Volume 4, Issue 1 S A M B A T A L K S - PAGE 1 June, 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. 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 know of any studies examining whether gender influences recovery
after ambulatory surgery under general anesthesia?

-- From Danilo Soto, Puerto Ordaz, Venezuela

REPLY:

I am not aware of any studies which have directly examined the influence of gender on recovery from general anesthesia in ambulatory surgery patients. One study of inpatients has shown that women emerge faster than men from general anesthesia with inhalational anesthetic agents (Myles PS et al, BMJ 2001;322:710-1). Another, which did not indicate the inpatient/outpatient status of their subjects, showed that women also emerge faster after general anesthesia with propofol/alfentanil/nitrous oxide (Gan TJ et al, Anesthesiology 1999;90:1283-7). The authors of these studies suggested that these findings may be due to women being less sensitive to the sedating effects of propofol, more rapid clearance of propofol in women than men, and/or hormonally-regulated functional changes in the γ -aminobutyric acid receptor (which is the site of action of most intravenous anesthetic agents).

Despite these differences in speed of emergence, gender has not been demonstrated to influence discharge time. Although I know of no studies which have specifically involved outpatients, two studies of inpatients and one study in which the inpatient/outpatient status of the subjects was not indicated, all demonstrated similar PACU discharge times for women and men (Myles PS et al, BMJ 2001;322:710-1; Waddle JP et al, Anesth Analg 1998;87:628-33; Taenzer AH et al, Anesthesiology 2000;93:670-5). These findings may be attributable to a higher rate of complications in women, which delay discharge from the PACU. For example, nausea and/or vomiting in the PACU are well known to occur more frequently in women than men, and hypertension in the PACU has also been demonstrated to occur more frequently in women (Rose DK et al, Anesthesiology 1996;84:772-81). Failure to find an effect of gender on PACU discharge may also reflect the predominance of other factors effecting time of discharge, particularly institutional system factors.

-- From D. Daley, M.D., Houston, TX

QUESTION 2:

What are your guidelines for pre-op lab requirements in the freestanding surgery center?

-- From Diana McDaniel, R.N., M.S.N.,  Evansville, IN

REPLY:

Preoperative laboratory tests in the freestanding surgery center should be the same as those used anywhere that elective surgery with anesthesia is performed. The ASA has developed a Practice Advisory for Preanesthesia Evaluation (last amended in 2003; available at http://www.asahq.org/publicationsAndServices/preeval.pdf) which applies the same recommendations to general anesthesia, regional anesthesia and moderate to deep sedation, for elective surgical and non-surgical procedures. They do not supply different recommendations for different anesthetizing locations.

Help in determining which tests to order can be obtained in the Practice Advisory mentioned above. This Advisory emphasizes that routine tests are not medically necessary, but tests should be performed on a selective basis, taking into consideration such factors as the patient's age, type and severity of pre-existing illnesses, and magnitude of the proposed procedure. Examples of indications for certain tests are included in the Advisory. Of course, any legal requirements in your region must be known and complied with.

-- Anonymous

- THIS MONTH'S COMMENT - TOP

Where is the limit in ambulatory surgery? Many meetings in ambulatory surgery around the world deal with this topic, but I want to expose two practical scenarios.

The general surgeons in my facility refuse to do cholecystectomies on an ambulatory basis; moreover, they have concerns about ambulatory hernia repairs. All of this is because we are in a rural setting. Despite this, our orthopedic surgeons are planning to do hip replacements as ambulatory procedures soon, and our neurosurgeon wants to do discectomies on an ambulatory basis. There are scientific papers supporting ambulatory discectomy and hip replacement, so …. How can I say "no" to them? Personally, I would like to try to do both of them as ambulatory procedures and develop our own experience. Surpassing the limit, what would you think if someone shows in a scientific paper that they have excellent experience with ambulatory renal transplantation (as an extreme example): would it be justified to go so far? Is it too much to say, “Let’s try it to see what happens?”

My second scenario focuses on social and postoperative conditions. What is the rate of a patient’s use of clinical care at home in your ambulatory centers? Do the patients have easy access to nursing care at home for the administration of drugs and management of catheters? What social conditions do your patients have? Do all of them have bathrooms in their houses? I am exposing this because in my country there is a great pressure for the public health system to do more ambulatory surgery, but without the same emphasis on the social conditions like those mentioned above. The systems providing clinical care at home are all private and very expensive, we have no nurses to go to the patients' homes, some of our patients don’t even have bathrooms at their homes, and in other cases, they sleep with 1 or 2 more people in the same bed. All of these conditions make it difficult to achieve the “ideal ambulatory surgery.”

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

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

The following two questions deal with similar issues and may be considered together when replying.

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

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

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