Volume 3, Issue 8 S A M B A T A L K S - PAGE 1 January, 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 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.

?? - LAST MONTH'S QUESTIONS WITH REPLIES - ?? - 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, M.D., Dallas, TX

REPLY 1:

"Obviously, better pain control is good for everyone. However, there are a couple of studies showing that children have a smoother emergence when given a narcotic. I don't know if this is because of something good about narcotics (such as decreased cough reflex or just being stoned), or just better pain control. If the kids are old enough, why not use a COX-2 agent orally rather than one that might inhibit platelet function? I'd also check with the dentists to see if they have any thoughts on the platelet issue."

-- From Alan P. Marco, M.D., M.M.M., Toledo, OH

REPLY 2:

"Unless there are specific contraindications to the administration of ketorolac, our group tries to make it a habit of administering 0.5 mg/kg of ketorolac as adjunct analgesic for pediatric dental cases. We perform 10-15 of those cases per week and have found ketorolac to be quite helpful. The oral surgery literature has a great wealth of information about NSAIDs and dental procedures. However, we do not use ketorolac in children less than 18 - 24 months of age due to its unknown affects upon the kidney."

-- From Andrew Herlich, D.M.D., M.D., Philadelphia, PA

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

REPLY:

SAMBA does not have any guidelines for this. Below is a description of my duties as Director of the Surgery Center at my institution. I hope this will be helpful."

"The purpose of this position is to supervise all of the operational aspects of the facility. The position is a combination of Medical Director and Administrative Manager. Responsibilities include the direct supervision of the Surgery Center OR Nurse Manager, the Perioperative Nurse Manager and Surgery Center Administrative Staff. In this role the Director is responsible for all JCAHO accreditation issues, QA/QI programs, employee evaluations, counseling and education, coordination of intra and interdepartmental communication, personnel scheduling, facility and equipment maintenance, and adherence to all safety and legal requirements. Daily responsibilities include the supervision of the daily functioning of the units in order to maintain the efficient and cost-effective provision of services while maintaining a high standard of patient care. These duties include the scheduling of surgical procedures and Anesthesiologists, determination of the appropriateness of individual patients and procedures for the facility, communication with all of the physicians that practice at the facility and the maintenance of an efficiently managed unit. The position is also responsible for budget preparation, budget monitoring, the operation of the units within budgetary constraints, and the budgeting and purchase of capital equipment. The Director functions as the liaison to hospital administration and the medical staff office as the representative of the department. As such the Director serves or delegates representatives to various hospital and medical staff committees as directed by hospital administration, maintains records of unit activity and projects unit needs and activities for future planning. The Director reports to the Associate Director for Ambulatory Services for hospital functions and to the Chairman of the Department of Anesthesiology for academic functions."

-- From Jonathan Pregler, M.D., Los Angeles, CA

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, M.D., Beaufort, SC

"I am a staff anesthesiologist at a small outpatient 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, M.D., Fayetteville, AK

REPLY 1:

"This was discussed at the SAMBA Mid Year meeting and at panels, but I don't think there was a consensus. These are higher risk patients, but I don't believe there is an actual cut-off. The most important factor may be the weight limit on the equipment (OR tables). I don't think there is a lot of data out there on this one. Perhaps the answer is to develop a better working relationship with the surgeons so they get some pre-op information about the patient and give you a call - then you could ask more questions or make a decision."

-- From Alan P. Marco, M.D., M.M.M., Toledo, OH

REPLY 2:

"One obvious consideration is your OR bed. OR beds have weight limits that should not be exceeded."

-- From Lance Lichtor, M.D., Iowa City, IA

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

QUESTION 1:

"I received a letter from an insurance carrier, citing that my group's "heavy use of single injection post-operative nerve blocks for pain control....are not medically necessary". The reviewer noted: "Heavy use of single injection post-operative nerve blocks for pain control." The exact commentary follows: "This practice, while within the current standard of care, is controversial. While pain control is clearly medically necessary, it is usually satisfactorily provided with oral narcotics, ketorolac, and NSAIDS. Post-op nerve blocks can, at best, provide only a few hours of relief, and then other means for pain control must be utilized (e.g. Vicodin, etc.). A better technique involves surgical insertion of a tiny catheter connected to a slow continuous infusion pump. These are quickly inserted (<1 minute) by the surgeon and provide relief for days to weeks....and have lower risk (inserted under direct vision by surgeon=no nerve trauma), and probably cost less....These blocks are not medically necessary". Does anyone have any comments regarding this?"

-- Anonymous

QUESTION 2:

The ambulatory surgery center my group covers has a policy that all surgical patients have a current history and physical prior to their procedure. Some of the podiatrists at the center have requested that the histories and physicals on their patients be performed by the anesthesiologists rather than sending them to a primary care doc. Would we be offering a valuable and convenient service to these patients or opening Pandora's Box in terms of added medical legal liability?

-- From John Martucci M.D., Downer's Grove, IL

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