Volume 3, Issue 10 S A M B A T A L K S - PAGE 1 March, 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.

?? - PREVIOUS MONTH'S QUESTIONS WITH NEW REPLIES - ?? - TOP

QUESTION 1:

Does anyone have specific guidelines/policies regarding Body Mass Index that would limit a potential patient candidate from undergoing a procedure at an ASC? 

-- From  M.T. Reichel, M.D., Beaufort, SC

NEW REPLY:

In our Ambulatory Surgery Center (also small with 2 OR's), after some bad experiences with morbidly obese patients, we decided to set up a cutoff regarding BMI of 35. Since 2 months ago, a trained nurse is running a preoperative evaluation (1 - 2 weeks before the day of surgery) and she uses this cutoff to decide which patients can be done on an ambulatory basis. Anyway, we take the patient's height and weight again the day of surgery and if the BMI is > 35, the anesthesiologist can decide to go on or cancel, depending on the anesthetic technique to be used. If the anesthetic technique chosen is a general, we cancel. We can tolerate a BMI up to 36 or 38 with other techniques if the patient doesn't have an illness like Obstructive Sleep Apnea (OSA). To avoid unhappy surgeons with last minute cancellations we sometimes overbook the OR ("waiting list") to resolve the situation of patients not showing up.

-- From Germán Seckel von Unger, M.D., Anesthesiologist, Chile


QUESTION 2:

I work in an ambulatory facility which occasionally has "special surgical days". On those days,   three to five times the regular daily number of surgeries are done in order to decrease the waiting list of patients (pediatrics, general surgery, and ENT). Does SAMBA have any guidelines or suggestions for this high-volume day?

-- From Celina Beatriz Contreras, M.D., Merida, Venezuela

NEW REPLY:

I think patient safety must be the first priority.  Don't push your team's limits but always have a good safety margin.  Don't let your surgical colleagues put you under pressure.  In case of severe complications, no one will be able to help you and, be sure, you will be criticized and/or punished.

-- From Wellingto Ferreira, M.D., VitÓria, ES, Brazil

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

QUESTION 1:

We do a significant number of cosmetic surgeries at our ambulatory surgery center.  Some of these operations last well over six hours.  We are currently considering limiting the length of surgery that can be performed without an automatic overnight admission for observation.  Are there any guidelines or recommendations currently available to assist in this decision process?

-- From C.C., M.D., Tampa, FL

REPLY:

As you so correctly indicate, many cosmetic surgery procedures can last several hours, and many/most are scheduled as same-day procedures. Unfortunately there are no guidelines or recommendations I am aware of regarding the upper limit of surgical duration which is appropriate for same-day surgery. Although there is evidence in the literature suggesting that longer surgery is associated with both an increased duration of PACU stay and an increased risk of unanticipated overnight admission after ambulatory surgery, these studies provide no information to help formulate specific length-of-procedure guidelines.

I assume you are already tailoring your anesthetic to optimize recovery from these prolonged ambulatory anesthetics. It may also be a good idea to schedule them first thing in the morning to optimize the availability of recovery area nurses and other support personnel at the conclusion of the procedures. I would recommend that you collect data regarding the length of surgery and the duration of postoperative stay and frequency of overnight admission at your center, and make any decisions regarding the maximum length of surgery based on this information. 

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

 
QUESTION 2:

A 28 y/o male is status/post MVA 14 days ago. He was treated then for pneumothorax. How long after a pneumothorax should an elective procedure be done? (I have polled anesthesiologists and thoracic surgeons at my old home (Mass General), and folks here in Phoenix. The consensus seems to be three weeks.)

-- From Joshua A. Bloomstone, M.D., Phoenix, AZ

 
REPLY 1:

The chest surgeons at our institution feel that one should wait 4 to 6 weeks before exposing a patient to a general anesthetic. Their rationale is that it takes at least four weeks for the lung and pleura to fully heal.

-- From Grover R. Mims, M.D., Winston-Salem, N.C.

REPLY 2:

Elective surgical procedures can be performed once the pneumothorax is resolving (i.e., the lung is healing).  If the chest tube drainage is minimal and there are no bubbles, the hole in the lung should be healing and positive pressure ventilation should not reopen it.  One does not have to wait until the pneumothorax is completely gone.  In our hospital (a major trauma center), chest tubes are commonly removed (once the criteria for removal are achieved) while the patients are still on positive pressure ventilation in the ICU. This suggests that ventilation during anesthesia should not be deleterious.  Of course, we should have a high index of suspicion in case problems do occur intraoperatively.

As well, the patient's clinical status plays a major role in the decision making. The patient should be maintaining saturation and not in respiratory distress. A case I had today illustrates some of these points:

A 17 year old with a pelvic fracture 2 days ago was scheduled for repair of the fracture.  On admission after the MVC, the chest X-ray showed some fluid and a pneumothorax.  However, as the patient was comfortable, with no signs of distress and the pneumothorax was small, no chest drain was placed.   Now that the patient was going to have to be ventilated during surgery, there were discussions as to whether we should place a chest tube prophylactically.  However, we decided not to place one and just observe the patient closely, as the pneumothorax was resolving, suggesting that the lung injury was healing.  No problems were experienced intraoperatively.

A chest X-ray on the morning of surgery is also recommended, as illustrated by another case I had today:

A patient with secondaries in the lung was scheduled for brain tumor resection   A lung biopsy was done 10 days ago, after which a chest tube was placed.  The chest tube was removed 3 days ago.  A chest X-ray this morning showed that the pneuothorax had reaccumulated.  Thus, we decided to place a chest tube after the induction of general anesthesia.

-- From Girish Joshi, M.D., Dallas, TX

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

QUESTION 1:

I am a nurse working in an Infertility office. I'd appreciate very much if you could give me feedback on which medicines should be kept in stock for emergency.  Our Anesthesia staff is currently using Versed, Fentanyl and Diprivan for IV sedation during egg retrievals.

-- From Karen R. Rich, Thousand Oaks, CA

QUESTION 2:

The orthopedic surgeons are building a three OR Ambulatory Surgical Center in conjunction with their new office. They want me to be the Medical Director and put my DEA on the line.

The proposed contract is technical and extensive.  The Medical Director shall have extensive responsibility with essentially no authority.  He (me) would provide the DEA number by which all scheduled drugs used in the OR and the PACU will be administered.  I would be responsible for establishing protocols throughout the ASC as well as providing anesthesia services. 

My malpractice will cover all my duties pertaining to anesthetic services, but what about HIPAA compliance, employee substance abuse, harassment issues, disgruntled employees, etc.  My guess is that my malpractice will NOT extend to these other issues. I recognize increased direct and vicarious liability. Is insurance available for me and how much will it cost?

-- From Tod Tolan,  M.D.

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