Volume 4, Issue 7 S A M B A T A L K S - PAGE 1 December, 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 QUESTION WITH REPLY - ?? - TOP

QUESTION :

I work with a Plastic Surgeon who insists on performing multiple procedures on his patients including liposuction, obtaining from 6 to 10 liters of fat, face lifts, tummy tucks etc. resulting in patient transfer to the nearest hospital for blood-transfusions. I am sure this is not for same-day surgery. The operations are usually 5 to 8 hours long. Guidelines? Suggestions? How do I convince him that this amount of liposuction is DANGEROUS!

-- Anonymous

REPLY:

This question raises several office surgery safety issues including the length of surgery, performance of combination procedures, large volume liposuction, and transfer of a patient from an office to hospital for treatment.

There are a number of studies that show that combination surgical procedures and extended length of surgery can result in poorer outcomes. Hughes, in the Anesthetic Surgery Journal March 2001, found when liposuction was combined with abdominoplasty the mortality was one in 3,281 procedures-a rate 14 times greater than that for lipoplasty alone. In 2000, the Florida Board of Medicine limited office procedures to 8 hours and in February 2004 the Board of Medicine enacted an emergency ban on combination of liposuction and abdominoplasty following an unusually high number of deaths that occurred subsequent to combination procedures.  The American Society of Plastic Surgeons' recommendation in Procedures for the Office Based Surgery Setting is that the overall duration of procedures should be completed in six hours (Plastic and Reconstructed Surgery, 110:1337, 2002).

There have been a number of reports regarding fatal outcomes following liposuction.  The American Society of Plastic Surgeons issued a Practice Advisory on liposuction in March 2003, which defined large volume of liposuction as that which exceeds 5000cc of total aspirate. It recommends that these procedures should only be performed in an Acute Care Hospital or in a facility that is accredited or licensed.  The Advisory also states that large volume liposuction combined with other procedures has resulted in "serious complications and such combinations should be avoided".

Finally, in the State of Florida any transfer of a patient from an office to a hospital for treatment requires that an Office Surgery Incident Report be filed. We analyze these reports and have published an article in the Archives of Surgery in September 2003, which showed a ten times higher rate a death following office surgery than when similar procedures were performed in an Ambulatory Surgery Center.  Subsequent analysis of these reports have indicated that the incidence of injury and death in Florida have declined following the implementation of rules that contain limitations on the time of surgery, the volume of liposuction, and in some cases the performing combination of procedures.

-- From Hector Vila, Jr., M.D., Tampa, FL

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

QUESTION 1:

Has SAMBA commented on the Canadian survey about BMI?  About 50% of the respondents stated they did ambulatory surgery on patients with a BMI of 45 or less with no other medical problems. Has SAMBA done a similar survey? If OR beds accommodate patients weighing 500 lbs., can we safely anesthetize patients with a BMI of 50 or greater if they are young and have no other medical problems? This issue is more of a problem at our ASC than the morbidly obese patient with concomitant medical problems. It is easier to convince the surgeons that these patients need to be done at the hospital. It is the "healthy" morbidly obese patients that we are constantly questioned about their suitability for ambulatory surgery.
 
-- From Nolana Bell, M.D., Auburn, WA.
 

QUESTION 2:

I am the Director of Nursing in a free standing surgery center. We had an increase of post-op nausea and vomiting (PONV). Calculated out there was 10% of the patients having postoperative PONV. It has since decreased to 6.25%. Are these numbers within normal range for PONV? We do general surgery, ENT, podiatry, and plastics.

-- From Cathy Smith, R.N., B.S.N.

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