Volume 4, Issue 3 S A M B A T A L K S - PAGE 1 August, 2004

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Do you have a problem case or situation in ambulatory anesthesia about which you would like some advice? Would you like to reply to questions others have raised about ambulatory anesthesia issues? Do you have any comments or opinions regarding any topic related to ambulatory anesthesia which you would like to share with other professionals? If you answered "yes" to any of the above, then "Join the Discussion" here.

To enter the Discussion with a question, reply, or other comment, please contact us. Your question/reply/comment will be published in this section of the next available issue of SAMBA TALKS. Include your name (or initials), city, and state, if you would like these published. Please note that because of the high volume of questions we receive, there is often a delay of 1 to 2 months before the questions can be published.

Questions and responses from previous months are available on the Web site. If you have any comments regarding the previous questions, please submit them to SAMBA Discussion, and they will be published here next month.

?? - LAST MONTH'S QUESTIONS WITH REPLIES - ?? - TOP

QUESTION 1:

Does anyone think that laparoscopic gastric banding is an acceptable procedure for a freestanding outpatient facility?

-- From Gerald Kranis, M.D., Miami, FL

REPLY:

Our group of 27 anesthesiologists has cared for 5500 bariatric patients over 5 years through 2003; 3000 were done in a full service 400+ bed hospital and 2000 at Fresno Surgery Center which is actually a 20 bed hospital. FSC has monitored beds in private rooms but no formal ICU. The vast majority of the procedures are laparoscopic gastric bypasses. The average LOS is 2 days. The transfer rate is extremely low and those transfers have not been for primary respiratory problems. None of the 2000 patients has required ventilatory support beyond very occasional CPAP.

Of the 2000 cases at FSC, I did 580 and 2 partners did 850 between them. We intubate under GA and SCH and need the difficult airway cart 1-2 times per year. We have concluded that BMI alone is not a limiting factor. The largest BMI was 85 and we routinely do patients with BMI's from 60-70. There are some co-morbid conditions that cause us to refer a patient to the larger institution. We assume that all patients have OSA and treat them accordingly. Most problems occur during the surgeon's learning curve (first hundred cases) and when the anesthesiologist is wedded to deep anesthesia with longer duration drugs. Extubation occurs only when patient can lift head, responds to commands and has appropriate VC. Average operating times are under 2 hours.

There are two procedures that have been discussed as outpatient procedures. They are the laparoscopic Roux-en Y gastric bypass (L-RYGB) and laparoscopic adjustable gastric banding (LAGB).

The L-RYGB procedure is the most accepted procedure by bariatric surgeons for weight loss. It is not generally considered an outpatient procedure. A series of 1000 outpatient L-RYGB's was recently presented. At first glance this series seems amazing but the "outpatient" stays included a 23 hour observation admission, which makes an actual LOS of 1-2 days depending on when one starts the 23 hour clock.

On the other hand, the LAGB is less invasive and could be done as an outpatient case with a number of caveats and considerations. The recent ASBS Meeting included a series of 700 LAGB's done as outpatients. While this operation does not involve bowel anastomoses, it is a major laparoscopic abdominal operation with its own set of complications such as esophageal injury.

Whatever procedure is done, it must be remembered that these are morbidly obese patients with a very high proportion having OSA and other co-morbid factors. Therefore the selection of anesthetic agents, technique and post-op analgesics is critical to safety and success. Our experience with obese patients has made us comfortable doing many as outpatients but it is still somewhat controversial and some centers still put these patients into an ICU setting overnight.

Our surgeons (three separate groups) all say that the LAGB is OK as an outpatient but it is not the best operation for obesity. They have also observed that the band was originally marketed to dedicated bariatric surgeons without overwhelming acceptance. It is now being marketed to the wider population of general surgeons who may not have the experience to furnish the required long-term support required in a bariatric program.

-- From Lou Freeman, M.D., Fresno, CA

QUESTION 2:

We are a small Ambulatory Surgery Center in Ft. Myers, Florida. Recently a surgeon requested time to do a total knee replacement (TKR) here. He said that this was done routinely in many places. I could not verify that with my literature search. To me it seemed in the experimental stages, requiring continuous infusion pumps, etc. Do you have any data, position, or opinion on doing TKRs in an ambulatory setting? We have no facilities to neither give blood nor provide prolonged pain control.

-- From Paul DeLeeuw, M.D., Ft. Myers, FL

REPLY:

First, Medicare will not reimburse for a total joint in an ambulatory setting. The other third party payors (e.g., Blue Cross / Blue Shield, Aetna, etc.) will, but the determining factors become the cost of the prosthesis, physical status of the patient, and (of course) postoperative analgesia care of the patient.

I have discussed this topic with many of our orthopedic surgeons, and we are first going to do a unicompartmental minimally invasive knee arthroplasty in our centers. These patients routinely go home on the first postoperative day from the hospital (with a psoas compartment catheter in place) and do very well.  The reimbursement for the center would be reasonable, and we could do the procedure for about one half the cost of doing it in the hospital, which should be attractive the insurance company. 
 
Also, we are fortunate to have a rehabilitation facility down the street from our center, and many of our patients are already going there after their total joint  replacements (performed as inpatient surgery). I have in-serviced the staff at that rehabilitation facility,  and have sent a few patients there after other procedures with nerve block catheters in place. This practice is permissible (from a reimbursement standpoint), since it is an admission "down," and not "up" to a higher level of care. It is illegal to admit to a higher level of care from an ambulatory setting.

The blood loss associated with a total knee replacement is surely a concern, since most ambulatory centers do not have protocols in place for transfusions. This is why I think it reasonable to start with a unicompartmental knee arthroplasty first thing in the morning, with both a psoas compartment catheter and a single shot sciatic block in place.  

For these patients, in order to minimize symptom variability (especially PONV), I preferentially use propofol as a total intravenous anesthetic. Avoiding volatile agents can decrease PONV, as well as unplanned admissions. Propofol in my experience allows for faster emergence and decreases nursing interventions in the PACU thereby increasing nursing efficiency. The combination of propofol with the stated nerve blocks allows for patients to return to baseline cognitive function sooner in PACU which pleases both the patient and loved ones caring for patient. When I use nerve blocks (especially continuous nerve blocks) and total intravenous anesthesia with propofol, I also avoid intraoperative midazolam and narcotics, in order to facilitate all of the above. 
  
After observing the patient in the recovery unit for a few hours, the patient can either be sent home if they have an appropriate caregiver, or to an assisted-care facility if necessary.  
  
One cannot underestimate the critical importance of patient selection in this process.
  
-- From Don Siwek, M.D.,  Sarasota, FL

QUESTION 3:

I am a consultant who assists physicians in the development of freestanding ambulatory surgical centers throughout the US.   Overall, the licensing requirements tend to be fairly uniform with one exception; there is a tremendous disparity among health department offices regarding requirements for emergency medications and equipment relative to the age of the anticipated patient population-- specifically, pediatric patients.

Most recently we were apprised by one agency official that a pediatric patient is defined as 18 years of age and younger and that in order to treat patients 14 years of age and older (which was our licensing request) the group would still be required to provide "pediatric
defibrillator paddles, pediatric emergency medications (unit doses), special resuscitative equipment, pediatric surgical instrumentation and pediatric stretchers."  In many other states 14 is considered the cut off for these items, and in some instances it is as low as age 12.Only a few state actually have written codes defining the specific qualifications of a pediatric patient.

Are there any published guidelines from professional organizations, specifically related to anesthesia or peri-operative emergencies, which I can use successfully in dealing with these agencies to provide some level of consistency?  I would appreciate any comments and recommendations you may offer.

-- From Mary Parker, Los Angeles, CA

REPLY:

The American Society of Anesthesiologists has published a document, "Pediatric Anesthesia Practice Recommendations", which is found at http://www.asahq.org/clinical/PediatricAnesthesia.pdf.  In that document, there is a section on equipment and drugs.  The requirement for medications and equipment should be based on the age of the patient that is expected to be treated.

-- From Lance Lichtor, M.D., Iowa City, IA

?? -- THIS MONTH'S QUESTIONS -- ?? - TOP

QUESTION 1:

I am the medical director of Canyon Surgery Center in Phoenix, AZ.  During a recent State inspection we were told that a death had occurred in a patient with a stent in a local outpatient facility. They felt that we needed to formulate a policy for when patients post insertion of a coronary stent are candidates for outpatient surgery.  I have been searching the cardiology literature only to find that the cardiologist do not agree with any specific time recommendation.  Their literature says anything from ok to do in first 2 weeks after insertion of stent, but not ok after 8 weeks, to should wait 4-6 weeks for anticoagulant therapy, and one paper noted a 30% restenosis rate within the first 6 months. 

I have asked several other medical directors in my area and we have all come up against the same problem of no real answer in the literature. I even contacted the American College of Cardiology who referred me to an article which didn't give a concrete answer either. In that article they basically took the position that cardiac clearance consists of "optimizing the patient", but didn't give any real guidelines either. I also contacted the ASA and was given the following response from Karen Williams, M.D., Chair of the Committee on Surgical Anesthesia:

"Your question regarding the timing of performing elective surgery following the recent placement of coronary stents was referred to me as Chair of ASA's Committee on Surgical Anesthesia. Your question was circulated to committee members who all agree with your research on the matter. The current literature is controversial regarding the timing of
elective surgery after stenting. There are no prospective, definitive studies. Empirically, some institutions wait until the antiplatelet therapy is maximized, others wait for 4 weeks up to 12 months for some types of stents if there is a high restenosis rate within the first few
months. It seems that your policy would be based on the multidisciplinary input with your cardiologists, based on your best judgment."

So, I am very interested to see if some sort of consensus can be reached and a standardized time agreed upon.

-- From Rebecca Dalmeida, M.D., Phoenix, AZ.

QUESTION 2:

I work in an outpatient unit that is connected by a bridge to a hospital that has no pediatrics or pediatricians.  The local pediatric surgeon has just adopted us to do all of his elective surgical cases.  What is the youngest appropriate age to care for non-premature infants for ambulatory procedures in this setting in order to minimize the risk of peri-anesthetic complications (apnea)?

-- Anonymous

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