SAMBA Talks eNewsletter - January, 2006

Volume 5, Issue 8

S A M B A T A L K S - PAGE 2

January, 2006

JOIN THE DISCUSSION - TOP

Need advice about a problem case in ambulatory anesthesia? Want suggestions about a difficult situation in your ambulatory surgery center? Have 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" here.

To enter the Discussion with a question, reply, or other comment, please contact us. Your submission 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 replies below does not represent SAMBA policy. The replies are solely the opinions of the individuals who wrote them.

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

CONGENITAL HEART DISEASE IN THE AMBULATORY SETTING

I work in a free standing outpatient surgery center and am anesthetizing patients presenting with congenital heart disease for non-cardiac surgery. What are the current recommendations for their peri-operative management in the ambulatory setting?

-- Anonymous

REPLIES:

Here at CHOP, we have a large population of kids with CHD, and 3 free-standing surgicenters in the surrounding community where we provide anesthesia services. We have no official policy, and there are no recommendations or guidelines by any official body that I know of. Kids with CHD who are actively being followed by their cardiologist need a letter of clearance for surgery. The cardiologist then makes the determination whether the child needs:

A cardiac anesthesiologuist, or
A regular anesthesiologist, or
OK for surgicenter.

Any child with inactive disease (ie palliated) and hemodynamically normal is OK for the surgicenter. Any child with active disease and hemodynamically normal is OK for a general anesthesiologist but in the Main hospital.

-- Ron Litman, MD, Philadelphia, Pennsylvania

It is difficult to give any set of recommendations that would apply to the broad spectrum of patients with congenital heart disease. Basic considerations regarding equipment, facility, and personnel for institutions where pediatric anesthesia is to be provided are addressed by the American Academy of Pediatrics Section on Anesthesia in the document "Guidelines for
the Pediatric Perioperative Anesthesia Environment."

Regarding cardiac disease per se, this is an excellent example of a situation where selection criteria for outpatient surgery may differ between a free-standing ambulatory center and hospital-based outpatient surgery. Even if the anesthesiologist is comfortable with the physiology of the particular patient's heart disease, the potential need for and availability of a consultant cardiologist and for postoperative admission (including intensive care) should be considered.

There are no specific written guidelines on this topic, but my opinion would be that children who have had anatomic correction of a congenital heart lesion and have good functional status would be reasonable candidates for minor outpatient surgery in a freestanding center. The anesthesiologist should still have prior access to information regarding the repair and any residual problems such as arrhythmia, heart block, remaining valvular stenosis or regurgitation, or pulmonary vascular stenosis. Patients with simple unrepaired lesions such as a small VSD with left to right shunt may be acceptable for outpatient surgery, but unrepaired complex lesions or palliated congenital heart disease (e.g children with Fontan physiology) are probably best cared for in a hospital setting, even if the procedure is done on an outpatient basis. Communication with the cardiologist if there is any question about the physiology or current status is helpful. The AHA guidelines for SBE prophylaxis, which stratify both on patient disease and planned procedure, should be followed.

References:

Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA 1997;277:1794-801.
Hackel A, Badgwell JM, Binding RR, et al. Guidelines for the pediatric perioperative anesthesia environment. American Academy of Pediatrics. Section on Anesthesiology. Pediatrics. 1999 Feb;103(2):512-5.

-- Lucy Everett MD, Boston, Massachusetts.

With regard to the January discussion about ambulatory surgery in patients with repaired congenital cardiac conditions, I have one comment about the role of the cardiologist. In my limited experience with these patients, the cardiologist showed a tendency to default to a decision that the patient needed a cardiac anesthesiologist. That may not be in agreement with the assessment of the anesthesiology team. I have found that the cardiologist provides invaluable advice in the preparation for surgery. However, I do give very significant weight to the judgment of the cardiac and ambulatory oriented anesthesiology staff with regard to the decision about staffing for the anesthetic.

-- Robert Knapp, D.O., J.D., Boston, Massachusetts

?? -- THIS MONTH'S QUESTION -- ?? - TOP

In an outpatient surgery setting, do the benefits of induction rooms outweigh the costs? If you are building or renovating an outpatient surgery center, should induction rooms be included in the plans? How does one begin to assess whether this is worthwhile?

-- Anonymous, Toronto, Ontario.

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