Operating without CRNA

[Catarockin]

Hoping for some honest advice here:

For reasons I won't get into, my employer is asking me to perform upcoming phaco cases under "nurse anesthesia" while we look into replacing our CRNA. Employer also owns the ASC and a few of us operate there.

I have serious hesitations about letting the nurses administer fentanyl without a CRNA present. Versed, fine. Propofol, obviously not.

Am I crazy to put my foot down on this? I'm not comfortable with recussitation and my patients are often elderly, sick, or drug/alcohol users. I'm a year out of training, at around 400 cases.

Really at a loss here because I am also paid on production and this will be a hit.

Thanks guys/gals.

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[salami bahama]

Others who do more office based anesthesia would probably be the best to comment, but I would feel exactly the same way as you. I have done one urgent glaucoma case with nurse anesthesia, but they only gave a small amount of versed, and that's all they were allowed to give. I'm sure you could say that they are only allowed to give versed, and this would essentially be similar to what patients receive via an MKO melt in the office.

I would see if they can schedule a CRNA from a private group in town that isn't employed directly by your ASC. I would personally say no to fentanyl. I'm sure your employer won't want to take the financial hit, so it's in everyone's best interest (obviously the patients being the most important) to work with you on this very reasonable expectation. Let us know how it goes!

 

[Dr Meow]

Isn't the existence of CRNA's bad enough as is? A regular nurse doing that is extra layer of bad?

 

[dantt]

For years I operated at a VA that was short staffed so I did 95% of cases topical only (no sedation) with a nurse monitoring. I occasionally had them give light sedation (1-2mg versed). There was always anesthesia available next door. Sedating patients with no anesthesia providers available is a terrible idea. I would recommend starting by suggesting you talk to risk management with your malpractice carrier. Consider taking your cases elsewhere (even the local hospital if necessary). If you're worried your employer gets offended and holds it against you...think hard about what kind of partner they'd be. With no anesthesia provider available, you're captain of the ship with nobody steering. An adverse event would ruin your career.

Is this the new employer mentioned in a prior thread or the old one? These practice buy outs regardless of eventual completion never end well.

 

[anonperson]

Hoping for some honest advice here:

For reasons I won't get into, my employer is asking me to perform upcoming phaco cases under "nurse anesthesia" while we look into replacing our CRNA. Employer also owns the ASC and a few of us operate there.

I have serious hesitations about letting the nurses administer fentanyl without a CRNA present. Versed, fine. Propofol, obviously not.

Am I crazy to put my foot down on this? I'm not comfortable with recussitation and my patients are often elderly, sick, or drug/alcohol users. I'm a year out of training, at around 400 cases.

Really at a loss here because I am also paid on production and this will be a hit.

Thanks guys/gals.

Employer is asking you to shoulder all the liability with no extra financial benefit.

Are they even throwing you extra compensation now that you are managing the anesthesia side of things now? Nope.

Bad enough they are using CRNAs (where you still may be at risk).

If a bad outcome happens, you get named in a lawsuit and the medical board. Maybe the hospital/ASC gets named, but it's funny, I never hear of anyone from administration getting named.

No wonder they are so cavalier...

 

[Dusn]

If you take on the responsibility and start generating the same revenue for your employer at a lower overhead cost, the CRNA won’t be replaced.

If they push back on this it’s time to start looking for a new job — preferably one that is run by the ophthalmologists and where you have a realistic chance at becoming a partner and your own boss. Are you working for a PE owned practice?

How is the job market for ophthalmologists right now? My residents don’t seem to be having much trouble finding jobs but maybe I’m not hearing the full story. It would be interesting to hear from others.

 

[Openglobetrotters]

If you take on the responsibility and start generating the same revenue for your employer at a lower overhead cost, the CRNA won’t be replaced.

If they push back on this it’s time to start looking for a new job — preferably one that is run by the ophthalmologists and where you have a realistic chance at becoming a partner and your own boss. Are you working for a PE owned practice?

How is the job market for ophthalmologists right now? My residents don’t seem to be having much trouble finding jobs but maybe I’m not hearing the full story. It would be interesting to hear from others.

If you take on the responsibility and start generating the same revenue for your employer at a lower overhead cost, the CRNA won’t be replaced.

If they push back on this it’s time to start looking for a new job — preferably one that is run by the ophthalmologists and where you have a realistic chance at becoming a partner and your own boss. Are you working for a PE owned practice?

How is the job market for ophthalmologists right now? My residents don’t seem to be having much trouble finding jobs but maybe I’m not hearing the full story. It would be interesting to hear from others.

Great advice. There’s a good amount of places hiring. AAO has postings all across the country. The ones I’ve talked to over the last year had no trouble finding a good job.

 

[TheLesPaul]

Hard pass. You are not an anesthesiologist. Lifelong liability for someone else's financial reward.

 

[Agast]

Nurse anesthesia means the physician is directing them how much of each drug to give. That means you. The liability is 100% yours like any other drug you order a nurse to give your patient. Do you know how much fentanyl and versed to give for a case and how to time it? The only specialty I can think of that routinely does this for their own procedures is GI for endoscopies.

 

[MstaKing10]

Some insurances (looking at you United Health Care) started pushing for this to cut costs. Pushback by AAO and other organizations stopped it but this will be a growing area of interest for those looking to cut costs. It's ludicrous. Unless they are going to take on the liability of a bad outcome then the answer is no. This is why the push to perform office based surgery is so nuts. Trying to save money may end your career. No thanks.

 

[OphthoApplicant04]

NO way. Doing oral anesthesia (e.g. valium) for a calm patient is one thing, needing to push IV meds while you are focusing on surgery is an entirely different matter. If a patient needs enough sedation that you require an IV push, that's too high risk for you to be focusing on their airway and vitals AND intraocular surgery.

 

[Catarockin]

If you take on the responsibility and start generating the same revenue for your employer at a lower overhead cost, the CRNA won’t be replaced.

If they push back on this it’s time to start looking for a new job — preferably one that is run by the ophthalmologists and where you have a realistic chance at becoming a partner and your own boss. Are you working for a PE owned practice?

How is the job market for ophthalmologists right now? My residents don’t seem to be having much trouble finding jobs but maybe I’m not hearing the full story. It would be interesting to hear from others.

Thanks for your reply. We are getting locums coverage. The job market for comp ophthalmology is fantastic right now so my threshold for this BS is dropping quickly. This is not a PE owned practice. Not yet at least..

 

[Catarockin]

Thanks to everyone for your honest opinions and insights. It's nice to get some validation here. We are getting locums CRNA coverage and a new hire is on board. I am shuffling my patients around based on this schedule to keep everyone safer. There's a huge demand for cataract surgery in my area so I feel compelled to stay, but working under the shadow of others' competing business interests v. patient care is quickly wearing me thin.

 

[Openglobetrotters]

Did they give you a reason why they are making that switch?

 

[Catarockin]

Did they give you a reason why they are making that switch?

No, I'm not involved in decision making outside of my own schedule/patients

 

[robellis]

This sounds like a recipe for an absolute nightmare..if there’s a complication you are completely screwed and you will have absolutely no leg to stand on in court you will get skewered as you decided to proceed without anesthesia available and that is certainly a deviation from standard of care

 

[2brads]

Radiologist here. We routinely do RN-administered sedation (IV fentanyl/versed) for image guided procedures. We only do so in hospital, and could call a code if warranted (codes that get called tend to be because of the procedure itself). I guess I'm confused why you guys aren't comfortable doing it. It seems pretty routine in radiology world.

 

[TheLesPaul]

We only do so in hospital, and could call a code if warranted

Exactly. It's fine until it's not fine, and who do you call in an ASC which apparently now has no anesthesia-trained physicians or CRNA on site and immediately available? Also -- why? Anesthesiologists exist for a reason. It makes operating easier.

 

[2brads]

So if you were in hospital you'd be fine running sedation through an RN like us?

 

[Agast]

Radiologist here. We routinely do RN-administered sedation (IV fentanyl/versed) for image guided procedures. We only do so in hospital, and could call a code if warranted (codes that get called tend to be because of the procedure itself). I guess I'm confused why you guys aren't comfortable doing it. It seems pretty routine in radiology world.

Great. Who shows up to run the code and who intubates your patient.

 

[2brads]

We start the code and the code team arrives within a few minutes. Why need to intubate? Just bag valve mask until code team arrives. Bagging is just as effective as intubation, just more work.

 

[Dusn]

So if you were in hospital you'd be fine running sedation through an RN like us?

When doing IR procedures you can generally stop focusing on the procedure and turn your attention to anesthesia-related issues mid-procedure. A little patient movement also doesn’t cause you much of a problem. It’s not the same for eye surgery.

 

[MstaKing10]

We start the code and the code team arrives within a few minutes. Why need to intubate? Just bag valve mask until code team arrives. Bagging is just as effective as intubation, just more work.

have you ever had to do this? If so, how often? Curious

 

[2brads]

For fluoro and US guided procedures movement isn’t much of an issue. But for CT guidance movement is a major issue. You’re correct that we will almost always immediately stop a procedure if the patient becomes unstable in order to start a code if needed. I don’t know enough about eye surgery to understand the mechanics of how you guys would initiate a code.

I’ve never had a patient code so far, but it definitely happens. When it does happen it’s almost always caused by the procedure itself (ptx, bleeding, air embolism, etc) so we are usually in position to provide definitive therapy (chest tube, gel foam, iv fluid). In the circumstance that we don’t know why a patient is unstable we can reverse mod sedation, draw labs and call a code. Basic cpr would begin and by the time the crash cart arrived the room would be full with the code team.

 

[LightBox]

You don't want to see an Ophthalmologist run a code lol.

 

[2brads]

I’m not coming at this question from the standpoint of superiority I.e. rads are amazing at codes (we are not). I was just curious why there’s such a “cultural” difference between the two specialties. In radiology residency, we just accept that we will generally be running moderate sedation and we better have some sort of plan if things go sideways. But it seems that optho has always been hands off when it comes to sedation. Maybe it’s radiology’s attempt at getting other people to take us seriously as doctors.

 

[MstaKing10]

I’m not coming at this question from the standpoint of superiority I.e. rads are amazing at codes (we are not). I was just curious why there’s such a “cultural” difference between the two specialties. In radiology residency, we just accept that we will generally be running moderate sedation and we better have some sort of plan if things go sideways. But it seems that optho has always been hands off when it comes to sedation. Maybe it’s radiology’s attempt at getting other people to take us seriously as doctors.

I guess this is an interesting take I never thought of. Could it be most of us operate at ambulatory surgery centers where regulations require anesthesia monitoring? Our surgeries are also quite fast and we want quick turnaround so not sure there is a time constraint issue? There is also the medical legal risk, and risk of falling below the standard of care. Not sure honestly

 

[Slide]

I’m not coming at this question from the standpoint of superiority I.e. rads are amazing at codes (we are not). I was just curious why there’s such a “cultural” difference between the two specialties. In radiology residency, we just accept that we will generally be running moderate sedation and we better have some sort of plan if things go sideways. But it seems that optho has always been hands off when it comes to sedation. Maybe it’s radiology’s attempt at getting other people to take us seriously as doctors.

I think for us, two big parts are that one, our procedures tend to be fairly quick and rarely causes the code itself. Second is that despite the faster nature of our surgeries, we all still have the surgeon mentality of focusing on the surgery and letting anesthesia do anesthesia so we can put all our mental effort on surgery. I'm sure we could all do a basic code if we wanted but from a legal and ethical standpoint, I think most ophthalmologists feel more comfortable with trained anesthesia support.

However, this might change in the future if in-office surgery becomes more commonplace for cataract surgery.

 

[2brads]

Most of the procedures I do run about 30 minutes. The vascular guys can have cases go for hours, but many diagnostic rads do nonvascular IR work. I think that it has to do with the fact that you guys are coming at this from a surgeon's perspective and rads come to it from, well, somewhere else. I acknowledge that it can be a little frustrating when a patient moves or the monitor starts *booping* and *beeping* when you've got good needle placement and you end up having to troubleshoot sedation because you didn't dial things in just right. As far as I can tell, from a medicolegal standpoint, we are gonna be named as defendants regardless of whether we had anesthesia in the room or not. I mean, if a pt dies because you put a needle in a bad place, it doesn't matter who was present to run the code. Does anesthesia have a magic bullet to stop massive hemorrhage or air embolus?

 

[MstaKing10]

Most of the procedures I do run about 30 minutes. The vascular guys can have cases go for hours, but many diagnostic rads do nonvascular IR work. I think that it has to do with the fact that you guys are coming at this from a surgeon's perspective and rads come to it from, well, somewhere else. I acknowledge that it can be a little frustrating when a patient moves or the monitor starts *booping* and *beeping* when you've got good needle placement and you end up having to troubleshoot sedation because you didn't dial things in just right. As far as I can tell, from a medicolegal standpoint, we are gonna be named as defendants regardless of whether we had anesthesia in the room or not. I mean, if a pt dies because you put a needle in a bad place, it doesn't matter who was present to run the code. Does anesthesia have a magic bullet to stop massive hemorrhage or air embolus?

Outside of some crazy complication like brainstem anesthesia from a bad retrobulbar block or asystole due to some vagal issue, eye surgery does not cause death. Systemic issues leading to death or near death related to eye surgery are going to be linked to some complication of anesthesia. As such, I think it makes sense to have an expert in the field of anesthesia available to take care of those issues. Or at least that's how likely most of ophthalmologists view it.

 

[anbuitachi]

Most of the procedures I do run about 30 minutes. The vascular guys can have cases go for hours, but many diagnostic rads do nonvascular IR work. I think that it has to do with the fact that you guys are coming at this from a surgeon's perspective and rads come to it from, well, somewhere else. I acknowledge that it can be a little frustrating when a patient moves or the monitor starts *booping* and *beeping* when you've got good needle placement and you end up having to troubleshoot sedation because you didn't dial things in just right. As far as I can tell, from a medicolegal standpoint, we are gonna be named as defendants regardless of whether we had anesthesia in the room or not. I mean, if a pt dies because you put a needle in a bad place, it doesn't matter who was present to run the code. Does anesthesia have a magic bullet to stop massive hemorrhage or air embolus?

Outside of some crazy complication like brainstem anesthesia from a bad retrobulbar block or asystole due to some vagal issue, eye surgery does not cause death. Systemic issues leading to death or near death related to eye surgery are going to be linked to some complication of anesthesia. As such, I think it makes sense to have an expert in the field of anesthesia available to take care of those issues. Or at least that's how likely most of ophthalmologists view it.

wasnt there a case similar recently, opthalmologist got sued and named captain of the ship because patient decompensated during cataract (?) surgery, and crna incorrectly placed the breathing tube in the esophagus? i think the nursing board supported the crna too

but i agree, IR and ophthal are super different. from my experience, IR like GI, has a much higher tolerability for movement. not that it is ideal, just that they can still often do the case with movement, especially once the wire is in. Obviously some IR cases also require no movement.

but agree with above. sure can do it. but why would you do that to yourself and jeopardize your career.

 

[airplanes]

I’m not coming at this question from the standpoint of superiority I.e. rads are amazing at codes (we are not). I was just curious why there’s such a “cultural” difference between the two specialties. In radiology residency, we just accept that we will generally be running moderate sedation and we better have some sort of plan if things go sideways. But it seems that optho has always been hands off when it comes to sedation. Maybe it’s radiology’s attempt at getting other people to take us seriously as doctors.

It's pretty simple to me.. We don't learn to do it during training. We operate in operating rooms with anesthesia. There are some people who are doing office cataract surgery and taking responsibility for their own anesthesia, although from what I hear it is a lot of oral sedation and not intravenous. I don't see our field in general wanting to take over anesthesia anytime soon, and believe me.. there are plenty of us out there that want to maximize reimbursement (and do that in borderline questionable ways) that they would cut anesthesia out if they thought they could do so and maintain efficiency and outcomes.

 

[nycitygas]

I am an anesthesiologist in Texas. We are expecting in the near future that insurance companies/Medicare will stop reimbursing for anesthesia services with routine cataracts.

 

[dantt]

I am an anesthesiologist in Texas. We are expecting in the near future that insurance companies/Medicare will stop reimbursing for anesthesia services with routine cataracts.

This was a potential issue a few years ago when Anthem proposed MAC anesthesia be limited to patients < 18, unable to cooperate or communicate due to dementia or other medical conditions, can't lie flat, known problems with anesthesia, or complex surgery. The community was outraged and we managed to get them to cancel the policy but I wouldn't be surprised if they tried again in the future. If this were to happen, would anesthesia be bundled or would we be able to charge patients a separate fee for anesthesia? You may or may not know, one cannot actually charge patients out of pocket for services that are "covered" or "bundled" when they have medicare. This is also the case with most insurances although it would be interesting to see how that would work when anesthesia is totally out of network.

Along those lines, how much does anesthesia typically charge for a cataract surgery? We have been entertaining groups that have an "out-of-network model." This personally sounded distasteful to me due to what's being done by teamhealth and others who spring these bills on unsuspecting patients. We are not anesthesia but I think this will certainly blow back on our practice. That being said, I've heard from our anesthetists they are routinely showed contracts by insurance with medicaid rates now.

 

[coffeebythelake]

Hoping for some honest advice here:

For reasons I won't get into, my employer is asking me to perform upcoming phaco cases under "nurse anesthesia" while we look into replacing our CRNA. Employer also owns the ASC and a few of us operate there.

I have serious hesitations about letting the nurses administer fentanyl without a CRNA present. Versed, fine. Propofol, obviously not.

Am I crazy to put my foot down on this? I'm not comfortable with recussitation and my patients are often elderly, sick, or drug/alcohol users. I'm a year out of training, at around 400 cases.

Really at a loss here because I am also paid on production and this will be a hit.

Thanks guys/gals.

why would your pt ever need propofol for a routine phaco?

 

[LightBox]

why would your pt ever need propofol for a routine phaco?

You'd be surprised by how nervous patients are with routine cataract surgery. At least 50% of my patients specifically request an IV to be "completely out" during cataract surgery. I do as good of a phaco as anyone, but there are many patients that want a seamless experience.

 

[coffeebythelake]

You'd be surprised by how nervous patients are with routine cataract surgery. At least 50% of my patients specifically request an IV to be "completely out" during cataract surgery. I do as good of a phaco as anyone, but there are many patients that want a seamless experience.

different patient populations perhaps.
or maybe need to set some expectations for the patients from the get go.
nowadays people look up all this stuff on the internet and have a general idea of what the anesthesia for cataracts should be like,
being "completely knocked out" with propofol sedation isn't it
speaking as an anesthesiologist who do a fair number of cataract surgeries,
using iv propofol for cataract surgery is introducing unnecessary risk -- of laryngospasm, of involuntary movements, of paradoxical reactions and disinhibition

 

[anbuitachi]

i mean insurance will try to not cover for anything possible to increase their bottom line. its not like they will pass on the savings to the patients.

if im having cataract done, id want an anesthesiologist there instead of the ophthalmologist be responsible for both.

its like insurances trying to not cover for anesthesia services for GI procedures. i definitely want anesthesia if im having a colonoscopy!

 

[dantt]

i mean insurance will try to not cover for anything possible to increase their bottom line. its not like they will pass on the savings to the patients.

if im having cataract done, id want an anesthesiologist there instead of the ophthalmologist be responsible for both.

its like insurances trying to not cover for anesthesia services for GI procedures. i definitely want anesthesia if im having a colonoscopy!

I cross posted a question about anesthesia models on the anesthesia forum. Interesting discussion there. Sounds like anesthesia really doesn't want our business...or at least the governments business anyways

 

[anbuitachi]

I cross posted a question about anesthesia models on the anesthesia forum. Interesting discussion there. Sounds like anesthesia really doesn't want our business...or at least the governments business anyways

yea its all relative. if other surgeries are getting reimbursed much better, makes sense financially they give up the cataracts to do the endoscopies, etc

unfortunately like many said, government insurance, medicaid/medicare, pays like 20% private insurance, which is not the case in surgical specialties... sad

 

[Southpaw]

I cross posted a question about anesthesia models on the anesthesia forum. Interesting discussion there. Sounds like anesthesia really doesn't want our business...or at least the governments business anyways

I would flip that, and say the government doesn't want anesthesia services involved. If ophtho as a field were getting $500 per cataract from Medicare, and next year Medicare said they'll give you $100, you're suddenly not feeling the love from the government any longer. I understand your field has high overhead and your margins are tight as is, but Medicare supports your currently salary and its solid as far as I can tell. Ophtho continues to attract a strong talent pool. I can assure you, if anesthesia cared for 100% medicare patients, or received no subsidy to support services in the hospital (overnight/weekend call, OB, trauma, etc.) then the field suddenly becomes far, far less attractive. Still, I don't support out-of-network billing, unless it comes from commercial and they are not negotiating in good faith (UnitedHealthcare is a good example, and recently BCBS with non-negotiable random contract rate cuts in NC). You can look at this one of two ways - blaming the anesthesia group or blaming the government. Again, if Medicare cuts you to $100 per cataract next year I would not blame you for finding other ways outside of cataract surgery to support your income.

 

[dantt]

I would flip that, and say the government doesn't want anesthesia services involved. If ophtho as a field were getting $500 per cataract from Medicare, and next year Medicare said they'll give you $100, you're suddenly not feeling the love from the government any longer. I understand your field has high overhead and your margins are tight as is, but Medicare supports your currently salary and its solid as far as I can tell. Ophtho continues to attract a strong talent pool. I can assure you, if anesthesia cared for 100% medicare patients, or received no subsidy to support services in the hospital (overnight/weekend call, OB, trauma, etc.) then the field suddenly becomes far, far less attractive. Still, I don't support out-of-network billing, unless it comes from commercial and they are not negotiating in good faith (UnitedHealthcare is a good example, and recently BCBS with non-negotiable random contract rate cuts in NC). You can look at this one of two ways - blaming the anesthesia group or blaming the government. Again, if Medicare cuts you to $100 per cataract next year I would not blame you for finding other ways outside of cataract surgery to support your income.

Medicare has repeatedly and relentlessly cut cataract surgery reimbursement over the past few decades. In my younger years, I travelled to rural communities to provide cataract surgery for them at their local hospitals. I've had colleagues who flew out to the middle of nowhere doing surgeries for patients there. Would I travel more than an hour now, possibly stay overnight, to do medicare cataracts at an inefficient hospital OR with a wife and kids at home? HELL NO!!!

What has now happened? Patients in rural communities have to travel to the big city to have cataract surgery. Even in the big cities, surgeons are pressured to constantly "sell" cash pay services to their patients. There are many surgeons who REFUSE to do medicare/insurance cataracts unless they upgrade. So no, medicare does not really support our current salary. Thankfully, patients understand the value of our services and at least the ones who can afford so choose to pay more out of pocket.

 

[Slide]

I would flip that, and say the government doesn't want anesthesia services involved. If ophtho as a field were getting $500 per cataract from Medicare, and next year Medicare said they'll give you $100, you're suddenly not feeling the love from the government any longer. I understand your field has high overhead and your margins are tight as is, but Medicare supports your currently salary and its solid as far as I can tell. Ophtho continues to attract a strong talent pool. I can assure you, if anesthesia cared for 100% medicare patients, or received no subsidy to support services in the hospital (overnight/weekend call, OB, trauma, etc.) then the field suddenly becomes far, far less attractive. Still, I don't support out-of-network billing, unless it comes from commercial and they are not negotiating in good faith (UnitedHealthcare is a good example, and recently BCBS with non-negotiable random contract rate cuts in NC). You can look at this one of two ways - blaming the anesthesia group or blaming the government. Again, if Medicare cuts you to $100 per cataract next year I would not blame you for finding other ways outside of cataract surgery to support your income.

Believe us, we’ve been hit by Medicare reimbursement cuts much more than you think. The reason why many ophthalmologists are holding steady is because we’re squeezing as blood out of a rock as possible. There’s a reason why you see ophthalmology clinics stacked with 40-80 pts a day, and doing 20-30 phacos a day. With the most recent cut, more established ophthalmologists are even sending out their surgeries because they make more in clinic.

 

[Catarockin]

why would your pt ever need propofol for a routine phaco?

It's rare but I can think of one patient in the past 6 months who cited bad reactions to versed and fent and this lady would not stop talking. Everyone has an off button, and for some, it's called propofol. Some are recovering addicts and I respect that they don't want benzos or narcotics.

 

[Openglobetrotters]

why would your pt ever need propofol for a routine phaco?

I think some still use for retrobulbar blocks.

 

[coffeebythelake]

I think some still use for retrobulbar blocks.

Do routine phacos typically require retrobulbar blocks?

 

[Slide]

Do routine phacos typically require retrobulbar blocks?

Only old school surgeons or those training residents, and these days it's easier and safer to do a sub-Tenon's block. I still do retrobulbar blocks b/c I'm retina but I rarely use propofol as well (versed/fentanyl only if possible, maybe precedex). IMO it's a dying art.

 

[Openglobetrotters]

I think some still use for retrobulbar blocks.

I didn’t do many retrobulbs in residency, but I know some of my colleagues did mainly that in residency. Because that’s what they did in residency, it’s what they’re comfortable in practice.

 

[MstaKing10]

retrobulbar for routing phaco kinda nuts. I retro/peribulbar all of my retina cases, especially buckles. Touch of propofol is all I need. By the time patient is prepped and draped they are awake an nothing more needed. I don't like versed due to longer duration. Harder to get patients to cooperate during critical moments of the surgery like membrane peels etc.

 

[dantt]

retrobulbar for routing phaco kinda nuts. I retro/peribulbar all of my retina cases, especially buckles. Touch of propofol is all I need. By the time patient is prepped and draped they are awake an nothing more needed. I don't like versed due to longer duration. Harder to get patients to cooperate during critical moments of the surgery like membrane peels etc.

Alfentanyl ftw