Volume 7, Issue 2 S A M B A T A L K S - PAGE 2 July, 2007

JOIN THE DISCUSSION - TOP

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 QUESTION WITH REPLIES - ?? - TOP

Question 1:

What is the consensus of free standing ambulatory surgery centers on the issue of: surgeries associated with higher risk of urinary retention and mandatory or individual necessity of voiding postoperative. How long do you wait? Do you restrict fluid in these cases? Narcotics?

-- From: Carolyn Sprague, West Bloomfield, MI (cspragu1@hfhs.org)

Reply 1:

Let us start off by saying that despite our large volume of cases, it is extremely rare that we have to admit a patient for postoperative urinary retention (whether dealing with low or high risk patients). Having said that, we rarely use spinal or epidural anesthetics for our cases simply due to the challenges with a timely discharge. We have remained “old-fashion” in the sense that we require almost all of our patients to void before discharge. If a patient must go to an ER for urinary retention after discharge, it is a major source of dissatisfaction with our care.  In cases where a patient has urgency, we may use our ultrasound capabilities in helping decide whether or not to straight catheterize these patients.  We do not necessarily fluid restrict but do try and reduce narcotic usage (for all of the “usual” reasons in addition to risk for urinary retention). 

As you know there is not a significant amount of information on this topic in the literature.  The study done by Pavlins group published in Anesthesiology in 1999 is the most recent classic and frequently referenced study on this topic.  Part of their conclusion recommends that high risk patients should have their bladder volume monitored and drained if they are unable to void despite a volume > 600 ml. In centers that do not have ultrasound capabilities, high risk patients should have their bladder evacuated if unable to void when otherwise ready for discharge. They also emphasize that all patients should be cautioned to seek medical attention if unable to void within 8-12 hours of discharge.  Hope this helps.

-- From: Douglas Mayers, MD,PhD and Ali Jahan, MD, Cleveland, OH

Reply 2:

This question balances the downside of delaying a patient’s discharge with the risk of a having a postoperative complication occur at home.  We do not require voiding before discharge with routine cases.  If urinary retention is a concern (as in the “high-risk” situation), patients should void prior to leaving.  Patients with appropriate fluid management should be able to void by the 2 hr mark. It is probably better to resolve the problem before discharge. Furthermore, adequate volume management should not be compromised. What benefit would result from fluid restriction; delayed diagnosis of urinary retention?  Also, adequate volume replacement is one of the cornerstones of nausea/vomiting prevention in the ambulatory setting.  Adjuvant analgesics or regional analgesic techniques can be used to spare opioid medication but should not result in inadequate pain control.

-- From: Marguerite Group, MD, Cleveland, OH

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

There is a lot of debate about the management/care of OSA patients in the outpatient surgical setting.  Can someone provide me with a general guideline that would not be overly restrictive to posting cases, but also serve to preserve quality patient care and safety (i.e., keep the owners, surgeons, nurses and anesthesiologists all happy)?

-- From: Anonymous

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