Volume 6, Issue 8 S A M B A T A L K S - PAGE 2 January, 2007

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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

What is your opinion of the feasibility of performing outpatient sinus surgery on patients with “longstanding minimally positive stress tests” with reasonable ejection fraction?
I should also clarify that the procedure requires general anesthesia for several hours and frequently involves 200-400 ml blood loss at my facility.

-- Heide Rice, MD, Miami, FL (HRice@med.miami.edu)

Reply

I think there are several issues that would influence my opinion on the feasibility of performing this procedure on an outpatient basis.  First, what is a “minimally positive stress test”, and more importantly what is their functional status.  Second, is the outpatient facility freestanding or connected to a hospital with the point being, how easy would it be to admit the patient?  Third, what is the patient’s baseline hematocrit and coagulation profile? Fourth, are they medically optimized; candidate for aggressive beta-blockade, statin etc… And finally, do they have a reliable escort and caregiver at home?  If all of these issues are in order (including ease to admit if needed), I would not have an issue with proceeding, otherwise I would be hesitant and evaluate on a case-by-case basis.

-- Ali Jahan, MD, Cleveland, OH

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)

Reply

We don’t have written guidelines about this topic probably because this is a rare occurrence at our institution. At the same time, I can appreciate the struggle with this issue. Anytime a newborn may be affected by a medical decision, we have to be extremely careful with the possible consequences; hence we usually error on the side of caution. 
Having said that, there is no good data to support the stance on discarding milk for the first 24 hours following an anesthetic, particularly with our newer generation of anesthetics.  Actually, there is a recent publication out of Northwestern University by Nitsun et al (Clin Pharmacol Ther 2006:79:549-57) that showed there was very little drug present in milk within the first 24 hours post-anesthesia.  They evaluated 5 mothers who received midazolam, fentanyl and propofol and concluded that it wasn’t warranted to recommend discarding of breast milk.  Another way I look at this is the following; in the unfortunate situation where a newborn needs an anesthetic for a procedure or a mother needs to have a general anesthetic for the delivery of her child, the baby is exposed to a significantly higher quantity of anesthetic than one can possibly imagine from nursing (with the baby still doing well). In terms of nursing, I have a much higher concern about mothers still taking herbal supplements, particularly ginseng and kava-kava (simply because they are two of the more common supplements which may cause a problem; a detailed list can be found in many references) than I do for mothers requiring outpatient anesthesia.
Hope this helps.

-- Ali Jahan, MD, Cleveland, Ohio

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

I am the medical director of a surgery center in New Jersey.  There is a transportation service used by the facility on a hardship basis to transport cataract patients.  These patients receive propofol for their procedures. The service is used 4-5 times per thousand cases. Clearly a taxi driver or bus driver is not a responsible adult for discharge purposes.  However, this is a patient transportation service which escorts the patients into their houses.  Is this considered a responsible adult?  I would appreciate any help with this dilemma.  Thanks

-- Richard Zalman, MD (Richard.Zalman@atlanticare.org)

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