Volume 4, Issue 9 S A M B A T A L K S - PAGE 1 February, 2005

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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 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 below replies 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:

We currently have a policy in place and do ambulatory procedures on patients with implanted automatic defibrillators. We turn them off if any form of electrocautery is to be used. We otherwise leave them on.

Is it appropriate to do such patients in a free standing center and should they always be turned off? We are somewhat concerned in that an AICD may simply be a marker of patients with enough cardiac pathology such that it may be best to simply exclude them.

-- From B. Evans, M.D.

REPLY:

Pacemakers and ICDs are complex implanted devices that have significant implications for perioperative care. Patients need these devices for various reasons and often have coexisting cardiac or other problems. Patients with ICDs may obviously have severe cardiac problems including ongoing ischemic cardiac disease (with previous myocardial infarctions) or severe cardiomyopathy. Only "minor" procedures would seem reasonable in a freestanding center for these type of ASA 3 and 4 patients. Your rapid access to cardiology assistance would also be a factor.

When you have a patient with cardiac devices you should consider:

• Why does the patient have the device? How long has it been there?
• Does the patient have a "Device ID Card"? (Make, model, serial number)
• When was the last time the device was checked? Battery status?
• Is the device near its replacement time? Replace it before an elective procedure!
• For pacemakers - is patient hemodynamically dependent on device? Underlying cardiac rhythm?
• For ICDs - what is the "shock" history?
• What is the hemodynamic response to electrical pacing? (Do all pacing "spikes" on ECG cause peripheral pulses?)
• What are the programming parameters? (Printout from interrogation)
• Does the device have "rate modulation" biosensors? What about battery saving auto-search routines? (Turn them off, usually)
• What will happen when a donut magnet is applied? Is the response programmable? (Ignored, fixed rate, shuts off, for how long?)
• Should the device be re-programmed prior to procedure?
• What heart rate will be appropriate to meet metabolic demands for the procedure?
• Are a defibrillator and an external pacing device available in your facility? (they should be)
• Have you consulted a knowledgeable Cardiologist and the device manufacturer concerning recommendations?
• ALWAYS consult with a Cardiologist if the patient has a device for Long Q-T or Cardiomyopathy, or is a pediatric patient.
• Re-interrogate device after the procedure to ensure proper functioning and battery life if electromagnetic interference (EMI) was present.

Preoperatively, you need to be sure the device is in good working order. Interrogation before the anesthetic is the only way to do this.

The following comments address ICDs. Pacemakers have an even longer set of issues (see Rozner reference).

Turning off the ICD is essential when EMI is anticipated. This prevents EMI induced ICD shocks. Turning it off with a programming device is the only way to do this with some ICDs. A donut magnet may elicit auditory (some Guidant) or no (Medtronic and others) indication of the active status of the ICD. With Medtronic ICDs, a Smart Magnet® is the only way to know if temporary magnet suspension of the device has been achieved. However, magnets may encroach on the surgical site, or slip off during the case.

Patients who have procedures performed without the use of electrosurgical units (ESU) or other EMI, may have an ICD left in the "active" mode. HOWEVER, if a shock is delivered by the device, the patient may move suddenly. If a sudden movement could cause surgical
injury during a procedure (e.g. during an eye or middle ear operation), then this is a plan with some risk.

After any case with EMI exposure, cardiac devices should be checked to ensure proper functioning before the patient leaves the facility. Check with the device manufacture about any new information. This is a rapidly changing area of medicine. Don't assume.

These patients take much more time to care for in the perioperative period. Only you can decide if this is worth it in your practice.

References:

1. Heart Rhythm Society (NASPE): http://www.hrsonline.org/
2. American College of Cardiology: http://www.acc.org/
3. Rozner MA. Intrathoracic Gadgets: Pacemakers and Defibrillators in the New Millennium. ASA Refresher Course Lectures 2004
4. ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices. Circulation 2002; 106:2145-61

-- From Scott R. Springman, M.D., Madison, WI

QUESTION 2:

Is pregnancy testing necessary for EGD/Colonoscopy on female patients?

-- From Mahendra Shah, M.D., Trenton, NJ

REPLY:

The practice of routine preoperative testing has been under constant review and revision with current practice tending toward more focused testing driven by the patient's coexisting physiologic disease states, and how information gained would alter the course of an anesthetic. The question becomes in early term pregnancy how would a positive pregnancy test change the management of the anesthetic? In our literature, there is currently no scientific data to support that any anesthetic drug can harm an early human pregnancy. Furthermore, the ASA Committee on Ethics has written that the "State of pregnancy is very personal information that belongs to the patient, and it does not alter her right to proceed with anesthesia and surgery if she so desires. Therefore, pregnancy testing should be offered to patients but should not be required by physicians unless there is a compelling medical reason to know whether the patient is pregnant." They continue, "The Committee on Ethics maintains that a blanket policy of non-consented testing for pregnancy cannot be ethically justified. Beyond not being ethical, it also may not be legal to test a patient for pregnancy without her consent."(1) So, if the provider or patient has a high index of suspicion then pregnancy testing should be offered, but as to being necessary or routine, the current scientific and ethical evidence would not support that opinion.

References:
(1) Palmer, S., Jackson, S. "What's New in Ethics, Hot Issues in Legally Sensitive Times", American Society of Anesthesiologists Newsletter, Oct 2003, Number 10, Volume 67,

-- From John Frenzel, M.D., Houston, TX

QUESTION 3:

Do any ambulatory surgery sites have criteria-based discharge phone call processes? We are currently attempting contact with 100%, reaching only 60% of patients.

-- From Christine Barrett

REPLY:

The scope of ambulatory surgery is evolving. Newer minimally invasive techniques continue to allow us to perform procedures in lesser intensity facilities with faster recovery. We need information on our patient’s well being quickly so that we can assess our programs and make continual improvements. Additionally our patients will appreciate the caring reassurance that a timely follow-up provides.

We should make every effort to call our patients post-operatively quickly. Given these great goals, getting call backs done successfully is a fine art.

I surveyed several of our units including outpatients processed in our large hospital based surgery units as well as two free standing surgery centers. Additionally we asked about a system that requires contacting patients for expedited appointments.

The hospital based unit performed at about the 50-60% rate. What we found was that they were using intake forms that did not have space for updating contact information. Subsequent calls were made using phone numbers stored in the main admitting system. We are modifying this approach but due to the lag time to change forms I don’t expect immediate improvement.

An additional problem that we encounter is not contacting the patient directly or with answering machines. Many patients having cosmetic procedures want this information guarded closely. This preference in combination with HIPPA guidelines have limited our aggressiveness of tracking down individuals.

Happily, our free standing surgery centers have had excellent (95+ %) success. Both centers ask for a contact number (cell, home, hotel, etc.) when they are giving discharge instructions. They inform the patients and their responsible adult that they will be called the next day. One of the nurses compares the discharge sheets to the surgical schedule to ensure that no one is missed. Also if they cannot contact the patient on day one they try again the following day.

One of our departments has a system for rapidly returning results for expedited appointments. When the patient cannot receive an appointment directly on the first phone contact, they are guaranteed a phone call within 24 hours. Patients have been very happy and with their motivation to get an appointment, usually give good contact options.

We have also used standardized scripts when we interview patients. By planting an encouraging word during our evaluation, we have seen definite improvements in our patient satisfaction results.

We need to continue to define our patients concerns, be they nausea and vomiting, pain, or scheduling problems to name a few. The only way we can make improvements is to find out this information. Based on our experience, finding an honest contact number prior to discharge is the most likely to yield results.

-- From Robert Helfand, M.D., Cleveland, OH

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

QUESTION 1:

I am a nurse working in GI Endoscopy. We are updating our protocols and procedures. I would like information regarding cardiac monitoring during GI Endoscopy in a patient receiving moderate sedation. What does the ASA recommend?

-- From Grace Smith, R.N., B.S.N., C.G.R.N., Rochester, NY

QUESTION 2:

Should pregnant patients receive anesthesia (general, Bier blocks, axillary blocks) for surgery in free-standing ASC's?  Would doing digital or wrist blocks place any risk on the ASC? 

-- Anonymous

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