Hip # ga vs spinal

[PpfSuxTube]

SPINAL OR GENERAL ANESTHESIA FOR HIP FRACTURE - NYSORA

I invite all of my anesthesiology colleagues, particularly those with expertise in regional anesthesia, to act now to atone the conclusion of the studies on Spinal versus General Anesthesia for Patients with Hip Fracture that is, potentially, harmful, both to our patients and to our profession...

www.nysora.com

Maybe already posted but I didn't see it.

What do you think?

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[PpfSuxTube]

I get the impression he is biased and ironically doesn't even see it himself. He claims amateurs did the spinals which is a needless personal jibe...
This finding must be awful for him as a big time regionalist.
I do think spinals can be useful for hip# but only for severe copd or some really bad heart failure...

To say that one way or the other is "saving lives" is a bit of a stretch tho

Some of these patients are just too delirious to stay still for the procedure even after spinal and sedation the end up needing GAWA

Comments?

 

[DocMcCoy]

I get the impression he is biased and ironically doesn't even see it himself. He claims amateurs did the spinals which is a needless personal jibe...
This finding must be awful for him as a big time regionalist.
I do think spinals can be useful for hip# but only for severe copd or some really bad heart failure...

To say that one way or the other is "saving lives" is a bit of a stretch tho

Some of these patients are just too delirious to stay still for the procedure even after spinal and sedation the end up needing GAWA

Comments?

I dunno. In my practice “very sick” patients are much MORE likely to have “hemodynamic interventions” with a spinal and prop drip compared to a little gas and a lot of muscle paralysis. I remember reading the articles a couple years ago and the only conclusion I walked away with is it probably doesn’t matter which method you choose as long as you are cautious and vigilant in your approach.

 

[TheLoneWolf]

I worked at a busy practice where ortho nearly always insisted on spinals for hips/knees and below navel traumas and fractures.

Cardiac and pulmonary cripples, age>90 did quite well with isobaric bupi spinals and prop gtt. Rare hemodynamic changes and never called to pacu for postop confusion.

 

[Coffee PRN]

I do isobaric/hyperbaric bupi for Ortho spinals and don't notice much hemodynamic change vs. hyperbaric bupi with fent for C-section. I am starting to think it is the inclusion of fentanyl that accounts for most of the hypotension after spinal.

 

[drmwvr]

our ortho's want spinals 'cause they think the room will turn faster.

 

[nimbus]

The topic has been debated and studied ad nauseum for at least 5-6 decades. If there was a clear and clinically significant benefit of one technique over another, you’d think we would have noticed by now.

 

[Remxed]

Any consensus or thoughts on practices that run patients on a propofol infusion after spinal? My training institution did that. Seems like that point it's a spinal and general with a native airway +\- oral or nasal airway.

 

[DrOwnage]

The topic has been debated and studied ad nauseum for at least 5-6 decades. If there was a clear and clinically significant benefit of one technique over another, you’d think we would have noticed by now.

This.

 

[PpfSuxTube]

our ortho's want spinals 'cause they think the room will turn faster.

Wow seriously?
I thought ortho was one of the smartest guys?

 

[Simba1711]

Yeah I don’t think is a strong difference either way as long as you are vigilant as someone suggested. A few of my colleagues give general anesthesia when they give sedation for their spinal defeating the purpose of doing the spinal with minimal sedation.

 

[DocMcCoy]

Any consensus or thoughts on practices that run patients on a propofol infusion after spinal? My training institution did that. Seems like that point it's a spinal and general with a native airway +\- oral or nasal airway.

This is my biggest pet peeve with the whole debate. A prop drip at 50-150 is responsible for a lot of hypotension and damn near general anesthesia in most of these patients.

I watched a couple of his videos including the protocol used for their spinals. I think he makes a couple really controversial statements.

So they all get a touch of ketamine followed by a suprainguinal FI block with 20-25mL 1/4 bupi, which he states reliably hits lumbosacral plexus? Then a touch of propofol for positioning after the block sets up. Spinal is lateral with a 22g cutting needle with 10mg isobaric bupi and no risk of PDPH. He doesn’t state what or if anything is given for maintenance during the case.

Not sure about the FI block claims about reliably tracking up to the lumbosacral plexus or the zero risk of PDPH. I get the risk is lower but I think it’s a bold claim to say zero. And saying the results are wrong because the investigators don’t know how to do spinals seems a bit extreme.

 

[neutro]

Case by case basis…that’s my take on this
There was intense debate on this issue last year on linked in

 

[neutro]

This is my biggest pet peeve with the whole debate. A prop drip at 50-150 is responsible for a lot of hypotension and damn near general anesthesia in most of these patients.

I watched a couple of his videos including the protocol used for their spinals. I think he makes a couple really controversial statements.

So they all get a touch of ketamine followed by a suprainguinal FI block with 20-25mL 1/4 bupi, which he states reliably hits lumbosacral plexus? Then a touch of propofol for positioning after the block sets up. Spinal is lateral with a 22g cutting needle with 10mg isobaric bupi and no risk of PDPH. He doesn’t state what or if anything is given for maintenance during the case.

Not sure about the FI block claims about reliably tracking up to the lumbosacral plexus or the zero risk of PDPH. I get the risk is lower but I think it’s a bold claim to say zero. And saying the results are wrong because the investigators don’t know how to do spinals seems a bit extreme.

I agree. Some statements he made are quite extreme.

 

[neutro]

This is my biggest pet peeve with the whole debate. A prop drip at 50-150 is responsible for a lot of hypotension and damn near general anesthesia in most of these patients.

I watched a couple of his videos including the protocol used for their spinals. I think he makes a couple really controversial statements.

So they all get a touch of ketamine followed by a suprainguinal FI block with 20-25mL 1/4 bupi, which he states reliably hits lumbosacral plexus? Then a touch of propofol for positioning after the block sets up. Spinal is lateral with a 22g cutting needle with 10mg isobaric bupi and no risk of PDPH. He doesn’t state what or if anything is given for maintenance during the case.

Not sure about the FI block claims about reliably tracking up to the lumbosacral plexus or the zero risk of PDPH. I get the risk is lower but I think it’s a bold claim to say zero. And saying the results are wrong because the investigators don’t know how to do spinals seems a bit extreme.

Agree. I typically will slip in an lma with 0.3 - 0.5 sevo just to prevent them from moving

Again I feel that this particular procedure is so variable and needs to be tailored individually.

Pinning I’ll just just do a quick general for instance

 

[pgg]

The benefits of spinal anesthesia in very ill patients are obvious to anyone who practices clinical anesthesiology.

At first, I couldn't roll my eyes hard enough at this statement.

But then ... I thought about how some CRNAs manage hemodynamics. We've had a couple locums come through that are just obstinate about it. Hypotension while waiting for incision. Wild swings as stimulation varies. Reluctance to just hit start on a phenylephrine infusion (one who insists she has "better control" with a microdripper). Their "wakeup" consists of "getting them breathing" and pulling the tube and taking them to PACU with the oral airway they shoved in to the edentulous patient as a bite block.

So maybe there's an argument for doing spinals in order to give them less room to be sloppy. An isobaric spinal gives them essentially nothing to do for the entirety of the case. Beyond mixing up the Ancef.


Me, I just put them to sleep and wake them up.

 

[pgg]

This is my biggest pet peeve with the whole debate. A prop drip at 50-150 is responsible for a lot of hypotension and damn near general anesthesia in most of these patients.

There's that, too.

 

[circleK]

We do a lot of really old, sick hips. I do isobaric spinals for nearly every hip fracture unless contraindicated or unable to position properly for it. Rarely need much sedation on top of it. Once the pain is gone for the first time since the fracture happened they’ll nap with just a whiff. Also no narcotics needed intraop or in PACU is a huge positive.

 

[makemoney2024]

SPINAL OR GENERAL ANESTHESIA FOR HIP FRACTURE - NYSORA

I invite all of my anesthesiology colleagues, particularly those with expertise in regional anesthesia, to act now to atone the conclusion of the studies on Spinal versus General Anesthesia for Patients with Hip Fracture that is, potentially, harmful, both to our patients and to our profession...

www.nysora.com

Maybe already posted but I didn't see it.

What do you think?

I have never gotten the hype of giving ketamine/versed to people and then laying them down on their fractured, painful side in order to do a spinal when I can just put them to sleep in their bed and move them over pain free.
I stopped doing that **** after residency unless I found some enthusiastic CRNA who was really into it and I didn’t want to fight them.
It seemed cruel. Have only done it when I felt like if I tubed the patient, they would end up on the unit.

 

[makemoney2024]

our ortho's want spinals 'cause they think the room will turn faster.

Hahaha. The joke is on them!!

 

[makemoney2024]

I worked at a busy practice where ortho nearly always insisted on spinals for hips/knees and below navel traumas and fractures.

Cardiac and pulmonary cripples, age>90 did quite well with isobaric bupi spinals and prop gtt. Rare hemodynamic changes and never called to pacu for postop confusion.

I bet if they were laying on a fractured hip they would prefer GA.

 

[pgg]

I have never gotten the hype of giving ketamine/versed to people and then laying them down on their fractured, painful side in order to do a spinal when I can just put them to sleep in their bed and move them over pain free.
I stopped doing that **** after residency unless I found some enthusiastic CRNA who was really into it and I didn’t want to fight them.
It seemed cruel. Have only done it when I felt like if I tubed the patient, they would end up on the unit.

Amen, amen, amen

Moving old people with broken hips onto their side, plus or minus sedation to stun them enough so they won't object, seems ridiculous and cruel to me.

100% every single time I tell (non-demented) patients in preop that I'll put them to sleep on the bed without moving them, their relief is obvious. That **** hurts.

Induce on the hospital bed, tube, move them over to the OR table.

 

[coffeebythelake]

our ortho's want spinals 'cause they think the room will turn faster.

Spinal done in preop holding?

 

[makemoney2024]

We do a lot of really old, sick hips. I do isobaric spinals for nearly every hip fracture unless contraindicated or unable to position properly for it. Rarely need much sedation on top of it. Once the pain is gone for the first time since the fracture happened they’ll nap with just a whiff. Also no narcotics needed intraop or in PACU is a huge positive.

What do you give them to lay them on their side? Which side down?

 

[Burned_Out]

At a large, un-named practice in Indiana, the orthos request spinal followed by GA for their elective hips and knee replacements. Other than wanting total relaxation to reduce the hip, I haven't figured out why this institution thinks that is superior anesthesia.

 

[drmwvr]

Spinal done in preop holding?

Mostly now, yep. But whatever improvement in 'wheels out, wheels in' is mostly unrelated.

 

[drmwvr]

Wow seriously?
I thought ortho was one of the smartest guys?

don't confuse a good test taker with a smart guy....

 

[coffeebythelake]

At a large, un-named practice in Indiana, the orthos request spinal followed by GA for their elective hips and knee replacements. Other than wanting total relaxation to reduce the hip, I haven't figured out why this institution thinks that is superior anesthesia.

U get total relaxation with the spinal.
Why doesn't the anesthesia staff push back on this? Totally unnecessary

 

[GravelRider]

Prop, roc, tube

 

[Hoya11]

U get total relaxation with the spinal.
Why doesn't the anesthesia staff push back on this? Totally unnecessary

The spinal probably is half the regular dose. Then GA to cover the rest.
This is a technique we use.
Baby spinal then GA LMA.
Spinal wears off and they are discharged an hour or two after surgery.
Goal of spinal is analgesia to get them home , not to provide anesthesia for the surgery..

 

[Hoya11]

Amen, amen, amen

Moving old people with broken hips onto their side, plus or minus sedation to stun them enough so they won't object, seems ridiculous and cruel to me.

100% every single time I tell (non-demented) patients in preop that I'll put them to sleep on the bed without moving them, their relief is obvious. That **** hurts.

Induce on the hospital bed, tube, move them over to the OR table.

Exactly , and you end up giving like 50 of fent for the whole case to those who say they are sparing opiates

 

[coffeebythelake]

The spinal probably is half the regular dose. Then GA to cover the rest.
This is a technique we use.
Baby spinal then GA LMA.
Spinal wears off and they are discharged an hour or two after surgery.
Goal of spinal is analgesia to get them home , not to provide anesthesia for the surgery..

Can you elaborate more on the technique? If the goal is to get them up and walking quickly after surgery you can use something shorter acting like mepiv?

Clearly, what you describe is not a commonly used technique. Seems like subjecting patient to risks of both neuraxial and GA by providing a mini dose of both. Neither one in-of-itself sufficient to provide an adequate anesthetic.

 

[coffeebythelake]

In any case @Hoya11 I find it amusing that while people are discussing the merits of spinal VS general, you are talking about doing both spinal AND general.

 

[Hoya11]

Can you elaborate more on the technique? If the goal is to get them up and walking quickly after surgery you can use something shorter acting like mepiv?

Clearly, what you describe is not a commonly used technique. Seems like subjecting patient to risks of both neuraxial and GA by providing a mini dose of both. Neither one in-of-itself sufficient to provide an adequate anesthetic.

The shorter acting local anesthetic have a short tail , we do low dose bupi for a long tail and prolonged analgesia compared to a shorter acting agent

You can do a hip under general without a spinal but the baby spinal is nicer once you see it IMO..

Technique was developed when doing outpatient joints needing to be discharged rapidly. Not my idea and I admit it sounds weird but now that I’ve been doing it a while it’s OK.

 

[GravelRider]

The shorter acting local anesthetic have a short tail , we do low dose bupi for a long tail and prolonged analgesia compared to a shorter acting agent

You can do a hip under general without a spinal but the baby spinal is nicer once you see it IMO..

Technique was developed when doing outpatient joints needing to be discharged rapidly. Not my idea and I admit it sounds weird but now that I’ve been doing it a while it’s OK.

What is the baby bupi dose? I played with 0.25% bupi spinals for ASC hip scopes in residency, but haven’t done it in a while.

 

[PpfSuxTube]

The shorter acting local anesthetic have a short tail , we do low dose bupi for a long tail and prolonged analgesia compared to a shorter acting agent

You can do a hip under general without a spinal but the baby spinal is nicer once you see it IMO..

Technique was developed when doing outpatient joints needing to be discharged rapidly. Not my idea and I admit it sounds weird but now that I’ve been doing it a while it’s OK.

You do realise you're talking to anesthesiologists here. None of that makes any sense.

Rapid discharge with bupi spinals aren't in any way reliable.
It's not a technique. It's nonsense and probably bad for patients

 

[TheLoneWolf]

I bet if they were laying on a fractured hip they would prefer GA.

I give them a small dose of prop, bad side up, and do the spinal in lateral. I never saw the benefit of the mixtures some of my partners gave prior to or after the spinal like fent/versed/ketamine.

 

[DocMcCoy]

I do isobaric/hyperbaric bupi for Ortho spinals and don't notice much hemodynamic change vs. hyperbaric bupi with fent for C-section. I am starting to think it is the inclusion of fentanyl that accounts for most of the hypotension after spinal.

Interestingly, one of our neurosurgeons gives 100mcg of IT fentanyl to nearly every back case. I don’t see a lot of hypotension. But they take awhile to come off the vent and itch like hell in pacu.

 

[neutro]

The issue with hip surgery as others have mentioned is simply sedation/ pain control for positioning for spinals is equivalent to a mini- general in this patient population. This patient population also doesn’t whine much post op. They’re generally good patients awaiting correction of fracture and they’re ok post op.

It’s not a drug seeking population where I’m concerned about giving opioids post op. Judicious use of opioids plus fascia iliaca block after repair under GA is typically ok. I’m not concerned about addiction in 85 year old and all this nonsense about opioids being gateway drug doesn’t apply here.

NYSORA tends to push that message and for them nerve blocks are the only way to manage pain. It’s like if you only have a hammer all you see is a nail.

Again, I find certain position regional anesthesiologists take quite impractical. It’s no different than pain docs doing “series of 3” epidurals without giving thought to specific patient situation.

Those who say that “spinal is life saving and better than GA”…well are you saying that holds true for other surgery? I mean older patients undergo all
Sorts of other surgery where spinals are non-applicable nor indicated. Often those surgeries are higher risk. Does that mean GA is unsafe for them?

Of course not. It depends on monitoring, vigilance and titration etc.

And I don’t know about you - but many of my patients are on blood thinners/ ASA and also on NSAIDs for their fractures. They’re kyohotic. Lateral spinals aren’t easy for everyone. Esp if you’re not doing them routinely.

And I can say that as someone who does interventional pain and tons of cervical epidurals etc, you really get to appreciate spinal anatomy once you’ve done a ton. Often you won’t see osteophytes on fluoro on older patients. Good luck trying to navigate through that blindly.

My cut off is 5 minutes. If I can’t do the spinal, the sedation I’m having to give to make the pt comfortable is already long enough for me to put them to sleep.

Thats why I said my position is case by case basis. I don’t make it into an ego thing.

 

[Hoya11]

You do realise you're talking to anesthesiologists here. None of that makes any sense.

Rapid discharge with bupi spinals aren't in any way reliable.
It's not a technique. It's nonsense and probably bad for patients

It sounds like maybe your just not familiar with it .. its a protocol at a major academic institution in my area

 

[Hoya11]

What is the baby bupi dose? I played with 0.25% bupi spinals for ASC hip scopes in residency, but haven’t done it in a while.

I do 0.8 ml of the 0.75 hyperbaric bupi . If it’s early in the day I’ll do 1cc

 

[GassYous]

The shorter acting local anesthetic have a short tail , we do low dose bupi for a long tail and prolonged analgesia compared to a shorter acting agent

You can do a hip under general without a spinal but the baby spinal is nicer once you see it IMO..

Technique was developed when doing outpatient joints needing to be discharged rapidly. Not my idea and I admit it sounds weird but now that I’ve been doing it a while it’s OK.

This sounds really dumb
Why don't you just do a mepivacaine spinal with a little fentanyl?

 

[ans2021]

At a large, un-named practice in Indiana, the orthos request spinal followed by GA for their elective hips and knee replacements. Other than wanting total relaxation to reduce the hip, I haven't figured out why this institution thinks that is superior anesthesia.

I know a practice not in Indiana that the orthos for anterior THA want full dose spinal plus GA with roc. State they can't do the procedure unless full relaxation. Anesthesia start to stop is 3+ hours. Knees they are ok with spinal and mac.

 

[troutangler]

This isn’t all that uncommon. I agree it’s a great technique to get patients discharge quickly for outpatient total joints especially at a surgery center. 0.8ml 0.75% huperbaric marcaine followed by propofol infusion and LMA. All the benefits of the spinal and tiva plus you are covered when spinal starts to wear off at end of case. I’ve had tkas walk and be discharged 45 min after getting to pacu. Majority of total joints I’ve seen done with a full spinal still and propofol are still a GA with the amount of propofol being ran.

 

[Hoya11]

This sounds really dumb
Why don't you just do a mepivacaine spinal with a little fentanyl?

similar idea, but i think bupi is better because of the slow offset when they get home they still have analgesia level of spinal for most of the POD0, whereas the shorter acting spinal local anesthetics like cpc, lido, and mepi have a faster offset and possibly return of pain sooner . i think bupi has a longer time in the sweet spot of numb but mobile, evidence for that? no

 

[GassYous]

This isn’t all that uncommon. I agree it’s a great technique to get patients discharge quickly for outpatient total joints especially at a surgery center. 0.8ml 0.75% huperbaric marcaine followed by propofol infusion and LMA. All the benefits of the spinal and tiva plus you are covered when spinal starts to wear off at end of case. I’ve had tkas walk and be discharged 45 min after getting to pacu. Majority of total joints I’ve seen done with a full spinal still and propofol are still a GA with the amount of propofol being ran.

Why would your spinal wear off? Total joints shouldn't take more than 2 hours. I know a few guys that can do a hip in under an hour.

 

[PpfSuxTube]

It sounds like maybe your just not familiar with it .. its a protocol at a major academic institution in my ararea

Oh well if it's at a major academic institution then that's OK.
Thanks ill check it out

 

[Simba1711]

Yeah I have heard of places requiring spinal and ga for hips too. Not sure of the rationale.

 

[PpfSuxTube]

Yeah I have heard of places requiring spinal and ga for hips too. Not sure of the rationale.

I feel it's related to the newer minimally invasive, anterior surgical approaches. Very difficult case for the surgeons, physically challenging... apparently the surgeons say much better results for the patients with less pain and incr mobility due to not having to divide certain muscles but I don't know anything about those outcomes.


After a list of these of surgeons are exhausted

 

[unc04]

I saw this video a couple weeks ago. He is clearly biased and agree there is no reason to say any general anesthesiologist doesn’t have the ability to do spinals correctly. It made me not watch any more of his videos and will avoid his website in the future.

Since he is making money by making videos discussing RA it seems he is pulling at straws to try to support his claims that regional is superior to GA which is not supported by that trial.

It undermines his credibility. I’ve suspected for years that there is no significant difference in RA vs GA for most patients and procedures unless they have bad lung disease or heart failure as said above.