SAMBA Talks eNewsletter - December, 2006

Volume 6, Issue 7

S A M B A

T A L K S - PAGE 2

December, 2006

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 QUESTIONS WITH REPLIES - ?? - TOP

QUESTION 1

I am an anesthesiologist at an ASC in Washington State. I am looking for post-operative guidelines on interscalene blocks to give to patients upon discharge so they know what is normal and what should cause concern. Do you have any such form or know where I can get one?

-- Mary Fischer, WA. (mfischer@yakasc.com)

Reply 1

As far as I know, there are no written instructions given to patients with long lasting nerve blocks in most institutions.
What I usually inform patients going home with an intact block is mainly the following which is based on our home instructions for ambulatory peripheral nerve catheters:

Residual block

Expect the limb to remain numb for 8-14 hours (depends on the drug used)
Don't use the blocked arm until sensation has been completely restored.
Protect the anesthetized arm as long as there is a residual block
Residual paresthesia is not uncommon (may take few weeks), usually affecting one or two fingers.

Residual side effects in case of interscalene block

Numbness of the face for few hours.
Blurry vision (+/- lacrimation) for few hours.
Hoarseness for few hours.
Awareness of breathing for few hours

Post operative pain

Take your pain medications around the clock instead of PRN.
Don't wait until the block has completely resolved to take pain medications.
Take pain medications before going to bed (even if the block is still intact)

Warning symptoms that require medical attention

Swelling or bleeding at the site of the block.
Motor deficit lasting more than 24 hours.
Paresthesia lasting more than 2-3 weeks.
Signs of infection (pain, redness, hotness, discharge) at the site of the block.

More importantly there should be a next day phone call by the anesthesia team to check for any residual side effects.

-- Loran Mounir-Soliman, MD, Cleveland, OH

Reply 2

Please refer to the following references

Boezaart AP. Perineural infusion of local anesthetics. Anesthesiology 2006; 104: 872-80 (gives good practical guidelines)

Wilson AT, Nicholson E, Burton L, Wild C. Analgesia for day-case shoulder surgery. Br J Anaesth 2004;92:414-5.

-- Girish P. Joshi, MB BS, Dallas, TX

Reply 3

We do not have a specific patient education form for interscalene blocks per se. I do discuss ahead of time with patients and their families that patients undergoing shoulder surgery with ISB may have a droopy eye and changes in the voice in addition to a feeling of SOB but that these are normal side effects of the block and will resolve. I don’t know of any specific references for patient education. I hope this helps

-- Kayser Enneking, MD, Gainesville, FL

QUESTION 2

I'm looking for some guidelines for managing insulin preoperatively, in the free-standing, outpatient setting. Do such recommendations occur within our literature, or within the endocrinology literature? Considering "sweet is better" is really no longer a viable option...

-- M. Herman, M.D. (franz16@comcast.net)

Reply

As your question supports, the medical community’s attention to maintaining ‘tighter’ blood glucose management during the acute perioperative process has increased. In fact, clinicians are no longer routinely telling diabetics ‘we’d rather see you a little bit high than low for surgery’. The reason: it appears that even acute hyperglycemia induces a depression of immune function, neutrophil activity, and physiologic response to endotoxin.

The cumulative effect of continued research into this area has resulted in recommendations that extend far beyond the clinical subgroups of cardiac surgery and ICU patients with the goal being to reduce the number of perioperative complications seen in hospital inpatients and ambulatory surgical patients.

A cross-section of journal articles and commentaries reveals a common experience in facilities that routinely check every patient’s fasting blood glucose pre-operatively. Some are finding upwards of twenty percent of patients have undiagnosed diabetes. It is noteworthy that anesthesiologists in the ambulatory surgical setting are particularly concerned with instituting insulin therapy to patients who have never been diagnosed with diabetes, and/or those who will be discharged home shortly after surgery. The fear here is of post-operative hypoglycemia. Understandably, it is particularly vexing for clinicians to agree on guidelines for stricter perioperative glucose management in the context of persuasive, yet still incomplete, clinical data.

Another method of diabetic detection and monitoring in the clinical setting may be found in the Hemoglobin A1c test (indicates a patient’s blood sugar control over the past two to three months). The hemoglobin A1c level of 8% has been associated with a cumulative/average blood sugar level of 205 mg/dl. In performing pre-op testing of known diabetics , anything over 8% is being seen as an indicator of ‘poor control’ and being referred to the internist or endocrinologist for better education and tighter management. Although guidelines will differ from patient to patient many practitioners will consider surgical case cancellation in known diabetics with Hb A1c values over 8%.

The following is a sample, simplified approach to managing hyperglycemia in surgical ‘outpatients’:

Every known diabetic receives an HbA1c level test—ideally checked within 7-10 days prior to surgery. Every patient over the age of 30 years receives a fasting blood sugar (FBS) ‘stick’ (if no fasting BG has been performed within 2 weeks prior to surgery).

Unknown Diabetics, with an abnormal FBS > 200mg/dL, receive a spot HbA1c test.

If HbA1c >8%, the Surgeon and Anesthesiologist will talk and come to an agreement as to whether to delay or proceed with the case.

If the FBS is greater than 250mg/dL, there is strong consideration for case cancellation; the patient is referred back to their PCP. All final decisions regarding case cancellation remain open to discussion between the surgeon and anesthesiologist.

-- Adam Frederic Dorin, M.D., MBA

QUESTION 3

I work at a free standing outpatient surgery center (not connected to a hospital /no lab/ no overnight rooms). One of our ENT Surgeons has requested privileges to perform parathyroidectomies. We are concerned about discharging the patient within the same day as well as inability to monitor labs, and potential airway complications. Any opinions would be welcome.

-- JM, CRNA, Houston, TX

Reply

This is another example of market pressures affecting medical care. Having said that, most of these cases can probably be safely managed as outpatients. In terms of airway concerns (excluding neck hematomas) most occur soon after surgery and should not be an issue. About half of the neck hematomas (overall incidence of 0.4%) evolve over 6-8 hours while rarely occurring past 24 hours. Furthermore, not being able to monitor labs should not be a limiting factor in deciding whether or not these procedures should be performed on an outpatient basis. There is just as much evidence supporting the need not to check calcium levels on asymptomatic patients as there is on checking calcium levels on all patients peri-parathyroidectomies. The keys to making this a safe practice involves 1) appropriate patient selection 2) extended monitoring, particularly for neck hematoma formation and 3) clear, protocolized patient instructions for postoperative concerns.

-- Allan Siperstein, MD, Cleveland, OH

QUESTION 4

This issue comes up almost weekly at the Ambulatory Surgery Center in our VA hospital. Many of our patients admit to cocaine use. I am sure there are many who deny it too. Our policy has been to urine test every patient who admits to use when having his or her preop evaluation. If the urine test is positive for cocaine, the surgery is cancelled. For marijuana, we go ahead and do the case. I would like to know what my colleagues do. We have been criticized for this policy because we are probably missing as many (+) tests due to the general unreliability of these patients. Thanks.

--Dana N Wiener MD, Durham, NC

Reply

In our practice we do not postpone the case for marijuana. For patient positive of cocaine, we go ahead with the case if the corrected QT interval is less than 500 ms. (reference Hill et al: General anaesthesia for the cocaine abusing patient. Is it safe? British Journal of Anaesthesia 2006; 97: 654-7, this study was done at our place).
Obviously, we have also to consider the patient as a whole. For example, even if the cQT is <500 if the patient has significant comorbidities, we may postpone the surgery. The practical problem is that there is no guarantee that the patient will be cocaine free for the next time around.

-- Girish P. Joshi, MB BS, Dallas, TX

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

QUESTION 1

What is your opinion of the feasibility of performing outpatient sinus surgery on patients with “longstanding minimally positive stress tests” with reasonable ejection fraction?

--Anonymous

QUESTION 2

I would like to know what advice my colleagues are giving to breast-feeding mothers post-operatively. We are still recommending that these patients pump and discard breast milk for 24 hours following their ambulatory surgical procedures. Given the fact that this can be onerous for some women and that such a small amount of drug ends up in breast milk, is this recommendation warranted?

--E.N. M.D. Hagerstown, MD (majopael@aol.com)

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