Is intraop monitoring really that necessary with regional anesthesia?

[ethilo]

I run into a scenario every now and then where I block a patient, they have a great block, come into the OR for their hand operation and get a propofol infusion essentially to just "pass the time." Their anesthetic is completely stable, boring, and the sedation is seemingly unnecessary.

My question is, with the right pre-screening, counseling of patient pre-operatively, sufficient lag-time for onset of block and safety monitoring, would it really be that unsafe to have the patient be in the OR without anesthesia support for say, only forearm procedures that are < 2 hours? Set up a TV for the patient with headphones, etc.

I am just imagining: what if you had a "hand, forearm, and lower leg surgical center" where it staffs 1 anesthesiologist for I dunno, 4 ORs. They just block all day without sedation given and send the patients in once their blocks are dense enough. I think it would cut costs down for surgeons, consolidate care and be safe. Am I missing something?

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[DrOwnage]

In a perfect world, maybe. But there's a reason we have standard monitors and I'm not getting sued for negligence.

 

[patriot6]

Patients are weird. When I describe regional techniques to patients, they frequently get this bug-eyed look and respond, "I'M GOING TO BE AWAKE?!" Just the other day, I was doing some MAC cases for cataracts and gave this lady 2 and 2. She just about tried to run out the OR once they draped. All that to say, it takes the right patient to be cool with watching a movie with headphones during their surgery. You're right to say that those patients don't need us after the block is placed, but it's hard to know who's who. Plus, I love billing for some chill time in the OR.

 

[narcotics999]

I want them to sleep so that I can play sudoku, check stocks, and don't have to talk to them.

 

[ethilo]

I'm wondering if most of the issue is poor communication and set up for the experience in the surgical clinic beforehand. Rarely do I have a patient that had ever heard the word "block" before meeting me on day of surgery. It's a waste of time and I bet if patients knew what to expect beforehand in an AMC they could handle itor would prove themselves otherwise.

 

[drmwvr]

All about the selling and the buying (and the reimbursement). Patients don't think twice about 'blocks' in their mouths without monitoring. It's just an expectation. But intra-op monitoring doesn't necessarily imply anesthesia involvement. Conscious sedation by nurses happens all the time with standard monitoring. Folks go home with dense surgical blocks.

 

[dannyboy1]

I run into a scenario every now and then where I block a patient, they have a great block, come into the OR for their hand operation and get a propofol infusion essentially to just "pass the time." Their anesthetic is completely stable, boring, and the sedation is seemingly unnecessary.

My question is, with the right pre-screening, counseling of patient pre-operatively, sufficient lag-time for onset of block and safety monitoring, would it really be that unsafe to have the patient be in the OR without anesthesia support for say, only forearm procedures that are < 2 hours? Set up a TV for the patient with headphones, etc.

I am just imagining: what if you had a "hand, forearm, and lower leg surgical center" where it staffs 1 anesthesiologist for I dunno, 4 ORs. They just block all day without sedation given and send the patients in once their blocks are dense enough. I think it would cut costs down for surgeons, consolidate care and be safe. Am I missing something?

Sure. Let’s all think of innovative ways to reduce demand for our services. Good job.

 

[woopedazz]

Fistula lists with axillary blocks and no sedation all the time.

Turnover is so fast you don't have time to be in the room anyway, just blocking.

 

[pgg]

We (and by "we" I mean "sometimes other people at my institution") will do this thing called "block and release" where someone will get a PNB and then go to the OR with a sedation nurse. These are typically cases that are done in the local-only OR that we don't normally staff, that normally just get local from the surgeon and a sedation nurse. Mostly young ASA 1s and 2s getting hand hardware removal or carpal tunnels or a deQuervains release, that kind of thing. Typically not for fistulas or bigger stuff. I guess sometimes the surgeons just want a denser block.

I think it's safe, but that always seemed kind of sketchy to me given the ASA's definition of "anesthetic" and standard monitors for an "anesthetic". The risk of delayed LAST is pretty low but not zero, and I'm not sure that's a defense I'd want to have to make.

 

[drmwvr]

Sure. Let’s all think of innovative ways to reduce demand for our services. Good job.

No one said stop doing blocks. And improving throughput with increasing surgeon/OR productivity is hardly reducing demand for our services.

 

[dannyboy1]

No one said stop doing blocks. And improving throughput with increasing surgeon/OR productivity is hardly reducing demand for our services.

It sure is. If there is no one sitting the stool in those rooms….

 

[ethilo]

Sure. Let’s all think of innovative ways to reduce demand for our services. Good job.

I'm just brainstorming ways that actually would best utilize my skillset. As nice as it is to babysit this patient in the OR, I think it's fair to say it's often well below even the necessity of even a CRNA.

 

[IMGASMD]

If you changed the way we are reimbursed, sued, or we get real incentives, then we can talk more.

 

[dhb]

We do a lot of these in Europe: block in pre op then send the patient to the room where the surgeon does his thing and the anesthesiologist only comes in if called for a pb. The patient will have been monitored for 15-20min so i don't really care if they get a pulse ox or nothing in the OR.
I'm surprised by the number of cases that you guys sedate on top of a perfectly functioning anesthetic spinal/block, i've never done that except maybe for amputations.

 

[GassYous]

Problem is that americans are a bunch of sissies and can't tolerate things that a child would tolerate anywhere else. Plenty of places do block only for surgeries but in America everyone says "I just want to be asleep, I don't want to know see or hear anything in the operating room". It is truly ridiculous. If you can't feel anything, what's the big deal? But psychological pathology is huge here. The number of people taking benzos or chronic opioids for nonindicated is completely unreasonable. When you don't have any real problems, I guess you have to make them up to feel better about yourself.

 

[drmwvr]

We do a lot of these in Europe: block in pre op then send the patient to the room where the surgeon does his thing and the anesthesiologist only comes in if called for a pb. The patient will have been monitored for 15-20min so i don't really care if they get a pulse ox or nothing in the OR.
I'm surprised by the number of cases that you guys sedate on top of a perfectly functioning anesthetic spinal/block, i've never done that except maybe for amputations.

They're sedated because we don't want to talk to them, not because the block isn't enough. In all seriousness, a patient that won't shut up is a terrible distraction for everyone in the room. Has nothing to do with the virtue that the patient possesses which is absurd on its face (not implying you made that claim).

 

[coffeebythelake]

Tell cataract patient this. 99% want some anxiolytic

 

[osumd]

We (and by "we" I mean "sometimes other people at my institution") will do this thing called "block and release" where someone will get a PNB and then go to the OR with a sedation nurse. These are typically cases that are done in the local-only OR that we don't normally staff, that normally just get local from the surgeon and a sedation nurse. Mostly young ASA 1s and 2s getting hand hardware removal or carpal tunnels or a deQuervains release, that kind of thing. Typically not for fistulas or bigger stuff. I guess sometimes the surgeons just want a denser block.

I think it's safe, but that always seemed kind of sketchy to me given the ASA's definition of "anesthetic" and standard monitors for an "anesthetic". The risk of delayed LAST is pretty low but not zero, and I'm not sure that's a defense I'd want to have to make.

How do you bill this? Just submit the block code as an acute pain procedure? I imagine you still write preop and post op evals?

 

[pgg]

How do you bill this? Just submit the block code as an acute pain procedure? I imagine you still write preop and post op evals?

We don't bill. Government hospital. There's some handwaving and unit counting in the background to kinda sorta track workload, but none of it really matters, and these rare block & release cases would be lost in the noise anyway. On rare occasions we have a patient for whom we are their secondary coverage, so sometimes their primary insurance gets billed. But that's a totally opaque process from the physician side and it just doesn't matter to us.

 

[MirrorTodd]

We don't bill. Government hospital. There's some handwaving and unit counting in the background to kinda sorta track workload, but none of it really matters, and these rare block & release cases would be lost in the noise anyway. On rare occasions we have a patient for whom we are their secondary coverage, so sometimes their primary insurance gets billed. But that's a totally opaque process from the physician side and it just doesn't matter to us.

We certainly don't get any year end bonuses for saving the hospital any money. lol

 

[dhb]

They're sedated because we don't want to talk to them, not because the block isn't enough. In all seriousness, a patient that won't shut up is a terrible distraction for everyone in the room. Has nothing to do with the virtue that the patient possesses which is absurd on its face (not implying you made that claim).

Haha... the horrors of having to be in the room.
I never go in to the room when the patient is blocked. (I wasn't implying either that your blocks were not good enough as stand alone anesthetic)

 

[Iso4ane]

Patients are weird. When I describe regional techniques to patients, they frequently get this bug-eyed look and respond, "I'M GOING TO BE AWAKE?!" Just the other day, I was doing some MAC cases for cataracts and gave this lady 2 and 2. She just about tried to run out the OR once they draped. All that to say, it takes the right patient to be cool with watching a movie with headphones during their surgery. You're right to say that those patients don't need us after the block is placed, but it's hard to know who's who. Plus, I love billing for some chill time in the OR.

I had a hand surgery once as a late teen, and got a block and no sedation. I thought it was the coolest ****ing thing ever, still do. But, yeah I realize that not all patients are like that. Even now, I question if i were to have the same procedure again, I wonder if I would do it the same (probably, I'd try to schedule it during a natural siesta period, block me and I'll nap through the procedure.)

 

[nimbus]

About 10 years ago there were a few centers that were promoting cataract surgery without anesthesia care but it never really gained acceptance.

Here’s a recent paper out of France.

https://www.nature.com/articles/s41598-021-87926-0.pdf

 

[Hoya11]

I'm just brainstorming ways that actually would best utilize my skillset. As nice as it is to babysit this patient in the OR, I think it's fair to say it's often well below even the necessity of even a CRNA.

i think the crna serves many purposes

you bill
you monitor in case of any events, every once and a while you get a vasovagal or freak out
the circulating RN is free instead of tied monitoring the patient
the patient gets anxiolysis at a minimum
staff in the room can talk and work freely

 

[Twiggidy]

Problem is that americans are a bunch of sissies and can't tolerate things that a child would tolerate anywhere else. Plenty of places do block only for surgeries but in America everyone says "I just want to be asleep, I don't want to know see or hear anything in the operating room". It is truly ridiculous. If you can't feel anything, what's the big deal? But psychological pathology is huge here. The number of people taking benzos or chronic opioids for nonindicated is completely unreasonable. When you don't have any real problems, I guess you have to make them up to feel better about yourself.

While I agree with your sentiment to an extent ......I LOVE putting people to sleep. I feel like if it's block only, ie like C-sections, then I also have the responsibility to talk to them which is something I really don't want to do 99% of the time. Last time I did a full on "block only" anesthetic, I hid a book behind my chart and was reading.

 

[nimbus]

While I agree with your sentiment to an extent ......I LOVE putting people to sleep. I feel like if it's block only, ie like C-sections, then I also have the responsibility to talk to them which is something I really don't want to do 99% of the time. Last time I did a full on "block only" anesthetic, I hid a book behind my chart and was reading.

That’s a major reason why I went into anesthesia. For me, talking to people all day is exhausting. Also why I don’t do OB.

 

[IlDestriero]

We used to do this in the .mil. Patient came to pain clinic, got block, wait 15m, check block is effective, then they went down to the ortho hand clinic for office procedure. Is this a great idea for a civilian practice, probably not.

 

[epidural man]

We don't bill. Government hospital. There's some handwaving and unit counting in the background to kinda sorta track workload, but none of it really matters, and these rare block & release cases would be lost in the noise anyway. On rare occasions we have a patient for whom we are their secondary coverage, so sometimes their primary insurance gets billed. But that's a totally opaque process from the physician side and it just doesn't matter to us.

We used to to this a lot when I was a resident for the ortho hand surgeons.

the patient would come to the block area. We would block them. Watch for 30-45 minutes, then send them back down to Ortho for their hand case. It worked really great.

I didn't see a problem with it (don't do it anymore). It was fast and a win for the orthopedics department. The alternative was to send a team down to do Beir blocks.