Cosmetic Surgery Leaves Thornton Teen Brain Damaged

[narcotics999]

Does anyone else get, like, daily dues statements from the AMA?

They must just shower the world with the dues statements and from time to time someone just pays it without thinking, probably by office staff.

1-2 times per month. AMA is desperate.

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[pgg]

That's clever, I am stealing that idea

When I was about 15 I worked in a library. Lame job endlessly shelving books but I didn't smell like fried chicken at the end of the day. Fun tasks like "reading" shelves which meant staring at the books to ensure they were in order ... people always put stuff back in the wrong spot and then the book was essentially lost.

Anyway, one day some old guy came in and asked if he could have all the postage-paid subscription cards from the back issues of Time or Newsweek or one of those news magazines. Plus a few other magazines he said were from the same publisher. He quite rationally explained that they supported "cop killers" because of some article they'd run, and he wanted to send them fan mail on their postcards. My boss said OK, have at it, don't damage the magazines.

He sat there for hours with a felt pen scrawling 3 or 4 word insults on the cards. He must have dropped at least 100 in the mail. Just a dedicated man with time on his hands and an ax to grind.

I have, once or twice, wondered if JAMA has those cards in it, and how many years of back issues there might be in the stacks of our medical library. But I'm not old and demented yet, perhaps one day ...

 

[zevilempire]

Most likely airway/respiratory. It’s always that. Probably “sedation” and CRNA left the room and patient obstructed. That being said it never hurts to give a young patient some glyco before incision .....

What exactly are you treating with the glyco prior to incision?

 

[NoodleIncident]

What exactly are you treating with the glyco prior to incision?

Yes, I don’t understand this either. You’d expect a sympathetic response with increased HR and BP, hence the volatile, narcotic, etc given in anticipation to blunt this. Are you expecting a vagal response to incision?

 

[Hoya11]

- CRNA gets called back into the room, dick in his hand and jaw agape like a deer in the headlights as if he never saw this coming despite having had the exact same thing happen to him previously under the same circumstances
- ROSC is achieved, but patient codes again several minutes later
- Again ROSC is achieved, patient is sent to PACU "I'm sure she'll wake up eventually and be fine, lets just watch her for 5 hours and see what happens"

Any ASC code is an immediate cancellation and hospital transfer - obviously.

However, once the brain ischemia occurred. I doubt that even if they transferred her right away to the hospital that the outcome would have been different. Doubtful that any cooling protocol would have made a significant difference in this situation.

This is strange, because typically (as someone who admittedly has gotten plastic surgery), the patient pays for the anesthesia and certainly one can ask for an anesthesiologist - they tried this switch and bait on me. I specifically asked for an anesthesiologist, was told yep. then on day of procedure the anesthesiologist comes and tells me "Ms so and so will be at the procedure." I was like ummm no. I specifically said and demand and anesthesiologist. He tells me - is there something I can tell you to change your mind? I was thinking - while he doesn't know I am a physician, I won't feel bad when so many of you are out of work as you are doing this to yourselves. I obviously said no - anesthesiologist or I go home. They surely got me an anesthesiologist within about 10 minutes.
So it's not to save money. The plastic surgeon does not eat the costs - the patient pays. Typically a lot of these procedures are an hour to a few hours long- so it typically increases the bill a few thousand which the patient pays.

The financial arrangement sometimes is different than what you are describing. Its all self-pay patients keep in mind so no insurance involved.

Sometimes the arrangement is a flat cash fee regardless of the time it takes to do the procedure. This flat fee is sometimes lumped into the larger fee including the surgeons cost/facility fee - so the patient may show up with one check covering everything that is then to be split later according to the agreement. Sometimes you get a separate check for anesthesia services specifically.

The charges are negotiated ahead of time and are usually the same for all patients having that procedure since time is not an issue. This negotiation is between the anesthesia group and the surgeon and is based on the actual cost of the providers of anesthesia. If they knew you were going to demand the higher price provider, they would have charged you more. But since you already paid, and paid the CRNA rate, and then demanded the anesthesiologist - there is money lost on the anesthesia group end and this is a violation of the agreement with the surgeon - and maybe the anesthesia group demands more of a split of the money which does indeed reduce the surgeons bottom line.

If it happens once in a while, no big deal - which is probably what happened in your case. But what also probably happened in your case is that the other anesthesiologist started your case and was given a break by CRNAs for god knows how long while you had no idea. So essentially they just placated your request. Personally I do not have a problem with receiving anesthesia under a good ACT model.

 

[Hoya11]

What exactly are you treating with the glyco prior to incision?

While I don't give glyco in this manner, I think the idea is to dry out your airway prior to a long case without a protected airway in a patient with possible airway reactivity and the ability to tolerate the increased SNS activity from the glyco

 

[coffeebythelake]

Any ASC code is an immediate cancellation and hospital transfer - obviously.

However, once the brain ischemia occurred. I doubt that even if they transferred her right away to the hospital that the outcome would have been different. Doubtful that any cooling protocol would have made a significant difference in this situation.

The literature doesnt show difference between 33 and 36 degrees celsius. But hyperthermia, as can happen after cardiac arrest, can be extremely detrimental.

 

[Piebaldi]

Any ASC code is an immediate cancellation and hospital transfer - obviously.

However, once the brain ischemia occurred. I doubt that even if they transferred her right away to the hospital that the outcome would have been different. Doubtful that any cooling protocol would have made a significant difference in this situation.



The financial arrangement sometimes is different than what you are describing. Its all self-pay patients keep in mind so no insurance involved.

Sometimes the arrangement is a flat cash fee regardless of the time it takes to do the procedure. This flat fee is sometimes lumped into the larger fee including the surgeons cost/facility fee - so the patient may show up with one check covering everything that is then to be split later according to the agreement. Sometimes you get a separate check for anesthesia services specifically.

The charges are negotiated ahead of time and are usually the same for all patients having that procedure since time is not an issue. This negotiation is between the anesthesia group and the surgeon and is based on the actual cost of the providers of anesthesia. If they knew you were going to demand the higher price provider, they would have charged you more. But since you already paid, and paid the CRNA rate, and then demanded the anesthesiologist - there is money lost on the anesthesia group end and this is a violation of the agreement with the surgeon - and maybe the anesthesia group demands more of a split of the money which does indeed reduce the surgeons bottom line.

If it happens once in a while, no big deal - which is probably what happened in your case. But what also probably happened in your case is that the other anesthesiologist started your case and was given a break by CRNAs for god knows how long while you had no idea. So essentially they just placated your request. Personally I do not have a problem with receiving anesthesia under a good ACT model.

I believe you are incorrect on this. Again as someone who did indeed have cosmetic surgery I can assure you that I am well versed in how it works. Obviously it's all cash based - it's cosmetic surgery. And you are incorrect - there is a flat fee paid for the anesthesia, and I can assure you that no switcharoo was done. There is no "arrangement" between the surgeon and the anesthesia peeps - there is a separate fee paid for anesthesia, and all of it is paid PRIOR to the procedure. When a patient demands an anesthesiologist that's what is provided. And there is an estimation of the anesthesia cost given the likely length of the procedure. If the procedure runs longer, it is what it is - the patient doesn't pay more, and the anesthesia service essentially eats it. There is a flat fee also paid for the OR which again if the procedure runs longer than the estimation of the surgery it is what it is. Obviosuly cosmetic surgery is a tightly run ship so the procedures tend to run on time. Again all of this is paid before hand not a bill as with other procedures tht is provided after the procedure is done. There is an already established flat fee for the anesthesia and OR costs. Given that except for the more involved procedures there is a short period of time, it tends to be a non issue.
There isn't a "CRNA rate" - there is an "Anesthesiology rate" again which is a flat rare that is estimated - and typically what tends to happen is that these procedures not infrequently are for less time than estimated -r eason why sometimes the results are meh. Rarely do they go over time given that the payment is ahead of time and there is a certain amount paid for anesthesia/OR so obviously they dont want to r un over.

What you describe above is incorrect.

 

[emergentmd]

I am just shocked that surgeons would allow an NP to do anesthesia. When was the last time a plastic surgeon intubated someone or run a code? How is this even legal?

In the ER, we have to jump through bunch of hoops just to push ketamine even though the Er docs have intubated hundreds and have anesthesia backup minutes away.

 

[woopedazz]

While I don't give glyco in this manner, I think the idea is to dry out your airway prior to a long case without a protected airway in a patient with possible airway reactivity and the ability to tolerate the increased SNS activity from the glyco

Nah it's to prevent a bradycardic arrest from vagal stimulation. They're using it as a vagolytic. I've occasionally done similar with surgical terminations as they can have massive vagal output in response to cervical dilatation, but to do it routinely in other cases is foreign to me.

 

[9blade]

I am just shocked that surgeons would allow an NP to do anesthesia. When was the last time a plastic surgeon intubated someone or run a code? How is this even legal?

In the ER, we have to jump through bunch of hoops just to push ketamine even though the Er docs have intubated hundreds and have anesthesia backup minutes away.

If I'm not mistaken, I believe oral surgeons can run their own anesthesia as well.

 

[nimbus]

I am just shocked that surgeons would allow an NP to do anesthesia. When was the last time a plastic surgeon intubated someone or run a code? How is this even legal?

In the ER, we have to jump through bunch of hoops just to push ketamine even though the Er docs have intubated hundreds and have anesthesia backup minutes away.

Plastic surgeons offices are the Wild West of medicine. Literally anything goes.

 

[nimbus]

Any ASC code is an immediate cancellation and hospital transfer - obviously.

However, once the brain ischemia occurred. I doubt that even if they transferred her right away to the hospital that the outcome would have been different. Doubtful that any cooling protocol would have made a significant difference in this situation.



The financial arrangement sometimes is different than what you are describing. Its all self-pay patients keep in mind so no insurance involved.

Sometimes the arrangement is a flat cash fee regardless of the time it takes to do the procedure. This flat fee is sometimes lumped into the larger fee including the surgeons cost/facility fee - so the patient may show up with one check covering everything that is then to be split later according to the agreement. Sometimes you get a separate check for anesthesia services specifically.

The charges are negotiated ahead of time and are usually the same for all patients having that procedure since time is not an issue. This negotiation is between the anesthesia group and the surgeon and is based on the actual cost of the providers of anesthesia. If they knew you were going to demand the higher price provider, they would have charged you more. But since you already paid, and paid the CRNA rate, and then demanded the anesthesiologist - there is money lost on the anesthesia group end and this is a violation of the agreement with the surgeon - and maybe the anesthesia group demands more of a split of the money which does indeed reduce the surgeons bottom line.

If it happens once in a while, no big deal - which is probably what happened in your case. But what also probably happened in your case is that the other anesthesiologist started your case and was given a break by CRNAs for god knows how long while you had no idea. So essentially they just placated your request. Personally I do not have a problem with receiving anesthesia under a good ACT model.

That patient was left unattended for 15 min. She may have been dead for 1min or for 15min. Nobody knows. The thing to do in that scenario is to go full court press.

 

[Hoya11]

I believe you are incorrect on this. Again as someone who did indeed have cosmetic surgery I can assure you that I am well versed in how it works. Obviously it's all cash based - it's cosmetic surgery. And you are incorrect - there is a flat fee paid for the anesthesia, and I can assure you that no switcharoo was done. There is no "arrangement" between the surgeon and the anesthesia peeps - there is a separate fee paid for anesthesia, and all of it is paid PRIOR to the procedure. When a patient demands an anesthesiologist that's what is provided. And there is an estimation of the anesthesia cost given the likely length of the procedure. If the procedure runs longer, it is what it is - the patient doesn't pay more, and the anesthesia service essentially eats it. There is a flat fee also paid for the OR which again if the procedure runs longer than the estimation of the surgery it is what it is. Obviosuly cosmetic surgery is a tightly run ship so the procedures tend to run on time. Again all of this is paid before hand not a bill as with other procedures tht is provided after the procedure is done. There is an already established flat fee for the anesthesia and OR costs. Given that except for the more involved procedures there is a short period of time, it tends to be a non issue.
There isn't a "CRNA rate" - there is an "Anesthesiology rate" again which is a flat rare that is estimated - and typically what tends to happen is that these procedures not infrequently are for less time than estimated -r eason why sometimes the results are meh. Rarely do they go over time given that the payment is ahead of time and there is a certain amount paid for anesthesia/OR so obviously they dont want to r un over.

What you describe above is incorrect.

while it may not be the case in this particular case - what I described is exactly how our group does it, and I have personally negotiated these deals, and if i knew i was going to be providing an anesthesiologist vs a CRNA i would have negotiated a higher number, but thx so much for your input

 

[dpmd]

while it may not be the case in this particular case - what I described is exactly how our group does it, and I have personally negotiated these deals, and if i knew i was going to be providing an anesthesiologist vs a CRNA i would have negotiated a higher number, but thx so much for your input

Kinda funny when people assume the one way they experienced is the only way things are done.

 

[PieOHmy]

I am just shocked that surgeons would allow an NP to do anesthesia. When was the last time a plastic surgeon intubated someone or run a code? How is this even legal?

In the ER, we have to jump through bunch of hoops just to push ketamine even though the Er docs have intubated hundreds and have anesthesia backup minutes away.

It is legal because the ASA in it's infinite wisdom caved in and let the verbage in medicare conditions of participation say CRNAS can be supervised by ANY physician.
Obviously, in non-opt out states in hospitals this would NEVER happen(surgeons supervising crnas) but in plastic surgery offices where every dollar counts.. Sure they'll do it. And this kinda **** happens. Im shocked that plastic surgeons would even remotely expose themselves and their practices like that but .... who i am to figure out what people do for money.. And also it may be an access problem too.. They cant find an anesthesiologist to do this kinda work.

 

[dpmd]

It is legal because the ASA in it's infinite wisdom caved in and let the verbage in medicare conditions of participation say CRNAS can be supervised by ANY physician.
Obviously, in non-opt out states in hospitals this would NEVER happen(surgeons supervising crnas) but in plastic surgery offices where every dollar counts.. Sure they'll do it. And this kinda **** happens. Im shocked that plastic surgeons would even remotely expose themselves and their practices like that but .... who i am to figure out what people do for money.. And also it may be an access problem too.. They cant find an anesthesiologist to do this kinda work.

Or they can't afford one without cutting in to their bottom line too much or pricing themselves out of the market.

 

[Noyac]

while it may not be the case in this particular case - what I described is exactly how our group does it, and I have personally negotiated these deals, and if i knew i was going to be providing an anesthesiologist vs a CRNA i would have negotiated a higher number, but thx so much for your input

I am gonna have to take Hoya’s side on this. thats the way it was arranged in my prior gig.

 

[nimbus]

It is legal because the ASA in it's infinite wisdom caved in and let the verbage in medicare conditions of participation say CRNAS can be supervised by ANY physician.
Obviously, in non-opt out states in hospitals this would NEVER happen(surgeons supervising crnas) but in plastic surgery offices where every dollar counts.. Sure they'll do it. And this kinda **** happens. Im shocked that plastic surgeons would even remotely expose themselves and their practices like that but .... who i am to figure out what people do for money.. And also it may be an access problem too.. They cant find an anesthesiologist to do this kinda work.

I thought opt out only regulates medicare reimbursement. It doesn’t have any effect on cash pay plastics.

 

[deleted162650]

I thought opt out only regulates medicare reimbursement. It doesn’t have any effect on cash pay plastics.

You’re correct. People talk about “opt-out” all the time despite not having a clue what it actually means.

 

[caligas]

You’re correct. People talk about “opt-out” all the time despite not having a clue what it actually means.

17 Medicare opt out states. So what’s this $hit?

27 states where CRNAs can practice independently

27 states where CRNAs can practice independently

www.beckersasc.com

Nursing boards just declare it but it doesn’t mean anything?

 

[PieOHmy]

I thought opt out only regulates medicare reimbursement. It doesn’t have any effect on cash pay plastics.

If the plastic surgery office takes ANY medicare than it would affect that office/surgery center. If they take zero percent medicare then they can supervise anyone do anesthesia except in NJ where I think CRNAS cannot work unsupervised anywhere and must be supervised by an anesthesiologist.

 

[deleted126335]

17 Medicare opt out states. So what’s this $hit?

27 states where CRNAs can practice independently

27 states where CRNAs can practice independently

www.beckersasc.com

Nursing boards just declare it but it doesn’t mean anything?

State law is a MINIMUM standard. Institutional or employer policy can mandate a higher standard.

 

[nofliesonme]

california plastic surgeon here, fyi, in my area, the difference in cost for CRNA's and MD anesthesologist is insignificant..there are some CRNA's that charge more than MD's.

 

[BLADEMDA]

As long as there is greed people will seek to make the most amount of money possible even if it means cutting corners. For every ethical plastic surgeon there will be another one more than willing to hire the next Meeker CRNA to do his/her cases.

The hubris of some plastic surgeons exceeds almost everyone in medicine except for Perhaps Neurosurgeons. These people think that the next death from a boob job won’t happen to them. So, this death likely changes nothing in terms of CRNAs doing anesthesia solo for plastic surgeons

 

[deleted126335]

And I think that is exactly why the surgeons must be held responsible when they hire CRNAs "under their supervision". They ****ing agreed to supervise them. They ****ing think they know safe anesthesia.

And that is exactly why some surgeons support totally independent CRNA practice. So they don’t have to “supervise” and own any responsibility for what CRNAs do.


Sent from my iPhone using SDN mobile

 

[PieOHmy]

IN the O.R. Anesthesiologists dont have any allies.

 

[chocomorsel]

california plastic surgeon here, fyi, in my area, the difference in cost for CRNA's and MD anesthesologist is insignificant..there are some CRNA's that charge more than MD's.

Who do you use?
FYI, locums groups keep wanting to pay docs $200 an hour while paying CRNAs 130 to 150. I told recruiter yesterday, No Thank you.
Really? Can’t wait to start my full time job.

 

[chocomorsel]

As long as there is greed people will seek to make the most amount of money possible even if it means cutting corners. For every ethical plastic surgeon there will be another one more than willing to hire the next Meeker CRNA to do his/her cases.

The hubris of some plastic surgeons exceeds almost everyone in medicine except for Perhaps Neurosurgeons. These people think that the next death from a boob job won’t happen to them. So, this death likely changes nothing in terms of CRNAs doing anesthesia solo for plastic surgeons

Neurosurgeons are the worst. Working in Vegas, with Neurosurgeons, was the real Wild Wild West. And that was in the ORs!!!!

 

[chocomorsel]

IN the O.R. Anesthesiologists dont have any allies.

Depends on the OR. My experience in the OR out west was very favorable from all the staff. Not necessarily the surgeons though.

 

[nofliesonme]

Who do you use?
FYI, locums groups keep wanting to pay docs $200 an hour while paying CRNAs 130 to 150. I told recruiter yesterday, No Thank you.
Really? Can’t wait to start my full time job.

I like to find one anesthesiologist to work with and use them all the time. I get feelers from CRNA's the last one was 100$ an hour more than what i pay my anesthesiologist. I pay more than the locums group above. I can find anesthesiologists for 300$/hour....longer cases less.
BTW, I regard anesthesiologists as among the best and most talented physicians...and have a great deal of gratitude for their ability to make mel look good.
Regarding the case in this heading, I would be surprised if this was an equipment issue. All board certified plastic surgeons have pledged, as part of their board designation, to operate only in facilities that are certified (in plastic surgery most common one is Quad A). The case in question takes about 45 minutes from incision to sutures. I use 50cc lidocaine 1% in 250cc NS, and 50cc .025 marcaine with epi in 100cc NS. This allows a "light" anesthesia. I don't usually care whether its IV sedation, ET, or LMA as long as the patient wakes up........while dressing is going on. One of the few rules i have is, no toradol. If there's an interest i'd be happy to offer some suggestions how anesthesiologists and plastic surgeons can work together for the benefit of the patient.

 

[WholeLottaGame7]

I like to find one anesthesiologist to work with and use them all the time. I get feelers from CRNA's the last one was 100$ an hour more than what i pay my anesthesiologist. I pay more than the locums group above. I can find anesthesiologists for 300$/hour....longer cases less.
BTW, I regard anesthesiologists as among the best and most talented physicians...and have a great deal of gratitude for their ability to make mel look good.
Regarding the case in this heading, I would be surprised if this was an equipment issue. All board certified plastic surgeons have pledged, as part of their board designation, to operate only in facilities that are certified (in plastic surgery most common one is Quad A). The case in question takes about 45 minutes from incision to sutures. I use 50cc lidocaine 1% in 250cc NS, and 50cc .025 marcaine with epi in 100cc NS. This allows a "light" anesthesia. I don't usually care whether its IV sedation, ET, or LMA as long as the patient wakes up........while dressing is going on. One of the few rules i have is, no toradol. If there's an interest i'd be happy to offer some suggestions how anesthesiologists and plastic surgeons can work together for the benefit of the patient.

How much of that local are you injecting?

 

[nofliesonme]

How much of that local are you injecting?

i inject half of the lidocaine and about 1/4 of the marcaine on the right side before draping.....then I scrub while draping occurs....i inject similar amounts on left side....after i am gowned....then i do right side surgery, then left....i'll inject some of the remainder of the marcaine at the end of the case....epi effect needs 12-20 minutes to maximize....doing the injections sequentially allows the anesthesiologist to see if there is a problematic effect...in 30 years of practice these levels have not caused toxicity......i almost always inject before the drape and often before the prep/

 

[WholeLottaGame7]

 

[narcotics999]

i inject half of the lidocaine and about 1/4 of the marcaine on the right side before draping.....then I scrub while draping occurs....i inject similar amounts on left side....after i am gowned....then i do right side surgery, then left....i'll inject some of the remainder of the marcaine at the end of the case....epi effect needs 12-20 minutes to maximize....doing the injections sequentially allows the anesthesiologist to see if there is a problematic effect...in 30 years of practice these levels have not caused toxicity......i almost always inject before the drape and often before the prep/

This is 500mg lido and 175mg bupi in 45mins. If the pt is around 50kg ( the girl in the case ), it is very high. Our recommendation is 7mg/kg lido or 3mg/kg bupi max. I believe there is still safety of margin but more than the double dose I will be concerned.


Sent from my iPhone using Tapatalk

 

[WholeLottaGame7]

This is 500mg lido and 175mg bupi in 45mins. If the pt is around 50kg ( the girl in the case ), it is very high. Our recommendation is 7mg/kg lido or 3mg/kg bupi max. I believe there is still safety of margin but more than the double dose I will be concerned.


Sent from my iPhone using Tapatalk

Even better was a case we had at M&M where the ortho injected 30mL of 1%lido and 30mL of 0.5% bupi, ON EACH SIDE, and then acted surprised when the patient ended up with LAST. "But I've done it this way for 10 years!"

Easiest M&M ever: Don't be a f***ing idiot. Go read a book.

 

[nofliesonme]

This is 500mg lido and 175mg bupi in 45mins. If the pt is around 50kg ( the girl in the case ), it is very high. Our recommendation is 7mg/kg lido or 3mg/kg bupi max. I believe there is still safety of margin but more than the double dose I will be concerned.


Sent from my iPhone using Tapatalk

Thank you for your recommendation. It is self evident that the lowest effective dose should be used. My population of patients is in the 80kg.+ range. While recommended doses are valuable, an alternative view is that maximum weight based doses does not necessarily correlate to the resulting blood level and does not take into account relevant patient factors, the site of injection or the dilution (tumescent lidocaine solutions up to 55mg/kg are used). BTW you may want to recalculate your analysis .....according to my math 5Oml of .25 bupivicaine is 125mg not 175 mg ...and my injection is 30mg per side initially and only at the end if ok with anesthesia...The point of my post was not to tout the value of local anesthetics in breast augmentation but to point out the need for the surgeon and anesthesiologist to communicate effectively before and during the case... before I use any local anesthetic or epinephrine containing solution I let the anesthesiologist know.

 

[nofliesonme]

Even better was a case we had at M&M where the ortho injected 30mL of 1%lido and 30mL of 0.5% bupi, ON EACH SIDE, and then acted surprised when the patient ended up with LAST. "But I've done it this way for 10 years!"

Easiest M&M ever: Don't be a f***ing idiot. Go read a book.

Was the anesthesiologist unaware that 600mg of lidocaine plain and 300mg of bupivicaine plain were on the field and/or injected?

 

[deleted697535]

..in 30 years of practice these levels have not caused toxicity......

How do you know?

No offense but I usually have to tell my surgeon friends when we're up on big ticket items like 2 litre blood loss...

It is a big dose man Esp when you. Didn't mention per kg basis which implies everyone gets the same...

 

[Mman]

If the plastic surgery office takes ANY medicare than it would affect that office/surgery center. If they take zero percent medicare then they can supervise anyone do anesthesia except in NJ where I think CRNAS cannot work unsupervised anywhere and must be supervised by an anesthesiologist.

Plastic surgery offices are a cash based business in my neck of the woods and occasionally bill insurance for a few things. They take zero CMS patients.

 

[deleted875186]

Thank you for your recommendation. It is self evident that the lowest effective dose should be used. My population of patients is in the 80kg.+ range. While recommended doses are valuable, an alternative view is that maximum weight based doses does not necessarily correlate to the resulting blood level and does not take into account relevant patient factors, the site of injection or the dilution (tumescent lidocaine solutions up to 55mg/kg are used). BTW you may want to recalculate your analysis .....according to my math 5Oml of .25 bupivicaine is 125mg not 175 mg ...and my injection is 30mg per side initially and only at the end if ok with anesthesia...The point of my post was not to tout the value of local anesthetics in breast augmentation but to point out the need for the surgeon and anesthesiologist to communicate effectively before and during the case... before I use any local anesthetic or epinephrine containing solution I let the anesthesiologist know.

I agree that the maximum doses recommended for local anesthetics are not necessarily very evidence based and do not take a lot of things into account.

On the other hand, the risk benefit is never such that using too much local anesthetic is worth it. Before we had intralipid, this **** was fatal.

 

[fakin' the funk]

I like to find one anesthesiologist to work with and use them all the time. I get feelers from CRNA's the last one was 100$ an hour more than what i pay my anesthesiologist. I pay more than the locums group above. I can find anesthesiologists for 300$/hour....longer cases less.
BTW, I regard anesthesiologists as among the best and most talented physicians...and have a great deal of gratitude for their ability to make mel look good.
Regarding the case in this heading, I would be surprised if this was an equipment issue. All board certified plastic surgeons have pledged, as part of their board designation, to operate only in facilities that are certified (in plastic surgery most common one is Quad A). The case in question takes about 45 minutes from incision to sutures. I use 50cc lidocaine 1% in 250cc NS, and 50cc .025 marcaine with epi in 100cc NS. This allows a "light" anesthesia. I don't usually care whether its IV sedation, ET, or LMA as long as the patient wakes up........while dressing is going on. One of the few rules i have is, no toradol. If there's an interest i'd be happy to offer some suggestions how anesthesiologists and plastic surgeons can work together for the benefit of the patient.

Can't tell which parts of this are the joking parts

 

[pgg]

This reminds me of our recurrent discussions with EM docs about NPO guidelines.

 

[chocomorsel]

xx

This reminds me of our recurrent discussions with EM docs about NPO guidelines.

You can only recommend to other docs what to do and not do.
If a complication occurs due to them using too much and not communicating with you or listening to your advice, then that should be on them and easily provable if documented correctly I would think.
But you still may initially get dragged in the lawsuit.
Personally, if the surgeon is comfy w all that local in their tumescent, then that is on them. And it seems like the papers out there allow much, much higher doses injected in the fat from my brief review. Not the same as IM or IV dose ranges which is what we are used to in our field.

 

[deleted162650]

And it seems like the papers out there allow much, much higher doses injected in the fat from my brief review

Plus they suck most of it all back out.

 

[Ronin786]

Thank you for your recommendation. It is self evident that the lowest effective dose should be used. My population of patients is in the 80kg.+ range. While recommended doses are valuable, an alternative view is that maximum weight based doses does not necessarily correlate to the resulting blood level and does not take into account relevant patient factors, the site of injection or the dilution (tumescent lidocaine solutions up to 55mg/kg are used). BTW you may want to recalculate your analysis .....according to my math 5Oml of .25 bupivicaine is 125mg not 175 mg ...and my injection is 30mg per side initially and only at the end if ok with anesthesia...The point of my post was not to tout the value of local anesthetics in breast augmentation but to point out the need for the surgeon and anesthesiologist to communicate effectively before and during the case... before I use any local anesthetic or epinephrine containing solution I let the anesthesiologist know.

In all seriousness, what do you expect your anesthesiologist to let you know? I know of nothing outside of math that can help predict whether or not LAST is going to occur. Especially in a sedated individual.

 

[dhb]

My population of patients is in the 80kg.+ range.

80+kg and breast augmentation?

 

[narcotics999]

80+kg and breast augmentation?

D to F, fantastic!


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[WholeLottaGame7]

Was the anesthesiologist unaware that 600mg of lidocaine plain and 300mg of bupivicaine plain were on the field and/or injected?

They were vaguely aware but the attendings who staff the ASC are, shall we say, mostly hands off. Also generally try to stay out of the way of surgeons. Those facts also did not escape the M&M.

Everything is fine, until it isn't. The question is, when something bad happens (which is unavoidable, regardless of how careful you are), how will history judge you? Obviously, you can find an expert witness to support or destroy whatever decision you make, but for me, personally, I'd want to know what the majority of my colleagues find reasonable. The case I mentioned was probably like 98:2 against that decision. Your example is still lower, maybe like 85:15, but still pushing it.

The risk:benefit for healthy patients having elective procedures is obviously way skewed compared to sick patients w/ sick procedures. If you end up with LAST because you're pushing the limits of LA toxicity to avoid a GA on a cardiopulmonary cripple, that's obviously a very different story than an 18yo having plastic surgery.

 

[nofliesonme]

80+kg and breast augmentation?

I do over 100 MTF transgender BA"s per year.