TheroleofRegionalAnesthesiainOutpatient ERAS
Transcript of TheroleofRegionalAnesthesiainOutpatient ERAS
A call for proficiencyThe role of Regional Anesthesia in Outpatient
ERAS
Katherine H. Dobie, M.D.Chief, Ambulatory Anesthesiology
Associate Professor of Clinical AnesthesiologyDepartment of Anesthesiology
Vanderbilt University School of Medicine
Current Ethos“Best experience I ever had!”
“Time to get back to work! Don’t forget your wellness prescription.”
“How can we do ALL of this, cheaper?”
“How can we improve and deliver consistent outcomes?”
“How can we deliver excellent patient experience?”
”How do we deliver anesthetics to ensure that the patient is ”back to life” the quickest, the safest?”
ERAS
Care Pathways
Perioperative Medicine
Enhanced RecoveryPerioperative Surgical Home
Decrease LOS
3
2
1
3
2
1
ASA Distribution(5 yr. comparison)
Courtesy Vanderbilt Anesthesiology &Perioperative Informatics Research (VAPIR)
Sg2 10 year forecast:16% growth in outpatient vol.3% decline in inpatient vol.
AQI Vand.
• 70 yom with distal radius fracture. He has mild-‐mod AS, 2 cardiac stents roughly a year ago, is anticoagulated, has COPD, uses O2 at night, and has an insulin pump.
• Can he come to your free standing surgery center (40 miles from hosp.) to get it fixed today? What if it was for a rotator cuff repair?
• “We cannot do this case here, because if the nerve block does not set up for a primary regional, we can’t do a general anesthetic on him this far from a cath. lab.” – said commonly at free standing ASCs.
• “Sure, we can do this ASA 3.5 here because we will achieve a primary regional anesthetic, (with a certainty similar to our ability to achieve GA on anyone,) with no need for a back up plan for GA” –said less commonly at free-‐standing ASCs.
“Achieving a new level of consistent proficiency with regional anesthesia will be critical to maximizing our value as perioperative physicians, as we innovate and lead our enhanced recovery future.”
At Vanderbilt ASCsAmbulatory Surgery Center Guidelines
Red Flags Yellow Flags Green Flags
BMI > 55 BMI > 50 Looks well BMI > 50 (moderate or major) BMI > 40 (major) No shortness of breath Severe aortic/mitral stenosis Moderate aortic/mitral stenosis or
other severe valvular disease Sees physician for DM, CAD, etc
Dialysis (moderate or major) or Cr > 4
Dialysis or renal insufficiency with Cr > 2
Compliance with medication
Known difficult intubation, awake FOI last time
Known difficult intubation Recent uneventful GA (< 3 years) with
Home O2 (major) Home O2 (moderate or minor) …same weight Active MRSA (skin lesions) AAA > 6cm …same glucose control Unstable angina Currently pregnant …same BP control New trache < 6 months Mastocytosis …no chest pain Malignant hyperthermia personal/family history
Radiation to neck with no subsequent intubation via DL
…no ER visits for chest pain
AICD Pacemaker DES off antiplatelets, any time Severe vascular or pulmonary
disease (e.g. s/p lobectomy)
CABG < 3 months (moderate or major), cardiac stent < 6 months, MI < 3 months
Significant electrolyte disorder (e.g. SIADH, Na<130, K<3, K>5.5)
Acute hepatitis Bleeding disorders History of cardiac arrest under anesthesia
CHF, EF < 30%, pulmonary hypertension, rapid a. fib
Thyroiditis Wound unrelated to surgery
Muscular dystrophy
3+ for moderate or major: OSA, tobacco, DM, BMI > 40, HTN, CAD, COPD
…or any procedure distal to mid-humerus
Into the ASCs…• Total joints• Complex ortho reconstructions with at-‐home CPNBs• BMI 55-‐60• Prone spinals for achilles repair (chloroprocaine)• Awake shoulders (for ASAs)• Anything distal to mid-‐humerus• Same for lower extremity? Sure, less common• Mastectomies (pecs, serratus blocks)
Hosp. Transfers
DOS cancelations Infections PACU time Complications
ASA 3, 4s Complex surgeries
Patient experience
Throughput, operational efficiency
Alongside innovation 1. RCT: LMA vs. ETT for outpatient sinus surgery. S Harvey, Dobie, Higgins, McQueen (manuscript in progress)2. PT: Perioperative Management of Patients with Implantable Cardioverter Defibrillators in Ambulatory Settings. Dobie, et al
(enrolling)3. RCT: Ultrasound-‐Guided Isolation and Blockade of the Upper Trunk For Shoulder Surgery – Time to replace the traditional
interscalene approach? Dobie, et al. (enrolling)4. RCT: Randomized controlled trial evaluating postoperative analgesia and muscle strength among multiple regional
anesthesia techniques for ambulatory ACL reconstruction. Sobey, Jaeger, Dobie (enrolling)5. RA: Quality and Medical Management in the Outpatient Surgical Home. Dobie, et al (analyzing data)6. RA: Effect of Transition to New Operating Environment on Perioperative Outcomes. Harvey, Dobie. (analyzing data)7. “Outpatient Surgical Home Model for the future: safety, efficiency, patient experience” – Dobie, Malcolm, Milstein (Stanford)8. RCT: Guanfacine for PONV and Pain After Sinus Surgery. Harvey, Dobie, Blair, Higgins. (enrolling)9. Utility of a Smartphone Application for Perioperative Communication in Outpatient Nasal & Sinus Surgery: A Pilot Study.
Chandra, Dobie, McEvoy, Wanderer, et al (IRB pending)10. Takeover of a private ASC practice by academic anesthesiologists: A Retrospective before and after study over two years.
Katherine Dobie, MD, Yaping Shi, MS, Matthew Shotwell, PhD, Warren Sandberg, MD, PhD – analysis complete, final stages of revision, sending to Anesthesiology this spring.
11. RCT: The effect of Pectoralis Block on Analgesia after Simple Mastectomy -‐ Shastri, et al (enrolling)12. FNB volume correlation to neurapraxia rates. Jaeger, Briggs, Katherine H. Dobie, M.D.13. Are sterile gloves necessary for peripheral nerve blocks? – a retrospective analysis. Katherine H. Dobie, M.D.14. Assessing the workflow and efficacy of patient-‐screening algorithm tool for ASCs – minimizing individual work and DOS
cancellations with one page. Katherine H. Dobie, M.D.
A call for proficiency
• Its not the block’s fault! • Time to move away from yesterday’s language• Rapid evolution in our specialty will demand our proficiency as well as innovation
• The days when it was acceptable to be an “ok” regionalist are numbered . . .
”the patient in room 4, her block did not set up…”