Decreased PE and bleeding risk with regional in hips

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GaseousClay

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Just wondering if anyone knows any data of using epidurals + GA vs GA alone vs regional alone for hips in terms of decreasing pe and blood loss risks. Is the consensus just GA vs regional?

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Just wondering if anyone knows any data of using epidurals + GA vs GA alone vs regional alone for hips in terms of decreasing pe and blood loss risks. Is the consensus just GA vs regional?


The benefits seen for neuraxial blockade may be conferred by multifactorial mechanisms, including altered coagulation, increased blood flow, improved ability to breathe free of pain, and reduction in surgical stress responses.2 In particular, major surgery induces a “stress response” that is substantially altered by neuraxial blockade but not by general anaesthesia.2 This observation, together with the subgroup comparisons shown here, suggests that these benefits are principally due to the use of neuraxial blockade rather than avoidance of general anaesthesia. Thus the key issue seems to be whether neuraxial blockade is used or not, and the way in which this is achieved is less relevant.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC27550/#!po=21.2500
 
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J Clin Anesth. 1997 May;9(3):200-3.
Comparison of general anesthesia with and without lumbar epidural for total hip arthroplasty: effects of epidural block on hip arthroplasty.
Dauphin A1, Raymer KE, Stanton EB, Fuller HD.
Author information

Abstract
STUDY OBJECTIVES:
To determine whether lumbar epidural anesthesia, when combined with general anesthesia, decreases perioperative blood loss, the incidence of postoperative deep vein thrombosis (DVT), cardiac dysrhythmias, and ischemia in patients undergoing total hip arthroplasty (THA).

DESIGN:
Randomized, controlled study.

SETTING:
A university hospital.

PATIENTS:
37 ASA physical status I, II, and III patients, undergoing elective THA.

INTERVENTION:
Patients were divided into two statistically comparable groups: Group GA = general anesthesia; Group CEGA = general anesthesia plus lumbar epidural anesthesia. All patients had 48-hour perioperative Holter monitoring, applied on admission, the day prior to surgery. In both groups, general anesthesia was induced with thiopental sodium and muscle relaxant, and maintained with oxygen, nitrous oxide, isoflurane, opioid, and muscle relaxant. Group B received lumbar epidural anesthesia with 10 ml 0.5% bupivacaine with 1:200,000 epinephrine prior to anesthesia induction. Blood loss was measured by suction bottle contents, sponge weights, and collection drainage. DVT was assessed with postoperative leg scanning, plethysmography, and venogram.

MEASUREMENTS AND MAIN RESULTS:
Intraoperative blood loss was less after combined epidural-general anesthesia (663.8 ml +/- 299.0 ml) than after general anesthesia alone (1,259.2 ml +/- 366.0 ml). The difference was found to be statistically significant (p < 0.00005). No difference was found between the two groups in postoperative blood loss, incidence of DVT, cardiac dysrhythmias, or ischemia.

CONCLUSION:
Combined regional-general anesthesia decreases intraoperative blood loss in THA, and thereby offers an advantage over general anesthesia alone.
 
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Perioperative Comparative Effectiveness of Anesthetic Technique in Orthopedic Patients
Memtsoudis, Stavros G. M.D., Ph.D., F.C.C.P.*; Sun, Xuming M.S.†; Chiu, Ya-Lin M.S.†; Stundner, Ottokar M.D.‡; Liu, Spencer S. M.D.§; Banerjee, Samprit Ph.D., M.Stat.‖; Mazumdar, Madhu Ph.D., M.A., M.S.#; Sharrock, Nigel E. M.B., Ch.B.§


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Abstract

Background: The impact of anesthetic technique on perioperative outcomes remains controversial. We studied a large national sample of primary joint arthroplasty recipients and hypothesized that neuraxial anesthesia favorably influences perioperative outcomes.
Methods: Data from approximately 400 hospitals between 2006 and 2010 were accessed. Patients who underwent primary hip or knee arthroplasty were identified and subgrouped by anesthesia technique: general, neuraxial, and combined neuraxial–general. Demographics, postoperative complications, 30-day mortality, length of stay, and patient cost were analyzed and compared. Multivariable analyses were conducted to identify the independent impact of choice of anesthetic on outcomes.
Results: Of 528,495 entries of patients undergoing primary hip or knee arthroplasty, information on anesthesia type was available for 382,236 (71.4%) records. Eleven percent were performed under neuraxial, 14.2% under combined neuraxial–general, and 74.8% under general anesthesia. Average age and comorbidity burden differed modestly between groups. When neuraxial anesthesia was used, 30-day mortality was significantly lower (0.10, 0.10, and 0.18%; P < 0.001), as was the incidence of prolonged (>75th percentile) length of stay, increased cost, and in-hospital complications. In the multivariable regression, neuraxial anesthesia was associated with the most favorable complication risk profile. Thirty-day mortality remained significantly higher in the general compared with the neuraxial or neuraxial–general group for total knee arthroplasty (adjusted odds ratio [OR] of 1.83, 95% CI 1.08–3.1, P = 0.02; OR of 1.70, 95% CI 1.06–2.74, P = 0.02, respectively).
Conclusions: The utilization of neuraxial versus general anesthesia for primary joint arthroplasty is associated with superior perioperative outcomes. More research is needed to study potential mechanisms for these findings.

http://journals.lww.com/anesthesiol...perative_Comparative_Effectiveness_of.14.aspx
 
We found that the utilization of neuraxial anesthesia (with or without general) in our sample was applied only in a minority of patients. Reasons for this distribution have to remain speculative but may include physician and patient preference, level of experience and familiarity with the techniques involved, and institutional approaches to perioperative anticoagulation. Despite these factors, examples of successful institutional conversions from primarily general anesthesia to using neuraxial techniques have been described along with marked improvements in outcomes.25 Furthermore, given the beneficial impacts on outcome found in this and other studies, the potential overall impact of higher utilization of neuraxial anesthesia is important for two reasons: First, as evidenced by our data, the proportional utilization of neuraxial anesthesia (with or without general) in the time period between 2006 and 2010 is approximately 24% and has therefore the potential for growth. Second, the number of hip and knee arthroplasties performed is expected to increase markedly from currently one million to more than four million within one generation.3
The question whether the performance of neuraxial anesthesia itself or the avoidance of general anesthesia is responsible for observed outcome benefits remains a topic of debate.2 Although our data may not be entirely conclusive, in this study, we were able to study a group of patients who received a combination of both modes of anesthesia. Interestingly, the odds for many of the outcomes fell between that of general-only and neuraxial-only approaches. This observation suggests that neuraxial anesthesia may by itself confer a positive modifiable effect. However, it is important to note that some outcomes remained unaffected by the choice of anesthesia.


http://journals.lww.com/anesthesiol...perative_Comparative_Effectiveness_of.14.aspx
 
So let me summarize:

Pure Regional technique is best. This means an epidural, spinal or CSE technique. However, is a surgical level nerve block plus TIVA equivalent to a spinal/epidural for total joint replacement?

A combined GA/Neuraxial technique is likely not as good as a pure Neuraxial technique but is significantly better than a pure GA.

Hence, there are documented advantages to a combined GA/Neuraxial technique over just a regular GA.
 
Mortality Following Revision Joint Arthroplasty: Is Age a Factor?
Thomas K. Fehring, MD; Susan M. Odum, MEd; Keith Fehring, MD; Bryan D. Springer, MD; William L. Griffin, MD; Anne C. Dennos, BS

  • Orthopedics
  • October 2010 - Volume 33 · Issue 10

Abstract
With the demand for total joint arthroplasty and overall life expectancy increasing, there will be an increase in the need for revision arthroplasty surgeries. Given that revision joint surgeries are more demanding for both surgeon and patient with longer operative times, increased blood loss, and multiple patient comorbidities, the current mindset is that older patients who undergo a total hip revision or total knee revision have higher mortality rates than younger patients. We identified 1737 revision total joint patients who were at least 2 years postoperative for inclusion in the study. The overall perioperative mortality rate (defined as deaths occurring between 0 and 3 months following revision joint surgery) was calculated and then stratified by revision knee surgery, revision hip surgery, and age. In addition, mortality rates were compared for patients younger than 70 years, between 70 and 80 years and older than 80 years. The overall perioperative mortality rate after revision total hip or knee surgery was 0.7%. After stratifying by age, the perioperative mortality rate was 0.2% in patients younger than 70 years, 0.8% in patients 70 to 79 years, and 2.63% in patients older than 80 years. Of the 1737 patients, 541 died >1 year following their revision surgery at an average time to death of 6.9 years. The observed perioperative mortality rates following revision total joint surgery at a single center were extremely low among all age groups. Therefore, the age of patients undergoing revision surgery should not be the sole determinant of perioperative survival. Additionally, it appears that the mean postoperative survival noted here seems to justify the additional resources used in revision surgery regardless of age. As limited resources exert pressure on an already overburdened healthcare system, rationing of care for certain procedures may ensue using age as a specific criteria. This study should add clarity to this issue.
 
The chance of dying after revision total joint hip replacement is 13 times greater at age 80 vs age 60.

While the overall incidence is still low at 2.6 percent the mortality is 13 times greater in the over 80 year old age group.
 
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As more Americans are living well into their 90s, the number of nonagenarian total hip replacement (THR) candidates continues to increase. In the study, "Total Hip Arthroplasty Proves Safe for Nonagenarian Patients," presented today at the at the 2014 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS), researchers reviewed patient characteristics and rates of postoperative morbidity, mortality and readmission among patients who underwent elective THR surgery between April 2001 and December 2011.

Of the 43,543 THRs performed during this period, only 183 were performed on nonagenarians (0.4 percent). Before surgery, nonagenarians had the highest prevalence of peripheral vascular disease, hypertension and valvular heart disease, increasing their risk of surgical complications. Nonagenarian patients had the highest incidence of death within 90 days (2.7 percent compared to the overall average of 0.4 percent), and the highest rate of readmission within 90 days (15 percent compared to 10.3 percent for patients aged 80 to 89, and 6.3 percent for those younger than 80).

Length of hospital stay was comparable for nonagenarians (3.4 days) to octogenarians (3.3 days), and the patients in their 90s showed no significant differences in the incidence of surgical site infection or pulmonary embolisms.

The authors of the study concluded that nonagenarian patients can safely undergo a THR, despite advanced age and a higher prevalence of comorbidities. Overall, the nonagenarian patients experienced a complication rate comparable to those of younger THR patients, and the higher mortality rate is well within expectations for individuals age 90 and older.
 
only one of our Ortho guys wants epidurals/spinals for their hips. the rest either think its not worth the wasted time in the OR or they don't really believe the evidence. very frustrating
 
only one of our Ortho guys wants epidurals/spinals for their hips. the rest either think its not worth the wasted time in the OR or they don't really believe the evidence. very frustrating

I suggest you use actual date of time in room til the patient is getting prepped between GA and spinal. I suspect they will be within < 5 minutes of difference. I then suggest you measure from end of procedure until out of room times for the same. Guaranteed spinal patients are out of room significantly faster since once the dressing is on they can instantly be moved to stretcher and out of room.

The reason I say this is that surgeons generally only pay attention to time in room til time to prep. You spinal might take an extra 60 seconds. They don't pay attention to the extra 10 minutes on the wake up which is equally important when they have 5-6 cases in the same room all day.
 
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The reason I say this is that surgeons generally only pay attention to time in room til time to prep. You spinal might take an extra 60 seconds. They don't pay attention to the extra 10 minutes on the wake up which is equally important when they have 5-6 cases in the same room all day.

My wake ups don't take any longer in either case, but in the case of the spinal they are sure alert and comfortable much sooner. I often wonder how much surgeons actually care about this, though :-(
 
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i've come to the reality that most surgeons don't really think we have any effect on outcome and get frustrated when we do anything out of the "norm"
 
An ortho I work with started doing all of her total hips via the anterior approach. With straight GA, transfusion was a given. Routinely lost 500 cc of blood or more. I did some research and found the papers Blade posted. I started putting spinals in every patient, and have yet to require a transfusion since.

I do intubate these patients because they are positioned with the arm of the opposite side secured across their chest, making intra op intubation very difficult should the operation last longer than the spinal.
 
An ortho I work with started doing all of her total hips via the anterior approach. With straight GA, transfusion was a given. Routinely lost 500 cc of blood or more. I did some research and found the papers Blade posted. I started putting spinals in every patient, and have yet to require a transfusion since.

I do intubate these patients because they are positioned with the arm of the opposite side secured across their chest, making intra op intubation very difficult should the operation last longer than the spinal.

I cannot make sense of this post...
 
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An ortho I work with started doing all of her total hips via the anterior approach. With straight GA, transfusion was a given. Routinely lost 500 cc of blood or more. I did some research and found the papers Blade posted. I started putting spinals in every patient, and have yet to require a transfusion since.

I do intubate these patients because they are positioned with the arm of the opposite side secured across their chest, making intra op intubation very difficult should the operation last longer than the spinal.

So you do a spinal and then GA? While the presented papers might confer this technique to be of benefit, I would question whether or not the GA group had similar hemodynamics to the neuraxial, and if not, could the BP be modified intraop and receive similar results?

In my experience I choose one technique, either spinal or GA, but this is with fairly fast private practice surgeons. Of note I have also noticed more blood loss with the anterior approach as well, spinal or not. Our main joint guy started asking for GA on his anterior hips recently. I tried both isobaric and hyperbaric bupiv spinals and neither got his desired degree of relaxation. Do you do spinal/GA on regular hips too? I'd actually rather move the arm and intubate on an anterior hip then stop the case and flip back to supine on a regular hip.
 
My surgeon only does anterior total hips now. I place a spinal when we get into the room, then I lay the patient down and intubate. Before when I did general only, I had to transfuse every patient. Now that I use the combined technique, I have not had to transfuse anyone.

Theoretically, I could do the case under spinal alone, but the patient is positioned with an arm secured over their chest. This makes accessing the airway in the middle of the case for whatever reason (apnea, code, case outlasts the spinal, patient complaining, etc) damn near impossible without reprepping. Thus I intubate these patients as well. I guess I could use an LMA, but if it became dislodged then I'd be back to the same problem.

I haven't done a regular hip in years.
 
My surgeon only does anterior total hips now. I place a spinal when we get into the room, then I lay the patient down and intubate. Before when I did general only, I had to transfuse every patient. Now that I use the combined technique, I have not had to transfuse anyone.

Theoretically, I could do the case under spinal alone, but the patient is positioned with an arm secured over their chest. This makes accessing the airway in the middle of the case for whatever reason (apnea, code, case outlasts the spinal, patient complaining, etc) damn near impossible without reprepping. Thus I intubate these patients as well. I guess I could use an LMA, but if it became dislodged then I'd be back to the same problem.

I haven't done a regular hip in years.
Do you have issues with hypotension? How light do you run them in terms of their inhalational anesthetic?
 
My surgeon only does anterior total hips now. I place a spinal when we get into the room, then I lay the patient down and intubate. Before when I did general only, I had to transfuse every patient. Now that I use the combined technique, I have not had to transfuse anyone.

Theoretically, I could do the case under spinal alone, but the patient is positioned with an arm secured over their chest. This makes accessing the airway in the middle of the case for whatever reason (apnea, code, case outlasts the spinal, patient complaining, etc) damn near impossible without reprepping. Thus I intubate these patients as well. I guess I could use an LMA, but if it became dislodged then I'd be back to the same problem.

I haven't done a regular hip in years.

This seems like a very strange approach. I do spinals for all the anterior hips and don't ever recall having all the issues you mentioned.
 
Spinal + GA has been linked to higher morbidity. I don't see why you would have less bleeding apart from the fact that your surgeon has become more experienced in the technique.
 
Do you have issues with hypotension? How light do you run them in terms of their inhalational anesthetic?
I run them at .75-1 MAC. I also have narcotics on board to prevent coughing. I preload with a bag of fluid, and often inject 25 mg of ephedrine IM. I'm not going to say I've never had an issue with hypotension, but its nothing that wasn't quickly managed.

Spinal + GA has been linked to higher morbidity. I don't see why you would have less bleeding apart from the fact that your surgeon has become more experienced in the technique.
I think my surgeon's skill level increase has just as much to do with the lack of bleeding than the spinal. That being said, she has started requesting the spinal for her patients, and I oblige.
 
I guess I could use an LMA, but if it became dislodged then I'd be back to the same problem.

Why would an LMA become dislodged? If it did, why couldn't you just reposition it?

My quibble with this technique is the unnecessary moving parts- volatile, narcotic, etc. I personally prefer a pure propofol sedation after a spinal for a hip. I understand the airway concern of a lateral patient, but TBH I don't really mind managing a sideways airway if I had to. And you'll almost never have to.

That said, nothing wrong with it, and if it works for you then great.
 
Transfusion requirement has more to do with surgical skill than anesthetic technique. I do all my hips (anterior/posterior) with GA. I haven't transfused a hip replacement patient in over four years.

Unless you have some sort of super sick, anemic patients, you don't need to transfuse for blood loss of 500mL.

LMA's are easily repositioned or replaced, even with the arm over the chest.

GA for a routine, healthy patient is 3-5 min from entering the OR to completion of induction, securing of airway, and turning patient over to surgeon. It takes me closer to 10 min to get a regional anesthetic in and get the patient turned over to surgeon.

The last hip I did with GA was an anomaly and took about to 20 minutes from door to turning patient over to the surgeon. Of course she had PA pressures documented in the 80-100 range so there were a few extra lines to do after induction. No transfusion. Minimal fluids. Intraoperative sildenafil when her PA pressures spiked at the end of the case as I started to wake her up. She did amazingly well. A traditional spinal probably would have killed her. A unilateral spinal or a spinal catheter might have been a good choice, but then you get into the pulmonary hypertension death zone when you add in a little sedation.


- pod
 
GA for a routine, healthy patient is 3-5 min from entering the OR to completion of induction, securing of airway, and turning patient over to surgeon. It takes me closer to 10 min to get a regional anesthetic in and get the patient turned over to surgeon.

We have an electronic database with 100s of thousands of anesthetic records (approaching a million) of which plenty are joints. Entering the OR until anesthesia ready time of 3-5 minutes is somewhere around 4-6 standard deviations better than the norm in a hospital based setting. At an outpatient center you can get a little closer to that but still won't average that on a case like a hip. Moving from stretcher to OR bed, placing monitors, preoxygenating, inducing, masking, DL, intubation, confirming intubation, taping tube, etc. take an average of 10-15 minutes depending on case type in our database. And this is in fast private practice setting with OR turnover times that are well faster than average for comparable institutions.

Total OR time with general anesthesia or spinal anesthesia for a hip is almost identical with a trend towards being faster in the spinal because on the back end of the case you can have the patient on the bed and out the door as soon as the dressing is on. And in a world in which many hip patients are old and frail the wake up from GA isn't as consistently rapid as you can achieve with a spinal. And for most situations the time from entering the OR until turning the patient over to the surgeon is within 1-2 minutes difference between a spinal and a GA.
 
We have an electronic database with 100s of thousands of anesthetic records (approaching a million) of which plenty are joints. Entering the OR until anesthesia ready time of 3-5 minutes is somewhere around 4-6 standard deviations better than the norm in a hospital based setting. At an outpatient center you can get a little closer to that but still won't average that on a case like a hip. Moving from stretcher to OR bed, placing monitors, preoxygenating, inducing, masking, DL, intubation, confirming intubation, taping tube, etc. take an average of 10-15 minutes depending on case type in our database. And this is in fast private practice setting with OR turnover times that are well faster than average for comparable institutions.

Total OR time with general anesthesia or spinal anesthesia for a hip is almost identical with a trend towards being faster in the spinal because on the back end of the case you can have the patient on the bed and out the door as soon as the dressing is on. And in a world in which many hip patients are old and frail the wake up from GA isn't as consistently rapid as you can achieve with a spinal. And for most situations the time from entering the OR until turning the patient over to the surgeon is within 1-2 minutes difference between a spinal and a GA.

Agree completely.
 
Did I say 3-5 min? Maybe I meant 35 min. :thinking:

Maybe I should learn to relax more :)

Obviously, I don't have that kind of case numbers, but I have an electronic record that I enter my data into and can query for my personal times. I hit start when the patient rolls through the door and induction complete when the tube/LMA is in and the surgeon can start doing whatever it is that they need to do. It is rare that this time span is longer than 5 min for routine cases unless I am having a really enjoyable conversation with the patient before I induce him. I can't imagine what could take 15 minutes except for a situation where the patient is in excruciating pain from a broken hip and something possessed me to move him to the OR table before induction.

It is all about efficiency of movement, parallel activity, and a nursing staff that understands and does what I expect of them, but it is possible.

At my institution, there is no sense of urgency to move the patient at the end of the case and I have no qualms about moving the patient to the gurney then extubating. Here, the time difference of spinal vs GA for dressing applied to PACU arrival time is minimal. Yes, occasionally I do get burned by a slow wakeup, but this usually happens with the long spine cases, not the shorter joint replacement cases.

Just my humble(?) experience in little old podunk, BFE Montana. Really it is awful here. I hear South Dakota is nice this time of year. ;)

- pod
 
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I was thinking about this a little more last night and realized that the difference between a 3 minute vs a 5 minute start or a 5 minute vs a 7 minute start could be as little as 2 seconds. e.g. If you came into the OR at 08:00:01 and induction was complete at 08:03:59, you have a 3 minute door to induction complete time, but that is only two seconds longer than the 5 minute time of 07:59:59 to 08:04:00.

Soooo, for gits and shiggles, I timed my case starts today.

I am not doing joints, but I am working with the fluoro table in in the cysto room which requires some care in positioning. I am also working with nurse Brownian, as in Brownian motion. The opposite of efficiency of movement. I have never seen somebody move so fast yet accomplish so little with all of that frenetic motion. It really is amazing to watch.



Anyway, here are my times.

14459639094_0edd25e7d2_n.jpg


14480912523_e319f34ba1_n.jpg


14459640684_b1a22e3b90_n.jpg


14460755175_54dc98dfe6_n.jpg


Ignore the lap time in the first three cases, I was timing something else simultaneously.

I have visited the practices of a couple of other docs here on SDN and watched them accomplish similar induction times.


- pod
 
I was thinking about this a little more last night and realized that the difference between a 3 minute vs a 5 minute start or a 5 minute vs a 7 minute start could be as little as 2 seconds. e.g. If you came into the OR at 08:00:01 and induction was complete at 08:03:59, you have a 3 minute door to induction complete time, but that is only two seconds longer than the 5 minute time of 07:59:59 to 08:04:00.

Soooo, for gits and shiggles, I timed my case starts today.

I am not doing joints, but I am working with the fluoro table in in the cysto room which requires some care in positioning. I am also working with nurse Brownian, as in Brownian motion. The opposite of efficiency of movement. I have never seen somebody move so fast yet accomplish so little with all of that frenetic motion. It really is amazing to watch.



Anyway, here are my times.

14459639094_0edd25e7d2_n.jpg


14480912523_e319f34ba1_n.jpg


14459640684_b1a22e3b90_n.jpg


14460755175_54dc98dfe6_n.jpg


Ignore the lap time in the first three cases, I was timing something else simultaneously.

I have visited the practices of a couple of other docs here on SDN and watched them accomplish similar induction times.


- pod
 
Our data is captured in 15 second intervals and it isn't reliant on a person in the room pushing a button to start it. In the room time is captured from an RFID on the patient wristband and it trips the OR in time as soon as the cross the doors into the room. And we are a fast private practice with helpful staff and quick turnover. It takes 10+ minutes for your average induction. You take 60 seconds or more just to get the patient from crossing the OR door to get fully moved on to the OR table. Then you can start preoxygenating and hooking up monitors. Preoxygenation itself should be 3 minutes. The NIBP cuff takes an average of 60 seconds from the time you start it until it finishes cycling. So after about 4 minutes in the best of circumstances you can be pushing induction drugs. If you do a true RSI on every single patient and flush the propofol in with the succinylcholine you can be doing a DL in about 45-60 seconds after starting to push the drugs. If you are using a nondepolarizer and have to ventilate for 2+ minutes, the clock is still ticking.


If your average patient is having the ETT taped 4 minutes after rolling through the OR door, I'll either say congrats on being the fastest draw in the west or congrats on not being safe with your preoxygenation.
 
3 minutes of preoxygenation is unnecessary for most patients in the real world.

I will preox a sick patient to the academic letter of the law, with a good seal and ETO2 80%.

A healthy knee scope with good lungs and a favorable airway? Nah. A few good breaths and the propofol goes in.
 
Somewhat back to the original topic, and my general skepticism of the purported benefit of regional anesthesia for hips, I will just leave this here.

Anesthesia Technique, Mortality, and Length of Stay After Hip Fracture Surgery

-pod


depends on the research

Regional Anesthesia Reduces Complications and Death for Hip Fracture Patients, Penn Medicine Study Finds

Dr. Neuman and his co-authors examined a retrospective cohort of patients undergoing surgery for hip fracture in 126 hospitals in New York in 2007 and 2008, which included a total of 18,158 patients. They compared rates of inpatient mortality, major pulmonary complications, and major cardiovascular complications among patients receiving regional anesthesia--including epidural, spinal or nerve block procedures--versus general anesthesia.

The researchers found a 29 percent lower adjusted odds of mortality among patients receiving regional versus general anesthesia. They also found a 24 percent decrease in the adjusted odds of any inpatient pulmonary complication with regional anesthesia.

"These findings have important implications for practice, policy, and research related to the treatment of older adults with hip fracture," said Lee A. Fleisher, MD, chair and Robert Dunning Dripps Professor of Anesthesiology and Critical Care and the senior author of the study. "Given the high rate of mortality associated with hip fracture and the large and growing worldwide public health burden attributed to complications of hip fracture care, our findings highlight an important potential opportunity to improve outcomes among a growing population of vulnerable surgical patients."

http://www.uphs.upenn.edu/news/News_Releases/2012/06/hip/







Anesthesia Type Affects Perioperative Outcomes in Orthopedic Surgery Patients

To determine whether spinal or epidural anesthesia produces better outcomes than general anesthesia, researchers from Weil Medical College of Cornell University, New York, utilized data collected from approximately 400 U.S. hospitals from 2006 to 2010. Patients who underwent primary hip or knee replacement were sub-grouped by the type of anesthesia they received: general (74.8 percent), spinal or epidural (11 percent), or combined spinal or epidural-general (14.2 percent).

In the 382,236 cases, neuraxial compared to general anesthesia resulted in an:
  • 80 percent lower 30-day mortality rate;
  • 30 percent lower risk of prolonged length of hospital stay and increased patient costs; and
  • 30 to 50 percent lower risk of major complications including stroke, pneumonia, kidney failure and the need for mechanical ventilation.

https://www.asahq.org/For-the-Publi...-Outcomes-in-Orthopedic-Surgery-Patients.aspx
 
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