Volume 4, Issue 12 S A M B A T A L K S - PAGE 1 May, 2005

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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. 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 below replies does not represent SAMBA policy. The replies are solely the opinions of the individuals who wrote them.

?? - LAST MONTH'S QUESTION WITH REPLY - ?? - TOP

QUESTION:

It is generally accepted that patients should be accompanied by an adult when they are discharged home from ambulatory surgery, but does anyone have any policies about requiring someone to actually stay with the patient overnight after their ambulatory surgery?

-- Anonymous

REPLY:

This is an excellent question, for which there is no simple answer. Unfortunately, there are no anesthesia or surgical organizations I am aware of who have published guidelines, practice parameters and/or policies regarding this topic. As well, there are no studies in the literature which specifically address this issue.

I believe the main concerns regarding having a patient spend the night alone after their surgery are: 1. will the patient be able to identify and obtain help for any postoperative problems which require urgent medical attention (eg. bleeding, uncontrollable nausea and vomiting…) ?; 2. will the patient be able to perform the necessary functions of daily living (eg. obtaining food and drink, using the toilet…) and/or manage his/her underlying medical conditions (eg. diabetes) despite potential limitations imposed by the anesthesia and/or surgery? Whether these concerns become actual problems will depend on a variety of factors, including the magnitude of the surgery, body area(s) effected by the surgery, type of anesthetic, underlying functional capacity (mental and physical) of the patient, and the presence of underlying medical conditions requiring special attention (such as diabetes with the need for blood glucose monitoring and insulin adjustments). On one extreme will be the young healthy adult having minimal sedation for very minor surgery, and on the other extreme will be the elderly patient with multiple medical problems who is barely able to function independently at the best of times and who has had one of the more invasive procedures which is "pushing the limit" for ambulatory surgery.

In the absence of guidelines from professional organizations or the literature, it is necessary for each institution to examine their patient populations to determine whether they should consider requiring a responsible adult to remain with the patient overnight on the day of surgery, either on a selective and/or universal basis. Unlike the requirement for patients to be discharged home accompanied by a responsible person, this stay-overnight requirement is not directly enforceable. However, proper patient education and early preoperative identification of those who will require this overnight care should aid considerably in maximizing cooperation with such policies.

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

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

QUESTION 1:

We are having an ongoing heated discussion with our ENT physicians about doing surgery at our ambulatory surgery center on patients who are known difficult intubations or appear to be difficult intubations by our standard anesthesia exam. They argue that they are airway experts also with an entirely difficult skill set than Anesthesiologists. Also, they say they have examined the patients in their office and have determined by their criteria that the patients can be intubated. We have brought up the arguments that we don't have the equipment, they say they'll purchase all the equipment. We argue we don't have the back up help, other Anesthesiologist, they argue that their presence constitutes another skilled set of hands as well as our CRNA. Their belief is that if they examined the patient and feel the airway is obtainable, it doesn't matter what our examine shows, even if they patient has been an awake fiberoptic intubation in the past after failed intubation, they will be able to safely obtain an airway in the patient. They have said they will schedule the case so no other cases are occurring so that the MDA can give the difficult airway their full attention. Does SAMBA have any official position on taking care of patients who are known to be difficult to intubate at ambulatory surgery centers?

-- Anonymous

QUESTION 2:

There has been a lot in the literature in the past 5 or 6 years about hypotension during anesthesia in patients treated with chronic ACE inhibitors for hypertension. We have even had a few cases over the years that have only responded to vasopressin. Does anyone have a policy about discontinuing ACE-I for 24 hours or more prior to surgery?

-- From Dana Wiener, M.D., Durham, NC

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