Volume 6, Issue 12 S A M B A T A L K S - PAGE 2 May, 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 at a freestanding multispecialty surgicenter. We do a lot of extensive liposuction procedures. Are there any guidelines about doing liposuctions at ASCs regarding the amount of fat that can be safely removed and fluid replacement?

-- From: Niraja Rajan MD FAAP, Hershey, PA   (hmcphys@HOSC.biz)

Reply:

A relatively 'recent' definitive answer to this very question was formulated by the '98 task force of the American Society of Plastic and Reconstructive Surgeons (ASPRS), which deemed the appropriate 'ceiling' for tumescent injection and aspiration to be "5,000 cc. in...and [roughly] 5,000 cc. out."  Although this issue was previously a significant point of contention between aggressive cosmetic surgeons and their anesthesiologist counterparts, most surgeons today are well-apprised of the safety risks to fluid and electrolyte balance and will religiously adhere to these recommendations.

Other plastic surgery organizations, such as the American Society for Aesthetic Plastic Surgery (ASAPS), also recognize these guidelines.  The American Academy of Cosmetic Surgery 2006 guidelines state the following:

"Liposuction surgery, using the tumescent technique, has been demonstrated to be safe for the routine removal of volumes up to 5,000 mL (supranatant fat). Volumes exceeding 5,000 mL should be removed in select patients without co-morbidities in an approved operating facility. Recommended maximum volumes should be modified based on the number of body areas operated on, the percentage of body weight removed, and the percentage of body surface area covered by the surgery. Liposuction may be safely performed utilizing tumescent local anesthesia only, local plus IV sedation, epidural blocks, or general anesthesia on an outpatient basis. Liposuctions within the recommended volume range typically do not require use of autologous blood transfusion."

Other considerations for the safety of patients undergoing liposuction include the following:

The average liter of tumescent solution contains fifty cc. of 1% lidocaine (=500 mg.).  So, five liters of this solution will contain 2,500 mg. of lidocaine (for a 70 kg. patient, this comes to 35 mg./kg. of lidocaine).  Recommended limits for lidocaine infusion in tumescent fluid range from 35-50 mg./kg.  Hence, any surgery that is planned (or suspected) to involve more than five liters of tumescent fluid should raise suspicion of pushing the safety envelope!

Regarding fluid management of the liposuction patient, there is some disagreement on this subject.  Most anesthesiologists, however, will find that judicious fluid management (the use of a foley--to gauge how much of the tumescent fluid has been absorbed, and to assess how well the patient is mobilizing that fluid for excretion) is safe and appropriate.  The best tools for managing a patient's 'I & Os' include vital signs, urine output, and vigilant attention to any changes in the patient's overall condition/skin turgor/airway.

-- From: Adam Frederic Dorin, M.D., MBA, San Diego, CA

Questions 2 & 3:

I head a free standing surgicenter (10 OR) in Massachusetts and wanted some information on duration of physician coverage: When can the anesthesiologist leave the surgicenter? Are they required to stay until the patients are physically out of the building or can we go when they move from Phase-1 to Phase-2? Your advice is highly appreciated.

-- From: Vijayendra Sudheendr, MD Rhode Island (vsudheendr@cox.net)

I am the Director of Nursing at a free standing ambulatory surgery center in California. I am concerned about not having a physician in our facility while patients are still there. The current anesthesia group does not see the necessity of staying. In the past an anesthesiologist was present until the last patient was discharged home, a system that my staff and I were very comfortable with. Does your organization have a position on this? Thanks.

-- From: Mena Reese, RN, San Francisco,CA (mena.brady@healthsouth.com)

Reply:

Although Medicare, state statutes, and various accrediting bodies will include vague language regarding the 'appropriate supervision' of patients awaiting discharge from the PACU, there should be no disagreement amongst anesthesiologists about this issue.  An anesthesiologist (be it a medical director or his/her designee) should remain in the outpatient surgical facility until which time all patients who received anesthesia (i.e., IV sedation, regional block, and/or general anesthesia) are formally released from the PACU and "discharged home."  In the case of straight local procedures performed by a surgeon and a registered nurse only (e.g., a procedure room case), it is also prudent (but not mandatory) that the surgeon or another physician remain in the facility until discharge home.  Strictly speaking, straight local cases are equivalent to non-O.R. office-based procedures and do not require observation or supervision by a physician during the brief 'STAGE II' PACU stay.  Other than the obvious, potential medical considerations to any patient who has received treatment and/or medications at a surgical facility, it is simply wise risk management and good customer service to have a physician present while patients are still 'in house' in any ambulatory surgery setting.

-- From: Adam Frederic Dorin, M.D., MBA, San Diego, CA

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

What is the consensus of free standing ambulatory surgery centers on the issue of: surgeries associated with higher risk of urinary retention and mandatory or individual necessity of voiding postoperative. How long do you wait? Do you restrict fluid in these cases? Narcotics?

-- From: Carolyn Sprague, West Bloomfield, MI   (cspragu1@hfhs.org)

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