Volume 3, Issue 7 S A M B A T A L K S - PAGE 1 December, 2003

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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 edition of SAMBA TALKS. Please include your name (or initials), city, and state, if you would like these 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.

?? - PREVIOUS MONTH'S QUESTION WITH NEW REPLY - ?? - TOP

QUESTION:

"I am an anesthesiologist in New Orleans at an outpatient center. A surgeon in the group where I work is starting to do thyroid surgery there. This includes both subtotal and total thyroidectomies where the patient goes home the same day (not a 23 hr. stay). What are your views on outpatient thyroid surgery?"

-- From D.M., New Orleans, LA

NEW REPLY:

"I can’t let pass this chance to give you my opinion about this topic. The most important risk of this surgical procedure is that it takes place in a tissue too close to the upper airway. There is an unavoidable risk of postsurgical edema, and moreover, the high risk of postsurgical hemorrhage is always present. In my modest opinion, these problems are seen in approximately 2% - 3% of cases, but when they occur, they place the patient at high risk because both can result in serious respiratory problems and lead to death. For all of above, I consider that this surgical procedure shouldn’t be included in a same day surgery program."

-- From Enrique Conde Gareca, M.D., Santa Cruz de la Sierra, Bolivia

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

"I work in an ambulatory facility which occasionally has “special surgical days”. On those days, three to five times the regular daily number of surgeries are done in order to decrease the waiting list of patients (pediatrics, general surgery, and ENT). Does SAMBA have any guidelines or suggestions for this high-volume day?"

-- From Celina Beatriz Contreras, MD, Merida, Venezuela

REPLY:

"This sounds like a real challenge! The "special surgical day" is not, as far as I know, something done in North American hospitals. Nor have I seen anything in the literature to describe how best to organize for such a day. The practice here is generally to try to even out the flow of cases and make things as predictable as possible. The obvious issues, such as increasing proportionately the number of anesthesia providers, OR nurses, and recovery personnel I am sure you've already thought of. You will need extra supplies, drugs and disposables. You will need to have all your care processes very streamlined, and here I imagine that preparation and planning with all the staff will be key. You will also need a good breakfast and probably a lot of coffee!"

"I would suggest sitting down with your administrator, and at least one representative from nursing and from your surgical group, to discuss the plan. Although the goal of reducing waiting lists is laudable, your primary objective should be to ensure patient safety. Because of the large case load, you will be especially vulnerable to "production pressure", but you should emphasize to the other staff that you cannot decrease vigilance or standards."

"I think that for your high volume day, you would be wise to select only your healthiest patients, and to avoid especially complex cases. It might be a good idea to have all your prospective patients seen preoperatively by a primary care person or anesthesiologist to make sure they are all in good shape, and having the right kinds of operations that are likely to go smoothly."

"Good luck!"

-- From Gary Kantor, MD, Cleveland, Ohio

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

QUESTION 1:

"Does anyone advocate the use of toradol in children for dental rehab? It seems to me that children are calmer on wake-up when it is used. They don't seem as wild on wake-up and don't require that extra dose of narcotic to settle them down."

-- From Debra Tyler, MD, Dallas, TX

QUESTION 2:

"Our institution will soon be opening up a new Ambulatory Surgery Center. Does SAMBA have any guidelines for the job description of the Director of an Ambulatory Surgery Center?"

-- Anonymous

QUESTIONS 3 and 4:
(The next two questions address similar issues and will be considered together.)

"Does anyone have specific guidelines/policies regarding Body Mass Index that would limit a potential patient candidate from undergoing a procedure at an ASC?"

-- From M.T. Reichel, MD, Beaufort, SC

"I am a staff anesthesiologist at a small out-patient surgery center. We do not have the staff to provide pre-op visits. We frequently get morbidly obese patients for general anesthesia. Many have undiagnosed conditions (i.e. sleep apnea). Do you feel there should be an absolute cutoff regarding BMI for outpatient surgery, as waiting to evaluate patients on the day of surgery means a lot of last minute cancellations and unhappy patients and surgeons? I gave a GAET for a breast biopsy (difficult to reach area) in a 5'4", 420 pound patient yesterday. She had asthma, hypertension and diabetes and was 31. Arkansas is now the most obese state in the nation. I am guessing that around 20% of our patients are morbidly obese. A cutoff of 40 BMI seems unreasonable to our staff (because it is so common). Any ideas? If we develop a guideline we are being asked to back it up with "data". I can't seem to find much, except the OSA articles by Jonathan Benumof."

-- From Sandra L. Stolzy, MD, Fayetteville, AK

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