Volume 7, Issue 3 S A M B A T A L K S - PAGE 2 August, 2007

JOIN THE DISCUSSION - TOP

Need advice about a problem case in ambulatory anesthesia? Suggestions about a difficult situation in your ambulatory surgery center? A reply to questions others have raised about ambulatory anesthesia issues?

If you answered "yes" to any of these questions, or would like to share with other professionals a comment or opinion on a topic related to ambulatory anesthesia then please "Join the Discussion".

Your question, reply or comment will be published in the next available issue of SAMBA TALKS. Include your name (or initials), email address, 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 publication.

SAMBA Talks will include all discussion questions we receive considered of interest to the membership at large. We will endeavor to publish a response to at least one of these questions. The response will be from experts in the field, and from those willing to express a view on a particular topic, backed by experience and/or published evidence. Where email addresses are published, those individuals have indicated their interest in discussing the published questions.

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

Please note: The information presented in the replies below does not represent SAMBA policy. The replies are solely the opinions of the individuals who wrote them.

?? - LAST MONTH'S QUESTION WITH REPLY - ?? - TOP

Question

There is a lot of debate about the management/care of OSA patients in the outpatient surgical setting.  Can someone provide me with a general guideline that would not be overly restrictive to posting cases, but also serve to preserve quality patient care and safety (i.e., keep the owners, surgeons, nurses and anesthesiologists all happy)?

Anonymous

Reply

Well, that's a tall bill to satisfy.  The following may serve as a reasonable guideline for your facility:
 

1. Attempt to post OSA patients first thing in the morning. (Allow enough time, up to 3-7 hours if necessary, for post-op PACU observation)
2. Attempt to give the ASC staff as much lead time in the posting of these patients to allow the nursing staff, anesthesiologist/medical director, and others to try to contact the patient in gathering maximal pre-op data.
3. Unless short cases, try to avoid more than one OSA patient per room per day.
4. Provide internal medicine/primary care doctor consultation for all patients to ensure that the patient's respiratory status is at its best possible pre-op condition.
5. As a back-up, ask all patients who use a CPAP device to bring it with them to the facility.

Consider posting directly for the Main O.R./hospital for any of the following:

1. A diagnosis of severe sleep apnea by sleep study.
2. A resting PaCO2 of greater than 50 mmHg.
3. Any ENT/airway surgery concomitant with obesity.
4. Any patient history of a previous 'difficult airway/intubation'.
5. Any patient with the expectation of extremely difficult pain management post-op, potentially necessitating treatment with high-dose opioids.
6. Any patient who is considered morbidly obese ("extreme obesity") by the published BMI scale. THIS MEANS ANY BMI GREATER THAN 40!
7. Any surgical case that is expected to take longer than 4 hours.
8. Any patient with concomitant medical issues involving symptomatic heart disease, COPD, complex diabetes management, or a resting oxygen saturation on room air of less than 95%.
9. Any ASA category IV patient or an ASA category III patient involving multiple systemic diseases.

This type of list can function as a useful guideline, but there will be gray areas--or issues of contention--that can hopefully be resolved through discussion.  The ultimate disposition of these patients (and length of stay in the PACU) will reside with the PACU staff/medical care team/medical director on a case by case basis.
 
I hope this helps.

-- From: Adam Frederic Dorin, M.D., MBA  San Diego, CA

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

Question 1

I am and anesthesiologists from the Philippines and I am interested in setting up an ambulatory clinic, with focus on cosmetic procedures.  Are there specific guidelines or protocols that need to be followed in setting up such facilities? Also, since I am based in a hospital I would also like to know what are the standard equipment and facilities needed for outpatient surgeries in general.
  
Thank you.

-- From: Irminia Montecillo M.D., Phillipines (icmontecillo@yahoo.com)

Question 2

I am an anesthesiologist interested in learning how to sedate patients in an office setting.  Do you know of any training I can get for this?

-- From: Donald Cochran,MD

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