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Total Joints and the “fluid situation”
Started by lolnotacop
Do you send your outpatient's home after intrathecal narcotic? Yes it's fentanyl and should be off by the time they're going home but from a pure liability perspective (a poor way to practice medicine but one has to cognizant of, any thirsty lawyer would pick this apart) I would think you'd have to keep them 23hr obs or overnight.
That's only for intrathecal morphine.
Systemic absorption of intrathecal fentanyl is very rapid so there is no requirement for extended observation for intrathecal fentanyl that I am aware of
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Seems like overkill. Adds excess invasive intubation, paralysis, reversal, hypotension from altered respiratory mechanics, atelectasis, ponv, etc
A short spinal with propofol is smooth, and patients generally love it postop.
Worse case, toss in an lma if spinal wears off.
There’s a lot of “You’re crazy” being tossed around in this thread when the reality is you do what you have to do for that specific patient.
The ultimate “check” on your spinal is the leave the patient away or mildly sedated which probably minimizes vasodilation and the negates the need to drown the patient. But of course that risks the dreaded “ouch” at incision and while I know we’re all the Lebron James of anesthesia here on SDN, no spinal is 100% perfect 100% of the time. Sixty percent of the time my spinals work every time. Depending on the patient and the airway, I’ll do a quality control anesthetic and mildly sedate with some propofol if I’m really feeling my spinal was a slam dunk. I don’t like lifting chins for asleep patients so if they’re wanting to or looking like they will obstruct the LMA goes in and yes it’s pretty much a GA at that point. I feel most of my patients at least want to be asleep regardless of getting or not getting the spinal.
Two liters isn’t unreasonable for a spinal and maybe it’s old information but back in the day I was taught these patients need 2L just to make up for being NPO and the vasodilation. That could be wrong as I was admittedly trained by hydrationist.
I don’t think anyone is wild if they need to give more that 2 L because no all patients are made the same, no all surgeons are the same (we definitely have a butcher ortho or two), and certainly all anesthetics shouldn’t be cookbook
To go back to the OP issue at hand, even if it means me getting handed a pink slip, I’m not sacrificing patient care/safety for corporate overloads. I give people what they need and I want to practice standard of care medicine. If we can’t do that then the elective stuff needs to be canceled until we’re back on our feet
The ultimate “check” on your spinal is the leave the patient away or mildly sedated which probably minimizes vasodilation and the negates the need to drown the patient. But of course that risks the dreaded “ouch” at incision and while I know we’re all the Lebron James of anesthesia here on SDN, no spinal is 100% perfect 100% of the time. Sixty percent of the time my spinals work every time. Depending on the patient and the airway, I’ll do a quality control anesthetic and mildly sedate with some propofol if I’m really feeling my spinal was a slam dunk. I don’t like lifting chins for asleep patients so if they’re wanting to or looking like they will obstruct the LMA goes in and yes it’s pretty much a GA at that point. I feel most of my patients at least want to be asleep regardless of getting or not getting the spinal.
Two liters isn’t unreasonable for a spinal and maybe it’s old information but back in the day I was taught these patients need 2L just to make up for being NPO and the vasodilation. That could be wrong as I was admittedly trained by hydrationist.
I don’t think anyone is wild if they need to give more that 2 L because no all patients are made the same, no all surgeons are the same (we definitely have a butcher ortho or two), and certainly all anesthetics shouldn’t be cookbook
To go back to the OP issue at hand, even if it means me getting handed a pink slip, I’m not sacrificing patient care/safety for corporate overloads. I give people what they need and I want to practice standard of care medicine. If we can’t do that then the elective stuff needs to be canceled until we’re back on our feet
I've got to disagree with you. How frequently are patients waking up in the morning and downing a 2L bottle of <insert beverage here>. They are not that volume down.
If you think the issue is vasodilation, counteract that with a whiff of phenylephrine gtt or some ephedrine. Now obviously if there is surgical volume loss that is a different issue.,
Id argue that most people are some form of dehydrated all the time, especially since our mostly obese population confuses dehydration with hunger and eats more than they should drink
But ignoring my soapbox moment, even with the simple 4-2-1 calculation I think pretty much all our OR patients walk in at very least a liter behind as the body loses water in various ways…::that’s if you believe in 4/2/1
I think dehydration is pretty well regulated by thirst personally. How thirsty are you in the morning after eating last at 8 pm? Combine that with your normal breakfast and there’s the answer
I’m certainly not 2L of water thirsty
I am perplexed by this notion that spinals are better for the purpose of postop pain for TKAs - whether posterior or anywhere else.
Unless the spinal has morphine in it, it's gone in a few hours. If there's morphine on it, they stay overnight. They ALL need PO opioids eventually.
They look better in PACU? Well of course they do, they're still fully anesthetized. At some point they won't be, and pain control will come down to the local you put in a block (or the surgeon injects) plus opioids and whatever NSAID/acetaminophen cocktail you chose. You can do that with general anesthesia and spare yourself the bother of sticking needles on geriatric spines.
Unless the spinal has morphine in it, it's gone in a few hours. If there's morphine on it, they stay overnight. They ALL need PO opioids eventually.
They look better in PACU? Well of course they do, they're still fully anesthetized. At some point they won't be, and pain control will come down to the local you put in a block (or the surgeon injects) plus opioids and whatever NSAID/acetaminophen cocktail you chose. You can do that with general anesthesia and spare yourself the bother of sticking needles on geriatric spines.
Anyone who feels strongly on the nausea, pain, patient satisfaction outcomes one way or the other just isn’t familiar with the literature. That’s all there is to it. Surgeons, CRNAs, anesthesiologists, pacu nurses, doesn’t matter.
Ignorance and practice calcification is a heck of a thing.
You seem to be arguing that one technique is clearly better and that educated and informed anesthesiologists known it. A few thoughts:
Literature hasn't shown a difference in outcomes between general and regional despite decades of trying to find a difference.
Less important and fuzzier outcomes are hamstrung by the fact that studies are typically general vs spinal+general because the standard spinal includes sedating the patient to the point of obtundation.
There is typically a wide, wide gap between the "statistically significant" secondary outcome differences and anything that's actually clinically significant. If I had a nickel for every study I've seen cited here that touts a significant p-value but turns out to be pain score of 3.1 vs 2.4, I'd jingle when I walk.
I certainly think there is a lane for spinals even if I'm not a fan of sticking needles in backs but I think naysayers also make a compelling argument. My missed spinals who end up with an adductor canal and an LMA do just as fine as far as I know. I mean even thoracic surgery is moving further and further away from thoracic epidurals as there are other pain control modalities without sticking a needle in someone's back and all the risks that come with it. I think it's especially true with older patients who tend not need a lot of anesthetic in the first place. I think orthopedic surgeons have just gotten so used to spinals being placed that they're almost considering it a standard of care at this point which we all now isn't true. I had an ortho case once where the patient had two spinal headaches in the past so we agreed to no risk it an just do a GA. I told the surgeon. He kind of made a stink and I had to remind him that "this was more of an FYI and not me asking permission" situation and even with all of that on his post of note he still wrote that the patient got a spinal despite her not getting one. They're just programmed at this point.
I was arguing that anyone who feels strongly for one technique versus the other doesn't know the literature. I didn't say that one is better than the other, because the literature is ambivalent on that point.
I generally go with whatever the surgeons feel strongly about because I don't want to educate them.
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In real life though , when the patient has to walk out of your facility within a few hours after TKA, how do you control that posterior pain?
I pack is not going to do it. I pack and dilaudid maybe. Then they go home in a lot of pain/ high opiate requirement
Sciatic block yes but then they can’t walk. I don’t really see a problem with that but ortho does.. ? This would be my favorite option.
Last option is what we do now: the tail of a receding spinal. That’s the advantage of neuraxial, not the intra - op, but the post op pain control. Spinals have a longer sensory “tail” then I once thought. , especially bupi spinals. That slow trail off when motor has returned but sensory still not 100 percent back may last hours, and it is what gets the patient home and walking and not on huge opiate doses.. it’s what covers the inadequate ipack block.
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deleted87051
So they’re no longer your problem when the spinal “tails” off 😂. Guess that’s no different than any other single shot block.
We can argue back and forth about which one is better… but I know one thing. If I was given the choice, and I know if most of you guys were given the chance, we would take the spinal and sedation over general anesthesia. This is taking all else out of the equation, pressure to turnover and discharge mainly. I think that says a lot about what is best for the patient, vs. what is the best for the hospital and surgeon.
Bupi spinals are the most variable duration thing... I wouldn't hang my hat on ppl walking out home after one. Some might, but a fair few will need admission.. Thats not up for debate, if you don't believe me
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deleted87051
I’m interested in hearing real-life experiences of people who do joints at freestanding surgery centers.
1. What’s the average time to discharge?
2. What percent of patients can’t be discharged?
A fair number (maybe 10-20%) of “outpatient” joints at our hospital end up being admitted. It’s no big deal because the patients are already in the hospital but it seems like a pain to transfer a patient from a freestanding surgicenter to a hospital.
Thanks.
We do spinals for all outpatients. They all go home.
If they are admitted, it's not related to the spinal. It's for other reasons
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deleted87051
How long after surgery are they typically discharged? What do you do for the ones who can’t pee? Do you straight cath them and send home?
Here’s the one thing. When you get a bone cement implantation syndrome or embolism you want a free flowing IV to resuscitate. I just had one happen right as they pressurized the bone cement. Immediate desats, hypotension, bradycardia. Luckily CRNA was on top of it and called me and started resuscitation. Despite doing everything right it progressed to PEA arrest. Got ROSC in 2 rounds of CPR and epi. But I would have been up a creek without a free flowing IV.
I wouldn’t pick total joints to skip IV bags.
I wouldn’t pick total joints to skip IV bags.
Confidently incorrect here , they all go home.
Not sure particularly. They spend time doing training, PT before they go. Probably 2-4 hrs. I don't wait around
Straight Cath and then send home. Doesn't happen too often since we decreased our spinal dosages.
For the hospital outpatients joints, some do end up staying. Usually that's because they were borderline patients and they end up being admitted out of caution since they are already there. I don't dose them any differently. My goal is patients can move their legs on arrival in pacu.
Our surgeons are pretty good, and predictable. 50-55 min tourniquet times, predictable routines, they inject periarticular plus our blocks.
We do >6,000 joint replacements a year, probably 98% of those with SAB - no blocks for hips, AC and Ipack blocks for the knees. Most are out the door within 2 hrs postop, frequently less. I had both my hips done as an outpatient. From the time I walked into the hospital to the time I walked out was under 5 hours. (and $60k net after insurance to the hospital)
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deleted87051
How long do you wait before you leave the facility? Until phase 1 criteria are met? Do they schedule joints in the morning and scopes in the afternoon or something like that?
I leave once patient responds to commands. What do I need to stick around for? I'll only stay around if I am concerned about something
If anything comes up after, I can handle by phone. I can always drive back if needed (happened maybe once in 10 years)
Otherwise, I can order meds, give transfer orders, order ekg, etc from home
I wait till the are gone unfortunately. Latest joint usually comes out around 1.
Had a partner get a bupi spinal for a knee at another ASC and his spinal didn't wear off for over 8 hours...
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deleted87051
Makes sense but different centers have different policies. The freestanding ASCs I’m familiar with require us to stay until patients are getting dressed and IV is out. If they’re ready to go but just waiting for a ride, we can leave.
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deleted87051
Yea that sucks.
The other center we were at just didn't allow us to start another case somewhere else for an hr after.
Hanging around would irk me
Look it up then and see... 3 to 9hour duration possible
Maybe your institution is the lucky one, or you're giving such low dose spinal it doesn't even do much anyways... Idk
All I know is a couple big centres around me wouldnt allow Bupi spinals for guys going home same day anymore and they presented the evidence for it...
This duration is well described in the literature which implies to me that the people on here saying it never happens to them just haven't done enough, been very lucky, or aren't involved in these centres at a high level to find the one in a couple hundred cases that requires admission purely done to Bupi spinal erratic duration
We use isobaric, and only 5-7mg.
Maybe hyperbaric can settle differently or form a pocket of sense LA and cause prolonged effects?
Just a theory
But yes, still a bell curve of duration for me. Sometimes patients can flex their knees on arrival in pacu, sometimes just wiggle toes.
I wouldn't recommend that light of a spinal for an awake patient.
They had to have put in an additive, no? An 8hr spinal is wild if it was just straight up 15 mg bupivacaine…..and yes I’m basing that on 10 years experience doing c sections and ortho. But as said above, maybe some anatomical variation can make the local just sit in the dural sac and prolong the action of the med. IDK
What do you put in it? Do you do any other blocks in addition?
20mcg fent
Adductor canal postop
Tiva with ketofol
Decadron
Zofran
I may give the remainder of fent IV if patient responds
15mg isobaric will usually give me 4-7 hrs of surgical time. I use that dose if it's a nasty revision on a patient who isn't walking anytime soon.
Way too much for a standard joint
Yeah that guys not going home today with the Bupi we have, 50 50 at best
Everyone is asked to drink a lot of water the night before and up to 2 hours before the case unless they have known CHF.
If SAB, 500 ml preload max, use bupivacaine 0.5% (seeing less BP drop anecdotally), and generous with phenylepherine. Will use ephedrine 20 mg IM here and there. Usually only 1 L per case in OR.
If want to do general for anterior hips, PENG and LFCN blocks help but a good periarticular injection by the surgeon can be enough. For knees, adductor, genicular, and maybe iPACK blocks. Still running phenylepherine drips.
I wish I could convince a patient to stay awake and use headphones or something. But most people want to be out and not see or hear anything. While I agree sections are done awake, there is a huge motivation factor and culture about seeing the baby while minimizing anesthesia to the baby. Same ladies would probably not be okay with staying awake for other cases (except a cerclage which have same reasons).
I’ve only done 2 cases ever with zero sedation. Both involve anesthesia attendings as patients who are super pro regional and thought GA ruins the brain. I think the general population would need a lot of coaching preop to make something like this work. Plus making small talk for almost 2 hours is sort annoying.
I’m okay with conversing with a comfortable patient under spinal or block. However, most surgeons will complain saying the patient needs to be more sedated
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That too. They wanna listen to music or gossip about whatever
If patients ask to be awake, I generally advise them against it unless they are a surgeon or OR nurse themselves.
It adds too much unpredictability. Sounds, smells, pulling, tugging, coughing..etc. All hard to predict how the patient will respond if they're awake.
Most importantly, I want the OR team to be comfortable and following their routine. If the OR team feels on edge because the patient is awake, or that they can't have their usual banter, it changes the flow and I think that increases the risk of mistakes.
C SXNs are different, as the expectation is to be awake.
Underrated comment. Never be the one screwing up the OR flow. It's half our job or more once you know the nuts and bolts of providing anesthesia
Oh God that sounds like hell to me. If I wanted to chat with patients I would have become a family practitioner. I titrate the propofol to the point of patient silence.
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You'll never need to titrate more than 200 mg of it if you chase it with sevoflurane. 🙂
