2-malchow-outpatient spinals and epidurals-handout

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


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):

hypotension, bradycardia, sedationRecommendation: Avoid

EPIDURAL-RECOVERY2CP VS LIDOCAINE VS MEPIVACAINE

Kopacz, 1990

CP Lido Mepiv

2 CHLOROPROCAINE-EPIDURAL ADVANTAGES

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

EFFICIENCY OF EPIDURAL VS GA

48 Knee Arthroscopy (Epidural vs GA vs SAB)

Epidural, 2CPGA/LMA, Prop/N2O/Fent Spinal, Procaine 75/ Fent 20mcg

All IA Bupiv

All IV Toradol

Upshot: CLE and GA:Similar discharge times (92 vs

104min)Spinal? Interpret due to procaine useslowest recovery, 146min> nausea and pruritis

Epidural Washout:10-20ml of N.S. in pacuRecovered 48min sooner (Lido/epi)Malchow, anecdotal: appears

helpful

Mulroy, 2000; DiFazio, 1997.

EFFICIENCY OF SPINAL VS GA

84 Knee ArthroscopySpinal: Lido 50mgGA/LMA:Propofol/N20/Fent

Similar discharge times (120 min) and pt sat

Spinal:< PACU pain> backache (35 vs 13%)

GA:>Sore throat, drowsiness, pain

< Costs w/ RA:2o to < pacu time, nsg

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


EFFICIENCY OF EPIDURAL VSSPINAL

63 Knee Arthroscopy30 Epidural: 2CP-3% x 15ml33 Spinal:Lido 25mgFentanyl 20 mcgDextrose

Similar failure rate (10%)

Similar Discharge Times (152 vs 142 m)

Similar satisfaction scores (>90%)

Nashville Surg Ctr:

Epidural-CP quicker recover than Spinal-L

Pollock, 2003

II. SUCCESS RATES:

EpiduralsAdjuncts

Why do they Fail?

SpinalsDose responseBaricityAdjuncts

REASONS FORCNB FAILURE

Poor patient selectionNeedle/orifice not in spaceSlow onsetInadequate / low doseTourniquet painMaldistribution of local

anesthetics (caudal aperture of pencil-ptneedles)

Unilateral blocks

Lengthy surgeryInexperienced surgeonsSubdural injectionsAbnormal anatomyCyst formation in

interspinous ligamentsOther

LIDOCAINE SPINALSDOSE-SUCCESS

(40MG LOWEST SUCCESSFUL DOSE W/O ADJUNCTS)

Surg Type

Bari-city

Dose Adjunct Failure Rate

Com-ments

Author

Knee Scope

Iso 80 3%

Urmey

199540 10

30 100

Knee Scope

Hyper 25 Fent 20 9% IA Bupiv

Pollock2003

20 Fent 20 0 Ben-David

2001

BUPIVACAINE SPINALDOSE-SUCCESS

(7.5MG DOSE LOWEST SUCCESSFUL DOSE W/O ADJUNCTS)

Surg Type

Bari-

city

Dose Adjunct Failure Rate

Com-ments

Author

Knee

Scope

Hyper 7.5 0% Ben-

David5 Fent 10 0

4-5 24

Knee Hyper 4-6 2-6% SSA Valanne

Hernia Hyper 6 Clon 15 0% SSA Dobryd-njon33

Hernia Hyper 6 Fent 25 5% Gupta

Alternative to CP or Lido spinals (knee scope, IHR)

with “low dose, low volume, low flow”

Local Anesthetic: usually hyperbaric bupivacaine (4-6mg)

Ipsilateral side down

Pencil point needle, aperture towards ipsilat side, slow injection (1-2min)

Maintenance of posn 10-15min (block room)

Results in < motor and sensory duration on contralateral side (Fig)

Quicker Recovery

home readiness 15min < than GA

> pt sat than GA

< Urinary retention

CONSIDER SELECTIVE SPINAL ANESTHESIA?

Enk, 1998 Valanne, 2001 DobrydnjovKorhonen, 2004Capelleri, 2005 Mulroy, 2005


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-

100mgprolonged discharge increased n/v, pruritisRecommendation:

Avoid

Prilocaine avail in Europe (not U.S.) high failure rate w/o fentanyl high rate of POUR (up to

25%)Recommendation: Avoid Articaine older drug, used in dentistry dosing: 60, 72. 84 mg similar duration of lido some concern with

neurotoxicityRecommendation: Avoid

OTHER SPINAL AGENTSArticaine: Forster, 2011; Kallio, 2006; O’Donnell, 2010; Bachmann, 2012

Prilocaine: Forster, 2011; Hendricks, 2009; Campanovo, 2010; Black 2011

SPINAL/EPIDURAL OPIOIDS

Synergistic effect with local anesthetics

Increased intensity/quality of block

Critical with low dose spinals

Pruritis: 30-100% Dose dependent

Recovery: No effect on motor block, nausea No effect on time to void,

discharge

Spinal DosesFentanyl 10-25mcgSufentanil 2.5-5.0mcg

Epidural DosesFentanyl 3-5mcg/ml0.5-1 mcg/kg/hr (inpts)Sufentanil 0.5mcg/ml

NSC: we avoid opiates


SUCCESS - SPINALS

90-95% averageNSC: 92.%

Higher failure rate with pencil point needles

Select drug, dose, adjunct, baricity for each procedure, surgeon

Higher success than epidural s/p lumbar fusion

Ensures sacral coverage more reliably

Consider 22gu quincke for patients > 50 yo

Opioid critical at low doses

IMPROVING SUCCESS- EPIDURALS

85-90% averageNSC: 91.5%

Block Room important

Place Epidural at Epicenter of incision

Confirmation of Epidural Space30% false positive rate with LOR10% false positive rate with ease of cath advancement p LOR

Avoid catheter advancement beyond 5cm

Consider use of CP, quicker onset (NSC CP 94%)

Consider opiate adjunct for synergy/ > quality

III. MINIMIZING CNB COMPLICATIONS

(INTRAOPERATIVE)

Hypotension

Bradycardia

Cardiac Arrest

HYPOTENSION AND BRADYCARDIAVS BLOCK HEIGHT

10% profound hypotension (esp elderly, hypovolemia, and hypertensive pts)

HYPOTENSION AND BRADYCARDIAvs AGE

Bradycardia

Hypotension

Note: Hypotension < common with low dose Spinals

SPINAL CARDIAC ARREST

Overall average cardiac arrest rate = 1:1500;

highest for any technique

Upshot: Judicious IVF’s, treat early w/ atropine, pressors

NSC: 1 Severe Bezold-Jarisch Reflex, 5 sec asystole 40min after lido 40mg; resolved w/ glyco; no sequela

Moore1996

Mackey1989

Tarkkila1991

Geffin1998

Auroy1997

Rate: 1:2900 3/180 1:630 > 1:570 1:1500

Comments: 11,574 spinals

Virg Mason 1881 spinals

12/< 4000 spinals

103,730 reg anes


III. MINIMIZING COMPLICATIONS(POST-OPERATIVE)

EarlyN/VUrinary Retention (POUR)

LatePDPHBackache Transient Radicular Irritation

NAUSEA AND VOMITING

PNB: < 5 %Epidural: 3-9%NSC: Nausea 11%, Vomiting 0%Spinal: 12-18%NSC: Nausea 10%, Vomiting 3%GA: 13-32%Mechanism: unopposed vagal activityEpinephrine associated with incr. N/VLipophylic opioids do not significantly incr. N/VAvoid opiates if possible (use of multimodal, pnb if appropriate)Antiemetics prn

POUR: SPINALS AND EPIDURALS

S P I N A L S :3-35% Incidence overall Depends on dose, adjuncts 3-4% for CP, lidocaine NSC: No POUR

Urge to void disappears immediately

Causes: overdistension of bladder/bladder

neck edema (ie > 600ml) urinary sphincter spasm

(pain/anxiety) bed confinement epinephrine: incr. time to void by

81min

E P I D U R A L S :

Low incidence 1% Similar to GA for CP, Lidocaine NSC: No POUR

Time to void (Kopacz, 1990): CP: 211 min Lido: 235 minMepiv: 308 min

URINARY TRACT NEUROANATOMY

*

Spinal anes blocks both afferent and efferent innervation to bladder fxn

URINARY RETENTION-SPINALKAMPHUIS, 1998

Hyperbaric 100mg

Hyperbaric 10mg

1=motor resolution2=detrusor resolution

Lasts until regression to S3

Consider epidural (esp CP) for higher risk pts (IHR)

Avoid excess IVFs< 1000 ml if possibleEarly use of ephedrine prn

Consider SSA

Local Anesthetics: Short acting LA-spinalsLow dose bupiv

Adjuncts:Avoid epinephrine, clonidineLipophylic opiates, esp w/ low

dose bupiv acceptableLimit opiate dose

Low threshold for catheterization (see algorithm)

Encourage sitting/walking asap

URINARY RETENTIONPREVENTION


POUR ALGORITHM:

High Risk Group: 5% POUR w/ GA

Hernia, Pelvic, Perirectal > 70 yo H/o POUR, BPH

Low Risk Group: No epinephrine or

clonidine, bupiv < 7.5 or short acting agents (CP, Lido) If not high risk group

Ben-David, 2001; Pavlin, 1999; Mulroy, 2002; Mulroy 2012

Condition: Action:

High Risk:

Not Voided w/i 60 min

Check BUS

BUS > 600ml In/out cath, thenDischarge or further obs

BUS < 600ml Wait add’l 60min and repeat

Low Risk: Discharge w/ low risk pts or BUS < 400ml; Instruct to return to ER w/i 8 hrs if no void

ESTIMATING BLADDER VOLUME:

Curvilinear ProbeProlate Ellipsoid EquationVol = lgth x width x hgt x 0.52 = (9.77 x 11.6 x 15.2) x 0.52= 895 ml

11.66 cm

9.77 cm

15.2 cm

Transverse View

SagittalView

LATE COMPLICATIONS:POST-DURAL PUNCTURE HEADACHE

FactorsAge, needle, guage, bevel orientation

Pencil-point important for younger patients

27gu/30gu offer little advantage

Equivalent risk: SAB vs CLE vs CSE 1-2% ave incidence w/ pencil pt needlesNSC: SAB: 2.1%; Epid: 2.1%CLE and wet-tap (4%): bevel parallel 30% incidence vs bevel

perpendicular 75%

LATE COMPLICATIONS: BACK PAIN

Chloroprocaine Still some assoc

with high volume (>25ml)

Consider Rare Complications

Epid hematoma in healthy 35yo knee scope w/ excruciating LBP 2hrs post-disch(Gilbert, 2001)

Duration of Surgery: (hr) Incidence of LBP: (%)

0-1 18

2-3 24

3-4 34

4-5 50

Technique: Incidence of LBP: (%)

Spinal 21

Epidural 30

General Anesthesia 19

Brown 1961; Finucaine, 1999; Gilbert, 2001

NSC: 4.2% LBP after Epidural

TRANSIENT NEUROLOGICAL SYNDROMETRANSIENT RADICULAR IRRITATION

POST-SPINAL MUSCULOSKELETAL SYNDROME

Description:Dysesthesias to buttocks, LE’s, 1-

4 days, w/ nml PE

Incidence: lido 70-100mg 16-80%<60mg 1-3%NSC: 0.5%mepiv 16-30% bupiv 3-13%CP rare

Epinephrine:animal studies: > sens deficits

comp to plain little reason to add to lidocaine

Increased Incidence:Obesity, lith posn, outpts

No significant role:GlucoseConcentration of LABaricityDoseAge

REASONS TO CONSIDER CONTINUED LIDOCAINE USE

Flawed studies- lack of random, sml studies

Phillips, 1969: 10,440 ptsw/ 5% lidocaine

40-100mg dose, mainly obstetrics 0.3% “TRI” type symptoms

Wong, 1999: 0% incidence in C/S pts

Malchow, NSC series:No reports of TNS

If present, “transient” w/o deficits

neg emg, ncv, ssep studies>40 years before 1st case

reportBack pain: common

regardless of anesthesiaPosition probably more impt

issue (Lith)If concerned, discuss w/ pt

and use lido < 60mg


IV. HIGH PATIENT/SURGEON SATISFACTION

Dependent on:EfficiencyHigh Success RateLow Complication

Rate

If these 3 conditions met, Goal IV will be achieved as well.

Jankowski, LPB vs spinal vsGA for knee scope. AA, 2003

Techniques:GA- Prop/Fent/LMASAB- B6, F15LPB- M1.5% w/ epiGA had lowest pt satisfaction

scores and higher postop painSAB and LPB similar

NSC Pat Satisfaction for both Epidural/Spinals: V.G.-Excellent: 97%, Good: 3%; Poor/Fair: 0%

Anesthesia for Knee Scope

GA-LMASAB/

Epidural

Leg Block (LPB-

LE/Sci-CP)

Pro:

Con:

“Asleep”Easier

PONV (30%)Delirium/ opiatesSore throatPainAspiration risk

PDPH 2%< BP, HRFear of “spinal”Possible prolonged recoveryBack pain (30%)

Able to observeSuccess (95%)PONV 10-20%

Good recoveryUnilateral blockHemodyn stabilityMin PONV (5%)

Procedure pain> Failure (10-20%)Epidural spread 5%LAST 1:1000 LPB

- Young, anxious, desires to be asleep

- Would like to avoid GA and CNB- Wants to watch?

- h/o PONV?- ? >40 yo?

SUMMARY OF OUTPATIENT SPINALS AND EPIDURALS

High Efficiency Possible: Intraop and Postop Esp w/ use of block room (epid) Short-acting agents (CP, Lido) Consider SSA, low dose

bupiv/opiate

Adjuncts: Avoid epinephrine, clonidine Lipophyllic opiates acceptable

High Success Rates PossibleConsider CNB/ PNB when

appropriate (ACL)

Minimize Complications Bradycardia, Cardiac Arrest PONV Urinary Retention – algorithm PDPH Backache TNS

High Patient / Surgeon Satisfaction

SELECT REFERENCES:

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.


2-malchow-outpatient spinals and epidurals-handout

Documents