Volume 4, Issue 2 S A M B A T A L K S - PAGE 1 July, 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 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 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:

Malignant Hyperthermia (MH) is an unusual event but dangerous when it happens. It can develop in any moment of an anesthetic procedure. Does someone have any experience with MH in ambulatory surgery? Is it possible that a patient can develop MH after being discharged to home? Knowing the higher safety of IV anesthetics, does anyone allow patients with known risks to develop MH, to be done on an ambulatory basis if only IV anesthetics are used?

-- From Germán Seckel V., M.D., Los Angeles, Chile

REPLY:

MH can and does occur in any setting where anesthesia trigger agents are administered, be it in a hospital, ambulatory center or office.

I do not believe that MH will occur if the patient has done well for four hours postoperatively and has had no unusual postoperative complaints.  However, some rare patients may develop rhabdomyolysis after being discharged, but not the full blown syndrome.

MH susceptibles may have anesthesia in an ambulatory setting.  Non trigger agents, local anesthesia, intravenous agents and nitrous oxide may be used without problem.  Patients should be monitored for 2-4 hours postoperatively .

Dantrolene sodium should be available wherever MH trigger agents are employed.

-- From Henry Rosenberg, M.D., C.P.E., Livingston, NJ

QUESTION 2:

Does SAMBA have any recommendations on performing surgery and anesthetics on patients at risk for Malignant Hyperthermia? For example, patients with a direct family history of MH or with a muscular disorder like Muscular Dystrophies?

I'm a medical director of a free standing surgicenter, and different anesthesiologists I've asked have differing opinions. What is your opinion?

-- From K. Ando, M.D., Phoenix, AZ

REPLY:

Patients who are MH susceptible or who suffer from muscular dystrophy or other myopathies may be anesthetized with regional or local techniques, with intravenous agents, with non-depolarizing neuromuscular blocking agents and nitrous oxide in combination with narcotics, sedative, hypnotics, etc.  However, dantrolene should be available wherever such patients are cared for.

-- From Henry Rosenberg, M.D., C.P.E., Livingston, NJ

EDITOR'S COMMENT: Readers are encouraged to visit the MHAUS web site, which includes a Professional's Information Center, a Message Board, and several other features.

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

QUESTION 1:

Does anyone think that laparoscopic gastric banding is an acceptable procedure for a freestanding outpatient facility?

-- From Gerald Kranis, M.D., Miami, FL

QUESTION 2:

We are a small Ambulatory Surgery Center in Ft. Myers, Florida. Recently a surgeon requested time to do a total knee replacement (TKR) here. He said that this was done routinely in many places. I could not verify that with my literature search. To me it seemed in the experimental stages, requiring continuous infusion pumps, etc. Do you have any data, position, or opinion on doing TKRs in an ambulatory setting? We have no facilities to neither give blood nor provide prolonged pain control.

-- From Paul DeLeeuw, M.D., Ft. Myers, FL
 

QUESTION 3:

I am a consultant who assists physicians in the development of freestanding ambulatory surgical centers throughout the US. Overall, the licensing requirements tend to be fairly uniform with one exception; there is a tremendous disparity among health department offices regarding requirements for emergency medications and equipment relative to the age of the anticipated patient population-- specifically, pediatric patients.

Most recently we were apprised by one agency official that a pediatric patient is defined as 18 years of age and younger and that in order to treat patients 14 years of age and older (which was our licensing request) the group would still be required to provide "pediatric
defibrillator paddles, pediatric emergency medications (unit doses), special resuscitative equipment, pediatric surgical instrumentation and pediatric stretchers."  In many other states 14 is considered the cut off for these items, and in some instances it is as low as age 12.Only a few state actually have written codes defining the specific qualifications of a pediatric patient.

Are there any published guidelines from professional organizations, specifically related to anesthesia or peri-operative emergencies, which I can use successfully in dealing with these agencies to provide some level of consistency?  I would appreciate any comments and recommendations you may offer.

-- From Mary Parker, Los Angeles, CA

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