What do you wish surgeons knew about anesthesia?

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RT2MD

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This is a question for those more experienced than I. I have to give a 45min presentation to a group of general surgery residents on anesthesia. Any particular topics that you wish surgeons had a bit more knowledge about?

Thanks in advance!

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I always thought that surgeons should do at least a month of anesthesia so they have some idea of what we are doing behind the curtain. Sadly, a 45min presentation won't change the fact they think we just play sudoku back there all day.
 
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But maybe you could cover the different ways we administer general anesthesa (volatile vs tiva), or when we can and can't use muscle relaxant. I can't tell you how many times a surgeon asked for monitored anesthesia care then asked during the case "So the patient isn't paralyzed right?"
 
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Maybe present an emergency case on a Pt will multiple co-morbidiites (Difficult air way maybe, CAD, etc), and how we take into consideration the case, co-existing medical conditions, how we will management that pt during the perio-operative period. That's a start.
 
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You could have fun and make it "the top 10 ways to get your patient delayed or cancelled"...

10. Don't make sure he's NPO, or tell him that NPO just means things you would put on your plate... you can have a milkshake, a package of Life Savers, and some chewing tobacco right before your surgery.

Etc, etc... And yep, nothing like that "He's breathing!" from the other side of the ether screen during a MAC case. Usually goes with having a relatively new surgical trainee on the 1s and 2s, the attendings usually know when to request GA.
 
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If a patient moves, they're not "waking up."

Reversal of paralysis takes time- it's not a switch that we turn on/off.

Just because a patient has significant cardiac disease doesn't mean you need a cardiac anesthesiologist.

We spend a lot more time in the OR than they do.

Good preop H&P's are hugely appreciated.

That's all I can think of off the top of my head, I'm SURE I'll think of more.
 
You would be surprised at how little they know. One recently asked me if we still use sux. I always hear them dictate "general endotracheal anesthesia" for LMAs or call them "tubes" not realizing what they are. And don't even get me started on basic NPO guidelines- no, I don't care if he had water four hours ago.

Nothing against them as I work with some great and very cordial surgeons. They just don't know, just like I couldn't tell you the difference among all the sutures they use.
 
As was previously mentioned, paralysis is not an on/off switch. Then maybe something about the logistics of what we do between when they leave the room and the time we wheel in the next patient. It's not an anesthesia delay because you finished your Starbucks in 15min and are anxiously waiting to start the next case.

Good preop H&P's are hugely appreciated.
No matter which surgical service is primary, all the surgery residents write the exact same thing in their H&Ps, "No significant medical changes. See Anesthesia H&P for further details." That's it. Literally nothing else other than blank headings for Past Medical, Social History, labs, etc. I'm not even sure how that's billable.
 
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Title of the presentation...."Movement is a sign of life"
 
Just had the on off switch muscle relaxant conversation in the OR last week with a very nice surgeon...he genuinely had no idea and asked some really great questions.
 
If a patient moves, they're not "waking up."

#1 complaint right there - movement does not imply consciousness. You (the surgeon) wanted no volatile, no muscle relaxant, no nitrous - this is what can happen. :)
 
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1. Basic NPO guidelines
2. If a patient does not move to repeated painful stimuli, that is (by definition) GENERAL anesthesia... if your patient is squirming during a MAC, use more local
3. Said local takes more than 5 seconds to set up
4. Guidelines for anticoagulation neuraxial blockade (I know a spinal needle is smaller than an epidural needle, but that doesn't mean I'm going to stick one in the dude who's xarelto you just stopped 2 days ago)
 
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Additions to the above:
5.) Induction and emergence are the most dangerous portions of an anesthetic. If you'd like me to be quiet during the critical portions of your case, please be quiet during the critical portions of mine.
6.) Preoperative optimization/workup of patients (i.e. how should they prepare a patient to come to the OR so I don't have to cancel the case DOS?)
 
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No matter which surgical service is primary, all the surgery residents write the exact same thing in their H&Ps, "No significant medical changes. See Anesthesia H&P for further details." That's it. Literally nothing else other than blank headings for Past Medical, Social History, labs, etc. I'm not even sure how that's billable.


Q: How do you hide money from a surgeon?

A: Put it in the notes.
 
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I was only ever a bystander in this particular conflict, but here is what I gleaned:

The anesthesiologist's insistence upon maintaining a measurable blood pressure is not the only possible reason for the increased bleeding in the field. Consider actually using the bovie, or perhaps some bone wax. Maybe one of the dozen hemostatic agents we have on hand. Or just supervise your assistant a little more closely and don't let them continue cutting through vascular structures like a drunken chimpanzee with a hacksaw. Consider any of these measures before shouting at the anesthesia team every time you happen to look up and notice that the pressure is up above 80/50, saying, "I knew it! See, that is why we are having all this oozing. Get that pressure down!"

Also, I once overheard an endoscopist ask, in all seriousness, if the anesthesiologist couldn't do something about the distracting motion that was complicating the retrieval of an esophageal foreign body.
Anes: "I can hold ventilation for a moment, if that helps."
Endo: "Do it."
Several moments of fumbling...
Endo: "You know, this is not working. It keeps moving around. Can't you do something to get it to stay still a minute?"
Anes: "Wait... The heartbeat, you mean? No, I won't stop that. I'm sorry if it increases the technical difficulty of the case, but we really do need that to keep going."

The endoscopist was the first to joke about it, later. He had just been so narrowly focused on the problem he was having retrieving the foreign body that he just wasn't thinking about what he was actually asking for. But that is the issue, and why a team approach is needed. Any of us can get tunnel vision, from time to time.
 
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A little adenosine could fix that.

I'd add what anesthesiologists need to know for a quick pre-op presentation for emergent/urgent cases, what the heck we're doing after the patient gets into the room during our MAFAT, and then open the floor for them to gripe/get ?s answered.

Please don't cover the new AHA guidelines. They're confusing.
 
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I was a CA1 doing a VP shunt revision with a neurosurgeon. He kept telling me "she isn't relaxed, she isn't relaxed." I check twitches and she barely had one. A minute goes by and he starts saying "she needs muscle relaxant". I am like WTF are you talking about. He then shows me how when he touches the muscle in her neck with the bovie it twitches. I basically tell him he is a ***** and that as a neurosurgeon he should have some basic understanding of neurology and the NMJ. I told him to look it up.

Same guy as a CA3. I am doing some simple interventional Angio case. He was asked to take a look at what the radiologist saw. He looks at my IV tubing and sees some small bubbles stuck to the side. "That's a lot of air, that could kill him." Me with my attending standing next to me: "he had an echo and doesn't have congenital heart dz or a PFO. Do you know how much air you need for an embolus to kill a persons?" Blank look on his face. My attending was just laughing.

I honestly wish some surgeons would hone up on some basic physiology and medicine because outside of knowing anatomy they are clueless.
 
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This is a question for those more experienced than I. I have to give a 45min presentation to a group of general surgery residents on anesthesia. Any particular topics that you wish surgeons had a bit more knowledge about?

Thanks in advance!
You have the opportunity to change some minds there, so don't take it lightly. You should focus on myths about anesthesia/anesthesiologists, hoping that they will spark a healthy discussion about what happens behind the blood-brain barrier, aka the drapes. I would try to focus on the really important stuff, hoping to make them curious and ask for more details.

I would first begin by explaining the main components of an anesthetic plan: analgesia, +/- hypnosis, +/- amnesia.

Then I would talk about ways of providing analgesia: inhalational gases, opiates, local anesthetics. The latter would lead to a presentation of types of blocks: neuraxial, regional, field etc., emphasizing what the surgeon can do both for better intraop and postop pain control (also pointing out that it's always easier to prevent pain than to treat pain). If time permits, I would touch a bit on the main advantages and disadvantages of each.

I would focus on explaining GA (controlled coma) and the sequence of doing things (induction, intubation, maintenance, emergence, extubation), the pitfalls and possible (severe or frequent) complications of each. I would explain what happens during each phase, and all the ways it can go wrong; this should be a lengthy discussion, that would also present examples of the complicated thinking that go into every single decision for an anesthesiologist. I would also try to point out what the surgeon can do to help the anesthesiologist, from simple things such as holding the tube for the anesthesiologist during intubation. The entire OR staff should be a team that works together for the benefit of the patient; nothing is beneath anybody (the best surgical attendings don't shy away from pushing the stretcher together with the anesthesia attending).

And then I would end with the message that's really important to walk away with: the importance of communication and mutual respect.

If you are still a resident, you don't really fathom yet the magnitude of collaboration between a good private surgeon and a good anesthesiologist who frequently work together. It's a dance, that can be downright beautiful when executed properly. It's also very helpful to present it to surgical residents, who many times see the academic egotistical version, where the surgeon just dictates and generally behaves like a primadonna/arsehole. The key to a safe procedure with the best outcome for the patient is communication. That goes both ways, and it does not happen in a clash of egos. The more friendly the surgeon and the anesthesiologist are towards each other, the better for the patient. The more information is being exchanged, the better for the patient. For example, the good surgeons will announce, and even ask permission for, anything that could significantly affect the patient: "Can I start?", "Injecting local...", "Incision!", "Insufflating...", "Will be done in 20 minutes." etc. On the other hand, the dance partner (the anesthesiologist) will facilitate the surgeon's work in every way possible, from moving cases around to accommodate the surgeon's schedule, to moving the table even when the surgeon does not ask and realize that s/he's operating in an uncomfortable position, to asking if the surgeon needs more muscle relaxation, to tying the surgeon's scrubs, to playing circulator while s/he's out of the room etc.

The better the couple works together the better the patient outcomes. This should be the message you want the future surgical attendings to walk away with. Everything else they can learn from their anesthesiologist buddies, while working together in the OR.
 
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I was a CA1 doing a VP shunt revision with a neurosurgeon. He kept telling me "she isn't relaxed, she isn't relaxed." I check twitches and she barely had one. A minute goes by and he starts saying "she needs muscle relaxant". I am like WTF are you talking about. He then shows me how when he touches the muscle in her neck with the bovie it twitches. I basically tell him he is a ***** and that as a neurosurgeon he should have some basic understanding of neurology and the NMJ. I told him to look it up.

Same guy as a CA3. I am doing some simple interventional Angio case. He was asked to take a look at what the radiologist saw. He looks at my IV tubing and sees some small bubbles stuck to the side. "That's a lot of air, that could kill him." Me with my attending standing next to me: "he had an echo and doesn't have congenital heart dz or a PFO. Do you know how much air you need for an embolus to kill a persons?" Blank look on his face. My attending was just laughing.

I honestly wish some surgeons would hone up on some basic physiology and medicine because outside of knowing anatomy they are clueless.
You could have explained that it takes tens of cc's of air for a life-threatening embolism, that bubbles in IV tubing seem bigger than they really are, that the 1 cc of air that gets into the patient's circulation will most probably just be eliminated by the lungs, without causing any harm etc.

Because, you know, he could have countered you with the fact that at least 10-15% of the general population have an undiagnosed PFO, in which case you could be sending air into the systemic arteries.

In the previous situation, I would have explained that while I was blocking acetylcholine-based impulse conduction at the neuromuscular junction, I could not block the muscular answer to direct stimulation, but I was doing everything possible, including deepening anesthesia with volatiles (a direct muscle relaxant), to facilitate the his work.

I am a big mouth and hate to be stepped on but I sincerely believe that, every time an OR exchange becomes adversarial, patient care suffers. So every time my brain-mouth filter fails, I apologize as soon as my common sense recovers.
 
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Thanks for all of your input, I plan on implementing a lot of what was touched on here. Appreciate the help, can't wait to actually be past my anesthesia appreciation year (aka intern year)!
 
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You could have explained that it takes tens of cc's of air for a life-threatening embolism, that bubbles in IV tubing seem bigger than they really are, that the 1 cc of air that gets into the patient's circulation will most probably just be eliminated by the lungs, without causing any harm etc.

Because, you know, he could have countered you with the fact that at least 10-15% of the general population have an undiagnosed PFO, in which case you could be sending air into the systemic arteries.

In the previous situation, I would have explained that while I was blocking acetylcholine-based impulse conduction at the neuromuscular junction, I could not block the muscular answer to direct stimulation, but I was doing everything possible, including deepening anesthesia with volatiles (a direct muscle relaxant), to facilitate the his work.

I am a big mouth and hate to be stepped on but I sincerely believe that, every time an OR exchange becomes adversarial, patient care suffers. So every time my brain-mouth filter fails, I apologize as soon as my common sense recovers.


While I agree with what you said at the bottom about patient care, my issue with being told by a surgeon how I should administer anesthesia is that I have atleast taken the time to understand what they are doing, yet the vast majority of surgeons don't give a rats @ss about why I am doing the things I am. One of the most useful books I have ever read for anesthesia training was Surgical Procedures and Anesthetic Implications. Give a good idea of most surgical procedures. I don't tell them to use number 2 silk instead of 0; don't tell me my job when you have no friggin clue.
 
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While I agree with what you said at the bottom about patient care, my issue with being told by a surgeon how I should administer anesthesia is that I have atleast taken the time to understand what they are doing, yet the vast majority of surgeons don't give a rats @ss about why I am doing the things I am. One of the most useful books I have ever read for anesthesia training was Surgical Procedures and Anesthetic Implications. Give a good idea of most surgical procedures. I don't tell them to use number 2 silk instead of 0; don't tell me my job when you have no friggin clue.
I completely sympathize.

You can't fix stupid. There are a lot of surgeons where the ego quotient is higher than the IQ by degrees of magnitude. With those I just try to act professionally, as in " you do your job, I do mine" and literally ignore them if they don't stop their crap. But I do believe that bad things can happen in that kind of atmosphere.

I used to have this kind of relationship with one of the surgeons until, one day, I approached him about avoiding GA in a fragile elderly lady, and trying to do the case under MAC + local. (I promised him that my MAC would feel to him like general if his local would feel to me the same.) He liked the idea and my reasons, the outcome was excellent, and in the weeks after he pointed out multiple times that I was the only anesthesiologist who discussed the plans with him, and how much he appreciated that. The ego is still there, we are still far from buddies, but if I say something he will now listen, and the patients will be better off because of that.
 
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On the other hand, the dance partner (the anesthesiologist) will facilitate the surgeon's work in every way possible, from moving cases around to accommodate the surgeon's schedule, to moving the table even when the surgeon does not ask and realize that s/he's operating in an uncomfortable position, to asking if the surgeon needs more muscle relaxation, to tying the surgeon's scrubs, to playing circulator while s/he's out of the room etc.
.

Sorry to be so immature, but I sure hope you mean gown, not scrubs.
 
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Too bad ortho isn't coming. You could let them know that muscle relaxant can't get past a tourniquet.
Oh, I just love when the orthopod asks me, at the end of the case, why I haven't given the Toradol yet (with the tourniquet still inflated).
 
Oh, I just love when the orthopod asks me, at the end of the case, why I haven't given the Toradol yet (with the tourniquet still inflated).

When I tell them that the muscle relaxant won't get to the NMJ, and they get that disappointed look, usually I follow up by mentioning that they can cheer up because the nerve signal won't get past the spinal anesthetic and the muscles distal to the tourniquet are probably too ischemic to squeeze anyway ... but at that point I admit I'm just playing with them.


Back on topic ... Toradol ... there's something you can talk about to the general surgeons. A lot of them seem to think that a dose of ketorolac will make their cholecystectomy patients bleed out in the PACU.
 
Back on topic ... Toradol ... there's something you can talk about to the general surgeons. A lot of them seem to think that a dose of ketorolac will make their cholecystectomy patients bleed out in the PACU.
I have one, otherwise outstanding, who just cringes when I mention Toradol. I don't even bring it up anymore.

The gynecologists and orthopods love it. They even ask for it. Go figure. I give Toradol before we even start the D&C.

Most surgeons don't understand that the antiplatelet effect (if any) occurs at much higher (and repeated) doses than the analgesic effect (which, to be honest, doesn't require our usual single dose of 30 mg in an average adult, only about 10).
 
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A MAC and "just place an LMA" are not done at the same time...
IV access is important and not always easy, I may need to obtain more after induction and before you start
Cardiac and pulmonary co-morbidities, Tburg, and seeing the forest for the trees
 
I wish surgeons knew just how much I hate hearing their stupid stories over and over again.
 
While I agree with what you said at the bottom about patient care, my issue with being told by a surgeon how I should administer anesthesia is that I have atleast taken the time to understand what they are doing, yet the vast majority of surgeons don't give a rats @ss about why I am doing the things I am. One of the most useful books I have ever read for anesthesia training was Surgical Procedures and Anesthetic Implications. Give a good idea of most surgical procedures. I don't tell them to use number 2 silk instead of 0; don't tell me my job when you have no friggin clue.
This book?

Surgical Procedures And Anesthetic Implications: A Handbook for Nurse Anesthesia Practice
 
1) Communication, both ways. Tell them the things we would like to know from them like positioning, approach, anticipated blood loss, expected post-operative pain, etc. They need to know what kind of access we are going to be getting, what type of anesthesia, what our concerns are. Which leads me to number two.

2) Risk assessment is totally fair game. No offense, and general surgeons as a whole know seem to know their patients much better than other surgical specialties, but they don't always understand how truly sick people are with their comorbid conditions. Talk about things that worry us: aortic stenosis, pulmonary hypertension, severe OSA/obesity, etc etc. On the flip side, the IM doctors appreciate how sick the patients are, but have NO IDEA what goes on during surgery.

3) For sure, go over definitions and components of anesthesia. ETT does not equal GA, nor GA does equal NMB. Propofol gtt @ 150 + fent/midaz does not equal MAC. Actually, every anesthetic is a MAC unless you want me to take the monitors off the patient and step out of the room.

4) Leave plenty of time for Q&A, though that might be asking for trouble if you're an intern. Would be a much easier topic if you had a couple of years of residency under your belt.

Best of luck
 
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I'd go over a little preop assessment, particularly touching on the question of how urgent a surgery is. If you show up for your elective carpal tunnel release with new onset chest pain, you probably need a work up. If on the other hand you have a ruptured AAA, doesn't really matter what any of your preop tests show you are going to the OR now.

I'd also go over questioning the surgeons on what they actually want from anesthesia on given surgeries. They might think a patient needs an ETT, but really they just want the patient to not be spontaneously breathing and I might be able to accomplish that with an LMA. They might think a patient needs GA for something but really they just need them to hold still and some good sedation and local might be all the need. We often get asked to do things the surgeon thinks they need but they really don't simply because they don't completely understand what we do and how we do it. Sometimes just communicating a little better is all that both sides actually need.

You could also touch on topics like muscle relaxation and how them asking you to keep them at a higher level of NM blockade at the end will necessarily slow down the wake up and start for their next case.


What we do is a little bit of a black box to much of the rest of medicine and if you have a chance, shedding some light on those topics might help them in the future.
 
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Make it interesting. A good surgeon is one who listens to the anesthesiologist and is predictable, fast and pleasant and has good medical judgement. I had the luxury of working with one such surgeon and obstetrician. The surgeon was always on time and was helpful in the or during intubation sand then we would be done with 5 lap cholas by 1230 pm.
They have to learn to be patient when there is difficulty and help in inserting lines when they can.
More importantly they need to be told that defensive practice is more important than their egos. They need to earn the trust of anesthesiologists by consistently paying attention and doing the right move at the right time in changing scenarios.
No talking socializing during critical parts of the op. They the. Become your friends and see what you are doing. And of course anesthesiologists are the most friendly bunch will return the favor multi fold. Remember we sit on the boards when new surgeons are being interviewed and the administrators want to make a decision.
 
Hope you guys don't mind a podiatrist joining in the conversation here. I have been out of residency less than a year, so wanted to ask for some opinions regarding where the line is drawn between a surgeon offering anesthesia suggestions vs. letting anesthesia do their job. I do cases under mac/local most of the time and was asked by the crna if I wanted Toradol recently and I replied no thanks. I was asked why not, and just kindly said I didn't think it was necessary. I probably should have explained that the duration of action of marcaine is adequate and close to the duration of action of Toradol, and I'd just rather not expose my patient to the Toradol unnecessarily, but didn't do this. The patient was pain free in recovery.

Then with the same crna I did another case under general, and infiltrated marcaine into the operative site at the end of the case which I felt was adequate for pain control of the surgery site for 4-8 hours after the case. The patient woke up rather violently, and the crna asked the patient if he was in pain about 4 different times, he finally muttered "confused". The crna then administered morphine. The patient then had low O2 sat values in recovery and ended up in the ED later that day with concern of shortness of breath and received a battery of blood tests and a chest CT with contrast, then had urinary retention symptoms. So I speak with the anesthesiologist a couple of days later and explain my concerns that generally my local blocks are adequate and I would suggest that post op systemic analgesics aren't necessary but I don't want to be inappropriate in making this suggestion. She replies that there is concern that the local may have worn off (really, marcaine wears off in 15 minutes...) and that they have to do things for the patients when they wake up to prevent problems with pain. I explain that I work on military patients who often have ptsd and wake up violently sometimes, but that I don't think its due to pain and ask that we hold off on administering systemic analgesics until we are more clear that the block isn't adequate, but am I crossing the line here?
 
You could also touch on topics like muscle relaxation and how them asking you to keep them at a higher level of NM blockade at the end will necessarily slow down the wake up and start .


This. I would stress not only delays, but the fact that residual paralysis is hard to monitor and leads to increased complications post op.
 
The patient woke up rather violently, and the crna asked the patient if he was in pain about 4 different times, he finally muttered "confused". The crna then administered morphine.

Typical CRNA M.O. Usually they give 10 mg of morphine or 2 mg of dilaudid all at once. Pt. usually does OK until a couple of minutes after they are dropped off in the PACU (at which point the anesthesiologist is called to straighten things out).
 
I would also stress that the success of a MAC is dependent on the amount of local they place. I cannot sedate pain to the point of immobility.

We had a breast surgeon in residency that sucked with local but wanted all her cases under MAC. You would be running 150mcg/kg/min of propofol with ~300mcg of fentanyl on board and an oral airway, yet the patients still tried to get off the bed.

Call your attending is all she knew what to say. Unfortunately they would not set her straight.
 
I would also stress that the success of a MAC is dependent on the amount of local they place. I cannot sedate pain to the point of immobility.

We had a breast surgeon in residency that sucked with local but wanted all her cases under MAC. You would be running 150mcg/kg/min of propofol with ~300mcg of fentanyl on board and an oral airway, yet the patients still tried to get off the bed.

Call your attending is all she knew what to say. Unfortunately they would not set her straight.

Not just amount but technique. Some surgeons actually put effort into it, while others just stab around haphazardly.

Long story...

1) While you might be the world's best ankle-blocker, I'm going to go out on a limb and say you fall within 2 SD of the mean, which means that you're going to end up with a subpar block every once in awhile. And while I wouldn't give ketorolac empirically, in anesthesia we like to have backup plans for our backup plans, so for me, knowing what I have available in my armamentarium in case the patient is hurting later is nice. Though honestly, I can't think of any foot procedures that would be a contraindication to a dose of ketorolac.

2) Your pt was experiencing what we call emergence delirium, which is a fairly self-limited phenomenon that will typically resolve within 15-20min regardless of treatment or not. We will often treat it, mostly so the PACU nurses will leave us alone, and sometimes for actual patient safety. Opioids are a valid option for treatment (particularly in kids or young adults with good pulmonary reserve), but probably less so in the typical podiatry population due to some of the adverse effects that you noted. Small doses of propofol would probably be a better choice, or even something like dexmedetomidine or clonidine, though those are longer-acting and might slow down your discharge time if you are doing outpatient surgery. Sounds like your CRNA wasn't really considering any of this, though...
 
Thanks for the replies. I am still trying to answer whether it is appropriate for me to take the approach of "this is my patient, I prescribe the postop meds and will handle the pain after the case, please don't give 10mg morphine after I have given a block and please don't give toradol as my post op protocol includes ibuprofen 400mg every 6 hours and my block will last as long as toradol anyway" versus "I'm just the surgeon and anesthesia is your domain and I won't tread on your territory."
 
Thanks for the replies. I am still trying to answer whether it is appropriate for me to take the approach of "this is my patient, I prescribe the postop meds and will handle the pain after the case, please don't give 10mg morphine after I have given a block and please don't give toradol as my post op protocol includes ibuprofen 400mg every 6 hours and my block will last as long as toradol anyway" versus "I'm just the surgeon and anesthesia is your domain and I won't tread on your territory."
It is reasonable for you to have a discussion pre op indicating that you don't want any long acting narcotics or ketorolac since you prefer to treat with local and ibuprofen.
 
I'm still a resident, but I think it's good medicine for you to communicate your plan. Seems reasonable too, but you would just have to leave room for the anesthesiologist to cover for any circumstances where plan A doesn't go as smooth as you would have thought. 10mg morphine sounds ridiculous in that situation though.
 
This is a typical example why it's so important that the same physicians and teams work together doing the same procedures in the same way every time.

One could blame communication and whatever else is politically correct, but the real culprit here is the industrialization of medicine, with employees/teams treated as replaceable parts. I know each of my frequent surgeons' techniques and plans, so we need 30 seconds to touch base, and then everything goes just right every time. And when I don't know what their plan usually is, my colleagues will, even before I get to talk to the surgeon.

A podiatry case is minor stuff (no offense), but this also happens with much more complicated ones. And the one who suffers from a poor surgeon-anesthesia team collaboration is the patient. And while everybody should be able to work with everybody else, there is a big difference between an OR where people work together, and an OR where people enjoy working together. (The latter leads to the best outcomes and rarely happens with random pairing of people and teams.)

P.S. Sorry for the "rant".
 
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Assuming communication does not improve with the anesthesia department at the surgery center, and I feel that my patients are being given way more narcotics then they need for local mac cases (for example, fentanyl for tourniquet pain, a drug 15 times more potent than heroin?), how feasible is it for me to perform cases that last less than 1.5 hours with say a vicodin tab and/or a diazepam tab 30 minutes before the case begins, without anesthesia? I know this would need to be for suitable patients that agree to be still and quiet during the case, but what is the potential downside to this assuming I do an adequate block?

I recently had elbow surgery under local only, nothing else. The staff was surprised at my request to have it done this way, but the tourniquet discomfort was negligible and I walked right out of pacu feeling great. It made me start thinking, why not offer this to my patients who may be interested?
 
Had an ortho surgeon ask me "what is the BP?" due to some oozing in his operative site. I replied "it's perfect, 110/70." What I wanted to say was "it's fine, and if the systolic is greater than your TOURNIQUET set to 250mm Hg, I'll let you know!" This was a finger case that lasted 3.5 hrs involving 3 pins for a proximal phalanx fx.
 
Assuming communication does not improve with the anesthesia department at the surgery center, and I feel that my patients are being given way more narcotics then they need for local mac cases (for example, fentanyl for tourniquet pain, a drug 15 times more potent than heroin?), how feasible is it for me to perform cases that last less than 1.5 hours with say a vicodin tab and/or a diazepam tab 30 minutes before the case begins, without anesthesia? I know this would need to be for suitable patients that agree to be still and quiet during the case, but what is the potential downside to this assuming I do an adequate block?

I recently had elbow surgery under local only, nothing else. The staff was surprised at my request to have it done this way, but the tourniquet discomfort was negligible and I walked right out of pacu feeling great. It made me start thinking, why not offer this to my patients who may be interested?

Based on your comments, you know absolutely nothing about potency of narcotics so you shouldn't be commenting on a patient getting "too much". It's quite possible that a Vicodan tablet is going to be a larger relative dose of narcotic than a dose of IV fentanyl since you didn't comment on what the actual fentanyl dose was.

As to what you do personally, you can offer whatever you want to a patient. If you'd like them to be wide awake during the case, that's up to them. If you'd like them to pop a Vicodin and diazepam 30 minutes prior to the procedure, have at it. Though I hope you'd be careful about elderly or potential sleep apnea patients with longer acting drugs that suppress respiratory drive as that'd be tough for you to defend a bad outcome in a lawsuit.

Also, when you say you had "elbow surgery under local only, nothing else", what do kind of surgery did you have? Was it superficial? Bone work tends to require some sedation even with perfect local to get a happy patient.
 
Assuming communication does not improve with the anesthesia department at the surgery center, and I feel that my patients are being given way more narcotics then they need for local mac cases (for example, fentanyl for tourniquet pain, a drug 15 times more potent than heroin?), how feasible is it for me to perform cases that last less than 1.5 hours with say a vicodin tab and/or a diazepam tab 30 minutes before the case begins, without anesthesia? I know this would need to be for suitable patients that agree to be still and quiet during the case, but what is the potential downside to this assuming I do an adequate block?

I recently had elbow surgery under local only, nothing else. The staff was surprised at my request to have it done this way, but the tourniquet discomfort was negligible and I walked right out of pacu feeling great. It made me start thinking, why not offer this to my patients who may be interested?
An elbow case that is bloody enough for a tourniquet, done under local only? Seems weird.

If you plan to do cases under local only, make sure the whole room is under local. Once the staff is reassigned don't expect them back. Also, be prepared to deal with your sedation complications.

Why are you complaining about fentanyl and morphine when you are happy to pop them with vicodin and diazepam? Doesn't make sense.

Potency has no bearing in anything. You just give less.
 
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