Dept. encouraging use of regional anesthesia when appropriate
During this pandemic, a collective goal must be to reduce the risk of aerosolizing respiratory secretions to minimize the spread of respiratory droplets to health care providers. Since many carriers of COVID can be asymptomatic, we must be wary of respiratory exposure from all patients. In the operating room, this risk is greatest during mask ventilation, intubation, extubation, suctioning and when the patient coughs. Airway manipulation with general anesthesia also increases the use of personal protective equipment, which is in limited supply.
To try to reduce the spread of COVID, we are encouraging the use of regional anesthesia when appropriate to bypass manipulation of the patient’s airway. Regional anesthesia will include neuraxial anesthesia (spinal, epidural, CSE) as well as peripheral nerve blocks. These techniques can be implemented as primary anesthetics and, as necessary combined with MAC sedation. They can be used for both inpatient and outpatient procedures. Any number of procedures in orthopedics, vascular surgery, plastic surgery, urology and others may be appropriate for regional anesthesia. Please discuss the possibility of regional with your anesthesia team, the responsible surgeon or the RAAPS team.
We realize this represents a change in practice for some of you. In the interest of efficiency and patient care, please call the AIC for assistance if you are having difficulty placing a spinal. An anesthesiologist who more regularly places spinals may be available to help or, the procedure can be done with a general anesthetic. Peripheral nerve blocks and epidurals can be placed preoperatively by the RAAPS team.
Patients with known COVID-19 or who is under investigation for COVID-19 infection should not be coming to the OR for anything other than emergency surgery. If your suspicion for an active COVID infection is high and the patient is deemed to require surgery, the patient should wear a surgical mask throughout the procedure (if you choose to use a regional anesthetic) or you can proceed with a general anesthetic with an endotracheal tube.
We continue to make practice decisions for the safety of our health care providers and welcome your suggestions.
The cystoscopy suite is one area where both outpatient and inpatient spinals may be ideal. Dr. Carly Davis from urology is eager to implement spinals there. For outpatient cases of 2 hrs or less, consider either 1.5% mepivacaine or 1% chloropropane. Both products will be available at the pharmacy window and in the anesthesia machine in cysto.
|Local Anesthetic||Dose (mg)||Effective Surgical duration (min)||Incidence TNS% ¹||Time to complete resolution (h)|
50 mg/5 ml), (isobaric)
|1.5% Mepivacaine, 30 ml (isobaric)||45 (3 ml)
60 (4 ml)
¹TNS = transient neurologic symptoms.
² To reduce the incidence of TNS, gently aspirate CSF into the spinal syringe to dilute the local anesthetic and inject slowly. The mg dose and clinical effect remains the same.
Like chloroprocaine, bupivacaine spinals have an incidence of TNS of nearly zero. Lidocaine spinals have the highest incidence of TNS, at over 30%. Subarachnoid administration of 1.5% mepivacaine (as well as 2% lidocaine, 0.5% bupivacaine, chloroprocaine, or fentanyl) is “off-label” use in the United States. The absence of FDA approval does not imply lack of safety or deviation from medicolegal standard of care.
At the discretion of the staff anesthesiologist, stable outpatients with short acting spinals may be able to bypass PACU and go directly to PAR (with an Aldrete score of 8 or more). As usual pts with primary peripheral nerve blocks and MAC can bypass the PACU to go to PAR or to the floor.
Rattenberry, W et al. Spinal Anesthesia for Ambulatory Surgery. BJA 2019;19:321-328.
Hejtmanek MR, Pollock, JE. Chloroprocaine for spinal anesthesia: a retrospective analysis. Acta Anaesthesiol Scand 2011; 55: 267–272.
O’Donnell D et al. Spinal mepivacaine with fentanyl for outpatient knee arthroscopy surgery: a randomized controlled trial. Canadian Journal of Anesthesia/Journal canadien d’anesthésie volume 57, pages32–38(2010).
Thank you and stay healthy,
Cynthia A. Lien, MD, John P. Kampine Professor & Chair
John Laur, MD, MSc, CPE, Associate Professor & Vice Chair
Medical Director, Perioperative Services
Kathy Lauer, MD, Professor & Vice Chair for Clinical Affairs
Karin Drescher-Madsen, MD, Associate Professor & RAAPS Division Director
Jeffrey Kirsch, MD, Professor, Associate Dean of Faculty Affairs & Vice Chair
Sr. Medical Director, Perioperative Services