100% day surgery

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jorgenaaa

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Been out of residency 6 years. Done quite a broad mix including lots of ICU. I want to go 100% day surgery but am a bit concerned about losing some skills with the acute stuff. I will be doing a lot of day surgery for paediatric patients down to about 12kg. Anyone have experience with this? Or specifically was it difficult to go back to acute cases after doing mostly elective for years?
 
jorgenaaa said:
Been out of residency 6 years. Done quite a broad mix including lots of ICU. I want to go 100% day surgery but am a bit concerned about losing some skills with the acute stuff. I will be doing a lot of day surgery for paediatric patients down to about 12kg. Anyone have experience with this? Or specifically was it difficult to go back to acute cases after doing mostly elective for years?
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How about going 100% day surgery and never looking back? 😉

To answer your question: the loss of skill is real. I've seen it happen. It applies to anything in anesthesia, not just acute cases. E.g. I didn't do spinals/epidurals for about 5 years, and it took me months to become proficient again. For somebody who has only done sick patients and long cases for years, a surgicenter can feel almost as hellish as the thoracic room for the ambulatory guy. The "art of MAC" is a real concept.
 
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I think if you try to stay in practice with tubes and IVs at least you may be able to transition back to heavy cases

I do know that we hired a long time all ambulatory guy for our large hospital practice and had to be let go for doing things like EVAR with a single 22 g IV
 
jorgenaaa said:
Been out of residency 6 years. Done quite a broad mix including lots of ICU. I want to go 100% day surgery but am a bit concerned about losing some skills with the acute stuff. I will be doing a lot of day surgery for paediatric patients down to about 12kg. Anyone have experience with this? Or specifically was it difficult to go back to acute cases after doing mostly elective for years?
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With 6 years of OR/ICU I think you should be fine.

It's like riding a bicycle.

I question whether you would want to go back to the grind after a cush job.
 
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urge said:
With 6 years of OR/ICU I think you should be fine.

It's like riding a bicycle.

I question whether you would want to go back to the grid after a cush job.
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What you don't use, you lose. You can pick it up again-with effort. A lot easier before age 40 then it will be at 50+. One man's opinion.
 
I have no personal experience with this, but I've been told by those with it that after 10+ years of doing everything you can back off and tend to be able to pick those skills back up with a little effort. The trick is mastering the skills first. You don't want to back off right out of residency or shortly thereafter when you are still a relative novice.
 
T-burglar said:
....I do know that we hired a long time all ambulatory guy for our large hospital practice and had to be let go for doing things like EVAR with a single 22 g IV
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I'd go out on a limb and say that this sort of thing had less to do with his ASC time than his lack of wits. Doing ambulatory anesthesia doesn't make one dumb.
 
drmwvr said:
I'd go out on a limb and say that this sort of thing had less to do with his ASC time than his lack of wits. Doing ambulatory anesthesia doesn't make one dumb.
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exactly. if someone is doing an EVAR and don't know u should have some large bore IV's/CVC, they are probably also doing some questionable **** at the ASC
 
eikenhein said:
exactly. if someone is doing an EVAR and don't know u should have some large bore IV's/CVC, they are probably also doing some questionable **** at the ASC
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Define "large bore". Most of our EVARs are done MAC with an 18 ga IV, no a-line, no CVC.
 
jwk said:
Define "large bore". Most of our EVARs are done MAC with an 18 ga IV, no a-line, no CVC.
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situation matters. comorbidities matter. elective vs urgent/emergent? location? standard or complex branched or fenestrated repair?
usually MAC
we do double 18g's and an a-line at minimum.
ideally more.
CVC if can't obtain decent access.
a lot can go wrong during an EVAR. "minimally invasive" surgery shouldn't lull into false sense of security.
large academic hospital with plenty of residents and fellows in all fields
 
Psai said:
18g is a lot larger bore than a 22
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i wouldn't put a 22g in anyone other than a child, unless 1. elective surgery on healthy patient with essentially no risk of bleeding and 2. for induction purposes and plan for more access when pt anesthetized.
 
eikenhein said:
i wouldn't put a 22g in anyone other than a child, unless 1. elective surgery on healthy patient with essentially no risk of bleeding and 2. for induction purposes and plan for more access when pt anesthetized.
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+1

We use 22’s for eyeballs. Even bunions get 20’s. I would not EVAR with a 22.
 
jwk said:
Define "large bore". Most of our EVARs are done MAC with an 18 ga IV, no a-line, no CVC.
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interesting. I've seen an elective EVAR turn into an exsanguination and now I get two large bore IVs and an a-line. I would love for them to just put a venous sheath in the groin for me while they're there but it wouldn't be for anything but a complication and theyre always in such a hurry

Sorry derailing the original point of this thread
 
As to the thread de-rail...this is kind of important...putting in an A-line is at least as easy as putting in a reasonable piv. To each his own, but, really? Why wouldn't you do at least that? Coronary artery flow is completely interrupted at least two times. I put in a-lines for less all the time and I never regret them. There is a bypass circuit primed and in the room for pete's sake....I, for one, choose not to listen to the siren's song of the cardiologist singing "what could go wrong?" If he's so confident, send the perfusionist home...

And I don't choose my lines based on the hubris of the cardiologist...
 
drmwvr said:
And I don't choose my lines based on the hubris of the cardiologist...
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Did a TAVR today. bil upper extremity with AVFs. cardiologist offered to place a femoral micro puncture awake for use to use for pre induction a line.

He basically needle dissected this patient's groin before going to Ultrasound. Got it after many more pokes.
After the TAVR is over, the pt wouldn't stop bleeding from the access site, literally squirting blood every time they let off pressure.

Hubris of Cardiologists indeed. Their training is long, but it really only 1-2 years max of technical skills training... never gonna take them up on that offer again....
 
dchz said:
He basically needle dissected this patient's groin before going to Ultrasound. Got it after many more pokes.
After the TAVR is over, the pt wouldn't stop bleeding from the access site, literally squirting blood every time they let off pressure.
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Arterial access is what cardiologists do...those micropuncture kits are pretty useful for patients with atherosclerotic/valvular dz. They're small gauge, long bevelled, very sharp needles that are designed for slicing through those crustaceal plaques that develop in these patients. What kills me is, as you identify, the reluctance to use u/s from the get go. We know it's going to be difficult...that's why the patient is there in the first place. Yet they insist on frogging around for several passes in a futile, blind effort in accessing these vessels when it would have been a one pass effort from the get go...makes me want to take a long drag from an isoflurane bottle....
 
drmwvr said:
Arterial access is what cardiologists do...those micropuncture kits are pretty useful for patients with atherosclerotic/valvular dz. They're small gauge, long bevelled, very sharp needles that are designed for slicing through those crustaceal plaques that develop in these patients. What kills me is, as you identify, the reluctance to use u/s from the get go. We know it's going to be difficult...that's why the patient is there in the first place. Yet they insist on frogging around for several passes in a futile, blind effort in accessing these vessels when it would have been a one pass effort from the get go...makes me want to take a long drag from an isoflurane bottle....
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not to be a smartass, but sevo would be faster.... 😉
 
T-burglar said:
interesting. I've seen an elective EVAR turn into an exsanguination and now I get two large bore IVs and an a-line. I would love for them to just put a venous sheath in the groin for me while they're there but it wouldn't be for anything but a complication and theyre always in such a hurry

Sorry derailing the original point of this thread
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i mean to be fair, a lot of cases can become exanguinations. a lap case can be too if you punch thru the aorta with your trocar. we do most of them MAC with 1 IV and A line. it's pretty dependent on surgeon
 
eikenhein said:
i wouldn't put a 22g in anyone other than a child, unless 1. elective surgery on healthy patient with essentially no risk of bleeding and 2. for induction purposes and plan for more access when pt anesthetized.
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Too dogmatic.
 
anbuitachi said:
i mean to be fair, a lot of cases can become exanguinations. a lap case can be too if you punch thru the aorta with your trocar. we do most of them MAC with 1 IV and A line. it's pretty dependent on surgeon
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OK.....but we're "punching" through diseased proximal arteries on purpose...every single time...so there's equivalency here? Don't know what the deal is there, but we have to have a primed bypass pump in the room. Never done that with a lap chole.
 
drmwvr said:
OK.....but we're "punching" through diseased proximal arteries on purpose...every single time...so there's equivalency here? Don't know what the deal is there, but we have to have a primed bypass pump in the room. Never done that with a lap chole.
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drmwvr said:
It has become fashionable of late to disparage "dogma", but as inelegant as it may be, in some settings, adhering to "dogma" will rarely result in regret.
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Not sure how bad your EVARs/vascular surgeons are, but I've never had perfusion involved with one.

And I disagree about dogma not resulting in regret. Half the **** that happens in medicine and is not backed by evidence is pure dogma. More and more studies show how harmful that thinking is. I.e. large tidal volume ventilation, or CVP management of fluids or many other "dogmas"
 
Ronin786 said:
Not sure how bad your EVARs/vascular surgeons are, but I've never had perfusion involved with one.

And I disagree about dogma not resulting in regret. Half the **** that happens in medicine and is not backed by evidence is pure dogma. More and more studies show how harmful that thinking is. I.e. large tidal volume ventilation, or CVP management of fluids or many other "dogmas"
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Medicine should be evidence based, but we all know that is fairly rare. Very little of what we do have been studied well with RCT etc. So we rely on expert opinion, physiological understanding in the management of our patients. Sometimes these understandings are so heavily ingrained in our teaching = dogma. I agree we should always have a bit of healthy skeptacism on such issues that are not proven with such incredibly high standards. unless you have something that proves thr dogma wrong, we are still using the best available knowledge
 
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eikenhein said:
And are we really having an argument about why 22g isn't appropriate for evar? There isn't dogma here. Pt crashes, you need big iv to give pt fluid and blood and pressors.
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Large bore access is definitely needed will only save you in the event of a partially contained rupture. I had a case with an emergent TEVAR that turned into a free rupture. Patient was asystolic within 10 seconds...
 
anbuitachi said:
i mean to be fair, a lot of cases can become exanguinations. a lap case can be too if you punch thru the aorta with your trocar. we do most of them MAC with 1 IV and A line. it's pretty dependent on surgeon
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I don’t know how fair that is. Sure a terrible surgeon could lacerate the aorta or Iliacs on any abdominal case. But we’re talking about a direct operation on an aorta that is really diseased.

As someone else said , a rupture will mean death unless the surgeons can endoballoon above it. But there can be injuries that cause brisk bleeding without instant exsanguination so it’s a good idea to have access and monitoring suitable for volume resuscitation
 
my fave story from residency was a TEVAR where the surgeons had a cap break on their sheath. Free flow from the iliacs through large bore access. Stuck their finger in the dike ASAP, but lots of blood loss while they rewired and replaced the sheath. Lost about 1500 cc blood in a very short time span before they got it under control. just a dumb equipment failure, but could have been bad news if the patient was sicker or the surgeon was all thumbs.
 
dannyboy1 said:
Large bore access is definitely needed will only save you in the event of a partially contained rupture. I had a case with an emergent TEVAR that turned into a free rupture. Patient was asystolic within 10 seconds...
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we can't even get the nurse to bring the blood into the room within a minute, then have to CHECK the blood with the nurse which takes what feels like a billion years.

obviously not saying to do the case with just a 22G IV. But to put IV access in perspective.. depending on your IV sets, a 22G can run at about 35ml/min, and a 18 about 110ml/min. Difference of about 70ml/min. If you can pop in a larger IV in 1 minute, that's a difference of 70 mL of fluid in that minute.
 
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Ronin786 said:
Not sure how bad your EVARs/vascular surgeons are, but I've never had perfusion involved with one.
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How bad they are? Less to do with the proceduralists than the patients. We have 7 perfusionists available system wide so having one around isn't a big deal.
 
EVARs always run an amusing spectrum. Once place I worked we did them all under spinal with an A-line and typically an 18g or 16g. Another place I worked we did them almost like a cardiac case with general, a central line, an A-line, and a peripheral. Where I am now is a more reasonable in between where it's general with an A-line and then dealer's choice of good peripherals vs. central.
 
DM27 said:
EVARs always run an amusing spectrum. Once place I worked we did them all under spinal with an A-line and typically an 18g or 16g. Another place I worked we did them almost like a cardiac case with general, a central line, an A-line, and a peripheral. Where I am now is a more reasonable in between where it's general with an A-line and then dealer's choice of good peripherals vs. central.
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arent there studies showing regional > general for EVARs?
 
I think its not well established, but when the data is massaged enough they are able to find something. I will say from my experience the regional ones look a hell of a lot better and we rarely ever converted. However, I will also say that I didn't find the general ones (when done considerately) to look at that bad either.
 
DM27 said:
I think its not well established, but when the data is massaged enough they are able to find something. I will say from my experience the regional ones look a hell of a lot better and we rarely ever converted. However, I will also say that I didn't find the general ones (when done considerately) to look at that bad either.
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No reason to think that the choice of anesthetic should affect the outcome (yes, if they have bad heart/lungs should avoid GA) if the EVAR is uneventful should be a quick extubation and recovery, if **** hits the fan during the EVAR it wasn’t because of your choice of anesthetic...
 
eikenhein said:
Perhaps, but I feel if u want to get by with less there should be a pretty damn compelling reason. Medicine is full of dogma.
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So if you have a non healthy patient for endoscopy, colonoscopy or carpal tunnel or whatever you won't do the case with only a 22?
 
Arch Guillotti said:
So if you have a non healthy patient for endoscopy, colonoscopy or carpal tunnel or whatever you won't do the case with only a 22?
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depends on what you mean by "sick old guy"
you're meaning to tell me you would be ok with a 22g for a pt with significant cardiopul dz even for a low risk procedure, even though you could reasonably place a larger IV? sick old guys wiggling about but w profound hypotension under minimal sedation for a colonoscopy because their bowel prep dried them...
 
eikenhein said:
depends on what you mean by "sick old guy"
you're meaning to tell me you would be ok with a 22g for a pt with significant cardiopul dz even for a low risk procedure, even though you could reasonably place a larger IV?
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:smack::smack::smack:

If a bigger IV can be had, great. If not, do the case anyway.

Sometimes you have to take what you can get.
 
eikenhein said:
And are we really having an argument about why 22g isn't appropriate for evar? There isn't dogma here. Pt crashes, you need big iv to give pt fluid and blood and pressors.
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Not sure where we got on the 22ga for an EVAR topic. Nobody in this thread said they did.

I think a lot of your arguments point out the differences between academia and private practice. No med students, no residents, no fellows. We do a ton of vascular, but don't do hearts, so we don't have bypass capability. We don't do a lot of unnecessary procedures routinely (e.g. CVC for every EVAR). We do those for indications - simply doing an EVAR is not, in and of itself, an indication for CVC or a-line at our shop.

You can argue that every case should have a 16ga - which in fact was the requirement when I was in anesthesia training nearly 40 years ago. We had to have an attending's approval for anything smaller, with the exception of cataracts, where an 18ga was OK.
 
jwk said:
Not sure where we got on the 22ga for an EVAR topic. Nobody in this thread said they did.

I think a lot of your arguments point out the differences between academia and private practice. No med students, no residents, no fellows. We do a ton of vascular, but don't do hearts, so we don't have bypass capability. We don't do a lot of unnecessary procedures routinely (e.g. CVC for every EVAR). We do those for indications - simply doing an EVAR is not, in and of itself, an indication for CVC or a-line at our shop.

You can argue that every case should have a 16ga - which in fact was the requirement when I was in anesthesia training nearly 40 years ago. We had to have an attending's approval for anything smaller, with the exception of cataracts, where an 18ga was OK.
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PP or not, I hope you are not defending the lack of large bore IVs or A-lines in a major vascular case. I don't care how endovascular the procedure is; if the site is not compressible, one should prepare for the worst.

The in-hospital mortality for unruptured EVARs is around 1%, so I get the part about not putting in a 11F central line in every pacient. But A-lines and large bore IVs? That's just laziness.
 
DM27 said:
I think its not well established, but when the data is massaged enough they are able to find something. I will say from my experience the regional ones look a hell of a lot better and we rarely ever converted. However, I will also say that I didn't find the general ones (when done considerately) to look at that bad either.
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The regional ones definitely "look better", its a very slick and impressive looking procedure to replace an aortic valve or repair a AAA with light or no sedation. Its most noticable in the elderly frail high risk patients. TAVR and EVAR have gotten so "safe" that its hard to argue against sedation when feasible for the patient. Complications are just so rare.

Converting to GETA in the midst of severe acute AR that is arresting or exsanguination really sucks though. I try to avoid it actually for as long as i can because it takes so much focus, and instead just focus on supporting the airway through the brainstem ischemia (respiratory arrythmia) phase with an assistant . Slapping on a mask with a strap to hold it tight and have someone else tilt the head back, i put some CPAP on too with the circuit. If they're doing even some negative pressure breathing then i let it go cause its better than converting to PPV.

That leaves me to transfuse/give epi until we can get proximal control or emergently deploy. If the patient needs to be paralyzed because its an annular rupture and they need a sternotomy then of course I'll intubate them. At that point paralysis is more important than anything else.

Anyway the point is its less stressful to have them all under GETA but I don't think you can justify it in the face of the reported complication rates at high volume centers. Sometimes the surgeon wants them all under general anyway for whatever reason and I don't mind.
 
This is an amusing discussion from the other side of the curtain...

Not responding to anyone specifically, but a few things... (which clearly people know, but need to be said)

Not all EVARs are the same in terms of risk of complications. A completely on label, by the book (IFU) EVAR with good access vessels in experienced hands carries an extremely low risk of major hemorrhage. But, they happen and while I can get a CODA up in the aorta in less than 15 seconds, as others have said, that is a ton of bleeding that can happen. On the other hand, at our institution, something like 60% of EVARs are performed outside of the IFU because simply put, there aren't devices made that cover the majority of aneurysms out there. Maybe some practices are different, but somewhat doubtful that there are many.

Beyond that, one thing that has repeatedly come up is the lack of appreciation for how diseased the blood vessels are. When I push a device through a blood vessel, I am constantly imagining/considering how that device is interfacing with the vessel wall. That is years of mapping flouro imaging/ultrasound imaging to vessel in my hand and appreciating what diseased vessels look like in person vs. on the screen. You have a profound respect for aneurysmal tissue and diseased vessels after you have dozens of them shred while reconstructing them with prolene. Obvious bias as a vascular surgeon, but for people with minimal technical training (<2y) and virtually zero open vascular exposure (feeling the vessel in their hands), I am terrified of them jamming 20Fr devices into things. I've dealt with iliac artery on the end of a stick 3 times so far. When you go back and review the fluoro feeds from the case, it isn't exactly surprising that it happens...

Long story short, I understand the inclination to do less monitoring/have less access, but I don't think it is reasonable to not have two large bore IVs and an A-line. Can you get away with it in a practice where you only do chip-shot EVARs, sure. But, you are committing to someone dieing eventually from the inability to detect and then resuscitate quick enough.
 
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