Spinal & ACB in pre-op area.

[sevoflurane]

Say you have a super star surgeon that consistently does 45 minute TKAs and he is on board with Spinals + ACB + sedation. Cut is at 7:15.
Turnovers are decently quick (15-20) and you do 5-8 TKAs on that particular day. You have the staff to get things ready on your next patient before you see them.
Maybe you call them the night before and let them know what to expect the day of surgery so you can move things along quickly.

Pre-op spinal +ACB or just do it in the room?

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[sevoflurane]

You are not allowed to say...

"give him an extra room" to bounce in and out of.

 

[pjl]

Spinal and ACB in room while staff gets ready is my opinion.
ACB in preop is fine too, but it takes minimal time in OR.
I dislike the idea of doing a spinal in preop, then traveling through the hall to the OR. You maybe could convince me if you are in one of those sweet setups where the preop room is literally connected by a doorway to the OR.
Our preop rooms are in no way equipped to handle a high spinal as well as being in the OR, and that is a lawsuit not worth defending. Maybe your setup is different.



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[deleted162650]

SAB in preop saves what, maybe 5 mins? Not worth it to me. SAB in OR then ACB while nurse places the foley.

 

[Ezekiel2517]

SAB in preop saves what, maybe 5 mins? Not worth it to me. SAB in OR then ACB while nurse places the foley.

If surgeon is that good and quick, pretty sure they ain't putting a foley. Most of our surgeons have done away with foleys for all total knees and hips.
How we do it is with block/nerve catheter done preop between cases (we have a person assigned for this and other tasks), spinal in room. You are playing with fire if you're doing spinals in preop. It just takes one.

 

[San Marzano]

We do CSE's on the labor floor all day and all night. We are equally prepared to treat a high spinal in the OB floor as we are in the pre-op/PACU area. Seems reasonable especially if transport from pre-op to OR is <2 min (assuming that this time in transport is the amount of time where capacity to handle an emergency is at its lowest... which also corresponds to the amount of time needed to get from labor room 1 to labor OR 2).

 

[GravelRider]

You would have to have extra staff to babysit the spinal in preop. Do the ACB in preop and the spinal in the room.

 

[dhb]

45min tka 20 min turnover so with 5 cases you are done around 1pm 8 cases would be 4pm. My question is what do you want to achieve? finish at 12:30 or 3:30 or do more cases? I don't see why you would want to save a couple of minutes per case.
I would definately do the acb in pre op.

 

[Noyac]

Personally I would prefer to do the SAB in the OR. But not because I think there is a risk of a high spinal. I have never seen a high spinal in a routine case. Only seen a couple go higher than I like after having an epidural in place and going to c/s. So I think the risk is extremely low.
But placing a spinal takes no longer than doing a general. So I don't really see the advantage. The issue in my facility is convincing the scrubs that the pt can come in the OR while they are still setting up. But then we put restrictions on them with noise etc.
Sevo, what's the reason you ask? I'm sure it's surgeon driven since they think every minute of the day must be moving towards saving them time. If someone takes their time placing a SAB then they might want to do it outside the OR with nobody peering down on them.

The ACB I would prefer to do in a block room but I'm flexible.

 

[Ronin2258]

Set up where I trained was nerve blocks done in pre-op (ACB vs. femoral with catheter +/- posterior block,) then SAB vs. general in the OR. 30 cases in 4 ORs , done by 2pm from a 0730 room time.

 

[Robotic Wis-Hipple]

Set up where I trained was nerve blocks done in pre-op (ACB vs. femoral with catheter +/- posterior block,) then SAB vs. general in the OR. 30 cases in 4 ORs , done by 2pm from a 0730 room time.

This is how we do it too. Aside from the small risk of SAB complications in the preop holding area I'd be more concerned about the RNs there who are busy running around getting antibiotics, IVs, bathroom runs etc not being able to recognize them.

But I know this is patient population dependent but if you spinalize them in preop you're going to have to move them to the bed once in the OR which at our spot would add time.....

 

[Ignatius J]

I wouldn't do a spinal until I was sure the room was ready, equipment was clean, reps were there, room is clean, etc. In other words, when we are ready to go to the room. How many times has everyone been ready to go back and then sterile processing needs 15 more minutes, surgeon needs to go see a patient quick, a rep is still accross town and they're waiting on something, etc.

Adductor block, fine. But a spinal takes minutes to do. You can do that easily in the room.

 

[Planktonmd]

At what point are we going to stop being pushed around and forced to compromise patient safety just to squeeze more cases in and make money for the bean counters and greedy surgeons?
I mean there has to be some limit on how far we can go in the industrialization of medicine and still be able to sleep at night!

 

[pgg]

The intrathecal dose of a labor CSE is a whole different animal than a surgical block spinal. I wouldn't walk away from a surgical block anywhere.

But the staff, equipment, and continuous monitoring required by ASA standards to manage an anesthetic are location agnostic, so if you meet those standards in preop holding, and you think it'll save you time, and you want to do it, go for it.

The headache:benefit ratio anyplace I've worked would be >>1.

 

[GA8314]

Say you have a super star surgeon that consistently does 45 minute TKAs and he is on board with Spinals + ACB + sedation. Cut is at 7:15.
Turnovers are decently quick (15-20) and you do 5-8 TKAs on that particular day. You have the staff to get things ready on your next patient before you see them.
Maybe you call them the night before and let them know what to expect the day of surgery so you can move things along quickly.

Pre-op spinal +ACB or just do it in the room?

We do spinals and ACB's in our block room for flip room total joints. We are ACT model so it's a no brainer. Efficiency is hard to beat.

 

[Ezekiel2517]

Let's just start inducing and tubing patients in preop holding too. And just bag em strolling into the OR. Once in the OR, it's just plug and play baby. We can shave a whole 15 min off our day! Then use it to sit in traffic.

 

[urge]

Let's just start inducing and tubing patients in preop holding too. And just bag em strolling into the OR. Once in the OR, it's just plug and play baby. We can shave a whole 15 min off our day! Then use it to sit in traffic.

We have somebody to do awake fiberoptic intubations in holding area while the patients wait for the room to be ready. They get their eyes tapped shut and an esophageal temp probe placed. Works great. Never have any airway susprises or corneal abrasions.

 

[deleted162650]

Isn't that sorta how things are done in the UK with "induction rooms"?

 

[narcusprince]

Spinal and ACB in the OR initially, Zu ze case. Mobile Pacu nurse takes patient to PACU, then you go to induction room/preop do ACB and spinal to the room and Zu ze case repeat.

 

[OB1🤙]

I see no problem with the practice if the right setting and personnel are present.

For me, I do the spinal in the room and do the ACB after the case before they put on the dressing. No need to wrangle preop nurses to do timeouts etc and it takes literally 1-2 minutes to do.

 

[deleted162650]

I see no problem with the practice if the right setting and personnel are present.

For me, I do the spinal in the room and do the ACB after the case before they put on the dressing. No need to wrangle preop nurses to do timeouts etc and it takes literally 1-2 minutes to do.

That's been my go to practice lately as well. My orthopods aren't exactly rockstars (more like the cover band in the parking lot) and take 2-2.5 hrs for knees so doing it immediately post-op is not only efficient but also gives the pt that much more analgesia post-op. If they're really pushing turnover I'll do the block in PACU right when I drop em off. Luckily those nurses are pretty laid back and don't make a production out of it.

 

[Planktonmd]

We have somebody to do awake fiberoptic intubations in holding area while the patients wait for the room to be ready. They get their eyes tapped shut and an esophageal temp probe placed. Works great. Never have any airway susprises or corneal abrasions.

What a fantastic idea! I also think that anesthesia could very well be induced in the parking lot when the patient arrives to the hospital, this would save plenty of time!

 

[vector2]

I tell most folks to relax in their favorite chair at home, take the entire bottle of vicodin they were being prescribed for arthritis, have EMS throw in an IV and a combitube while they're in the bus and just wheel them directly into the OR.

 

[deleted162650]

I tell most folks to relax in their favorite chair at home, take the entire bottle of vicodin they were being prescribed for arthritis, have EMS throw in an IV and a combitube while they're in the bus and just wheel them directly into the OR.

I've heard post-op pain scores were excellent with this technique.

 

[urge]

I tell most folks to relax in their favorite chair at home, take the entire bottle of vicodin they were being prescribed for arthritis, have EMS throw in an IV and a combitube while they're in the bus and just wheel them directly into the OR.

LOL

 

[sevoflurane]

Sounds like most would do the SAB in the OR. Probably the most appropriate of the choices for a one man show.

A couple of comments:

I agree with Noyac. It’s reasonable to do a SAB not because it’s “safer”. I NEVER have had a high spinal. I have had however, a high epidural spread with a LPB that was placed in the block room. I can manage a high spinal easily in our pre-op room if that ever happened to me. So for me, location and patient safety is a non-issue. I could get a high spinal in an OR room just like I could get one in a pre-op holding room. There is no real difference in management or resources at my current practice.

Personally, I’ve done them both ways. I’ve practiced with induction rooms in the past which are da bomb—> but your are literally attached to the OR, so a SAB in the induction room would be a no brainer if your set-up is like this.

I’ve also placed spinals + ACB in pre-op holding btw/ turnovers and wheeled patients into the room— prep and go. I don’t find this practice to increase morbidity in the least, but it does make for a very, very busy day. It’s efficient as all get out if the wheels are greased appropriately.

In a long line of cases you might be able to help everyone go home an hour or so earlier. Always nice to set sail out of the hospital around 2pm rather than 3:30pm.

My current practice is to do the SAB in the room and ACB at the end of the case before heading to pacu. Works great… but even then, it’s still a busy day: spinal, start propofol gtt, chart, get block stuff ready, prepare for the next case, do block, catch up on charting all in a relatively fast room. Rinse and repeat all day at nauseum. Busy.

Turnovers are somewhat of a downtime as these patients are delivered to pacu pretty much wide awake so the handoff is quick. So the possibility is there to move things a long if so desired. Again, shaving an hour a day off everybody’s work day (not just yours) is a benefit to all.

Now, we are in the process of getting a dedicated acute pain service (1.0 FTE + 2 NPs to do blocks pre-op, round, stomp out fires, floor consults, maybe some occasional acute care cases, help with epidurals on OB while the primary OB guy has a line of C/S, etc).

I think this is the perfect scenario to do a pre-op spinal AND ACB if that team is available.


So you have 8 tka's scheduled this Friday starting at 9am. What's the downside if you have the staff to do it? WOWI of 15 minutes and cut at 20 minutes is efficient.
Given 2 rooms, it’s ultra efficient.

We do spinals and ACB's in our block room for flip room total joints. We are ACT model so it's a no brainer. Efficiency is hard to beat.

You can still be in the water on the boat by 3pm on Friday.

 

[OB1🤙]

I would also add that when using isobaric marcaine, the risk of high spinal is fleetingly small.

 

[fakin' the funk]

I would also add that when using isobaric marcaine, the risk of high spinal is fleetingly small.

True, but clinically significant hypotension +/- bradycardia isn't...

 

[deleted162650]

True, but clinically significant hypotension +/- bradycardia isn't...

Aren't those things symptoms of a high spinal that you agree is fleetingly rare?

 

[Urzuz]

As others have said, I don't necessarily see the harm in doing a spinal in preop if the correct resuscitation equipment is readily available. However, dealing with the hypotension that you can get may be more trouble than it's worth. Additionally, something else to consider -- for our total joints, the goal is ambulation once they get upstairs to their room. The goal is also to make it such that they aren't stuck in the PACU forever waiting for them to get motor function back (ideally patients are able to wiggle their toes as you get to PACU). To accomplish this, dosing a spinal just right is important...for one of our surgeons who is very consistent in his operative time, I use between 7.5-10mg of hyperbaric bupivacaine routinely. Maybe at your guys' hospitals it's a bit different, but we have a lot of variability in turnover time based on what nurses and techs are in the room...and if I did the spinal in the preop holding area, it would be tough to dose it appropriately to accomplish those above goals since there could be anywhere between 15 and 45 minutes of turnover. Anyway, just something else to consider.

For ACBs I do them in preop usually, though I also used to regularly throw them in after the surgery before pulling the LMA. I haven't noticed a huge difference one way or another.

 

[dhb]

My current practice is to do the SAB in the room and ACB at the end of the case before heading to pacu. Works great… but even then, it’s still a busy day: spinal, start propofol gtt, chart, get block stuff ready, prepare for the next case, do block, catch up on charting all in a relatively fast room. Rinse and repeat all day at nauseum. Busy.

Turnovers are somewhat of a downtime as these patients are delivered to pacu pretty much wide awake so the handoff is quick. So the possibility is there to move things a long if so desired.

Sorry but i'm not getting your drift. Downtime is turnover so do the block in the pacu, skip the propofol gtt and have yourself an easy day. (preparing for the next spinal can't be all that hard...)

 

[sevoflurane]

Sorry but i'm not getting your drift. Downtime is turnover so do the block in the pacu, skip the propofol gtt and have yourself an easy day. (preparing for the next spinal can't be all that hard...)

Yup. You don't get it.

 

[Noyac]

We don't keep pts in PACU until they are moving their legs. We just make sure they are "stable" by PACU terms and that the spinal is regressing.
Urzuz, while I appreciate your ability to fine tune your spinal I prefer to just give the full dose so I nearly eliminate the chance of running out of time. It really only going to last a short period longer in the grand scheme of things. I think I could pull off the timing you have with one surgeon of mine but the rest are still too unpredictable.

 

[dhb]

Yup. You don't get it.

Well it just comes down to what the timing difference is between doing the spinal in the room vs moving the patient under spinal to the or table multiply by 8 and see if it's worth the hassel. I'm guessing on average it should be around 3 to 5min...

 

[fakin' the funk]

Aren't those things symptoms of a high spinal that you agree is fleetingly rare?

Clinically significant hypotension? Very common. Though to qualify, that's WITH lotsa propofol on board. I wouldn't know the natural history of BP effects of an isobaric bupi spinal WITHOUT prop...

Bradycardia? Yeah pretty rare...