Volume 6, Issue 10 S A M B A T A L K S - PAGE 2 March, 2007

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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 QUESTIONS WITH REPLIES - ?? - TOP

Question 1

I work with a high volume plastic surgery group performing extensive procedures on outpatients. What information is there regarding DVT prophylaxis/risk stratification for outpatients? Thanks.

-- Jill Hester MD, Williamsburg, VA (whester3@cox.net)

Reply 1

Plastic surgery DVT prophylaxis is truly a necessity. The moratorium on abdominoplasty with liposuction in Florida seemed to find DVT as one of the causes of mortality with this procedure. The plastic surgery society, although vague, are very aggressive in supporting DVT prophylaxis. The issues are firstly the fear from the surgeon of bleeding, particularly when a face lift is in the mix. I strongly recommend Lovenox with most abdominoplasties. This is not easy to achieve as an outpatient. We send a nurse to their homes until we are satisfied. Many of these patients are at high risk for a variety of reasons; poor ambulation, presence of abdominal binder (leading to venous stasis), obesity, elderly, previous DVTs, and on hormonal replacement therapy just to list a few.

I have no doubt that "SOME" of these patients should be “prohylaxed”; the question is how, for how long and which patients. There are several DVT risk scores that can be used, details of which will be the topic of discussion at the upcoming SAMBA annual meeting.
I hope that helps

-- F. Barry Florence MD, Stony Brook, NY

Reply 2

The American Society of Plastic Surgeons has several “practice alerts” which address DVT

Iverson RE; ASPS Task Force on Patient Safety in Office-Based Surgery Facilities.  Patient safety in office-based surgery facilities: I. Procedures in the office-based surgery setting. Plast Reconstr Surg. 2002 Oct;110(5):1337-42.

Iverson RE, Lynch DJ; American Society of Plastic Surgeons Committee on Patient Safety. Practice advisory on liposuction. Plast Reconstr Surg. 2004 Apr 15;113(5):1478-90.

-- Lucy Everett MD,  Boston, Massachusetts

Reply 3

Dr. Everett is correct- the references above are the most authoritative ( I actually am part of that ASPS Task Force that develops those  Patient Safety Advisories ) - Another useful reference is Most D, Koslow J, Heller J. Thromboembolism in Plastic Surgery. Plastic Reconstructive Surgery, 2005: 115 (2) 20e-30e.  and provides a list of risk factors for DVT and PE. Patients can then be stratified to low, medium and high risk depending on patient's age, number of risk factors, surgical time and surgical type to determine need for prophylaxis.

-- Rebecca Twersky, MD MPH, Brooklyn, New York

Question 2

The MHAUS guidelines say it's OK to anesthetize MHS persons as outpatients providing triggering agents are not used, and that they can be discharged after 1 hour in PACU plus 1.5 hours in secondary PACU.  However, my colleagues refuse to anesthetize MHS or any first-degree relatives of MHS persons at our freestanding, non-hospital affiliated surgery center.
What opinions do others have on this issue?

-- AG Pashayan MD, Greensboro, NC (agpashayan@earthlink.net)

Reply 1

We constantly have the same discussion here since some of our anesthesia colleagues will not anesthesitize 1st degree relatives and some will. I am aware of the opinion of MHAUS allowing MH patients at an ASC but old habits die hard. The individual practitioner must be comfortable.

-- Doug Mayers MD, Cleveland, OH

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

I would like to hear opinion regarding patients with AICDs having surgery at an ambulatory surgery center.  The question pertains to cataract surgery as well as other surgical procedures performed at the center.  We have one Ophthalmologist who uses retro bulbar blocks which requires sedation levels that currently meet the general anesthesia definition.  According to current guidelines set forth by ASA and the American College of Cardiologist, all AICDs need to be interrogated following surgery prior to removing the patient from continuous cardiac monitoring.  The manufacturing representatives tell me that this is not necessary with their new devices. When I ask them to give me written documentation from their companies stating post op interrogation is not necessary their companies won't put this in writing.  When a Cardiologist writes in his note that a patient has an AICD because they are a constant threat for sudden cardiac death I find it hard to allow that patient to undergo a procedure at an ambulatory center, even if it is a cataract that requires "general anesthesia" for placement of a retro bulbar block.

Gary Thompson, MD, Beaufort, SC (anesmd@bmhsc.org)

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