Spinal for TKA and THA post-op pain

[NoodleIncident]

I am curious as to ya'lls thoughts on this. I have learned that some docs are placing a plain Bupivacaine spinal for a TKA or THA, then routinely laying the patient down and placing a LMA and starting inhalational anesthetic. The patient gets a periarticular cocktail injection from the surgeon prior to closing. The patient is then billed for a GA and the plain local spinal is billed as a post-op pain procedure, even though the post-op pain relief is only the time between the 60-90 min of surgery and when the Bupivacaine wears off. Apparently, insurances do pay for this additional hour or so of post-op pain relief. Anyone out there do something similar?

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[Psai]

Why would you need an inhalational agent when you did a spinal?

 

[NoodleIncident]

Why would you need an inhalational agent when you did a spinal?

Exactly. The spinal should work fine for the operation.

The conclusion I draw is the inhalational is used so that the practioner can get the additional RVUs of a post-op pain procedure.

 

[okayplayer]

Extraordinarily shady and would prompt an internal review in my large MD practice. **** like this gives us all a bad name and needs to not happen IMO.

 

[NoodleIncident]

Extraordinarily shady and would prompt an internal review in my large MD practice. **** like this gives us all a bad name and needs to not happen IMO.

Every TKA then goes from 7 base RVUs + time to 7 + 8 + time.

 

[acidbase1]

Why would you need an inhalational agent when you did a spinal?

Exactly. We have a old OB here who wants CSE + GETA + OnQ + epidural duramorph

Makes zero sense. Since when do we do spinals for post op pain control? An epidural on the floor is one thing, but spinal?

His logic in putting in a tube is so the patient isn’t coherent for the procedure. Won’t let you run low dose propofol or precedex

 

[Southpaw]

Exactly. We have a old OB here who wants....

Won’t let you run low dose propofol or precedex

For a CS? Regardless, he’d need to explain that one to our entire department. It wouldn’t fly where I am.

With regards to post-op pain control spinal cocktails, our biller has said you can only bill for post op pain control when you add long-acting pain relief (duramorph) to the spinal, and see/evaluate/write note for the patient on POD1.

I don’t think duramorph adds much if anything to knees (we do adductor canals) and more harm than good for hips as they don’t hurt much. I dropped the practice a while back. However, some of my partners still do it, and it’s true that some docs will do just about anything to generate a few more RVUs. Those docs are in the clear minority though, in my experience.

 

[Urzuz]

In residency we used to do spinal + propofol infusion for total joints.

Once I joined my practice, most people would sink an LMA in a patient in addition to a propofol infusion. At first I thought it was silly and unnecessary, but in all honesty it began to make a little more sense to me as time went on. In training, it was way too common for patients to either get disinhibited if the propofol infusion wasn't high enough, or obstruct if it was too high. One of my attendings in residency used to just put an oral airway in them, which is really no different than placing an LMA. Placing an LMA seems to solve all those problems -- you run them deep enough so they aren't moving and are able to tolerate an LMA, you have an airway so they won't obstruct (and can even throw on PSV if their respirations are shallow), and most importantly you can just set it and forget it for the case.

A couple of my partners run a little gas because I guess it makes them feel better regarding intraoperative awareness. I don't do it myself, but I assume that is their reasoning. As a matter of practice, we do not bill for postoperative pain control with plain spinals -- only if you have an additive like PF morphine -- so the gas+LMA definitely isn't for $ purposes.

 

[Urzuz]

For a CS? Regardless, he’d need to explain that one to our entire department. It wouldn’t fly where I am.

With regards to post-op pain control spinal cocktails, our biller has said you can only bill for post op pain control when you add long-acting pain relief (duramorph) to the spinal, and see/evaluate/write note for the patient on POD1.

I don’t think duramorph adds much if anything to knees (we do adductor canals) and more harm than good for hips as they don’t hurt much. I dropped the practice a while back. However, some of my partners still do it, and it’s true that some docs will do just about anything to generate a few more RVUs. Those docs are in the clear minority though, in my experience.

UCSF recently did a large retrospective analysis of their total joints and found that PF morphine does help with postoperative pain scores, ambulation distance, etc, even in addition to multimodal analgesia. As with all things in medicine, I'm sure the true best practice is somewhere in the middle between adding 500 mcg of Duramorph and completely avoiding it altogether.

 

[dchz]

Why would you need an inhalational agent when you did a spinal?

You can bill for spinal AND general if you do so. Spinal for post op pain, general for the case.

Ludicrously Lucrative 🙂

 

[acidbase1]

For a CS? Regardless, he’d need to explain that one to our entire department. It wouldn’t fly where I am.

With regards to post-op pain control spinal cocktails, our biller has said you can only bill for post op pain control when you add long-acting pain relief (duramorph) to the spinal, and see/evaluate/write note for the patient on POD1.

I don’t think duramorph adds much if anything to knees (we do adductor canals) and more harm than good for hips as they don’t hurt much. I dropped the practice a while back. However, some of my partners still do it, and it’s true that some docs will do just about anything to generate a few more RVUs. Those docs are in the clear minority though, in my experience.

It’s for total abdominal hysterectomies + BSO actually. He and i got into it big time the first day we worked together over this. He had no logic as to why he wanted it done, rather, this was “the way they’ve done it forever”. Had never done an open TAH/BSO until arriving here since they were all robotic in residency.

 

[acidbase1]

Can someone explain the spinal for post operative pain control? I’ve never heard of spinals being conducted for post op pain. Clearly adding duramorph to the spinal would be the post op pain component.

But a CSE with epidural duramorph would qualify for post op pain correct?

 

[dchz]

Can someone explain the spinal for post operative pain control? I’ve never heard of spinals being conducted for post op pain

You bill for it. To the standard biller without expertise in our field. Sounds legit.

???

Profit.

 

[NoodleIncident]

Can someone explain the spinal for post operative pain control? I’ve never heard of spinals being conducted for post op pain

I had never heard of it either (for spinals with LA only). I learned of some doctors doing it and actually being reimbursed handsomely for it. Makes me think it should undergo an internal review as well.

 

[Southpaw]

Can someone explain the spinal for post operative pain control? I’ve never heard of spinals being conducted for post op pain. Clearly adding duramorph to the spinal would be the post op pain component.

But a CSE with epidural duramorph would qualify for post op pain correct?

You can bill whatever you want, but my understanding is that insurance only reimburses when duramorph is given via spinal or epidural. When we do it (post op pain control after CS is most common) we are entering orders, managing pain, dealing with complications for the first 24 hours. We also must see/eval/write note on POD1. In my group it bills for 2-3 units, so if that’s Medicaid/Medicare it’s not worth your time. If it’s private, it’s decent, but no one is getting rich off of it.

 

[Southpaw]

It’s for total abdominal hysterectomies + BSO actually. He and i got into it big time the first day we worked together over this. He had no logic as to why he wanted it done, rather, this was “the way they’ve done it forever”. Had never done an open TAH/BSO until arriving here since they were all robotic in residency.

Yeah that’s absurd.

 

[Arch Guillotti]

A couple of my partners run a little gas because I guess it makes them feel better regarding intraoperative awareness.

How in the world can you consider someone to have intraoperative awareness when you have a functioning spinal?

 

[Urzuz]

How in the world can you consider someone to have intraoperative awareness when you have a functioning spinal?

Well if you tell a patient "you'll be asleep for the surgery", put an LMA in them, tape their eyes shut, and afterwards they are able to recall specific events during their operation, that would classify as intraoperative awareness. A patient does not need to have pain to have intraoperative awareness.

Practice Advisory for Intraoperative Awareness and Brain Function Monitoring:A Report by the American Society of Anesthesiologists Task Force on Intraoperative Awareness | Anesthesiology | ASA Publications

 

[Arch Guillotti]

Well if you tell a patient "you'll be asleep for the surgery", put an LMA in them, tape their eyes shut, and afterwards they are able to recall specific events during their operation, that would classify as intraoperative awareness.

Maybe you shouldn't put an LMA in a patient with a functioning spinal then!😵

 

[acidbase1]

Also, my guys “run them on a little gas” too with LMA or OETT. In the case of the LMA, aren’t you worried about them getting too light and gagging/laryngospasm/aspirating/awareness?

The whole concept is absolutely ridiculous

 

[NoodleIncident]

Also, my guys “run them on a little gas” too with LMA or OETT. In the case of the LMA, aren’t you worried about them getting too light and gagging/laryngospasm/aspirating?

The whole concept is absolutely ridiculous

Yes, it’s ridiculous unless your goal is to pad your billing, which unfortunately may be why I’m seeing it.

 

[Psai]

Well if you tell a patient "you'll be asleep for the surgery", put an LMA in them, tape their eyes shut, and afterwards they are able to recall specific events during their operation, that would classify as intraoperative awareness. A patient does not need to have pain to have intraoperative awareness.

Practice Advisory for Intraoperative Awareness and Brain Function Monitoring:A Report by the American Society of Anesthesiologists Task Force on Intraoperative Awareness | Anesthesiology | ASA Publications

Is there something wrong with intraoperative awareness? I've talked to patients under spinal but none of them have remembered our conversations after I brought them out

 

[Urzuz]

Maybe you shouldn't put an LMA in a patient with a functioning spinal then!😵

That's fine, don't put an LMA in. But you will definitely come by patients that will get disinhibited and/or obstruct if you run them on propofol with the intention of having them lose consciousness and not remember anything during their surgery.

Is there something wrong with intraoperative awareness? I've talked to patients under spinal but none of them have remembered our conversations after I brought them out

In a private practice where "the customer is always right" and patients do not want to be conscious or aware during surgery, then yes, there is plenty wrong with intraoperative awareness, even if the patient is not in pain.

Also, my guys “run them on a little gas” too with LMA or OETT. In the case of the LMA, aren’t you worried about them getting too light and gagging/laryngospasm/aspirating/awareness?

The whole concept is absolutely ridiculous

The presence of an LMA does not directly change the incidence of aspiration, awareness, or of patients "getting light" -- those things are all influenced by the medications you give to a patient.

To be clear, I don't run gas along with spinals (I do a straight propofol infusion + spinal + LMA), but it isn't that far fetched to understand why people do so. Sure, some of it may be purely for billing purposes, but it seems like a perfectly acceptable way to do a joint replacement.

 

[BLADEMDA]

Hmm... 100 micrograms of Duramorph via an SAB generates a lot of RVUs and is acceptable practice for a Total Joint Replacement:

Post-operative analgesia following total knee arthroplasty: comparison of low-dose intrathecal morphine and single-shot ultrasound-guided femoral n... - PubMed - NCBI

Intrathecal morphine versus femoral nerve block for pain control after total knee arthroplasty: a meta-analysis. - PubMed - NCBI

Post-operative analgesia following total knee arthroplasty: comparison of low-dose intrathecal morphine and single-shot ultrasound-guided femoral n... - PubMed - NCBI

Postoperative pain relief after total hip arthroplasty: a randomized, double-blind comparison between intrathecal morphine and local infiltration analgesia | BJA: British Journal of Anaesthesia | Oxford Academic

Optimizing the dose of intrathecal morphine in older patients undergoing hip arthroplasty. - PubMed - NCBI

 

[NoodleIncident]

Hmm... 100 micrograms of Duramorph via an SAB generates a lot of RVUs and is acceptable practice for a Total Joint Replacement

Yes, it is. But the issue here is a plain Bupivacaine SAB being claimed as being used for post-op pain. It generates a lot of RVUs, but is it appropriate?

 

[BLADEMDA]

Okay, so why don't I use intrathecal Duramorph for post-op pain control for total joint Arthroplasty?


High rates of postoperative urinary retention following primary total hip replacement performed under combined general and spinal anaesthesia with ... - PubMed - NCBI

Urinary Retention is Rare After Total Joint Arthroplasty When Using Opioid-Free Regional Anesthesia. - PubMed - NCBI

Comparison of intrathecal and local infiltration analgesia by morphine for pain management in total knee and hip arthroplasty: A meta-analysis of r... - PubMed - NCBI

The bottom line is I don't add intrathecal duramorph to my spinal cocktail.

 

[BLADEMDA]

Yes, it is. But the issue here is a plain Bupivacaine SAB being claimed as being used for post-op pain. It generates a lot of RVUs, but is it appropriate?

No. But, proving that the "provider" placed the spinal for billing fraud is very difficult to do. Some "providers" like to do GA plus SAB. That's not my technique but it is not billing fraud.

"Patients in the general anesthesia group were admitted to the PACU with a higher pain score and needed more analgesics than patients in the spinal group (2)"

Spinal anesthesia: the new gold standard for total joint arthroplasty?

 

[BLADEMDA]

No. But, proving that the "provider" placed the spinal for billing fraud is very difficult to do. Some "providers" like to do GA plus SAB. That's not my technique but it is not billing fraud.

"Patients in the general anesthesia group were admitted to the PACU with a higher pain score and needed more analgesics than patients in the spinal group (2)"

Spinal anesthesia: the new gold standard for total joint arthroplasty?

So, before anyone posts that my comments above are basically "rubbish" I want to agree with them. There is no good evidence out there that pain scores are better after an SAB (no opioids added) vs a GA with LIA. A few small, anecdotal studies does not add up to scientific fact.

Recovery after total intravenous general anaesthesia or spinal anaesthesia for total knee arthroplasty: a randomized trial. - PubMed - NCBI

Neuraxial vs general anaesthesia for total hip and total knee arthroplasty: a systematic review of comparative-effectiveness research. - PubMed - NCBI

 

[BLADEMDA]

Yes, it is. But the issue here is a plain Bupivacaine SAB being claimed as being used for post-op pain. It generates a lot of RVUs, but is it appropriate?

It's a very "shady" practice at best; but is it illegal/billing fraud? Nope.

 

[caligas]

Why would you need an inhalational agent when you did a spinal?

You dont need both, but here is why some people do both:

Spinal for all the benefits of the spinal: post op pain control, reduced blood loss, smooth hemodynamics with surgical stimulation.

gas for all the benefits of the gas: cheap, easy, patient has no memory of procedure, patient doesn’t move or talk during surgery which some surgeons like, let’s you have a secure airway without episodes of apnea/obstruction.

Everything has risks, but doing both will give you happy patient and happy surgeon in some centers.

 

[NoodleIncident]

Doing both may be all fine and well for those reasons stated. However, is it right to bill the patient and insurance/government for both? The GA for the procedure and the SAB for that hour or so of post op pain control.

 

[nimbus]

Is there something wrong with intraoperative awareness? I've talked to patients under spinal but none of them have remembered our conversations after I brought them out

It’s a pain in the ass to talk to patients. That’s why I went into anesthesia and love the LMA.

 

[Ezekiel2517]

You dont need both, but here is why some people do both:

Spinal for all the benefits of the spinal: post op pain control, reduced blood loss, smooth hemodynamics with surgical stimulation.

gas for all the benefits of the gas: cheap, easy, patient has no memory of procedure, patient doesn’t move or talk during surgery which some surgeons like, let’s you have a secure airway without episodes of apnea/obstruction.

Everything has risks, but doing both will give you happy patient and happy surgeon in some centers.

Exactly, this is how I do it as well. Didn't do it in residency but came to like it in PP. And the surgeons prefer this as well (plain spinal, LMA). You don't need much gas at all, less than half a mac. I don't bill for the spinal.

 

[facted]

You dont need both, but here is why some people do both:

Spinal for all the benefits of the spinal: post op pain control, reduced blood loss, smooth hemodynamics with surgical stimulation.

gas for all the benefits of the gas: cheap, easy, patient has no memory of procedure, patient doesn’t move or talk during surgery which some surgeons like, let’s you have a secure airway without episodes of apnea/obstruction.

Everything has risks, but doing both will give you happy patient and happy surgeon in some centers.

Worked at a busy PP doing 6-7 total joints a day 3 days a week. In three years I can count on one hand the patients I had to LMA because of either talking or obstruction I couldn't relieve with an oral airway, nasal trumpet, or moving the head slightly to the side.

You guys are telling me that for your own surgery you'd rather have an LMA and 1/2 MAC sevo vs 75 mcg/kg/min prop with spontaneous airway?

 

[Hoya11]

I am curious as to ya'lls thoughts on this. I have learned that some docs are placing a plain Bupivacaine spinal for a TKA or THA, then routinely laying the patient down and placing a LMA and starting inhalational anesthetic. The patient gets a periarticular cocktail injection from the surgeon prior to closing. The patient is then billed for a GA and the plain local spinal is billed as a post-op pain procedure, even though the post-op pain relief is only the time between the 60-90 min of surgery and when the Bupivacaine wears off. Apparently, insurances do pay for this additional hour or so of post-op pain relief. Anyone out there do something similar?

Maybe this will help explain: We do our total joints this way and ill admit it does sound weird at first... this technique is designed for the outpatient world/eras

The spinal IS NOT a FULL spinal. Its 1-1.2ml of the 0.75% bupi. No narcs.
This creates a dense sensory block, with no need for additional analgesics intra-op.
However it allows some motor movement to occur. Hence the LMA/tube.

When the patient wakes up, IME from watching them at the center, there is no pain for 3+hrs but usually full strength within 30 mins to 1hr.
This allows PT to happen with the spinal still blocking sensory. Ambulation to happen with crutches and a close observer. Urination is the last step occuring in 3-4 hrs.
It also allows me to do an ACB while still no sensation post op.
Patients leave the center completely comfortable with maybe 1-2 percocet in addition to the above.

If I were to give a FULL dose spinal, ambulation and PT would be very delayed, urination would be very delayed, and this all might hold up the DC from the ASC.
But yes then it would give you full anesthesia intra-op and the LMA/tube becomes redundant.
I think the idea you may be missing is that the spinal is PARTIAL in order to wear off faster for eras purposes.

 

[dannyboy1]

To be clear, I don't run gas along with spinals (I do a straight propofol infusion + spinal + LMA), but it isn't that far fetched to understand why people do so. Sure, some of it may be purely for billing purposes, but it seems like a perfectly acceptable way to do a joint replacement.

If they are deep enough to tolerate an LMA they are pretty much under GA. why are people getting so hung up on propofol vs gas?

 

[BLADEMDA]

Doing both may be all fine and well for those reasons stated. However, is it right to bill the patient and insurance/government for both? The GA for the procedure and the SAB for that hour or so of post op pain control.

So, we agree it isn't "the right thing to do" to bill for both an SAB and a GA because a patient only needs one or the other. The argument that the spinal (without opioids) provides postop pain relief is a weak one IMHO. That said, is this "illegal" or "billing fraud" to charge for both of them even if the postop pain relief only lasts for 1 hour due to the SAB? Nope.

 

[caligas]

Worked at a busy PP doing 6-7 total joints a day 3 days a week. In three years I can count on one hand the patients I had to LMA because of either talking or obstruction I couldn't relieve with an oral airway, nasal trumpet, or moving the head slightly to the side.

You guys are telling me that for your own surgery you'd rather have an LMA and 1/2 MAC sevo vs 75 mcg/kg/min prop with spontaneous airway?

What I would want and what works the best for our patients and our surgeons are different questions. Also as hoya noted we also do a smaller dose spinal to allow early ambulation/PT, minimize urinarary retention etc.

 

[acidbase1]

Worked at a busy PP doing 6-7 total joints a day 3 days a week. In three years I can count on one hand the patients I had to LMA because of either talking or obstruction I couldn't relieve with an oral airway, nasal trumpet, or moving the head slightly to the side.

You guys are telling me that for your own surgery you'd rather have an LMA and 1/2 MAC sevo vs 75 mcg/kg/min prop with spontaneous airway?

This is my point exactly. A tube or LMA is unnecessary. Do you put an LMA in all of your colonoscopies?

 

[Urzuz]

If they are deep enough to tolerate an LMA they are pretty much under GA. why are people getting so hung up on propofol vs gas?

I think that's my whole point. The people who are liking your post are the ones getting hung up on it.

Let's go back to some basic definitions that you may have forgotten. CONSCIOUSNESS defines whether a patient is under GA, NOT the presence of an LMA.

You guys are saying, spinal + propofol infusion + no airway but spontaneous breathing = great. Spinal + propofol infusion + LMA with spontaneous breathing = stupid, "makes no sense."

Now explain to me that logic? If a patient is under the true definition of GA and is obstructing, and you don't feel it appropriate to reduce the amount of anesthetic given that they may wake up and become disinhibited, why is placing an LMA so ludicrous?

You guys have to understand that there are 100 different ways to do an anesthetic, and the more close minded you are about the "right" and "wrong" ways are to do things, the more you will stifle your own learning and growth as physicians.

 

[Urzuz]

This is my point exactly. A tube or LMA is unnecessary. Do you put an LMA in all of your colonoscopies?

If a colonoscopy took 2 hours I would. Why do LMAs scare you so much? You really need to unlearn a lot of the academic dogmatic nonsense that you've learned in residency.

Worked at a busy PP doing 6-7 total joints a day 3 days a week. In three years I can count on one hand thepatients I had to LMA because of either talking or obstruction I couldn't relieve with an oral airway, nasaltrumpet, or moving the head slightly to the side.

You guys are telling me that for your own surgery you'd rather have an LMA and 1/2 MAC sevo vs 75 mcg/kg/min prop with spontaneous airway?

See, this is the most ridiculous post that tells me you guys just don't know what you're arguing against. How much propofol do you think it takes for a patient to tolerate an LMA? Hint: it's pretty much what you're running them on.

And to answer your question, give me the propofol infusion plus an LMA so I don't obstruct and get hypercapneic. Best of both worlds -- no PONV, wake up great, and I won't have a PaCO2 70.

 

[BLADEMDA]

I don't typically place an LMA for patients who have received an SAB. But, I certainly have no issues adding an LMA to the mix if it's needed at all. By "needed" I mean any obstruction of the airway during the case or the spinal level starts wearing down unexpectedly. This isn't a big deal and since I supervise CRNAs I have a low tolerance for placing an LMA.

FYI, I personally have no qualms about getting just propofol (been there) or an LMA (done that) or an ETT (yes, that as well). I'd be more corned about my BP, Sat, HR and CO2 levels than any of the airway devices.

IMHO, the advantages of a Regional anesthetic are mostly maintained even if an LMA is added to the mix. I do think the ELDERLY benefit the most from a more "pure" Regional technique with minimal Propofol combined with NO vapor. But, for your "average" patient the addition of an LMA with Propofol (spontaneous respirations) to the SAB still keeps the benefits without much downside.

For those out there who haven't personally performed a lot of a cases give it a try. You may be surprised at the negligible difference between a pure SAB with propofol vs an SAB with an LMA plus Propofol IV. Typically, the insertion of the LMA Does require a higher basal infusion rate of propofol but not necessarily by that much more.

The key part of this equation is that the provider must be "slick" with LMA insertion so there are minimal sore throats in the PACU. That means the LMA goes in BLOODLESS and comes out BLOODLESS.

 

[facted]

What I would want and what works the best for our patients and our surgeons are different questions. Also as hoya noted we also do a smaller dose spinal to allow early ambulation/PT, minimize urinarary retention etc.

1.3-1.5 ml of 0.5% bupi. Early ambulation and all that. Still propofol sedation.

 

[facted]

See, this is the most ridiculous post that tells me you guys just don't know what you're arguing against. How much propofol do you think it takes for a patient to tolerate an LMA? Hint: it's pretty much what you're running them on.

And to answer your question, give me the propofol infusion plus an LMA so I don't obstruct and get hypercapneic. Best of both worlds -- no PONV, wake up great, and I won't have a PaCO2 70.

Not saying you can't place an LMA. I'm just telling you it's 100% overkill and not necessary.

 

[Urzuz]

Not saying you can't place an LMA. I'm just telling you it's 100% overkill and not necessary.

The same can be said about giving any sedation at all after the spinal is in.

To each his own. Let's just say I'm a fan of "set it and forget it" anesthesia - a safe, reliable anesthetic where a patient gets a great outcome and they're on cruise control for the entire anesthetic (and as the poster above said, I don't need to carry on a conversation with them for the duration of the case).

All I'm trying to explain to others is that their minds shouldn't be blown where they hear that people do anesthetics differently -- all safe, effective, with similar outcomes.

 

[okayplayer]

The issue I have isn’t with putting an LMA in after the SAB (though it’s unnecessary the vast majority of the time IMO), it’s with billing the SAB for postop pain and a GA (especially when we are talking about a plain bupi spinal). That is subjecting a patient to an unnecessary procedure (either the SAB or the GA) for the sole purpose of billing them more. It’s unethical and it’s bushleague bullshi* period.

 

[acidbase1]

If a colonoscopy took 2 hours I would. Why do LMAs scare you so much? You really need to unlearn a lot of the academic dogmatic nonsense that you've learned in residency.



See, this is the most ridiculous post that tells me you guys just don't know what you're arguing against. How much propofol do you think it takes for a patient to tolerate an LMA? Hint: it's pretty much what you're running them on.

And to answer your question, give me the propofol infusion plus an LMA so I don't obstruct and get hypercapneic. Best of both worlds -- no PONV, wake up great, and I won't have a PaCO2 70.

Not at all afraid to place LMA. i rotated through 15-20 facilities in residency never once seeing this in practice. Clearly if the situation necessitated needing an LMA I’d place one. However, there would be little need to run someone that deep purely for sedation to need an LMA. It’s OVERKILL

The nurses place a LMA/OETT every single time they place a pure bupivicaine SAB and it’s the dumbest thing I’ve ever seen.

 

[Ezekiel2517]

lol people getting their panties in a bunch bc of a glorified oral airway and a little bit of gas. classic sdn

 

[Urzuz]

Not at all afraid to place LMA. i rotated through 15-20 facilities in residency never once seeing this in practice. Clearly if the situation necessitated needing an LMA I’d place one. However, there would be little need to run someone that deep purely for sedation to need an LMA. It’s OVERKILL

The nurses place a LMA/OETT every single time they place a pure bupivicaine SAB and it’s the dumbest thing I’ve ever seen.

I'll just leave it at this: You have a lot to learn, not the least of which is getting over your arrogance in thinking you know better than everyone else (see above - you are directly contradicting people, including Blade, who were practicing while you were probably in Huggies), and thinking your practice is far and away the best and safest without even seeing the "other side." I hope for your patients' sake you open yourself up to learning and modifying your practices based on experiences of others -- or at the very least acknowledging and seeing the utility in other practices, even if you don't adopt them yourself.

 

[acidbase1]

^^^ lol okay. Clearly I’m not the only one with this logic.