Ambulatory regional anesthesia and support person

[ethilo]

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Hi all,
Had a situation come up where a skinny 71 year old woman without much else going on medically who was getting rotator cuff repair with subacromial decompression. She planned to get a ride home with her neighbor but not have them stay with her, stating "my neighbor is just a call away." Surgeon is cool with this arrangement from his standpoint.

Now I typically do interscalenes with just about every shoulder operation but I decided it as contraindicated in this patient because she didn't have help at home. Is that reasonable? Would anyone feel comfortable performing a single-shot and sending them home where they admittedly are going to be alone? I probably wouldn't do a catheter since it's an ongoing infusion of local but maybe single shot?

 

[Pluto201]

Blocking her arm probably safer than have her overdose on narcotics.


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[deleted87051]

Is she going home in her pajamas?

 

[deleted162650]

Is she going home in her pajamas?

Reminds me of another Mitch Hedburg line:

“Sometimes I fall asleep with my clothes on. I’m gonna have all my clothes made out of blankets”

 

[deleted162650]

Why would you not do a single shot?

 

[psychbender]

Blocking dominant or non-dominant arm? Would still block, but I could understand your rationale if it was her dominant arm.

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[ethilo]

Why would you not do a single shot?

Well I agree with you, I think it comes down to it they can take care of themselves well enough or not. I also agree it probably would have been better with this than a bunch of narcs unsupervised.

What about a catheter? Different situation?

 

[deleted162650]

Blocking dominant or non-dominant arm? Would still block, but I could understand your rationale if it was her dominant arm.

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She had an RCR on the arm, and it’s in a big immobilizer sling anyways. Block or no block it’s a useless limb. Only with a block it doesn’t hurt.

 

[Ronin786]

Block or catheter. If she's safe for discharge for PACU, she's safe to be at home.

 

[DrZzZz]

While I'm certainly pro-block in this situation, we have a hard-line stance on having someone stay with the patient overnight. This patient wouldn't get operated on if they admitted they'd be alone for the night. Anyone else have that liability concern, or is my place just too strict?

 

[AdmiralChz]

Our hospital policy is EVERY anesthetized patient has to have someone with them for the first 24 hours. Can’t be a neighbor next door, the Medicaid cab driver, a minor, or your Uber app. This comes up a couple times a month, but it’s made explicitly clear ahead of time. So we wouldn’t be doing the case at all unless the patient is having her neighbor stay over. If that’s the case, I’d be fine with a catheter if that’s your standard.

 

[Planktonmd]

Letting patients go home after anesthesia (of any kind) when they clearly tell you that they live alone is a risky business in this litigious world we live in.
Anything that happens to the patient at home becomes your responsibility, even if they sign AMA, since that AMA signature will be seen as invalid after anesthesia.

 

[Hoya11]

Hi all,
Had a situation come up where a skinny 71 year old woman without much else going on medically who was getting rotator cuff repair with subacromial decompression. She planned to get a ride home with her neighbor but not have them stay with her, stating "my neighbor is just a call away." Surgeon is cool with this arrangement from his standpoint.

Now I typically do interscalenes with just about every shoulder operation but I decided it as contraindicated in this patient because she didn't have help at home. Is that reasonable? Would anyone feel comfortable performing a single-shot and sending them home where they admittedly are going to be alone? I probably wouldn't do a catheter since it's an ongoing infusion of local but maybe single shot?

Do the block, 2 of versed.

Catheter is not necessary

Keep her a little longer in PACU until she is clear-headed.

Send her on her way.

Have someone from the center or yourself call and check on her later that evening.

 

[deleted87051]

Do the block, 2 of versed.

Catheter is not necessary

Keep her a little longer in PACU until she is clear-headed.

Send her on her way.

Have someone from the center or yourself call and check on her later that evening.

What is the next step if she doesn’t answer?

 

[Mman]

nobody to stay with you = no surgery. No exceptions unless you are admitted overnight.

 

[coffeebythelake]

What is the next step if she doesn’t answer?

Hoya will drop by and do a welfare check. Obviously

 

[Hoya11]

Hoya will drop by and do a welfare check. Obviously

But what are you concerned about?

This is someone with no pain, a numb arm, and has been monitored for a couple of hours in the PACU after an uneventful LMA anesthetic, is awake and asking to go home. What is your concern for her at home that you are going to cancel her case and rearrange her life/rehab schedule and the surgeons day?

If she didn't answer I would contact the neighbor or the police... but obviously not ideal 😉

Obviously not a practice you would do routinely but on a rare occasion if the person was reliable Id be ok with it, and have done this

 

[Hoya11]

Our hospital policy is EVERY anesthetized patient has to have someone with them for the first 24 hours. Can’t be a neighbor next door, the Medicaid cab driver, a minor, or your Uber app. This comes up a couple times a month, but it’s made explicitly clear ahead of time. So we wouldn’t be doing the case at all unless the patient is having her neighbor stay over. If that’s the case, I’d be fine with a catheter if that’s your standard.

Right but you get that that neighbor is not staying over in reality..

 

[AdmiralChz]

Right but you get that that neighbor is not staying over in reality..

Of course, but their word is good enough for hospital policy and cautious enough for me. We document who they say is going to stay with them, and if they don’t follow through then that’s on them. Im asked frequently if I’ll “bend” on this rule - its VERY easy to fall back on the written policy here.