Prolonged Tourniquet Times

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MoMoGesiologist

MoMoGesiologist

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So I thought I would get some advice on this. Sometimes during ortho cases like TKAs, the extremity tourniquet is on at 250mmHg for two hours and the OR nurse tells the surgeons and they will ask for 15-30 more minutes of tourniquet time. All the texts I read say that two hours is the safe limit before risking ischemic injury to the peripheral nerves etc.

Do you guys encounter this? Do you say something to the surgeons or document a discussion in the record? Insist on 15min of the tourniquet being down? It kinda drives me crazy when the attending surgeon leaves the room and the ortho resident takes forever to close but insists the tourniquet stays up so he can have a bloodless field. I did find an old thread where someone mentioned they avoid PNBs in cases where they know the specific surgeon has prolonged tourniquet times.

Thanks for any advice!
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MoMoGesiologist said:
So I thought I would get some advice on this. Sometimes during ortho cases like TKAs, the extremity tourniquet is on at 250mmHg for two hours and the OR nurse tells the surgeons and they will ask for 15-30 more minutes of tourniquet time. All the texts I read say that two hours is the safe limit before risking ischemic injury to the peripheral nerves etc.

Do you guys encounter this? Do you say something to the surgeons or document a discussion in the record? Insist on 15min of the tourniquet being down? It kinda drives me crazy when the attending surgeon leaves the room and the ortho resident takes forever to close but insists the tourniquet stays up so he can have a bloodless field. I did find an old thread where someone mentioned they avoid PNBs in cases where they know the specific surgeon has prolonged tourniquet times.

Thanks for any advice!
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I think most just let it slide. It's like some people induce without preoxygenating even though it may be textbooks to preoxygenate. But should the surgeon be telling us to preoxygenate? Should we be telling the surgeon to stop tourniquet?
 
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Who preoxygenates?

OP, don't worry, once you are out of training it will all go away.

I would consider an academic position (if I did t like my current gig so much) except that this **** would set my hair on fire. I would drop the tourniquet on the resident and tell them to learn to suture faster. But I would be an attending and therefore have more leeway.
 
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anbuitachi said:
I think most just let it slide. It's like some people induce without preoxygenating even though it may be textbooks to preoxygenate. But should the surgeon be telling us to preoxygenate? Should we be telling the surgeon to stop tourniquet?
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Not our call - but then again, in our place, it's not the surgeon's either. Hospital policy is two hours. Amazingly, the nurses, or their managers, will insist that the surgeon follow the policy. If they don't, it gets dealt with at the medical staff level. If it continues to happen, there is the potential of loss of privileges. Fortunately in private practice, this is not a common problem, and our surgeons with extended tourniquet time (most often podiatrists) know the drill about letting the tourniquet down and how long it has to be left down before reinflation.
 
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Noyac said:
Who preoxygenates?
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notsure-1.jpg


Don't you practice at altitude too??
 
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SaltyDog said:
notsure-1.jpg


Don't you practice at altitude too??
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I don't preox! At least not like we were taught. I do place a mask on the pts face as they are positioned on the table and the nurse in the room thinks she is doing something by holding it down. But I have already given the meds, so the pt might take one or two breaths with something more than 21% Fio2. I definitely do not wait in order for the pt to preox.
 
dayuuum, two hour tourniquet times for a tka?? that seems excessively slow. he would probably loose his privileges at my place. we had a OB/GYN loose her davinci privileges recently because she was to slow.
 
sleepallday said:
dayuuum, two hour tourniquet times for a tka?? that seems excessively slow. he would probably loose his privileges at my place. we had a OB/GYN loose her davinci privileges recently because she was to slow.
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I doubt that. If they are bringing pts in, then they will have privileges barring SCIP infractions or the like.
 
Noyac said:
I doubt that. If they are bringing pts in, then they will have privileges barring SCIP infractions or the like.
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Its possible. In my experience, the slow ones don't generally bring in boat loads of patients. the guy doing 14 tka's in a day doesn't have 2 hour tourniquet times.
 
It's an academic place and the only place I've ever known but everyone here makes it sound like things move five times faster in private practice, i.e. 20min lap choles and c sections etc
 
1 hr for upper extremity. 2 hrs for the lower. I verbally announce and the alarm goes off on the tourniquet as well as document in chart

Patient underwent a ACL reconstruction for 5 hrs in a San Jose hospital. Ended up with compartment syndrome and a dead necrotic leg that was amputated by another surgeon. Related to excessive tourniquet time.
 
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Noyac said:
I don't preox! At least not like we were taught. I do place a mask on the pts face as they are positioned on the table and the nurse in the room thinks she is doing something by holding it down. But I have already given the meds, so the pt might take one or two breaths with something more than 21% Fio2. I definitely do not wait in order for the pt to preox.
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Surely you don't mean never?

I think most of us aren't real diligent about preoxygenating to an EtO2 of 85%, most of the time. But when that patient rolls around that you know is going to desaturate like a falling brick ... I don't give that patient induction drugs as the monitors go on.
 
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pgg said:
Surely you don't mean never?

I think most of us aren't real diligent about preoxygenating to an EtO2 of 85%, most of the time. But when that patient rolls around that you know is going to desaturate like a falling brick ... I don't give that patient induction drugs as the monitors go on.
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A morbidly obese pt with a beard that I need to intubate I will preox.
 
Ok Archie, I don't know if you are being a smartass or just jerking my chain. The point is, I don't preox my pts "routinely".

Is that better? I clarified it for you.

If I were new at this, then I might do it more often.
 
Like @pgg said, I don't think may of us pre-ox the "right way" we were taught in residency. My routine is to place the mask on as soon as the pt is moved over and just let it rest on their face with the circuit supported by the christmas tree. I don't have the nurse or anyone else ensure a tight seal unless it's a high risk pt (that way they are free to do whatever else they need to do to get the case start). This way the pt comfortably pre-oxygenates while the rest of the monitors go on, and by the time the BP cuff cycles the SpO2 is up to 100% from wherever it started. Sure it's not the textbook way Benumof taught me, but it's not quite as cavalier as Mr. Mountain Man either ;).

Oh, and don't make the nurse hand you the ETT either. Just tuck it under the table mattress with the package 1/2 peeled open like a banana so you can grab it yourself once you get a view and the friction/weight from the mattress and the pts head will hold onto the wrapper and let the ETT slide out by itself. That way the circulator can Foley/prep/whatever as soon as the pt's eyes close.
 
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SaltyDog said:
Just tuck it under the table mattress with the package 1/2 peeled open like a banana so you can grab it yourself once you get a view and the friction/weight from the mattress and the pts head....
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Ummm..... :eek:

Dude... Salty... WTF ?!?...
 
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First thing that goes on my patient isn't any of the monitors... it's always the mask as you describe. It's easy to do and by the time I push drugs they have had several deep breaths. I don't wait for my expired O2 is 85% for routine easy AWs.

I didn't for a second think that @Noyac was not giving pre-O2 for a morbidly obese patient with a beard. C'mmon guys... cut the man some slack already!
 
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Mask, BP cuff + cycle, EKG leads, Pulse OX, propofol burn. Takes less time than moving the patient to the bed.
 
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SaltyDog said:
Oh, and don't make the nurse hand you the ETT either. Just tuck it under the table mattress with the package 1/2 peeled open like a banana so you can grab it yourself once you get a view and the friction/weight from the mattress and the pts head will hold onto the wrapper and let the ETT slide out by itself. That way the circulator can Foley/prep/whatever as soon as the pt's eyes close.
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I release the nurse as soon as the pt falls asleep. She or he has **** to do like place a foley or prep. So I let them do their tasks while I intubate and whatever else I need to do.
 
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I have an attending that lectures me abt placing the O2 mask on the face while i place the monitors. He says "until youre ready to place the mask with a good seal dont even put it up there, its not doing anything." Which i dont understand, 10L of O2 blowing on the mouth and nose has to be doing something more than room air.
 
IkeBoy18 said:
I have an attending that lectures me abt placing the O2 mask on the face while i place the monitors. He says "until youre ready to place the mask with a good seal dont even put it up there, its not doing anything." Which i dont understand, 10L of O2 blowing on the mouth and nose has to be doing something more than room air.
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its better than nothing but obviously pretty bad. you get big leaks from the two sides usually. your FiO2 effectively is probably 40-50%. i imagine it's similar to a patient breathing in nasal canula blasted at 10L. you cap out at 40 or so%
 
IkeBoy18 said:
I have an attending that lectures me abt placing the O2 mask on the face while i place the monitors. He says "until youre ready to place the mask with a good seal dont even put it up there, its not doing anything." Which i dont understand, 10L of O2 blowing on the mouth and nose has to be doing something more than room air.
Click to expand...
But this attending still has you preox everyone?
It must take forever to get the pt off to sleep.
 
IkeBoy18 said:
I have an attending that lectures me abt placing the O2 mask on the face while i place the monitors. He says "until youre ready to place the mask with a good seal dont even put it up there, its not doing anything." Which i dont understand, 10L of O2 blowing on the mouth and nose has to be doing something more than room air.
Click to expand...

To play devil's advocate here, it's not always wrong for an attending to insist on the small things being done by the book, when working with residents, because often the residents don't have the experience to know when the small things matter and when they don't. It can be annoying on the receiving end, that's for sure.

I think we're all aware of the difference between providing supplemental oxygen, and carefully preoxygenating (denitrogenating). Maybe the attending wasn't aware that you were aware. Or maybe he's just weak and feels the need to assert authority by finding something to criticize.

SDN sarcasm aside, 99% of academic anesthesiology attendings are well qualified to practice anesthesia :) ... but have minimal or no formal training on how to be teachers. I make a specific effort to be a good teacher but I'm mostly winging it. The average 4th grade teacher is surely a better teacher than most every anesthesia attending out there, including me.

Anyway what I'm getting at is that he might simply be a bad teacher, not a bad anesthesiologist or a jerk.
 
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sevoflurane said:
I didn't for a second think that @Noyac was not giving pre-O2 for a morbidly obese patient with a beard.
Click to expand...
Noyac said:
Ok Archie, I don't know if you are being a smartass or just jerking my chain. The point is, I don't preox my pts "routinely".

Is that better? I clarified it for you.
Click to expand...

So why didn't you say so in the first place?

I see patients all the time that require preoxygenation/denitrogenation.
 
pgg said:
To play devil's advocate here, it's not always wrong for an attending to insist on the small things being done by the book, when working with residents, because often the residents don't have the experience to know when the small things matter and when they don't. It can be annoying on the receiving end, that's for sure.

I think we're all aware of the difference between providing supplemental oxygen, and carefully preoxygenating (denitrogenating). Maybe the attending wasn't aware that you were aware. Or maybe he's just weak and feels the need to assert authority by finding something to criticize.

SDN sarcasm aside, 99% of academic anesthesiology attendings are well qualified to practice anesthesia :) ... but have minimal or no formal training on how to be teachers. I make a specific effort to be a good teacher but I'm mostly winging it. The average 4th grade teacher is surely a better teacher than most every anesthesia attending out there, including me.

Anyway what I'm getting at is that he might simply be a bad teacher, not a bad anesthesiologist or a jerk.
Click to expand...

You are overestimating teachers in the US. I still remember the time my 6th grade math teacher marked all my answers wrong because she didn't know that you do multiplication/division before addition/subtraction. I had to teach her that as a 6th grader.
 
anbuitachi said:
You are overestimating teachers in the US. I still remember the time my 6th grade math teacher marked all my answers wrong because she didn't know that you do multiplication/division before addition/subtraction. I had to teach her that as a 6th grader.
Click to expand...

I think you miss my point. :) There's a difference between knowing a subject and teaching it.

You had a 6th grade teacher who screwed up some basic math. She still probably knew, knows, and has forgotten more about teaching than all of us on this forum put together. Teaching was her profession, not algebra.

Teaching itself, the art and science of imparting information to learners, requires accounting for pre-existing knowledge and experience, fuzzier things like individual learners' strengths and weaknesses, and a dozen other things I'm only superficially aware of. Teaching is a field all in its own right. K1-12 teachers get degrees in education theory - often advanced degrees. There's a credentialing process for the act of teaching, independent of the subject matter being taught.

You can argue that the profession of K1-12 teaching in the USA doesn't attract the uniformly brilliant minds that go in to medicine and i-banking, but you can't argue that they are untrained teachers. Doctors on the other hand ... we're still stuck in this ancient bizarre OJT apprenticeship model, and that's stupid.


One of the most ridiculous and backward things about graduate medical education in the USA is that there is no requirement at all for the people doing the teaching to have any formal instruction on how to teach. 99% of anesthesiology attendings know how to safely administer an anesthetic, and lots are really excellent at it. But ask them a question about learning theory and I bet a large majority are barely even peripherally aware that these theories exist. That's the point I'm trying to make.

Throughout residency we're being taught by people who have never been taught how to teach. There are a rare few who choose to invest some extra time in occasional seminars or conferences on things like curriculum development, how to give feedback, remediation strategies, how to deal with problem learners, etc. Even rarer are the ones who make teaching a priority, that take on program director jobs, do things like write or edit textbook chapters, or run the PBLDs or workshops at conferences.

But most of us in academia are just winging it. I bet your 6th grade teacher who boned up algebraic order of operations would be legitimately appalled at the way doctors are taught how to doctor.
 
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pgg said:
I think you miss my point. :) There's a difference between knowing a subject and teaching it.

You had a 6th grade teacher who screwed up some basic math. She still probably knew, knows, and has forgotten more about teaching than all of us on this forum put together. Teaching was her profession, not algebra.

Teaching itself, the art and science of imparting information to learners, requires accounting for pre-existing knowledge and experience, fuzzier things like individual learners' strengths and weaknesses, and a dozen other things I'm only superficially aware of. Teaching is a field all in its own right. K1-12 teachers get degrees in education theory - often advanced degrees. There's a credentialing process for the act of teaching, independent of the subject matter being taught.

You can argue that the profession of K1-12 teaching in the USA doesn't attract the uniformly brilliant minds that go in to medicine and i-banking, but you can't argue that they are untrained teachers. Doctors on the other hand ... we're still stuck in this ancient bizarre OJT apprenticeship model, and that's stupid.


One of the most ridiculous and backward things about graduate medical education in the USA is that there is no requirement at all for the people doing the teaching to have any formal instruction on how to teach. 99% of anesthesiology attendings know how to safely administer an anesthetic, and lots are really excellent at it. But ask them a question about learning theory and I bet a large majority are barely even peripherally aware that these theories exist. That's the point I'm trying to make.

Throughout residency we're being taught by people who have never been taught how to teach. There are a rare few who choose to invest some extra time in occasional seminars or conferences on things like curriculum development, how to give feedback, remediation strategies, how to deal with problem learners, etc. Even rarer are the ones who make teaching a priority, that take on program director jobs, do things like write or edit textbook chapters, or run the PBLDs or workshops at conferences.

But most of us in academia are just winging it. I bet your 6th grade teacher who boned up algebraic order of operations would be legitimately appalled at the way doctors are taught how to doctor.
Click to expand...

No i think its just really easy to be a teacher in this country. The bar is set really low. I had several history teachers just straight read out of the book during class. Anyone can do that. I had health teacher who had us watch movies most of the time in class. We are also pretty bad at producing great students.
 
pgg said:
To play devil's advocate here, it's not always wrong for an attending to insist on the small things being done by the book, when working with residents, because often the residents don't have the experience to know when the small things matter and when they don't. It can be annoying on the receiving end, that's for sure.

I think we're all aware of the difference between providing supplemental oxygen, and carefully preoxygenating (denitrogenating). Maybe the attending wasn't aware that you were aware. Or maybe he's just weak and feels the need to assert authority by finding something to criticize.

SDN sarcasm aside, 99% of academic anesthesiology attendings are well qualified to practice anesthesia :) ... but have minimal or no formal training on how to be teachers. I make a specific effort to be a good teacher but I'm mostly winging it. The average 4th grade teacher is surely a better teacher than most every anesthesia attending out there, including me.

Anyway what I'm getting at is that he might simply be a bad teacher, not a bad anesthesiologist or a jerk.
Click to expand...
Fantastic post.
All residents need to have the basics drilled into them deep so that when they find themselves in a precarious position it's second nature. My post stating that I don't preoxegenate is coming from years of doing this gig and knowing when those annoying things my attendings made me do every single case are actually needed at this point. It becomes second nature and you don't even realize you are doing it.

Don't let up on the little bastards, pgg. ;)

And I realize that people like me don't make your job any easier.
 
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Arch Guillotti said:
So why didn't you say so in the first place?

I see patients all the time that require preoxygenation/denitrogenation.
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really?
Ok. But that tells me a few things about you that I will keep to myself.
I never said it was wrong to preox or that it didn't help in certain circumstances. Don't try to cast judgement on me here. I don't find the need to preox every pt like I see done so many times. I mean really, is it necessary to preox the 18yo for an ACL that is scared sh*tless because it's his or her first surgery ever? Hell no. Get that pt off to sleep as fast as safely possible. Hell, I'd argue that monitors are not even necessary here. Pulse ox and go.
Now bac to my practice, I don't preox pts "usually". Is that better for you?
 
I'm academic. My preoxygenation usually is blowby FM as I'm putting the other monitors on. If I'm lucky and the room is stocked with headstraps then I'll put that on to get a better seal. Between the NIBP cuff going off the first time and the pre-induction timeout that's usually a minute. Then I tell the patient to take 10 deep breaths, but usually I'm pushing the drugs on breath 2. So not really an official 3 minute preox denitrogenation, but usually effective. Obviously if I'm really concerned I'll take a little more time, but yeah even I don't have time for the 3-5 minute ETO2 > 90% stuff.

I did see a CRNA one time take the FM off the circuit and just had the patient breath through the elbow... very odd but not gonna lie it was pretty effective when it came to making a seal. She justified it by saying that the patients don't get all anxious/claustrophobic like some do withthe mask on their face. To each their own...
 
sigrhoillusion said:
I did see a CRNA one time take the FM off the circuit and just had the patient breath through the elbow... very odd but not gonna lie it was pretty effective when it came to making a seal. She justified it by saying that the patients don't get all anxious/claustrophobic like some do withthe mask on their face. To each their own...
Click to expand...

Not gonna lie, CRNAs have some interesting/good tips and tricks...
 
I was taught the elbow in the mouth trick in residency. Works great for the super claustrophobic pts that don't tolerate the mask and also for the big bushy homeless Santa beard dudes as well.
 
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Noyac said:
Who preoxygenates?

OP, don't worry, once you are out of training it will all go away.

I would consider an academic position (if I did t like my current gig so much) except that this **** would set my hair on fire. I would drop the tourniquet on the resident and tell them to learn to suture faster. But I would be an attending and therefore have more leeway.
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I preoxygenate. Something wrong with that? We got tons of fatties in America. But I preoxygenate everyone. Guess you wouldn't hire me as I am not so slick?
 
Ok, I guess I give supplemental O2 and as I push the induction agents, I create a good seal. But a mask always goes on their face before induction and as monitors are going on.
 
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