Spinal Analgesia - A. Jacob

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Spinal Analgesia
Adam K. Jacob, M.D.
jacob.adam@mayo.edu or @ajake74
Department of Anesthesiology and Perioperative Medicine
Mayo Clinic

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No Disclosures or Conflicts

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“Patients should receive continuous epidural
midthoracic low-dose local anesthetic and opioid
combinations (grade A) for approximately 48 hours
following elective colonic surgery and approximately
96 hours following pelvic surgery”
Arch Surg 2009;144(10):961-9

4. ©2019 MFMER | slide-4Eur J Anaesthesiol 2016; 33:160–171

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Objectives
• Discuss the role of spinal analgesia in multimodal analgesia
protocols
• Discuss the adverse effects, monitoring after spinal opiate
analgesia

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PeriopMed2017;6:7

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Why Good Analgesia is Important
• Mayo CRS Practice
• Multimodal analgesia, single-injection intrathecal analgesia
• Predictors of dismissal within 48 hours
• ERP compliance (OR 2.4)
• Surgeon volume (OR 1.5)
• OME < 30 mg 48 hr postop (OR 2.0)
• 26% of patients never took a narcotic
• <10% of patient required a PCA
• Conversion to open procedure (OR 0.4)
Larson et al. Br J Surg 2014;101:1023–1030

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• 175 patients, observational, laparoscopic CRS,
ERAS protocol
• Benefits of spinal analgesia…
• Lower pain scores, less IV opiate consumption
• Earlier mobility and hospital discharge
• ADE equivalent
• 14% epidural failure rate
Virlos et al. Br J Surg 2010;97:1401-6

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• 99 patients, RCT, laparoscopic CRS, ERAS protocol
Levy et al. Br J Surg 2011;98:1068-78
0
1
2
3
4
5
6
7
8
9
10
PACU Day 0,
PM
Day 1,
AM
Day 1,
PM
Day 2,
AM
Day 2,
PM
Day 3,
AM
VRSPainScore
Epidural
Spinal
PCA

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Intrathecal vs TAP analgesia in Colorectal Surgery
0
0.5
1
1.5
2
2.5
3
3.5
4
Postop 4 hr Postop 8 hr Postop 16 hr POD 1 POD 2 Discharge
VRSPainScore
Intrathecal TAP
0
5
10
15
20
25
30
POD 0 POD 1 POD 2
MedianOME(mg)
Intrathecal TAP
No difference in complications, gut recovery, hospital LOS
Colibaseanu et al. Br J Surg 2019; In Press

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Intrathecal vs IV Lidocaine in Colorectal Surgery
No difference in average
VAS pain scores, nausea,
ileus, time to first BM,
hospital LOS
Jacob et al. In press
0
5
10
15
20
25
30
0 - 24 hours 24 - 48 hours
OpioidUse(OMEmg)
Intrathecal
(n=105)
IV Lidocaine
(n=32)

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No difference in activity levels, complications, or gut recovery
Wongyingsinn et al. Br J Anaesth 2012;108(5):850–6

13. ©2019 MFMER | slide-13Koning et al. RAPM 2018;43:166–73

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• CRS practice review (600 patients)
• Analgesia
• Hydromorphone 75 mcg, observed a plateau in…
• Opiate consumption
• Pain scores
• Adverse Effects
• Pruritus (req nalbupine) = 1.2%
• Sedation/respiratory depression (req naloxone) = 0.2%
• PDPH = 0 cases
Merchea et al. Surg Res Pract 2018 Mar 1:8174579

15. ©2019 MFMER | slide-15Sviggum et al. Anesth Analg 2016;123:690–7
0
10
20
30
40
50
60
Morphine 100 Morphine 150 Hydromorphone 50 Hydromorphone 75 Hydromorphone 100
Nausea(%)
6 hours
12 hours
24 hours
0
10
20
30
40
50
60
70
80
Morphine 100 Morphine 150 Hydromorphone 50 Hydromorphone 75 Hydromorphone 100
Pruritus(%)
6 hours
12 hours
24 hours
ED90morphine = 150 mcg
ED90hydromorphone = 75 mcg

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• Monitor all patients receiving neuraxial opioids for adequacy of
ventilation (e.g., respiratory rate, depth of respiration [assessed
without disturbing a sleeping patient]), oxygenation (e.g., pulse
oximetry when appropriate), and level of consciousness
• Monitor for a minimum of 24 h after administration
• Monitor at least once per hour for the first 12 h after administration,
followed by monitoring at least once every 2 h for the next 12 h (i.e.,
from 12 to 24 h)
• After 24 h, frequency of monitoring should be dictated by the patient’s
overall clinical condition and concurrent medications
Anesthesiology 3 2016, Vol.124, 535-52

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Summary
• Multimodal, opiate-sparing analgesia is a must
• Intrathecal analgesia is one good option
• Effective analgesia for 24(ish) hours
• Use in combination with infiltrative analgesia
• ADE present, but manageable
• Still an invasive procedure, requires resources/monitoring
• The best option is the one that is consistent,
reproducible, and agreeable to everyone

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Thank You!!
jacob.adam@mayo.edu or @ajake74