Workflow with nerve blocks

[ethilo]

Curious to hear how people at different places incorporate blocks into their turnover flow, especially when cranking out a lot of procedures (shoulders all day). Do you take patients back to OR then do a SS block in the room during a case turnover? Do you block in PACU before coming back? Do you have a block team that floats around in the pacu to block before the OR? Do you leave catheters in? Do you manage your own epidural you place on the floor?

I'm in residency and we have a separate block team that blocks while we're in the OR so it's set in by the start of the case, and a pain service manages catheters on the floor post op. The regional team manages pumps that are sent home if the call in.

Just curious what it'll be like after I leave the big academic institution, thanks. I suspect people will say it's done in between cases but I wonder how you get the block to set up fast enough to be adequate for surgery that way.

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[Hoya11]

There are two common ways:

If you are supervising, you do it between cases while the resident/crna is in the room.

If you are solo, you usually do it in the room and then go right to sleep. Even with this set up, after you do the block you have to position, prep and drape the patient which takes 10-20+ mins and by that time the block should be set up.

 

[Noyac]

I interview the pt for 1min and block them the other minute.

 

[Gas you down]

a busy surgeon gets two rooms. block while in room, go to sleep immediately. pretty much works for all ortho. no indwelling catheters. all ss, throw in decadron +/- epi. that's it.
epidurals for thoracotomies. most all abdomens are laparoscopic and don't need them.

 

[sleepallday]

In between cases.

After dropping patient off in the pacu, walk over to block area where nurses will have everything ready. Single shot blocks take less then 5 mins. This leaves me with plenty of time to grab a coffee and check on all the cryptocurrencies. Catheters usually take about 20 mins. By the time I'm done with the catheter, the OR nurse shows up a few mins later to interview the patient and take them back to the OR.

 

[Ezekiel2517]

Depends on the facility. Some hospitals may have departments utilizing a specific MD and nurse to do blocks all day, among other things. At other places, the block will be done by yourself between cases in the preop or pacu area. At some surgicenters this is not possible, so the block is done in the OR before putting the patient to sleep. I actually once was in a group where most people did the block after induction with the patient already asleep.

 

[deleted171991]

In between cases.

After dropping patient off in the pacu, walk over to block area where nurses will have everything ready. Single shot blocks take less then 5 mins. This leaves me with plenty of time to grab a coffee and check on all the cryptocurrencies. Catheters usually take about 20 mins. By the time I'm done with the catheter, the OR nurse shows up a few mins later to interview the patient and take them back to the OR.

This. Minus the coffee and the currencies. And ACT model, not solo.

 

[Wiscoblue]

Solo model. Block between cases. Takes two minutes if everything is all set up and the patients surgical site is already marked etc


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[Aether2000]

The key is having the nursing staff with all the equipment ready, drugs drawn up, skin prep ready to go, and the patient expecting the block. Versed helps significantly. The ISB, SCB, and adductor canal blocks take 1-2 minutes. Popliteal blocks and sciatic blocks are longer due to positioning. Epidurals take 5 minutes. However if the nurses are clueless or the system is not set up to have all equipment at the bedside and available, then it can drag on and on. Usually we do these in the preop holding area immediately after interviewing the patient. Some places do the blocks asleep under anesthesia and others do the blocks postop in the PACU. Depends on the system and local practices.

 

[GA8314]

Curious to hear how people at different places incorporate blocks into their turnover flow, especially when cranking out a lot of procedures (shoulders all day). Do you take patients back to OR then do a SS block in the room during a case turnover? Do you block in PACU before coming back? Do you have a block team that floats around in the pacu to block before the OR? Do you leave catheters in? Do you manage your own epidural you place on the floor?

I'm in residency and we have a separate block team that blocks while we're in the OR so it's set in by the start of the case, and a pain service manages catheters on the floor post op. The regional team manages pumps that are sent home if the call in.

Just curious what it'll be like after I leave the big academic institution, thanks. I suspect people will say it's done in between cases but I wonder how you get the block to set up fast enough to be adequate for surgery that way.

This is where an ACT model works very well. We block them in advance while the other patient is still in OR. If same equipment for, say, shoulder arthroscopy, then turn overs can be quick. So, it works very well to keep things moving.

 

[GravelRider]

I actually once was in a group where most people did the block after induction with the patient already asleep.

When I was applying for malpractice insurance there was a specific question about whether or not I routinely perform nerve blocks while a patient is under general anesthesia.

 

[Scotty_G]

I think it is safe to do nerve blocks asleep in adults, HOWEVER there are a few I would avoid. University of Washington (Seattle) has data from over ten years in the adult population in regards to asleep nerve blocks. Long story short no difference in outcomes. The big trauma/ortho hosp (Harborview) does all of the blocks asleep in PACU/postop unless it is a case under regional/block aka hand. Besides don't tell me this doesn't happen in residency programs. When I trained we would give boluses of propofol because it could take time for new res to do a block.

 

[Ezekiel2517]

When I was applying for malpractice insurance there was a specific question about whether or not I routinely perform nerve blocks while a patient is under general anesthesia.

Not surprised. But if I recall correctly, there's actually quite a bit of data from nerve blocks done in the pedi and adult population. With ultrasound guidance, there was no higher incidence of complications when the block was done with the patient asleep. Obviously operator dependent tho

 

[caligas]

I interview the pt for 1min and block them the other minute.

Funny, but be careful. I testified once as an expert on behalf of an anesthesiologist (he received a defense verdict). One of the things the plaintiffs lawyers made an issue of was how long (a few minutes) he took to pre-op the patient. I think it's even trickier now since we pretty much know everything we need to know ahead of time with the electronic records. I do two things: I assure them that I have spent time reviewing their records and I ask to make sure they are satisfied that their questions and concerns are addressed. But all that said, yes pre ops can be done pretty quickly, and everyone on SDN can do a block in under a minute!

 

[GravelRider]

Not surprised. But if I recall correctly, there's actually quite a bit of data from nerve blocks done in the pedi and adult population. With ultrasound guidance, there was no higher incidence of complications when the block was done with the patient asleep. Obviously operator dependent tho

Malpractice risk and clinical outcome data don't always match.

 

[kmurp]

The key is having the nursing staff with all the equipment ready, drugs drawn up, skin prep ready to go, and the patient expecting the block. Versed helps significantly. The ISB, SCB, and adductor canal blocks take 1-2 minutes. Popliteal blocks and sciatic blocks are longer due to positioning. Epidurals take 5 minutes. However if the nurses are clueless or the system is not set up to have all equipment at the bedside and available, then it can drag on and on. Usually we do these in the preop holding area immediately after interviewing the patient. Some places do the blocks asleep under anesthesia and others do the blocks postop in the PACU. Depends on the system and local practices.

Agree but a question. Are the nurses drawing up just the sedatives or also the local? Also, for the sedative, how do you do the ordering? Do you have a Preop anesthesia order sheet that you fill out after the block with the amount of fentanyl/ versed actually given?

 

[anbuitachi]

Blocks are time consuming here..

It's done in between cases in the holding area. Everyone (surgeon, nurse, anes, etc) need to talk to the patient first before we can even start the block, and since it's academic, you know someone will be slowing you down. After that we have to find someone to do the block time out (very annoying since you either track your nurse down, or pull someone away from whatever they are doing to help you out). Then we give some midaz with patient on monitors. (finding monitors can be slow too). Next is the setup, single shots not much to set up. Block itself usually not difficult. Must be nice to have nurse setup for you...

But yea i imagine in many practices their style may be hard to defend in court, but again outcomes and malpractice is a bit different.