Sedative-free Surgery

[bigchoader]

I am not sure about the correct terminology but I think that the title gets the idea across.

I will be having arthroscopic knee surgery in a couple of weeks. I want to do it without sedation. I have heard that the best thing to do is a spinal epidural and a femoral block. Is this what I should mention when speaking with the Anesthesiologist? Are there any alternative suggestions?

Aside from the fact that I believe putting me to sleep for such a minimally invasive, rapid surgery is unnecessary, as a future medical student, I am very interested in watching the surgery on the screen with a clear head.

Would any anesthesiologist here object to a request such as mine? Thanks for your help.

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[coprolalia]

I would try to do the case without sedation, if that's what you wanted. You'd get a single-shot triple block (femoral, obturator, and sciatic), and we'd test a level before we went into the room.

The only thing you have to know is that if the block fails (you develop pain mid-procedure) and/or you start to move too much, you'd have to go under. This is the deal, and you can certainly talk with your anesthesiologist about approaching the case in this way. So, you still can't eat or drink anything after midnight the day before surgery (unless you have normal morning medicines; you can take those with a small sip of water). You'll probably be asked to stop any anti-inflammatory medications for a time before the surgery as well. These won't interfere with the block, but may affect bleeding in and around the surgical site.

Good luck!

-copro

 

[Planktonmd]

I would try to do the case without sedation, if that's what you wanted. You'd get a single-shot triple block (femoral, obturator, and sciatic), and we'd test a level before we went into the room.

The only thing you have to know is that if the block fails (you develop pain mid-procedure) and/or you start to move too much, you'd have to go under. This is the deal, and you can certainly talk with your anesthesiologist about approaching the case in this way. So, you still can't eat or drink anything after midnight the day before surgery (unless you have normal morning medicines; you can take those with a small sip of water). You'll probably be asked to stop any anti-inflammatory medications for a time before the surgery as well. These won't interfere with the block, but may affect bleeding in and around the surgical site.

Good luck!

-copro

How do you do Femoral+ Obturator + Sciatic in one shot?
did you mean a femoral block followed by an anterior approach sciatic block through the same hole?

 

[Tenesma]

personally i would just ask for a one sided-spinal

 

[urge]

How do you do Femoral+ Obturator + Sciatic in one shot?

With a BIG f-ing needle I guess!

 

[Gas]

I agree with Tenesma. If this were me, and I really wanted to watch, I would ask for a spinal. If you are concerned about it being a really short case and do not want lidocaine in the spinal, use low-dose bupivacaine or do an epidural dosed with lidocaine.

 

[coprolalia]

How do you do Femoral+ Obturator + Sciatic in one shot?
did you mean a femoral block followed by an anterior approach sciatic block through the same hole?

Well, okay, it's technically not a "triple block" in the classic sense (fem, obturator, psoas), but you do move a bit medially and do the anterior approach to the sciatic. This is a nice way to do it because you don't have to flip the patient over to do the sciatic... and it's faster (which is always key). Not often taught in most residency programs...

And, why do a spinal? I'm sure the dude is going to be awake and doesn't want a Foley. I know I wouldn't. A spinal is the jackhammer to my delicate chisel. We're talking about being elegant and effective here.

-copro

 

[saratoga733]

copro, would you kindly outline your technique for this "triple block" you are describing? not something i am familiar with...

 

[coprolalia]

copro, would you kindly outline your technique for this "triple block" you are describing? not something i am familiar with...

http://www.nysora.com/techniques/sciatic_nerve_block_anterior_parafemoral/

You essentially block the medial strip of the knee with this approach (missed by the femoral field) providing adequate anesthesia to the lower half of the leg as well. This gives good anesthesia for the entire leg, with the standard femoral block, and also makes sure you cover the tibial plateau, where some of this particular surgery can stimulate, especially if the inferior portion of medial collateral and lateral collateral ligaments are operated on. It is not commonly done in most places if the patient can roll to one side because the posterior approach provides easier access (classic Labat) to the sciatic nerve at a higher take-off point. However, for knee surgery the anterior approach is sufficient, and is definitely faster. Key if you're trying to get into the OR in a timely manner.

Enjoy!

-copro

 

[jwk]

Well, okay, it's technically not a "triple block" in the classic sense (fem, obturator, psoas), but you do move a bit medially and do the anterior approach to the sciatic. This is a nice way to do it because you don't have to flip the patient over to do the sciatic... and it's faster (which is always key). Not often taught in most residency programs...

And, why do a spinal? I'm sure the dude is going to be awake and doesn't want a Foley. I know I wouldn't. A spinal is the jackhammer to my delicate chisel. We're talking about being elegant and effective here.

-copro

I'm wondering how many would actually do this type of block in a high-volume private practice. I doubt we would. Epidural or spinal? Sure.

 

[coprolalia]

I'm wondering how many would actually do this type of block in a high-volume private practice. I doubt we would. Epidural or spinal? Sure.

Actually, at one of my moonlighting gigs, this is the only way they do it. Speed, baby, speed.

-copro

 

[gas87]

Copro,
Thanks for the tips on this technique. A few more questions (pardon my lack of knowledge, I'm an intern):
1) Would you inject local at the femoral depth or at the sciatic depth first?
2) Which angle do you go in at? (For the femoral nerve block, the NYSORA site says to angle superiorly, and for the sciatic nerve block, the NYSORA site says to angle slightly inferior-laterally.) Do you try to change your angle at all in-between the two blocks.
Thanks!

 

[Planktonmd]

This block is nice and definitely can be helpful when a patient can not be positioned for a posterior sciatic block.
The problem though is that you have to go really deep through several layers of soft tissue that you can't effectively anesthetize to reach the sciatic nerve which makes this approach difficult unless the patient is deeply sedated.
Many people don't like doing regional anesthesia on deeply sedated patients.

 

[coprolalia]

Copro,
Thanks for the tips on this technique. A few more questions (pardon my lack of knowledge, I'm an intern):
1) Would you inject local at the femoral depth or at the sciatic depth first?
2) Which angle do you go in at? (For the femoral nerve block, the NYSORA site says to angle superiorly, and for the sciatic nerve block, the NYSORA site says to angle slightly inferior-laterally.) Do you try to change your angle at all in-between the two blocks.
Thanks!

Well, I don't want you to think I'm an expert. I've only done a few of these myself, and they have been directly under the supervision of our acute pain attending.

But, what we do is lay down a nice skin wheal of 3% chloroprocaine. When you go deeper, there really isn't too much pain as most of the pain reception is superficial. Some patients will wince a little and you can't do anything about the pressure of the needle (this is why light sedation with 1mg midaz and 50mcg of fentanyl helps). You use the the 150mm needle (described on the NYSORA site), which is the 6-inch one, and you shoot for the femoral first (by watching for quad twitches). When you've turned-down and have a good 0.3-0.4 mA twitch, you inject around the femoral sheath. Some will completely remove the needle at this point and reposition. One of our attendings just pulls back to the skin and slightly rotates the leg outward (slightly lateral and supinated), then plunges down through the layers. He feels that it doesn't matter if he hits "big red" at that point, so doesn't aspirate as advancing (not sure that's necessarily good advice, though... you risk completely traversing a big vessel, which also means you might be out of position). Once he gets to about 8cm (or half the needle length) he aspirates as he looks for foot twitches while dialing down the stimulator. When in the appropriate spot, he injects ("Raj" test) and then administers the med.

Now, some might argue that it's better to do the sciatic first, because if you can't get it anteriorly, you can roll them more easily and do a Labat approach, then flip them back. But, if you start with confidence and that you're going to get it, then you only have to do one prep (also an advantage) and use one needle, so I guess it doesn't matter which order you do them in. But, femoral first is also the way one of the private practice groups I know does it. Plus, doing the femoral first prevents you from confusing yourself (as the first block starts to set-up, which you really shouldn't be confused anyway though because the sciatic is deep... man is it deep) with femoral twitches or having the patient move a lot or be uncomfortable as you're pushing the needle posteriorly.

I've had some limited success myself with this technique (and with help), but is something I feel that should be practiced as it is much easier to sell to some patients than a spinal/epidural, and is certainly a lot quicker.

-copro

 

[leaverus]

I, as a future medical student, I am very interested in watching the surgery on the screen with a clear head.

Would any anesthesiologist here object to a request such as mine? Thanks for your help.

No, we occassionally get requests like that - it's usually kind of weird though 'cause most people are too nervous and don't "want to remember anything." I'm just curious why you'd want to watch - as surgeries go, orthopedics are the most BORING...ugh. Now if you were having a CABG and wanted to be awake for that, i'd love to put in an epidural...

 

[coprolalia]

I'm just curious why you'd want to watch - as surgeries go, orthopedics are the most BORING...ugh.

Only when you see them every day and aren't the one being operated on...

-copro

 

[jwk]

No, we occassionally get requests like that - it's usually kind of weird though 'cause most people are too nervous and don't "want to remember anything." I'm just curious why you'd want to watch - as surgeries go, orthopedics are the most BORING...ugh. Now if you were having a CABG and wanted to be awake for that, i'd love to put in an epidural...

And we KNOW that's possible because we saw it on Grey's Anatomy!

 

[bigchoader]

So I told the surgeon's staff that I did not want general anesthesia and that I would rather go in the direction of the epidural. She said she wasnt sure if they could do that at the surgery center i was scheduled at but she would tell the anesthesiologist and he would call me.

The gas doc calls me and in no kind manner told me that he wouldn't do an epidural. I didn't even have time to talk about sedative free surgery because I couldn't get passed the "OK, no general." milestone. He says that for a 23 year old, general is the way to go and he won't do an epidural so I should go to another center for surgery. Somewhere in his diatribe I believe he alluded to not having ever done an epidural for a knee surgery. He also said something about a spinal headache that will put me out for few days after surgery.

Anyway I am going to be having surgery at a hospital now and the surgeon's scheduler said that they will do an epidural. So I have a few questions.

Why would a doctor completely refuse an epidural?

When I talk to the hospital doc that will do an epidural, can you all foresee it being a problem like this one if I ask for no sedation? Am I asking too much?

 

[Planktonmd]

So I told the surgeon's staff that I did not want general anesthesia and that I would rather go in the direction of the epidural. She said she wasnt sure if they could do that at the surgery center i was scheduled at but she would tell the anesthesiologist and he would call me.

The gas doc calls me and in no kind manner told me that he wouldn't do an epidural. I didn't even have time to talk about sedative free surgery because I couldn't get passed the "OK, no general." milestone. He says that for a 23 year old, general is the way to go and he won't do an epidural so I should go to another center for surgery. Somewhere in his diatribe I believe he alluded to not having ever done an epidural for a knee surgery. He also said something about a spinal headache that will put me out for few days after surgery.

Anyway I am going to be having surgery at a hospital now and the surgeon's scheduler said that they will do an epidural. So I have a few questions.

Why would a doctor completely refuse an epidural?

When I talk to the hospital doc that will do an epidural, can you all foresee it being a problem like this one if I ask for no sedation? Am I asking too much?

The best anesthetic for a patient is the one the anesthesiologist is most comfortable providing.
This means: If an anesthesiologists tells you he prefers doing a GA for a procedure don't pressure him into doing regional because this is not what he is comfortable doing, and you might not like the result.

 

[jwk]

The best anesthetic for a patient is the one the anesthesiologist is most comfortable providing.
This means: If an anesthesiologists tells you he prefers doing a GA for a procedure don't pressure him into doing regional because this is not what he is comfortable doing, and you might not like the result.

Great advice.

I think the other factor might be the time involved. A surgery center wants quick cases, quick turnover. If this is a facility where there is a single anesthesia provider for each room, it might slow them down if that person has to finish their previous case, then come do your epidural or spinal, as opposed to putting you to sleep quickly and moving on. In particular, if they don't do many spinals or epidurals, it will definitely slow them down.

 

[bigchoader]

The best anesthetic for a patient is the one the anesthesiologist is most comfortable providing.
This means: If an anesthesiologists tells you he prefers doing a GA for a procedure don't pressure him into doing regional because this is not what he is comfortable doing, and you might not like the result.

As stated I think you have a good point, however, is it right that the patient should feel pressured to do GA when he/she is not comfortable with it? GA just isn't my cup of tea. I have spoken with a Gas Doc recently and we talked about how people who have problems giving up total control generally are not big fans of GA. The same people have trouble flying on commercial airliners. Having absolutely no control is very scary to some people, myself included.

That said, I did not put any pressure on the anesthesiologist. I simply stated the I didn't want a general and he seemed to almost take offense to this. I have no problem going somewhere else and finding a doctor that is a good match with me.

 

[jetproppilot]

The best anesthetic for a patient is the one the anesthesiologist is most comfortable providing.
This means: If an anesthesiologists tells you he prefers doing a GA for a procedure don't pressure him into doing regional because this is not what he is comfortable doing, and you might not like the result.

Its may not be that he is uncomfortable. Epidural for a 20-30 minute knee procedure means you'll be delayed in PACU recovering from the block and run a high chance of urinary retention. Ambulatory centers are set up for speed. They want you on the pavement within an hour after the surgery is over. Not possible with an epidural, even if 3% chloroprocaine is used.
Too disruptive to the flow of the place.

 

[bigchoader]

Its may not be that he is uncomfortable. Epidural for a 20-30 minute knee procedure means you'll be delayed in PACU recovering from the block and run a high chance of urinary retention. Ambulatory centers are set up for speed. They want you on the pavement within an hour after the surgery is over. Not possible with an epidural, even if 3% chloroprocaine is used.
Too disruptive to the flow of the place.

Maybe I am just a naive premed but why do people not place any concern with the patient's feelings. It is the patient that is going under the knife (though barely for an arthroscopic knee surgery). Why is the turnover rate more important than the patient's feelings?

Edit: In my minds eye I am seeing a big yellow and red 'McSurgery' sign.

 

[numbmd]

You are 100% right. You Absolutely have the right to whatever you want, within reason. There are ways to give a short acting spinal or a regional block. You just make your preference known to your surgeon when he books the surgery and as soon as you see your anesthesiologist. However realize that there can be medical reasons you need a general. But the time constraints of the center nor the inflexibility of the anesthesiologist should factor into your medical care.

 

[jwk]

You are 100% right. You Absolutely have the right to whatever you want, within reason.

But the time constraints of the center nor the inflexibility of the anesthesiologist should factor into your medical care.

Mostly right IMHO, not 100%. Patients demand things all the time that they don't get, including some that are reasonable. The "triple block" approach mentioned previously wouldn't even be considered at my facility because no one is doing them. It's a reasonable request, but if no one is proficient at the block, it won't be an option.

The time issue is important for an outpatient center. Some smaller yet very busy centers may simply not have the space/personnel available to accomodate a patient for two hours in their PACU, or doing a regional with an anesthesiologist that's not proficient or adept at doing them can really disrupt the flow of things. It may not be a consideration for the patient, but it certainly is for that center.

In the end, he's doing the right thing - he's not happy with what's being offered, so he's found somewhere else to go that will accomodate his desires.

Patient choice - a radical concept that is already rapidly disappearing because of "managed care", and that will probably be near impossible under Hillary-care.

 

[dhb]

Epidural for a knee scope is way overkill if they're just having a look and chopping your meniscus (you might have more back pain due to the epidural than pain from the scope). If you want sedative free surgery the reasonable option is a spinal, if you're having an acl repair or something more invasive you can add a femoral catheter but anything else is nor beneficial to you or the surgery center...