Complexity of Caseload

[Stillwater45]

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Im an M1 who is now taking Physiology. I am amazed at the complexity of the cardiac/pulmonary system and how easily it can be manipulated. I have a few quick questions. What percentage of patients/cases go routinely (ie. you put them under and pretty much let them be), and what percentage of patients are you constantly required to micromanage? I am guessing that certain peds and cardiac cases are more complex/volitile and may require more micromanagement? Also are regional blocks mostly reserved for ortho cases?

Sorry if I this is a ridiculous and naive question, I have a lot to learn yet ;-)

 

[jetproppilot]

Im an M1 who is now taking Physiology. I am amazed at the complexity of the cardiac/pulmonary system and how easily it can be manipulated. I have a few quick questions. What percentage of patients/cases go routinely (ie. you put them under and pretty much let them be), and what percentage of patients are you constantly required to micromanage? I am guessing that certain peds and cardiac cases are more complex/volitile and may require more micromanagement? Also are regional blocks mostly reserved for ortho cases?

Sorry if I this is a ridiculous and naive question, I have a lot to learn yet ;-)

Not at all a ridiculous/naive question. Actually your questions are very good.

Surprisingly, most ASA 4 patients having routine surgeries (hernias, knee scopes, knee replacements, hip replacements, etc) and ASA 4 patients having complex surgeries (thoracotomies, CABGs, valve replacements) do quite well. An astute clinician recognizes that preoperative co-existing disease increases the risk for perioperative morbidity/mortality, and tailors the anesthetic with that in mind. The science of anesthesia has progressed to the point that, as a specialty, it is quite safe, as reflected by our reasonable malpractice premiums (mine is about 28K/year). Combine that with the skill of a well trained anesthesiologist/CRNA/AA and you'd be surprised how many very sick patients behave in the operating room.

The use of regional anesthesia is probably more dependent on the clinicians performing the anesthesia, rather than the type of case. Some anesthesia groups prefer general anesthesia for most cases, ortho included. Some groups gear their practices more to the regional technique, when appropriate. Since the literature is devoid studies showing GA is safer than regional, or vice-versa, you'll continue to see this trend (groups leaning towards whatever floats their boat, general or regional) until well controlled studies are published showing a clear morbidity/mortality advantage of one technique over the other.

 

[Noyac]

Jet is right. It depends on the group and the anesthesiologist, as to whether general or regional is used. I am a regional guy for the most part, for a few reasons. 1) they leave the pacu earlier and I can also leave earlier in the day. That means that a pt put to sleep will take longer to recover than one that is kept awake due to regional. 2) they seem to be happier with their anesthetic as a whole when they have NO pain. 3) Regional is something different from the usual propofol/roc/fent/ - tube.

Now, the usual case is very simple even when they are sick pts. It is a rare occurance to need to really manage all the physiologic aspects of a pts medical condition unless you screw yourself with too much of something (ie: propofol or narcotics). Generally you are just on cruise control even with the sick pupppies. Even when doing hearts (which everyone here seems to think is a big deal, but really is one of the easier cases to do b/c you know exactly what to expect and when to exect it) you are on cruise control. It is the traumas in my opinion that can catch you off guard. You think that everything has been evaluated, CT'd, X-ray'd, etc but from time to time it will surprise you. And then there are those surgeons that haven't really got a clue (hacks) that really make things difficult.

So what was your question? oh yeah, how many pts need to be micromanaged? Very little. Maybe 5% but that is a guess. I am a micrmanager for the most part. I keep the heart rate less than 70 on anyone over 50 yrs, CO2 around 30, and I rarely paralyze my pts. BP is always within 20% of norm, etc,etc. But that is me. My partners don't manage as closely and have equally good outcomes (probably why it is difficult to do a study showing the benefits of a crna vs a MD). So it depends on your style mostly. For the most part, it doesn't matter how much micromanaging you have to do b/c you become extremely good at it.

 

[jetproppilot]

Im an M1 who is now taking Physiology. I am amazed at the complexity of the cardiac/pulmonary system and how easily it can be manipulated. I have a few quick questions. What percentage of patients/cases go routinely (ie. you put them under and pretty much let them be), and what percentage of patients are you constantly required to micromanage? I am guessing that certain peds and cardiac cases are more complex/volitile and may require more micromanagement? Also are regional blocks mostly reserved for ortho cases?

Sorry if I this is a ridiculous and naive question, I have a lot to learn yet ;-)

And to your question of what patients need to be micromanaged,

I think carotid surgery patients have the most labile hemodynamics. During induction they can be 200/100 one second, then 80/50 1 minute later. What I've found to combat their hemodynamic lability is to give some volume initially (most, if not all CEAs have hypertensive histories with concominant volume contraction) like Hespan 500 mL or the LR/NS IV with a pressure bag for the first liter, OR, do the case with a Precedex foundation...

if you are running the board, about 45 minutes before you anticipate going into the OR, have transport bring the patient to holding and tell your holding-room nurse to start a Precedex infusion...so by the time you arrive in holding the patient is somnulent...place your A-line...go back to taking care of other stuff...

when the patient is in the room and CRNA is ready for induction, zip in there...the Precedex reduces induction agent/opiod/volatile agent requirements, AND reduces intraoperative hemodynamic lability.

And no, I'm not a paid Precedex consultant. Just a clinician that recognizes the advantages it affords.

 

[Noyac]

And to your question of what patients need to be micromanaged,

I think carotid surgery patients have the most labile hemodynamics. During induction they can be 200/100 one second, then 80/50 1 minute later. What I've found to combat their hemodynamic lability is to give some volume initially (most, if not all CEAs have hypertensive histories with concominant volume contraction) like Hespan 500 mL or the LR/NS IV with a pressure bag for the first liter, OR, do the case with a Precedex foundation...

if you are running the board, about 45 minutes before you anticipate going into the OR, have transport bring the patient to holding and tell your holding-room nurse to start a Precedex infusion...so by the time you arrive in holding the patient is somnulent...place your A-line...go back to taking care of other stuff...

when the patient is in the room and CRNA is ready for induction, zip in there...the Precedex reduces induction agent/opiod/volatile agent requirements, AND reduces intraoperative hemodynamic lability.

And no, I'm not a paid Precedex consultant. Just a clinician that recognizes the advantages it affords.

I totally agree Wolfe. I use volume on these cases from the start. I don't necessarily use starch but I have at least a liter of crystal in at the start and probably give about 3L for a 1 1/2 hr case. I have been using precedex on these cases but I am not happy with the slow wakeup. I turn it off about 30 min b/4 emergence and they are still slow to awaken. Don't get me wrong, they follow commands and all that BS, but I like them a little more with it. The key is the surgeon. If he will use alot of local then things are good. I mean at the incision with the disection and around the carotid bulb. This really makes a difference in the hemodynamics.

 

[jetproppilot]

I have been using precedex on these cases but I am not happy with the slow wakeup. I turn it off about 30 min b/4 emergence and they are still slow to awaken. .

half the intraoperative rate.

 

[Noyac]

half the intraoperative rate.

I run it at 4cc/hr. It just seems to be too much for some of these guys.

 

[jetproppilot]

I run it at 4cc/hr. It just seems to be too much for some of these guys.

hmmmmm...how much opiod are you giving?

 

[Stillwater45]

Thanks guys, your expertise is really appreciated. This board has become a great resource fors med students.