Comments on: Review Article: Postoperative pain management following scoliosis surgery http://www.raeducation.com/2009/05/postoperative-pain-management-following-scoliosis-curr-opin-anaesthesiol-2008/ Regional Anesthesia Education...and Discussion Sat, 06 Mar 2010 17:52:08 -0500 http://wordpress.org/?v=2.9.2 hourly 1 By: Adolfo Gonzalez http://www.raeducation.com/2009/05/postoperative-pain-management-following-scoliosis-curr-opin-anaesthesiol-2008/comment-page-1/#comment-102 Adolfo Gonzalez Fri, 29 May 2009 17:29:36 +0000 https://www.anest.ufl.edu/gator-rap/?p=614#comment-102 Nice article. Were i trained we stayed away from epidural in spines just for the reason Dr. Boezaart stated, we tried one epidural cath placed under direct vision by surgery. We found a poor spread of local. We managed our spines with intrathecal morphine on induction, ran a low dose ketamine in fusion 0.1 mg/kg/hr for intraop and 1st 24 hrs, followed by 0.06 mg/kg/hr for another 48 hrs, mith morphine pca with continous infusion, and q 8hr. lorazepam or diazepam for spasms. We found this mix to provide a great deal of pain relief and the patients were up in chair within 24 hours. Nice article. Were i trained we stayed away from epidural in spines just for the reason Dr. Boezaart stated, we tried one epidural cath placed under direct vision by surgery. We found a poor spread of local. We managed our spines with intrathecal morphine on induction, ran a low dose ketamine in fusion 0.1 mg/kg/hr for intraop and 1st 24 hrs, followed by 0.06 mg/kg/hr for another 48 hrs, mith morphine pca with continous infusion, and q 8hr. lorazepam or diazepam for spasms. We found this mix to provide a great deal of pain relief and the patients were up in chair within 24 hours.

]]> By: aboezaart@ufl.edu http://www.raeducation.com/2009/05/postoperative-pain-management-following-scoliosis-curr-opin-anaesthesiol-2008/comment-page-1/#comment-101 aboezaart@ufl.edu Fri, 29 May 2009 10:13:52 +0000 https://www.anest.ufl.edu/gator-rap/?p=614#comment-101 Brilliant article as you can expect from the Borgeat group. Epidural is fine, but as everything in Acute Pain Medicine and RA, you can't expect the block to work on nerves not reached by the local anesthetic agent. One needs really large infusion volumes and rates to cover the large extent of this surgery if only one or not enough catheters are used. I think that is where the controversy comes from. I have always (and with great success and satisfaction) ascribed to my "Rule of 5's": That is one catheter for every 5 segments operated; tread the catheter 5 cm into the epidural space (so it does not dislodge); and infuse 5 mL per hour of a low concentration local anesthetic, with or without hydromorphone (say 10mcg/mL for example) maybe through the middle catheter. This is anecdotal only based on experience and thus not yet proved standard of practice. We are currently in the process of designing a formal study to evaluate the "Rule of 5's" and present the evidence (either way). Thanks for a great blog Patrick. André P. Boezaart Brilliant article as you can expect from the Borgeat group.

Epidural is fine, but as everything in Acute Pain Medicine and RA, you can’t expect the block to work on nerves not reached by the local anesthetic agent. One needs really large infusion volumes and rates to cover the large extent of this surgery if only one or not enough catheters are used. I think that is where the controversy comes from.

I have always (and with great success and satisfaction) ascribed to my “Rule of 5’s”: That is one catheter for every 5 segments operated; tread the catheter 5 cm into the epidural space (so it does not dislodge); and infuse 5 mL per hour of a low concentration local anesthetic, with or without hydromorphone (say 10mcg/mL for example) maybe through the middle catheter.

This is anecdotal only based on experience and thus not yet proved standard of practice. We are currently in the process of designing a formal study to evaluate the “Rule of 5’s” and present the evidence (either way).

Thanks for a great blog Patrick.

André P. Boezaart

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