technique will not only assure a good airway and ventilatory support but will also enable one to use a lower concentration and volume of local anesthetic preventing a profound sympathetic blockade. However, as with combined/spinal epidural (see separate thread regarding this), the use of both regional and general techniques exposes the patients not only to the benefits of both but also to the RISKS inherent in both techniques. Therefore, do not attempt to use this technique unless you are adept and managing the complications and/or side effects of both regional and general anesthesia.