Fast-tracking and regional anesthesia

[ethilo]

Hey folks,
I'm trying to explore whether or not incorporating a block bay into our community hospital would result in more fast-tracking of patients. Ideally, I want to reduce the numbers of GAs so we can bypass PACU more often and send straight to phase 2 by relying on a surgical block and mild propofol sedation. From folks who are regional heavy, I want to get a sense of which kinds of cases could be done under a surgical block and which couldn't, based solely on generalities about procedures, independent of patient factors.

It's been a long time since residency where I had a robust block bay program, currently all of my blocks have to be done in-room prior to induction. This unfortunately makes it such that if done absolutely perfectly I would only have about 15 minutes until time to incision after block is done, which makes doing cases under regional anesthesia alone prohibitively challenging.

If one had a block bay to place blocks in a timely fashion, and your options for local anesthetics are bupi 0.5%, ropi 0.5%, lido 2%, you have dexamethasone and precedex as adjuncts available, would you be able to do dense enough and reliable enough surgical blocks to be able to do:
- Radius fracture ORIF
- Ankle fusions
- Olecranon ORIF

If YES to all of those, are there extremity procedures you think WOULDN'T be covered by this? Off the top of my head, joint replacement obviously, and anything with a longer tourniquet time.

Thanks

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[DrZzZz]

I don't like doing ankles under regional/MAC, but pretty much anything upper extremity elbow to fingers is fine. We use either 0.75% ropi or 0.5% bupi with epi for our blocks. Usually don't use adjuncts except for shoulders (which we do GA for so not really what you're asking about).

 

[Endee]

Even better after the block is skip the propofol and just build or buy an iPad stand, put it next to the bed, give the patient noise canceling headphones, and just let them watch a movie or TV show during the procedure.

 

[Arch Guillotti]

I don't like doing ankles under regional/MAC, but pretty much anything upper extremity elbow to fingers is fine. We use either 0.75% ropi or 0.5% bupi with epi for our blocks. Usually don't use adjuncts except for shoulders (which we do GA for so not really what you're asking about).

.75% ropi? Never even seen that before!

 

[DrZzZz]

.75% ropi? Never even seen that before!

It comes in a convenient plastic twist-top container, so you don't need a needle to draw it up. Nice for days with a lot of blocks and quick turnover cases.

 

[GassYous]

Even better after the block is skip the propofol and just build or buy an iPad stand, put it next to the bed, give the patient noise canceling headphones, and just let them watch a movie or TV show during the procedure.

I could use one of those for me

 

[IMGASMD]

I could use one of those for me

“May I suggest the new episode of The Expanse, since I have not seen it yet. “

 

[ethilo]

.75% ropi? Never even seen that before!

Our hospital has 0.75% bupi, hadn't seen that one before either! It's in a 50 mL vial too! I'm not so sure what the application would be.

 

[Justice4all]

Our hospital has 0.75% bupi, hadn't seen that one before either! It's in a 50 mL vial too! I'm not so sure what the application would be.

We had the 0.75% ropivicaine at our surgicenter . 20 ml vial. Most of the patients get 20 hrs from it

 

[deleted875186]

For surgical anesthesia, I recommend 2% mepivicaine. I’ve added some 0.25 bupi or 0.5 ropi after injecting the mepivicaine to try and get a little longer lasting anesthesia as well. I know they say mixing local doesn’t make onset necessarily faster, but in my experience the onset is quite fast with this mix. Would be interested to hear others if they mix local?

In residency we used to block bedside in preop and then go back immediately to the OR with this mix and block had always set up in time.

 

[Simba1711]

I mix 2 % lidocaine and 0.5% bupivicaine for most of my blocks

 

[Low Flow]

On my outpatient rotation now in residency and we do a lot of breast cases and hand plastics. Blocks are done by the block team before rolling back to the OR. Breast cases I see PVB with 0.5% bupi with epi. 90% of the time coverage is wonderful and I’ve been able to just do propofol sedation. Every once in a while they get up in the axilla and the pt feels it, but can usually get it done without an LMA/general.

Also, I just happened to be reading the ambulatory chapter in Miller today and it cited some studies showing that “fast tracking” patients didn’t really decrease time to discharge, it just shifted nursing demand to a different unit. Didn’t look at the specifics of the studies, just thought I’d see what other people’s thoughts were on that.

 

[abolt18]

Hey folks,
I'm trying to explore whether or not incorporating a block bay into our community hospital would result in more fast-tracking of patients. Ideally, I want to reduce the numbers of GAs so we can bypass PACU more often and send straight to phase 2 by relying on a surgical block and mild propofol sedation. From folks who are regional heavy, I want to get a sense of which kinds of cases could be done under a surgical block and which couldn't, based solely on generalities about procedures, independent of patient factors.

It's been a long time since residency where I had a robust block bay program, currently all of my blocks have to be done in-room prior to induction. This unfortunately makes it such that if done absolutely perfectly I would only have about 15 minutes until time to incision after block is done, which makes doing cases under regional anesthesia alone prohibitively challenging.

If one had a block bay to place blocks in a timely fashion, and your options for local anesthetics are bupi 0.5%, ropi 0.5%, lido 2%, you have dexamethasone and precedex as adjuncts available, would you be able to do dense enough and reliable enough surgical blocks to be able to do:
- Radius fracture ORIF
- Ankle fusions
- Olecranon ORIF

If YES to all of those, are there extremity procedures you think WOULDN'T be covered by this? Off the top of my head, joint replacement obviously, and anything with a longer tourniquet time.

Thanks

Vascular cases like AV fistulas, amputations, I&Ds, like you said, ankle and foot stuff, hand stuff. I've done some shoulder scopes later with just propofol sedation after a block.

I don't think surgical blocks necessarily need adjuncts, as you really just need the surgical anesthesia for the duration of the case... Unless of course you want them to last longer.

I have subjectively seen a faster onset very sense block by mixing our 0.5% ropi with 2% lido, seems like 5-10 minutes and they're totally insensate in the extremity, whereas straight 0.5% ropi can sometimes take a solid 20-30 minutes to set up fully.

Honestly though, if you have a block bay, and you're able to do these blocks >20 minutes before you roll back, you could just use 0.5% or greater of ropi or bupi and by the time you roll back, prep, and drape, the patient is ready.

 

[BLADEMDA]

Abstract​

Visualization of the nerve structures of brachial plexus allows anesthesiologists to use a lower dose of local anesthetics. The content of this low dose is not unequivocal, consequently, the pharmacokinetics of local anesthetics used by various authors are difficult to compare. In this study, the onset times and duration of the analgesic effect of local anesthetic mixture solutions used for brachial plexus blocks are investigated and the quality of anesthesia is compared. 85 unpremedicated American Society of Anesthesiologist physical status I-III, 19-83-year-old patients scheduled for upper limb trauma surgery are assigned to four groups for the axillary-supraclavicular block with lidocaine 1% and bupivacaine 0,5% 1:1 mixture (Group LB) or bupivacaine 0.33% (Group BS) or lidocaine 0,66% (Group LS) or bupivacaine 0.5% and lidocaine 1% 2:1 mixture (Group BL). 0.4 ml/kg was administered to the four groups. The onset time was significantly shorter in the lidocaine group (LS 13.0 ± 1.02) than in the other study groups (LB 16.64 ± 0.89; BS 17.21 ± 0.74; BL 16.92 ± 0.51 min ±SEM, p = 0.002). No differences were observed in the onset times between LB, BS, and BL groups (p > 0.05). Statistical differences were found in the duration of local anesthetics between LB (392.9 ± 20.4), BS (546.4 ± 14.9), LS (172.85 ± 7.8), and BL (458.7 ± 11.9 min ±SEM, p = 0.001). Lidocaine does not shorten the onset times, but significantly decreases the duration of action of bupivacaine when used in mixture solutions. Lidocaine exhibits a good quality of block in the applied dose, while other solutions have excellent quality. Bupivacaine without lidocaine has the longest duration of action to achieve the longest postoperative analgesia.

Onset times and duration of analgesic effect of various concentrations of local anesthetic solutions in standardized volume used for brachial plexus blocks

Visualization of the nerve structures of brachial plexus allows anesthesiologists to use a lower dose of local anesthetics. The content of this low do…

www.sciencedirect.com

 

[abolt18]

Abstract​

Visualization of the nerve structures of brachial plexus allows anesthesiologists to use a lower dose of local anesthetics. The content of this low dose is not unequivocal, consequently, the pharmacokinetics of local anesthetics used by various authors are difficult to compare. In this study, the onset times and duration of the analgesic effect of local anesthetic mixture solutions used for brachial plexus blocks are investigated and the quality of anesthesia is compared. 85 unpremedicated American Society of Anesthesiologist physical status I-III, 19-83-year-old patients scheduled for upper limb trauma surgery are assigned to four groups for the axillary-supraclavicular block with lidocaine 1% and bupivacaine 0,5% 1:1 mixture (Group LB) or bupivacaine 0.33% (Group BS) or lidocaine 0,66% (Group LS) or bupivacaine 0.5% and lidocaine 1% 2:1 mixture (Group BL). 0.4 ml/kg was administered to the four groups. The onset time was significantly shorter in the lidocaine group (LS 13.0 ± 1.02) than in the other study groups (LB 16.64 ± 0.89; BS 17.21 ± 0.74; BL 16.92 ± 0.51 min ±SEM, p = 0.002). No differences were observed in the onset times between LB, BS, and BL groups (p > 0.05). Statistical differences were found in the duration of local anesthetics between LB (392.9 ± 20.4), BS (546.4 ± 14.9), LS (172.85 ± 7.8), and BL (458.7 ± 11.9 min ±SEM, p = 0.001). Lidocaine does not shorten the onset times, but significantly decreases the duration of action of bupivacaine when used in mixture solutions. Lidocaine exhibits a good quality of block in the applied dose, while other solutions have excellent quality. Bupivacaine without lidocaine has the longest duration of action to achieve the longest postoperative analgesia.

Onset times and duration of analgesic effect of various concentrations of local anesthetic solutions in standardized volume used for brachial plexus blocks

Visualization of the nerve structures of brachial plexus allows anesthesiologists to use a lower dose of local anesthetics. The content of this low do…

www.sciencedirect.com

I'd be curious to see how this is affected by a higher concentration of lidocaine (2% in the 1:1 solution).

 

[deleted875186]

Mepivicaine seems to last longer than lido, but with same onset time and dense surgical block.

 

[BLADEMDA]

The effect of mixing 1.5% mepivacaine and 0.5% bupivacaine on duration of analgesia and latency of block onset in ultrasound-guided interscalene block - PubMed

For ultrasound-guided interscalene block, a combination of mepivacaine 1.5% and bupivacaine 0.5% results in a block onset similar to either local anesthetic alone. The mean duration of blockade with a mepivacaine-bupivacaine mixture was significantly longer than block with mepivacaine 1.5% alone...

pubmed.ncbi.nlm.nih.gov

Conclusions: For ultrasound-guided interscalene block, a combination of mepivacaine 1.5% and bupivacaine 0.5% results in a block onset similar to either local anesthetic alone. The mean duration of blockade with a mepivacaine-bupivacaine mixture was significantly longer than block with mepivacaine 1.5% alone but significantly shorter than the block with bupivacaine 0.5% alone.

 

[Volatile]

We cover multiple hospitals in our area. We always have a doc available to help out with pre-ops, blocks, pacu, extra set of hands in the OR. Also, have at least one CRNA free for breaks/lunches, extra set of hands. Sounds like you guys run more lean. Almost all of our cases distal to mid humerus and distal to knee are blocks/Mac. We usually have plenty of time for block set up so 0.5 ropi, if we have less then 30mins we’ll use mepi or lido ropi mix.

 

[Hoya11]

Hey folks,
I'm trying to explore whether or not incorporating a block bay into our community hospital would result in more fast-tracking of patients. Ideally, I want to reduce the numbers of GAs so we can bypass PACU more often and send straight to phase 2 by relying on a surgical block and mild propofol sedation. From folks who are regional heavy, I want to get a sense of which kinds of cases could be done under a surgical block and which couldn't, based solely on generalities about procedures, independent of patient factors.

It's been a long time since residency where I had a robust block bay program, currently all of my blocks have to be done in-room prior to induction. This unfortunately makes it such that if done absolutely perfectly I would only have about 15 minutes until time to incision after block is done, which makes doing cases under regional anesthesia alone prohibitively challenging.

If one had a block bay to place blocks in a timely fashion, and your options for local anesthetics are bupi 0.5%, ropi 0.5%, lido 2%, you have dexamethasone and precedex as adjuncts available, would you be able to do dense enough and reliable enough surgical blocks to be able to do:
- Radius fracture ORIF
- Ankle fusions
- Olecranon ORIF

If YES to all of those, are there extremity procedures you think WOULDN'T be covered by this? Off the top of my head, joint replacement obviously, and anything with a longer tourniquet time.

Thanks

Which cases can be done as MAC depends on a lot on other factors. Surgeons, tourniquets, patients, etc...

It's way more efficient to do the blocks in pre-op. The blocks are already dense at the time you are just going into the room.

I still do GA for:

TKA
ACL
Hip Scope
Knee Scope
Shoulder Scope
Achilles with high BMI

Also, surgeons and patients usually do better when the patient is asleep plus the block. The staff wants to talk freely in the room. The patient doesnt want to "watch a movie". They want to be asleep. So a gentle propofol drip after the block which is turned off early usually is the best option. Awake prior to PACU , but asleep during the surgery. 20ish minute recovery time.

Great cases to do as light prop gtt with a dense pre-op block

Distal Radius ORIF
Elbow ORIF
Ankle ORIF (if no tourniquet and/or fast surgeon)
Achilles Repair
Scaphoid ORIF

 

[kmurp]

Are you practicing without CRNAs? If so, it’s quite a bit more challenging to do what you want to do. That said , a designated room with a nursing staff trained to help by having everything ready for you will make things pleasant for you. As to what can be done : we do all our extremity cases with the exception of hip scopes with neuraxial or major regional including ACLs and knee scopes (unless patient refuses). Time to discharge from OR is often a half an hour for the peripheral blocks.

 

[Arch Guillotti]

Are you practicing without CRNAs? If so, it’s quite a bit more challenging to do what you want to do. That said , a designated room with a nursing staff trained to help by having everything ready for you will make things pleasant for you. As to what can be done : we do all our extremity cases with the exception of hip scopes with neuraxial or major regional including ACLs and knee scopes (unless patient refuses). Time to discharge from OR is often a half an hour for the peripheral blocks.

What regional are you doing for knee scopes? Sounds like unnecessary work to me.

 

[kmurp]

What regional are you doing for knee scopes? Sounds like unnecessary work to me.

Mostly chloroprocaine spinals. Epidurals if they are younger.

 

[deleted162650]

Mostly chloroprocaine spinals. Epidurals if they are younger.

That’s silly.

 

[Simba1711]

What do you guys do when the incision is just proximal to the elbow? Mostly superficial cases like av fistula or I and d ? I do a supraclavicular block with deep sedation with surgeon giving local but wondering if it would be better to do interscalene or do block between Sc and interscalene.

 

[Arch Guillotti]

That’s silly.

I don’t get it either.

 

[Arch Guillotti]

What do you guys do when the incision is just proximal to the elbow? Mostly superficial cases like av fistula or I and d ? I do a supraclavicular block with deep sedation with surgeon giving local but wondering if it would be better to do interscalene or do block between Sc and interscalene.

Why not deposit the local in between the two usual locations?

 

[Simba1711]

I was just curious if there was a way to limit the number of injections and amount of local as I’ve heard different things. Like that large volume in interscalene should give ulnar coverage in the proximal arm or that it’s better to go in between the two blocks or supraclav often covers entire arm

 

[GassYous]

What do you guys do when the incision is just proximal to the elbow? Mostly superficial cases like av fistula or I and d ? I do a supraclavicular block with deep sedation with surgeon giving local but wondering if it would be better to do interscalene or do block between Sc and interscalene.

Can do interscalene and pecs2 or supraclav alone.

 

[MirrorTodd]

What do you guys do when the incision is just proximal to the elbow? Mostly superficial cases like av fistula or I and d ? I do a supraclavicular block with deep sedation with surgeon giving local but wondering if it would be better to do interscalene or do block between Sc and interscalene.

How many of you all are having surgeons specifically request no block for av fistulas just above the elbow? Did a case the other day, where the pt was adamant about no general anesthesia and no block. The surgeon said they actually prefer just a little sedation cause they can do it under local anyway. So we gave 1 of versed, 50 fent, and 10 ketamine and the guy chilled while they did the fistula. He was out of the hospital in like an hour.

 

[kmurp]

I don’t get it either.

Works for us. Don’t have to be available for induction either so I can be placing the next block.

 

[dhb]

What do you guys do when the incision is just proximal to the elbow? Mostly superficial cases like av fistula or I and d ? I do a supraclavicular block with deep sedation with surgeon giving local but wondering if it would be better to do interscalene or do block between Sc and interscalene.

Axillary and infiltrate under the veins on the ulnar side to get the ant. cut. nerve.
Sometimes i'd do a infraclav but you sometimes miss the acn so you have to get it at the axilla when you see you haven't covered the medial cutaneous zone just above the elbow.

 

[Simba1711]

How many of you all are having surgeons specifically request no block for av fistulas just above the elbow? Did a case the other day, where the pt was adamant about no general anesthesia and no block. The surgeon said they actually prefer just a little sedation cause they can do it under local anyway. So we gave 1 of versed, 50 fent, and 10 ketamine and the guy chilled while they did the fistula. He was out of the hospital in like an hour.

I think av fistula is totally doable with just sedation and local if the surgeon is generous with local. We have one surgeon who refuses blocks on av fistulas but barely gives any local and wants sedation for his cases. We don’t like working with him.

 

[GassYous]

How many of you all are having surgeons specifically request no block for av fistulas just above the elbow? Did a case the other day, where the pt was adamant about no general anesthesia and no block. The surgeon said they actually prefer just a little sedation cause they can do it under local anyway. So we gave 1 of versed, 50 fent, and 10 ketamine and the guy chilled while they did the fistula. He was out of the hospital in like an hour.

Our surgeons are ok with blocks but can do it well with sedation and local. Key is to be generous with local in the area where the nerves are. Dump a bunch proximal.