TheroleofRegionalAnesthesiainOutpatient ERAS

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A call for proficiency The role of Regional Anesthesia in Outpatient ERAS Katherine H. Dobie, M.D. Chief, Ambulatory Anesthesiology Associate Professor of Clinical Anesthesiology Department of Anesthesiology Vanderbilt University School of Medicine

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.

We  will  lead

We  will  innovate

…  but  we  also  need  to  maximize  the  value  of  our  current  skillset

Fixed  outcomes”not  sure,  because  if  the  block  does  not  set  up,  then….”

• 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…”