Volume 4, Issue 6 S A M B A T A L K S - PAGE 1 November, 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. 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 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.

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

QUESTION 1:

Cox-2 inhibitors, such as Celebrex (celecoxib), and Bextra (valdecoxib) are now very popular. They are touted for their safety profile, with reduced, if not absent, anti-platelet, renal and GI side effects.

Nevertheless, some of our surgeons are nervous about patients continuing to take these agents preoperatively. Have we reached the stage where we can safely instruct our patients to take their Cox-2 inhibitors on the day of surgery before coming to the ambulatory surgery facility? Or should we continue the traditional practice that was prevalent with standard NSAIDs, of advising that patients discontinue their Cox-2 drugs for some period before surgery?

-- From Gary Kantor, M.D., Cleveland, OH

REPLY:

The selective COX-2 inhibitors (celecoxib and valdecoxib), a new group of anti-inflammatory and analgesic drugs, were developed to avoid some of the side effects associated with traditional nonspecific nonsteroidal anti-inflammatory drugs (NSAIDs). The selective COX-2 inhibitors appear have similar analgesic efficacy as the nonspecific NSAIDs; however, they do not affect platelet function and reduce the risk of gastrointestinal ulceration. Of note, the cardiovascular and renal effects of selective COX-2 inhibitors remain controversial.  It is suggested the cardio-renal effects of selective COX-2 inhibitors are similar to that of nonspecific NSAIDs. Rofecoxib was recently withdrawn from the market because it has a higher incidence of cardiovascular adverse effects.

Because the selective COX-2 inhibitors do not affect platelet aggregation and thus do not affect perioperative bleeding, they can be safely administered preoperatively. However, one of the major concerns with the perioperative use of selective COX-2 inhibitors is the associated risk of delayed bone and ligament healing.  This is one of the reasons many orthopedic surgeons are reluctant to use selective COX-2 inhibitors for surgical procedures in which delayed bone healing is a concern. However, the effects of selective COX-2 inhibitors on bone and ligament healing remain controversial as there is no good clinical study available.

In summary, selective COX-2 inhibitors need not be discontinued prior to surgery (unless if there is concern of delayed bone and ligament healing).  In fact, the doses may have to be increased preoperatively to achieve superior postoperative pain relief (e.g., if the patient is on celecoxib 200 mg per day it needs to be increased to 400 mg preop). In addition, they need to be administered on a regular "round-the-clock" basis with, opioids used as "rescue" analgesics on an "as needed" basis. Furthermore, combination of selective COX-2 inhibitors with local anesthetic techniques provides superior pain relief. Based on numerous publications, the doses for celecoxib are 400 mg preoperatively followed by 200 mg twice daily, and valdecoxib 40 mg preoperatively followed by 20 mg twice daily.  Because both nonspecific NSAIDs and selective COX-2 inhibitors act by inhibiting the COX-2 isoenzyme, it is imperative that the two groups of drugs are not administered simultaneously. For example, if the patient has received a selective COX-2 inhibitor preoperatively, it is not necessary to administer ketorolac intraoperatively.

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

QUESTION 2:

We are considering doing vaginal hysterectomies at our outpatient ambulatory center. Concerns are related to potential blood loss and post-op pain management. Are there any guidelines regarding doing vaginal hysterectomies at an ASC? This includes both laparoscopic assisted and regular vaginal hysterectomy, and would include a 24 hour stay.

At our facility, 95% of our cases are done as outpatients, being discharged directly from the facility, usually within one hour of their surgery. However, on occasion we do a case that requires the patient stay overnight in the facility, where they are monitored and attended to by an RN, with the backup of a physician available by phone. This is usually procedures such as laparoscopic cholecystectomy and shoulder surgery. The patient usually stays overnight for pain management, especially if they live a distance from the center. There is also an occasional patient that has uncontrolled nausea and/or vomiting, and they also stay until that is controlled. Therefore, I would predict that a high percentage of vaginal hysterectomy patients would require 24 hour stay to observe for bleeding and/or pain control with the option of transferring to the hospital (which is just across the street) if necessary.
 
-- From William E. Strong, M.D., Provo, UT

REPLY:

You have mentioned that your group is considering doing laparoscopic assisted and regular vaginal hysterectomy at your ambulatory surgical center and that it would include keeping the patient at your facility for 24 hours after surgery.  As you have correctly pointed out, postoperative monitoring and observation by a registered nurse, with physician back-up would be necessary.  I am not aware of any guidelines for doing vaginal hysterectomy at an ASC facility.  However, I know of gynecologists who work out of private hospitals and send their patients home the day after undergoing laparoscopic assisted/regular vaginal hysterectomy, if the patients are stable. Obviously, you have to ensure that the patient does not have any ongoing or anticipated bleeding, is hemodynamically stable, is comfortable with adequate pain control, does not have any nausea/vomiting, is preferably voiding urine voluntarily, and is awake, alert, and oriented before discharge from your ASC facility the morning after surgery.  It is reassuring that you have the option of transferring patients to the hospital, across the street, if needed.

-- From Ashu Wali, M.D., F.F.A.R.C.S.I., Houston, TX

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

QUESTION:

I work with a Plastic Surgeon who insists on performing multiple procedures on his patients including liposuction, obtaining from 6 to 10 liters of fat, face lifts, tummy tucks etc. resulting in patient transfer to the nearest hospital for blood-transfusions. I am sure this is not for same-day surgery. The operations are usually 5 to 8 hours long. Guidelines? Suggestions? How do I convince him that this amount of liposuction is DANGEROUS!

-- Anonymous

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