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LA Infiltration

Recommendation for LA Dosage in Uni/Bi-Lateral TKA/THA Patients 

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  • The dosage recommendation constitutes maximum allowable dose

    • Reduce dosage as clinically indicated (in elderly, renal/hepatic failure)​

  • Preference for local is Ropivacaine > Bupivacaine with Epi > Bupivacaine Plain​

Procedure for Referral in event of Peripheral Nerve Injury

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The current main contact person is Dr. Kristine Chapman of Neurology. Please follow the outlined steps below.

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  1. Refer the patient for EMG using the requisition form.

  2. Provide as much detail as possible including injury date on the req. Check "urgent" and "Dr. Chapman". Provide your name and MSP number so you can receive a dictated consult. Note the patient's MRN so you may follow up on results on PCIS.

  3. The patient will automatically get a complete neurologic consult and if indicated, be arranged for referrals (surgery, rehab etc) or further tests.

  4. Timing for referral is recommended to be 10 days after injury to identify denervation. Any inpatient referral will get an expedited assessment and may be brought back for follow up testing.

Injury

Hip Fracture Regional Anesthesia Pathway

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Finding Patients to block:

a) ER calls slater during day time per protocol and the block is performed there.

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b) Checking the teletracker for cases that have been booked. Arrange to have these patients brought down early pre-op, or bring down just to perform block if case not going to occur same day. Check with PCU leadership regarding space and RN availability. There is usually space while there may not be a RN for the 30 min monitoring. This is circumvented if Anesthesiologist or extender does the monitoring. Some people will use that time to do the consult.

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c) Some patients do not show up on the teletracker right away, but there are consults for them in the box. They can be brought down for block and consult at same time, but generally eyeball them first to ensure they are appropriate candidates.

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Documentation:

a) There is now an official "Hip Block Post-Monitoring" PPO that should be used after the block is performed in ER. Please show the ER nurse this order before walking away. They will use this PPO to provide the mandatory 30 min monitoring.  

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b) Please fill out the Hip Block Record sitting in the binder beside Diane/Rea. Original to chart, one photocopy back to binder.

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c) Block signage (with date/time) taped to bed a good idea especially if the patient will return at later time for surgery and may receive further block.

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HIP Pathway

Guideline on Performing Blocks in the PCU

Blocks in PCU

Rib Fracture Pathway - Sept 2020

Rib #

PAIS Duties

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Starting in January 2022, the PAIS position is to be staffed by Regional Anesthesia Anesthesiologists. The primary focus of this position is peri-operative nerve blocks and patient care in the PACU. 

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Job Description:

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  1. ​PACU Care from 7:00 to 13:00. Receiving the unit from N1 and handing off to POA. Hold the POA pager. 

  2. Facilitate or perform any blocks for patients going through the OR. This includes planning ahead such as looking at the slate the day before and marking patients as "PAIS". 

  3. Facilitate or perform any Hip blocks: PENG, Fascia Iliacus, femoral. This could take place in ER or require bringing patients down from the ward early or brought down just for the block if surgery is not scheduled. Hip patients are found by checking teletracker and the consult box or checking in with Ortho Trauma. 

  4. Facilitate or perform any rib fracture related blocks in conjunction with POPS: Serratus Anterior catheter, epidural, PVB, erector spinae. These patients usually require being brought down from trauma ward or consider doing this in BTHA. 

  5. To be seen as using the "Block Area" bays in our third floor PCC. Any block performed must be monitored for 30 min unless the OR team assumes care prior to that. The 30 min monitoring needs to be done by a PACU level nurse and not a PCC nurse. As there are PACU nursing constraints, the 30 min monitoring may need to be done by Anesthesia or an extender (resident/fellow/AA). Patients are sent back to ward after 30 min, or care assumed by PCC nurse if still waiting for OR.

  6. Consults. With emphasis on consults for patients that are being blocked by PAIS. ​

  7. We will not perform epidurals at this time. The only exception is for POPS/Rib fracture patients and PACU level​ nursing or Pain Nurse available.

  8. We can perform artlines if the patient is going to the OR imminently or if they are monitored by Anesthesia team. PCC level nurse are not compatible with artlines.

  9. Anesthetic care in and out of OR as demands and needs dictate.   

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General Rules:

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  • Take care to limit delays for the OR especially the first case of the day. Historically, the first case of the day has been omitted for PAIS. Where possible, use clinical discretion. 

  • When doing a block for a patient pre-operatively:

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  • Discuss timing with the OR anesthetist/surgeon

  • Ensure PACU charge nurse is aware and that there is adequate RN coverage and work space

  • Ensure PCC nurses are aware to facilitate early check in

  • Ensure OR nursing is aware, to facilitate early surgical check in. This can occur after the block as long as no sedation has been given. Judicious opioids are tolerated. 

  • If the limb is not marked, it should be done by PAIS prior to the intervention

  • Ask an AA to lend a helping hand  

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  • It is a good idea to look at the slate the day before and add "PAIS" to the slating comments to make various parties aware of your intention to perform a PAIS intervention. This is done by calling x 54423​

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  • See above Guideline on Performing Blocks in the PCU

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PAIS

VCH Regional Anesthesia Pre-Block Checklist

Regional Checklist
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