Sending patient back to the floor after a block

[Sonny Crocket]

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So we have this new partner who thinks he is a regional guru (whatever that means). Our ortho stat schedule can get bumped around significantly during the day and especially around 2pm when the OR staff is preparing to change shifts. I don't like to block patients pre operatively this late in the day unless I know that they will be going to the OR for sure. Otherwise they could be blocked and then not operated until the next day. This has happened.

This partner says so what if we block them and they don't go the OR, at least they will be pain free for the day. Then block them again the next day before the OR. Or put in a catheter.

Any thoughts?

I see his point but also think it is increases risk to do a single shot twice for one operation. And I don't want to put in catheters that are really unnecessary.

Thanks.

 

[BLADEMDA]

No surgery means no block. If you are uncertain about whether the case will go that day then wait until the PACU to do the block. Also, I'm not sure it is legal to do a postop pain block on a patient without a surgeon's request for such block. I assume if the patient isn't having surgery that day the surgeon won't be requesting a postop pain block.

 

[nap$ter]

So we have this new partner who thinks he is a regional guru (whatever that means). Our ortho stat schedule can get bumped around significantly during the day and especially around 2pm when the OR staff is preparing to change shifts. I don't like to block patients pre operatively this late in the day unless I know that they will be going to the OR for sure. Otherwise they could be blocked and then not operated until the next day. This has happened.

This partner says so what if we block them and they don't go the OR, at least they will be pain free for the day. Then block them again the next day before the OR. Or put in a catheter.

Any thoughts?

I see his point but also think it is increases risk to do a single shot twice for one operation. And I don't want to put in catheters that are really unnecessary.

Thanks.

did he do a regional fellowship?

i'm with you - i won't do a block unless the pt is certain to get surgery. you might not get payed, and you will be liable for any complications. also, it might not be safe to do a second block the next morning if the previous day's block is still hanging around. your "guru" sounds like a doofus.

i've started doing a lot of my blocks in the OR preinduction (i have replaced catheters with decadron). i just drag the pt back a little early - most of my blocks take <5 min and it saves the trouble of coordinating with the schedule runner..

 

[Sonny Crocket]

Completely agree with you guys. I do my blocks as well under 5 min and I pretty much do everything myself with regards to drawing up local, getting the ultrasound etc.. And I like to do them in the OR so I don't have to deal with the pre op area and double my work. This slows down when teaching residents.

My partner also has all these ideas about standardizing how we do blocks with regard to draping, dosing, the type of needle etc.. I don't want to do this at all as this would just slow me down and wastes money. Heck, I stopped using tegaderm on the probe for single shots. I just make sure where I stick the needle is sterile. He wants do this huge production with drapes all over the place, having nurses at our beck and call to get all the equipment ready and stuff like that. In theory, a good idea but all the nurses are different and this is not realistic. All I need is an ultrasound, gloves, a needle, local, some gel and a choraprep stick and GO. He is overglorifying and overcomplicating this stuff.

 

[BLADEMDA]

Completely agree with you guys. I do my blocks as well under 5 min and I pretty much do everything myself with regards to drawing up local, getting the ultrasound etc.. And I like to do them in the OR so I don't have to deal with the pre op area and double my work. This slows down when teaching residents.

My partner also has all these ideas about standardizing how we do blocks with regard to draping, dosing, the type of needle etc.. I don't want to do this at all as this would just slow me down and wastes money. Heck, I stopped using tegaderm on the probe for single shots. I just make sure where I stick the needle is sterile. He wants do this huge production with drapes all over the place, having nurses at our beck and call to get all the equipment ready and stuff like that. In theory, a good idea but all the nurses are different and this is not realistic. All I need is an ultrasound, gloves, a needle, local, some gel and a choraprep stick and GO. He is overglorifying and overcomplicating this stuff.

He wants to be the big man. This isn't about healthcare or blocks as much as it is his ego.

 

[sleepallday]

Completely agree with you guys. I do my blocks as well under 5 min and I pretty much do everything myself with regards to drawing up local, getting the ultrasound etc.. And I like to do them in the OR so I don't have to deal with the pre op area and double my work. This slows down when teaching residents.

My partner also has all these ideas about standardizing how we do blocks with regard to draping, dosing, the type of needle etc.. I don't want to do this at all as this would just slow me down and wastes money. Heck, I stopped using tegaderm on the probe for single shots. I just make sure where I stick the needle is sterile. He wants do this huge production with drapes all over the place, having nurses at our beck and call to get all the equipment ready and stuff like that. In theory, a good idea but all the nurses are different and this is not realistic. All I need is an ultrasound, gloves, a needle, local, some gel and a choraprep stick and GO. He is overglorifying and overcomplicating this stuff.

Is he draping for single shot blocks too? That seems a little overkill. But whats wrong with the nurses having everything set up and ready to go for you. I literally do my single shots in <1 min.

 

[Sonny Crocket]

Blade, you are right. Total egomaniac.

It would be great to have our own block nurse.

Yes he is draping for single shots. The problem is that it is hard for me to argue against measures to be more sterile. Other than its a waste of money and time.

 

[BLADEMDA]

Blade, you are right. Total egomaniac.

It would be great to have our own block nurse.

Yes he is draping for single shots. The problem is that it is hard for me to argue against measures to be more sterile. Other than its a waste of money and time.

I use a tegaderm over my probe some of the time. It adds about 20 seconds to the procedure and provides "sterility" for a single shot block. More importantly is to use those small gel packs instead of the ketchup U/S bottle whenever you are doing a block where there is small chance of going through the gel.

Contamination of the U/S gel in the large bottles has been reported.

 

[Oggg]

If you are talking about patients with broken bones (broken ankle, hip), then I agree with your partner that an early block is actually useful even if surgery isn't for another day. You reduce pain scores (HCAPS, improve pt sleep and satisfaction) and narcotic requirement (reduce side effects). I try to let pts know that the block will be useful to them even if they don't have surgery today, and they are always grateful. Nerve injury risks are over stated.

Many ERs are starting to do femoral nerve blocks or FICBs for acute hip fracture patients, within one hour of hitting the door. Some ER docs are doing them, sometimes it's an anesthesia pain service. Indication is acute pain control and you get paid. For hips I prefer single shot with possible repeat. For ankles I try to give them a sciatic catheter and single shot ACB, in the hopes that they go home after surgery and don't have to be admitted for pain control.