IR Arrival to Groin Puncture:Times for Stroke Interventional Neurorad Procedures

[Aether2000]

What kind of times are achieved in your hospital for stroke patient arrival in interventional radiology to groin puncture under general anesthesia? Currently we are 36 min and are attempting to reduce this.

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[KaoticMessiah]

We don't do general anesthesia based on data that has been generated by the (massive) NeuroIR group here showing that outcomes are worse for patients undergoing general vs. "MAC" (we hardly give them any sedation, they basically just get Precedex and comforting words).
This isn't likely due to general anesthesia being necessarily worse, but that families may be more likely to shift directions towards comfort care if they see their loved one intubated and sedated vs. natural airway. That being said, induction of general anesthesia may delay the start of the procedure by even a few minutes, which may be enough time to have a lasting neurologic effect.

 

[deleted875186]

We don't do general anesthesia based on data that has been generated by the (massive) NeuroIR group here showing that outcomes are worse for patients undergoing general vs. "MAC" (we hardly give them any sedation, they basically just get Precedex and comforting words).
This isn't likely due to general anesthesia being necessarily worse, but that families may be more likely to shift directions towards comfort care if they see their loved one intubated and sedated vs. natural airway. That being said, induction of general anesthesia may delay the start of the procedure by even a few minutes, which may be enough time to have a lasting neurologic effect.

All of the studies with general vs MAC for this have big confounding factors. Sicker people to begin with tend to get general more often than MAC.

 

[anbuitachi]

We do mostly MAC too with almost no medication. General only if not cooperating or some other reason.
When does the 36 min start? Arrival to IR? Once they are in IR all we need to do is attach some monitors, transfer onto IR table and start the case. Not sure when your 'arrival to IR' starts from

 

[Robotic Wis-Hipple]

We have had this issue at our place as well, I remember quite a few cases where the attending staffing the case made an assessment of “GCS less than 8, intubate” and NeuroIR guys always lost it based on the same thing, saying outcomes are worse if a GA. So now it’s basically light sedation and that’s it.

 

[Aether2000]

I have just been tapped by the anesthesia group and administration to evaluate and correct the issues. Our neuroIR guys have requested general on all cases, but dexmedetomidine sounds like a great alternative. Our time from IR arrival has apparently been protracted due to lack of equipment immediately available in the IR suite (anesthesia machines, carts, glidescopes must be brought from another floor). The currently employed modus operandi is to place an aline prior to induction (due to severe hypotension on induction of several patients even when using etomidate) but it appears the femoral sheath is placed within a few minutes after induction and we can transduce that. Also cited is our anesthesia group prolonged family interview time prior to induction, and there is data to back up that assertion. I have read about straight admission from the ER (or bypass ER) to the IR suite based on stroke scores, which significantly reduces overall hospital to groin times by 75%, however I am not sure if we are ready for that yet. So it appears we have several avenues to pursue to improve our times.

 

[Robotic Wis-Hipple]

I have just been tapped by the anesthesia group and administration to evaluate and correct the issues. Our neuroIR guys have requested general on all cases, but dexmedetomidine sounds like a great alternative. Our time from IR arrival has apparently been protracted due to lack of equipment immediately available in the IR suite (anesthesia machines, carts, glidescopes must be brought from another floor). The currently employed modus operandi is to place an aline prior to induction (due to severe hypotension on induction of several patients even when using etomidate) but it appears the femoral sheath is placed within a few minutes after induction and we can transduce that. Also cited is our anesthesia group prolonged family interview time prior to induction, and there is data to back up that assertion. I have read about straight admission from the ER (or bypass ER) to the IR suite based on stroke scores, which significantly reduces overall hospital to groin times by 75%, however I am not sure if we are ready for that yet. So it appears we have several avenues to pursue to improve our times.

Do you guys have in house techs? How are you notified of incoming stroke? Sounds like suite readying could be improved by earlier notification of the Anesthesia team (whatever that consists of) or having a dedicated suite for Anesthesia assisted cases/interventions with a machine and airway equipment at the ready, though this of course requires multiple suites etc. But if the goal is to be a stroke center of excellence I think it’s hard to accept all Anesthesia equipment being a floor away.

The patient and/or family interview time is a little more difficult as we all understand trying to assess induction risk etc but I think you have to treat it like a trauma with an abridged history using questions aimed at getting the absolute minimum of pertinent details. This also could be improved with an ED handoff or doc to doc call seeing as how they’ve already gotten most of the details (minus airway exam, prior anesthetic hx, and perhaps allergies) and the ED docs note won’t be in for hours though I completely understand that all of us are more likely to see pigs fly than get that sort of communication.

 

[deleted171991]

We have had this issue at our place as well, I remember quite a few cases where the attending staffing the case made an assessment of “GCS less than 8, intubate” and NeuroIR guys always lost it based on the same thing, saying outcomes are worse if a GA. So now it’s basically light sedation and that’s it.

That belongs to the history of medicine. Possibly the attending, too.

Most reflexive actions purely based on numbers, without regard to clinical status, are dumb.

 

[Aether2000]

We do have techs during the day but not at night. However we are not notified until the patient actually leaves the CT scanner on the way to the IR suite. Earlier notification would indeed make things easier. We will acquire more equipment to be housed in IR- I am working on $$ for that. For the time being, I will be involved with all stroke alerts and this will familiarize me with their processes and where we can reduce times.

 

[Psai]

We do have techs during the day but not at night. However we are not notified until the patient actually leaves the CT scanner on the way to the IR suite. Earlier notification would indeed make things easier. We will acquire more equipment to be housed in IR- I am working on $$ for that. For the time being, I will be involved with all stroke alerts and this will familiarize me with their processes and where we can reduce times.

Just pick up an old draeger off ebay. Cart should be easy to get.

 

[Shimmy8]

1. Stroke room setup and ready to go at all times. Machine in room, basic setup, Pyxis in room, etc.

2. GA for all cases. No delay getting case going for arterial line. If I get it quick, great, if not we’ll slave off groin puncture.

3. When a patient is coming in we get a call from nursing supervisor.

4. I often meet patient at ED with IR/neurosurg attending when they’re arriving while CRNA gets room ready.

5. From door arrival to groin puncture we are often under 30 min, even 15-20 is IR staff is there. We haul ass.

That’s honestly the biggest time constraint for us, IR staff, if it’s middle of night and they’re at home. We’re in house call so always there.

I don’t know what our official times are but I do know at a recent hospital exec meetings the anesthesia and IR dept were recognized for being like top percentile for time to groin puncture.

 

[Aether2000]

Wow!!!! That is rocking! What an extraordinary response time.

 

[anbuitachi]

We get notified when they are on the way to hospital or sometimes when they are going to CT scan. Half of them end up being cancelled after CT scan since the stroke is at a location IR can't do anything about. For those that do go we put arterial line as soon as possible but not delaying the start. We do our thing they do theirs

 

[Shimmy8]

I mean I think it’s all about institutional support. All of us if given proper support can get these cases going quickly. Just have to recognize where you need support.

 

[deleted875186]

That belongs to the history of medicine. Possibly the attending, too.

Most reflexive actions purely based on numbers, without regard to clinical status, are dumb.

Then again, following these studies blindly is also stupid, as all the IR people seem to do. I did a case with an MCA stroke where lady was vomiting in the ED. Came into IR and moved to IR table and started vomiting copious amounts. The IR folks come in and see us tilting them sideways and auctioning and ask, “so we’re doing MAC?”

 

[deleted171991]

Then again, following these studies blindly is also stupid, as all the IR people seem to do. I did a case with an MCA stroke where lady was vomiting in the ED. Came into IR and moved to IR table and started vomiting copious amounts. The IR folks come in and see us tilting them sideways and auctioning and ask, “so we’re doing MAC?”

On the other hand, wasting time for getting a preinduction A-line is almost as stupid. Time is brain. We anesthesiologists have the tendency of short-term tunnel vision; we just don't think much about what happens once the patient leaves our care.

 

[anbuitachi]

Then again, following these studies blindly is also stupid, as all the IR people seem to do. I did a case with an MCA stroke where lady was vomiting in the ED. Came into IR and moved to IR table and started vomiting copious amounts. The IR folks come in and see us tilting them sideways and auctioning and ask, “so we’re doing MAC?”

Well if the IR guys are confident they can do the case with the patient vomiting, i guess you can do it under MAC. its not like you'll give the patient any meds

 

[Arch Guillotti]

Well if the IR guys are confident they can do the case with the patient vomiting, i guess you can do it under MAC. its not like you'll give the patient any meds

So why are you there?

 

[deleted875186]

On the other hand, wasting time for getting a preinduction A-line is almost as stupid. Time is brain. We anesthesiologists have the tendency of short-term tunnel vision; we just don't think much about what happens once the patient leaves our care.

Touche

 

[Psai]

Well if the IR guys are confident they can do the case with the patient vomiting, i guess you can do it under MAC. its not like you'll give the patient any meds

That is local and they are wasting your time while shifting the liability onto you.

 

[leaverus]

?? your IR guys use anesthesia for those cases? my hospital is a stroke center and as far as I know, none of us have ever been requested for one of their emergent interventions.

Just pick up an old draeger off ebay. Cart should be easy to get.

how much?

 

[Temeraire]

?? your IR guys use anesthesia for those cases? my hospital is a stroke center and as far as I know, none of us have ever been requested for one of their emergent interventions.

So jealous. Home call at our institution started sucking a whole lot more since IR started ramping up their stroke code numbers. I’ve been called in at buttf*ck-o’clock in the morning to set up for an emergent thrombectomy only to have the case cancelled because the patient didn’t have a favorable CT scan.

 

[Ezekiel2517]

1. Stroke room setup and ready to go at all times. Machine in room, basic setup, Pyxis in room, etc.

2. GA for all cases. No delay getting case going for arterial line. If I get it quick, great, if not we’ll slave off groin puncture.

3. When a patient is coming in we get a call from nursing supervisor.

4. I often meet patient at ED with IR/neurosurg attending when they’re arriving while CRNA gets room ready.

5. From door arrival to groin puncture we are often under 30 min, even 15-20 is IR staff is there. We haul ass.

That’s honestly the biggest time constraint for us, IR staff, if it’s middle of night and they’re at home. We’re in house call so always there.

I don’t know what our official times are but I do know at a recent hospital exec meetings the anesthesia and IR dept were recognized for being like top percentile for time to groin puncture.

Why are you doing GA for all cases? Seems completely unnecessary. Shouldn't do MAC for all cases either.

 

[cchoukal]

There was a randomized trial comparin general with sedation in JAMA Neurology this past January that showed no difference in infarct size or short term outcomes, but longer term outcomes at 90 days were actually better with general.

 

[deleted875186]

That is local and they are wasting your time while shifting the liability onto you.

That’s exactly what it is. At some point it’s unsafe to give any meds to these patients, and some it’s unsafe to let lay supine without protecting heir airway. I agree, having anesthesia present for such cases doesn’t make sense.