OR until the end of a case that runs long and have only a brief win-
dow of opportunity to perform a block on the next patient. The super-
vision care team model (MDs overseeing the work of nurse anes-
thetists) frees up anesthesiologists to perform blocks in advance of
cases, as opposed to trying to squeeze them in between procedures.
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The "90-minute rule"
We bring all patients, regardless of whether they have planned
blocks, into the facility 90 minutes before their scheduled
start times. That gives us plenty of time to place blocks and ensures
that non-block patients won't spend too much time waiting for their
cases to begin. From a logistical standpoint, it's best to maintain a
standard arrival time for all patients, one in which non-block patients
arrive early enough for the pre-op staff to address unforeseen issues
and block patients arrive far enough in advance to avoid delaying the
OR.
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Ultrasound guidance
Imaging technology can speed the placement of blocks,
depending on the skills and experience of the anesthesia
provider. Someone who has spent his entire career performing land-
mark-based femoral nerve blocks for total knee replacement is going
to be less efficient with ultrasound. It's a tricky comparison, because
many factors contribute to the overall efficiencies of a regional pro-
gram. But if all else is equal, ultrasound guidance in the hands of a
skilled provider definitely speeds things along. A straightforward
block is relatively easy to perform, whether the landmark technique
or ultrasound guidance is used. But when trying to place blocks in dif-
ficult anatomy, when you're otherwise fishing in and out with the nee-
dle trying to find the nerve, ultrasound can "turn the lights on" and
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