SAMBA Talks eNewsletter - March, 2006

Volume 5, Issue 10

S A M B A T A L K S - PAGE 2

March, 2006

JOIN THE DISCUSSION - TOP

Need advice about a problem case in ambulatory anesthesia? Want suggestions about a difficult situation in your ambulatory surgery center? Have 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" here.

To enter the Discussion with a question, reply, or other comment, please contact us. Your submission 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 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

FIBEROPTIC BRONCHOSCOPES IN SURGICENTERS

Should fiberoptic intubation equipment be required in Surgicenters?
Are alternatives such as the Glidescope acceptable?

-- Nancy Fisher MD, Salem, OR

I think any anesthetizing location, including Surgicenters, should have a difficult airway cart available, with facilities for awake intubation. One never knows what comes through the door. Time and again, physicians and nurses are surprised to be confronted with unanticipated difficult airway patients.

Even though it is invaluable, it is not necessary that a fiberoptic bronchoscope be available. Fiberoptic bronchoscopy was the gold standard of difficult airway management and awake intubation in the past. I do not think it is true anymore. Currently, there are so many other devices, including the various fiberoptic laryngoscopes (in alphabetical order - Bullard Scope, Glidescope, Levitan Scope, Shikani Stylet, Upsher Scope, and WuScope) that can assist in visualized tracheal intubation.

In addition, it should be mandatory to have supraglottic airways available on the difficult airway cart, including the Combitube and the LMA family for rescue oxygenation. Of course, the classic LMA, Fastrach, and now the C-trach can be used for both ventilation and as conduits for tracheal intubation. A gum elastic bougie can come in handy, at times, to assist in intubation.

Finally, it is the comfort level and the skill set of the operator that matters. Such attributes come with experience which, in turn, can be fine tuned by electively practicing on mannekins and simulators, at difficult airway courses, and in patients with normal airways.

-- Ashu Wali, MD, Houston, TX

The glidescope is not an alternative to fiberscopes; thus it cannot replace the fiberscope; it may alleviate the need for a fiberscope in some situations but certainly cannot replace the fiberscope. Addiitionally, pediatric sizes of the glidescope are still not commercially available.

Are fiberscopes a requirement in surgicenters?
No, they are not a requirement but are listed as a suggested method to an alternative non-invasive approach to take care of a patient with a difficult airway. If the anesthesia practitioner is not comfortable with fiberscope technology use but is familiar with a supraglottic device (such as an LMA), then fiberscopes are not a requirement; however, in many instances fiberscopes are very helpful and most practitioners are currently familiar
with their use.

-- Kumar Belani MD, Minneapolis, MN

I think the fiberoptic bronchscope is still the gold standard for difficult intubation. However, this requires that the user be skilled in the use of this instrument. Just having a fiberoptic bronchoscope available is not enough. There are other devices available but I am not
ready to give up my fiberoptic scope at this time.

-- Grover Mims MD, Winston-Salem, N Carolina

I agree that the fiberoptic scope is the gold standard; however for those of us practicing OBA, we usually don't have one available & we certainly can't afford to stock them in every office. We do have a cricothyroidotomy setup in every anesthesia machine in the office. We
also have LMAs (FastTrach in one office) & Cobras - no combitubes, but that is a good idea.

While office based anesthesiologists will say that the key is patient selection - meaning any pt with potential for difficult airway is excluded from the office, we can & have had difficulties. I recall a liposuction of the neck under MAC (not my pt) where the surgeon got
into either the EJ or IJ & the anesthesiologist had a very difficult time intubating the pt - so it can & indeed does occur in OBA!

-- Melinda Mingus MD, New York, NY

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

QUALITY ASSURANCE - HOW TO BEGIN?

Our anesthesia group has obtained the exclusive contract at a new outpatient surgery center to open in Feb 2006. I have been assigned the duty of QA/QI. Does anyone have any pointers on where to begin this process. I have been doing research on the JCAHO and OSHA web sites. Any other pointers. Thanks.

-- Shonna Parks

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