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Ambulatory spinal anaesthesia, the efficient choice - Dr Robbie Erskine
- 1. Guidance on Ambulatory Spinal Anaesthesia: Covid-19 response Ambulatory spinal anaesthesia, the efficient choice Dr Robbie Erskine Consultant Anaesthetist, University Hospital, Derby @DrRobbieErskine Supported by an unrestricted educational grant from #RAUKSpinal
- 2. Dr Robbie Erskine Ambulatory Spinal Anaesthesia The Efficient Choice Robbie Erskine RAUK August 2020
- 3. Dr Robbie Erskine Ambulatory Spinals • Pandemic and RA • Spinals in UK …state of play • Evolution of short acting spinals • How to do it? • The efficient choice
- 4. Dr Robbie Erskine Apologies! • I work in a “regionally permissive” environment • Experience-based talk • European bias • “How to use” guide for Spinal Prilocaine and 2- chloroprocaine • Practical hints and considerations
- 5. Dr Robbie Erskine Recent article for references
- 6. Dr Robbie Erskine Pandemic and RA • Increased RA interest (Good or Bad?) • GA risks …Staff, Patient, Anaesthetist • Theatre efficiency, PPE etc • Recovery area/PACU staff • Patient involvement / Less follow ups?
- 7. Dr Robbie Erskine Spinals in UK • UK 75% awake surgery under spinal • Commonest/simplest regional anaesthetic • Still underused • Observational study from Guy’s and Thomas’: Emergency surgery during covid-19 46% of regional anesthetics were spinals
- 8. Dr Robbie Erskine Spinals in UK • Basic competency for ALL anaesthetists • Low failure rate • Highly effective operative analgesic • Suitable for most infraumbilical surgery
- 9. Dr Robbie Erskine Evolution Enhanced recovery(ERAS) and Knee Arthroplasty Hand in Hand 1990s→2000s →2010s →2020s
- 10. Dr Robbie Erskine Evolution Enhanced recovery(ERAS) and Knee 1990s Spinal Bupivacaine + Epidural2000s Spinal Bupivacaine Femoral and Sciatic Block2010s “Analgesic Spinal” Low Dose Bupivacaine +/- Opioid Local Infiltration (LIA) Propofol infusion 2020s Normal Volume Prilocaine/Chloroprocaine Spinal LIA Fem Triangle Block iPACK Block ?Sedation?
- 11. Dr Robbie Erskine How to do it? Low-dose bupivacaine +/- opioid Hyperbaric 2% Prilocaine Isobaric 1% 2-chloroprocaine
- 12. Dr Robbie Erskine How to do it? • Bupivacaine may be too much? • Heavy legs • Retention is a significant risk • Opioids cause pruritis • Delayed discharge • Avoid if possible for procedures < 120 mins
- 13. Dr Robbie Erskine Principle IF A 3hr GA is too long for a 60min procedure THEN A 3hr Spinal is too long for a 60min procedure
- 15. Dr Robbie Erskine Heavy Prilocaine 2% • Widely used in Europe >10 years, NOT in US or Australasia • “Intermediate” spinal duration • Licenced for 90 minutes of surgical time • Up to 120 minutes can be achieved for knee/foot/ankle surgery…less so for hip surgery • Hyperbaric property allows for manipulation of height of block • Evidence of increased CV stability compared with Bupivacaine • Fills “gap” between Bupivacaine and Chloroprocaine • Allows day case surgery WITHOUT the need for intrathecal opioid
- 16. Dr Robbie Erskine Isobaric 2-chloroprocaine 1% • UK since 2013 • Licenced in US too since 2018 • “Short” duration • Licenced for 40 minutes of surgical time • 60-80 minutes can be achieved for knee/ankle surgery….Not for hip surgery • Less easy to manipulate height ..rarely above T10 for long • No case reports of urinary retention • Very little “perineal lag” • Patients very confident to mobilise sooner
- 17. Dr Robbie Erskine Targeting spinals to the procedure • Pragmatic approach to decision making • 3 questions: Saddle block only? High block required? Short or intermediate procedure? • No opioid required • “Per-Operative Analgesic Spinal” • Follow-on regional block and multimodal analgesia
- 18. Dr Robbie Erskine Aide Memoir for your Anaesthetic Room
- 23. Dr Robbie Erskine How does this translate to a typical theatre session?
- 24. Dr Robbie Erskine Low dose bupivacaine with opioid 0 50 100 150 200 250 300 TKR Bupivacaine ACL Bupivacaine ARTHROSCOPY Bupivacaine ARTHROSCOPY Bupivacaine ARTHROSCOPY Bupivacaine Surgical time Block regression Traditional Approach
- 25. Dr Robbie Erskine 0 50 100 150 200 250 300 TKR Bupivacaine ACL Prilocaine ARTHROSCOPY Chloroprocaine ARTHROSCOPY Chloroprocaine ARTHROSCOPY Chloroprocaine Surgical time Block regression Targeted Approach
- 26. Dr Robbie Erskine First Time Users Follow the guidelines on the decision making chart • Try prilocaine first if unsure • Be generous…remember these are: NOT low dose BUT short acting • DON’T use opioids…not licenced and not necessary • Know your surgery/surgeon • Expand your use as you become more confident
- 27. Dr Robbie Erskine Derby Experience • 1% 2-chloroprocaine 50mg (5ml) • 625 knee arthroscopies over 5 years • Procedures 20 to 80 minutes spinal to dressing time • 4 required repeat spinal (0.6%) before surgery • 2 required supplementary Alfentanil on skin incision(0.3%) • No conversions to GA/delayed discharge • No urinary problems • Only 1.2% would NOT choose this again Prize presentation BSOA Nottingham 2018 R J Hudson, R Erskine
- 28. Dr Robbie Erskine Which spinal drug to choose? • Know your surgery/surgeon…WHO meeting 1. Simple ACL? Allograft 2-CP Lateral tenodesis Prilocaine Meniscal repair? Prilocaine 2. Ankle fracture Lateral fixation only? 2-CP More complex? Prilocaine
- 29. Dr Robbie Erskine Which spinal drug to choose? 3. Perianal/Perineal surgery (saddle) Choose small dose Prilocaine 0.5ml for its baricity 4. Inguinal hernia Bilateral or Large Prilocaine Unilateral 2-CPC 5. Umbilical hernia/Ureteric stent Choose high dose Prilocaine 3ml for its baricity
- 30. Dr Robbie Erskine Recent Advances • Hemiarthroplasty/DHS Prilocaine 2.5ml (50mg) • Hip screws 2-CPC 5ml (50mg) Reliable effect, quick onset, ?CV stability Less prolonged sympathetic block in recovery
- 31. Dr Robbie Erskine Recent advances • Uni Knee Arthroplasty/Simple TKA 2-CP 5ml (50mg) • Trickier TKA Prilo 3ml (60mg) • Primary THA Bupiv 2ml (10mg) OR • Slim THA Prilo 3ml (60mg)
- 32. Dr Robbie Erskine Trauma list 85 min 55 min 47 min 35 min 88 min
- 33. Dr Robbie Erskine The Efficient Choice • No AGP… increased safety…time saving……low cost • Offer sedation(if appropriate) and allow patient to change their mind (make them part of the team) • Match your spinal to the procedure • Keep dentures in! • Free clear fluids • Patient may observe procedure or discuss treatment with surgeon ?Follow up visit • No “wake up” or airway removal time in theatre • Safer for recovery/PACU staff (AGP) • Shorter recovery stay • Rapid mobilisation and discharge
- 34. Dr Robbie Erskine Spinal Anaesthesia The non-regionalist’s regional Simple Safe Effective Efficient #RightDrugRightPatientRightProcedure