Episode 84: Anesthesia for spine surgery with Alyson Russo

In this episode, episode 84, I welcome back Dr. Alyson Russo to discuss anesthesia for spine surgery.

10 Replies to “Episode 84: Anesthesia for spine surgery with Alyson Russo”

  1. Great episode, very consistent with how we do spines at our institution. Some questions I have are how commonly are there adverse events associated with lidocaine infusions and how to select appropriate patients? We had a patient having a 2-3ish hour lumbar procedure in an elderly patient with borderline reduced renal function. We used lidocaine 2mg/kg/hr and precedex 0.3mcg/kg/hr infusions for opioid sparing but were stopped shortly before emergence. The patient was hypotensive and bradycardic post op requiring vasopressor/inotropy (epi or norepi) that didn’t really resolve until the next day. My attending hypothesized it was the lidocaine that slowed nerve transmission that affected her because of her age but I haven’t been able to find cases like this in the literature. Echo was normal,ekg showed preexisting 1st degree av block, and ischemic work up was negative. I read that 2nd and 3rd degree heart blocks, among other things, are contraindications to lidocaine infusion, but none of these were present. Anyone have any guidance regarding this?

    1. It’s hard to tell if the inotropy dependence was due to the lidocaine/dexmetomidine combination although there is animal study data that does suggest that this combination has a different effect on nerve conduction than lidocaine alone.(Dalkilic, Nizamettin, Seckin Tuncer, and Ilksen Burat. “Dexmedetomidine Augments the Effect of Lidocaine: Power Spectrum and Nerve Conduction Velocity Distribution Study.” BMC Anesthesiology 15 (2015): 24. PMC. Web. 23 June 2018.) .

      This might be of interest as well.

      https://www.omicsonline.org/open-access/dexmedetomidine-the-anesthetic-as-an-antiarrythmic-2329-6607-1000153.pdf

      cheers,

      jmr

    2. Hi A,

      I think it’s likely that the outcome was unrelated to the precedex and lidocaine. There are cardiac groups using higher doses of these two meds together without issue. Of course it’s always possible that there was something specific about the physiology of this particular patient that led to this outcome but there’s no way to know. In general you should be able to use precedex and lidocaine at those doses and be fine. Alternatively, ketamine and precedex is another option and more commonly used for these cases.

      Best,
      Jed

    3. Did you load either drug, especially the precedex? A little precedex goes a long way, and PACU hypotension and prolonged emergence are big problems as much as I love the drug. Conservative loading dose or no loading dose at all has helped tremendously.

  2. We are already reaching this conclusion in many institutions, but 10 years from now I believe we will look back and be terrified we titrated anesthetic requirement to something as complicated as BP and HR.
    An attending before I left residency told me, safety first l, but that’s not good enough:
    “Preempt the pain, measure the brain, and emetic drugs abstain.”
    What about a podcast on BIS/Sedline/EEG monitoring? It is just one of many monitors
    And should not be interpreted in isolation, but with increased awareness of postop delirium and demand for higher quality anesthesia, anesthesiologist-driven brain monitoring seems like it should be getting more attention.
    Also, nice to know where pt is anesthetic-wise if having hypotension. MAC is a bell-curve and more and more TIVA requested.

  3. Hello Jed. I spoke with Ki Jinn Chin as our article on ESP PNB for spine officially went into print today.
    We noted that around 28:30 in this episode there seems to be a question about whether regional is used for spine surgery. We have done so with a high level of safety and success for the last 2 years now (Sutter Sacramento and University of Toronto)
    https://www.springer.com/?SGWID=0-0-1003-0-0&aqId=3512803&download=1&checkval=82c67a64381acad8a76e2e5e72d14377&wt_mc=Internal.Event.1.SEM.ArticleAuthorOnlineFirst
    We would love to raise awareness on a high benefit:low risk PNB for a surgery and group of pts in dire need opioid sparing in a safe and meaningful way. My email is jmelvin240@gmail.com if Dr Russo is interested in getting in touch with us about our success with ESP blocks for spine surgery. Thanks!

    1. Thanks Josh. Interesting stuff you guys are doing! I’ll pass it on to Dr. Russo. Perhaps others can comment here as well if they have similar experience to yours.

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