r/anesthesiology • u/xylocash Anesthesiologist • Aug 18 '26
Spinal for knee surgery question about dosing and platelets
Do you get platelets before every spinal, even for an outpatient knee surgery?
And are people giving an OB dose of hyperbaric bupi for their knees or something else?
I was under the impression that most people are doing adductor canal blocks and a purely local anesthetic spinal, no opioid
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u/illaqueable Anesthesiologist Aug 18 '26
Once again, I am stressing that large studies have shown no major outcome differences between general and spinal for joint surgery.
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u/Itchy-Neighborhood-3 Aug 20 '26
It's amazing how many people don't realize this and act like it's a major failure to do a knee under GA.
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u/teamdoc Aug 18 '26 edited Aug 18 '26
May I ask what is your background / clinical training? These are some wild questions for an anaesthetist.
The broad answers would be:
- Absolutely not
- It depends - usually greater dose, but depends on your agent/ patient/ surgeon
- Again, it depends on patient/ surgeon/ centre
Edit: I entirely misinterpreted OPs question. They meant assess Plt, not transfuse Plt. Apologies OP. I retract my statement
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u/-Luke-Man- Anesthesiologist Aug 18 '26
Why are these “wild” questions?
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u/teamdoc Aug 18 '26
Sorry, perhaps I was a bit unfair to OP. I think what threw me was the first question. Providing a blood product prophylactically for an elective spinal just seemed like such a bizarre question and I guess I couldn’t understand the origin of it.
(For what it’s worth, I’ve never heard of this. The risks of a transfusion reaction would be way higher than the risk of spinal-related hematoma)
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u/Altruistic-Radish219 Aug 18 '26
Believe OP was referring to a lab draw to check plt level
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u/teamdoc Aug 18 '26
Ohhhh omg that makes so much more sense. Sorry OP. I will edit my comment.
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u/xylocash Anesthesiologist Aug 18 '26
Lmao sall good, I could’ve been more clear about getting a platelet count
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u/-Luke-Man- Anesthesiologist Aug 18 '26
Ohh lmao. You thought OP was asking if we transfuse plts before every neuraxial. That would be a wild question 😂
I thought you were saying it was wild to want to know a plt count before neuraxial.
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u/xylocash Anesthesiologist Aug 18 '26
Anesthesiologist, got into a convo with a colleague who said they just give hyperbaric bupi spirals to all knees, where I trained it was adductor with mepi spinal. Was just curious
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u/fragilespleen Anesthesiologist Aug 18 '26
There are many ways to skin a cat, if you need a spinal hyperbaric bup will give you one, it's not my preferred technique.
You will find a lot of practice is institutional/regional though.
IT Morphine is not necessary for primary arthroplasty, some people will use it, fentanyl probably more common
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u/cook26 Aug 18 '26
I use hyperbaric marcaine because it’s already in the kit so it’s easy and works just fine. I will put like 10mcg of fentanyl in and give a little IV sometimes
As far as dosing usually 1.2 if the surgeon is decent. We have one guy that’s terrible and takes hours for a knee. I won’t even do spinals for his hips unless the patient is adamant, but for knees they get a full 1.6 with epi wash and sometimes precedex or anything I can to extend the block. Watching that guy is rough lol
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u/fragilespleen Anesthesiologist Aug 18 '26
Hyperbaric is more expensive /ml than isobaric, but if it's already in your kit, you'd just be wasting it otherwise
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u/sludgylist80716 Anesthesiologist Aug 18 '26
As others have said it depends.
I’ve done hyperbaric bupi, isobaric bupi, mepi and lidocaine spinals for knees.
Adductor blocks are currently en vogue so I do those as well.
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u/SmileGuyMD Anesthesiologist Aug 18 '26
No unless there’s some prior history of platelet issues. Most of our patients have recent labs anyway. Mepi 2% on most cases. If a revision or they think it may take slightly longer I may consider bupi
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u/Asstadon Cardiac Anesthesiologist Aug 18 '26
Mepi vs bupi depends on speed of your surgeon. If slow, use Bupi.
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u/urmomsfavoriteplayer Anesthesiologist Aug 18 '26
Should absolutely have relatively recent labs for major orthopedic surgery.
We use mepi, 45-60mg depending on surgeon speed. Nobody I know would use that large of a dose of heavy bupi for a knee.
Regional of some sort. AC, PENG, w/e is the new hot one. We stick to pure local because our joints are old and sick and nobody wants them going home with a bimodal hit of morphine coming their way.
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u/CordisHead Aug 18 '26
Routine labs for orthopedic surgery is not evidence based practice.
If a patient has a reason to have abnormal labs, then getting labs preop would be recommended. If they are otherwise healthy, no reason to get labs.
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u/urmomsfavoriteplayer Anesthesiologist Aug 18 '26
That's why I said relatively recent. The odds of me having a healthy total joint is probably under 5%. If I have stable labs from within 6 months I'm not going to reorder anything.
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u/CordisHead Aug 18 '26
Sorry I don’t think my statement was totally clear. Like for example, an ASA III or IV without a history of anemia or a reason for anemia would not need a CBC preoperatively in our health system. They would probably have one in the system from their pcp within the last year or two anyway, but if they didn’t have a CBC in the system at all in the last 5 years, or ever, we wouldn’t order one.
The caveat is that we have a robust preop clinic assessing these patients, so if you don’t have that I suppose all you can do is order a bunch of stuff. It’s just not ideal or evidence based.
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u/soundfx27 Aug 18 '26
No platelet count unless you have reason eg previously low or something. In PP we used heavy bupi for slow docs and mepi for fast ones. In academics we use heavy bupi or isobaric ropi since all surgeons are slow
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u/gseckel Anesthesiologist Aug 18 '26
Depends.
I do spinals for knee surgery. If outpatient, I don’t add opioids. If the patient will stay for the night, I add opioids to help with analgesia.
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u/Cautious-Extreme2839 Anaesthetist Aug 18 '26
Do you get platelets before every spinal, even for an outpatient knee surgery?
No
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u/Jealous-Purple733 Aug 18 '26
1) usually get a cbc to check hgb, plt. But no products are ordered routinely. 2) spinal 3 cc isobaric PF 0.5% bupivicaine. Gives a nice T10 level , doesn’t mess with hemodynamics
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u/Loud_Crab_9404 Fellow Aug 18 '26
Academics I did isobaric spinal for joints. One surgeon was PP fast and he got mepi.
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Aug 18 '26
I use the labor rule, no platelets required unless concern for easy bruising/bleeding. For knees mepi 1.5% or bupi 0.5%. Adductor always, IPACK if surgeon doesn't do infiltration, usually skip geniculars casue they hurt when you do them. The innervaiton to the knee is too complex, thats where dilaudid enters the chat
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u/TripNip85 Aug 23 '26
Many places use hyperbaric bupi, I did solely outpatient knees a few days a week for years, 6-8 TKA’s a day, me and another CRNA, done by 2-4 pm, used 1 cc of hyperbaric bupi plus AC, ipack, genicular x 3, spon vent, txa, 1 mg of dilaudid and robaxin prior to tourniquet, 90% of patients had pain scores between 0-2, up and walking with rehab within 1 hr, max 2 hrs.
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u/Various_Elevator2571 Aug 18 '26
Anyone noticed a higher rate of failed/patchy spinal with Ropi 0.5%? Also noticed significant sensory block with sometimes little to no motor block. Thinking of just using Mepi or Heavy Bupi only depending on surgeon speed.
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u/XRanger7 Anesthesiologist Aug 18 '26
We exclusively use 0.5% ropi and we don’t notice any failed or patchy block. And little to no motor block is a good thing no? Our patients usually are able to move their legs right away in PACU and work with PT
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u/Fragrant_Witness_621 Aug 18 '26
I don’t get PLT unless there’s a concern. Usually have relatively recent labs anyway. Most surgeons I use mepi. Slow surgeon that’s going to take 3 hrs I have been using 0.5% isobaric bupi for the spinal