SAMBA Talks eNewsletter - November, 2006

Volume 6, Issue 6

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

November, 2006

JOIN THE DISCUSSION - TOP

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 REPLY - ?? - TOP

QUESTION 1

I am a bit confused on the role of NSAIDs; where I practice, we tell our patients not to use NSAIDs for at least 7 days prior to their scheduled surgery (I think that is due to the bleeding concerns). At the same time I understand that other places use NSAIDs (or at least advocate usage) as part of the pain management regimen by administering the drug either preoperatively, intraoperatively and/or postoperatively.

What is the best way to use NSAIDs and do we have to worry about bleeding? Thanks.

-- Anonymous

REPLY 1

It appears that it is common practice to discontinue non-selective NSAIDs approximately a week before the surgery. The reasons provided for this practice are increased perioperative bleeding and potential effects on bone healing (for orthopedic procedures). Although the effects of NSAIDs on bone healing remains controversial, increased perioperative bleeding may be a concern for certain surgical procedures (e.g., tonsillectomy, plastic surgery procedures, hip replacement, etc.). This is one of the reasons why most practitioners give NSAIDs at the end of surgical procedure rather than preoperatively.

An alternative is to use COX-2 specific inhibitors (the only one approved in the US is celecoxib), as they have no effects on platelet function and thus, no effects on perioperative bleeding. Of note, unlike non-selective NSAIDs, COX-2 specific inhibitors do not have to be discontinued preoperatively for concerns of bleeding. However, the controversy of bone healing with theses drugs still exists (although not very well substantiated in human studies).

However, I believe that discontinuation of NSAIDs may be detrimental to our patients, as it may increase perioperative pain, which may increase postoperative pain as well as have deleterious effects on postoperative outcome (e.g., return to daily function) [Brander et al: Clin Orthop 2003; 416: 27-36].

-- Girish P. Joshi, MB BS, Dallas, TX

CONFLICT OF INTEREST DISCLOSURE: I have received research grants and am a speaker for Pfizer, manufacturer of celecoxib.

REPLY 2

Most surgeons here stop NSAIDs preop. Re-starting NSAIDs *after* surgery provides suboptimal benefit. For ambulatory patients having procedures with risk of blood loss (e.g. large-dissection laparoscopies) or if small bleeding will impact outcome (eg plastic & breast ops), we give celecoxib preop with sip of water as soon as we see the pts, which is ~ 1/2 hr before room entry. For all other patients, we give nonselective NSAIDs preop as soon as the IV is started. Ortho has different issues.

-- Beverly K. Philip, MD, Boston, MA

QUESTION 2

I provide anesthesia services at several independent surgery centers, none of which are attached or affiliated with hospitals. One is owned by an ENT surgeon, who does a good deal of tonsillectomy operations. I am having to deal with increasing pressure to perform "rebleed after tonsillectomy" cases, on patients who have been discharged from the center, either earlier the same day or from days previous. These cases frequently occur after my CRNA has left, so I am the only anesthesia provider in the facility. I feel uncomfortable with these cases in a surgery center for the following reasons:

We have no lab facilities, so there is no way to check a CBC,
We are not able to give blood,
I consider these patients to be full stomachs and difficult intubations, and
I consider these cases to be emergencies (relatively, at least) and not proper for a surgery center.

Does anyone do rebleed tonsil surgery at an outpatient surgical facility?

Also, what about the scenario where the patient is bleeding after tonsillectomy surgery, but hasn't been discharged from the surgery center. Do you do the surgery or send the patient by ambulance to a hospital?

Many thanks.

-- W. M. MD, Quakertown, PA (wmailman@pol.net)

REPLY 1

This is a prime example of how economic pressures of practice and medical decisions are often in conflict. I agree that a redo on a bleeding tonsillectomy who has been discharged is always an emergency and always a full stomach. Is this a frequent occurrence? I am told by my ENT surgeon colleagues that the published rebleed rates are about 4%. We do several hundred tonsillectomies a year in our freestanding ASC and we perhaps have only two or three rebleeds a year.

If a tonsillectomy patient bleeds in PACU on the day of surgery before the OR staff (including anesthesia backup) has left for the day and if the patient has been adequately hydrated and not eaten postop, it seems reasonable to do the correction at the ASC. I say it is reasonable but if the bleeding is heavy it may still be the correct decision to get the patient to the hospital ASAP. These are difficult decisions and must be evaluated on an individual basis.

However, if it is after hours or days after this patient’s surgery, it does not seem reasonable to me. All these patients are considered to have a full stomach so an induction in this situation should have two trained anesthesia personnel especially if it is a child. Furthermore with no lab to check hemoglobin levels and inadequate resources to give blood the patient is subjected to unnecessary risks. It is essential that the patient have proper laboratory evaluation in addition to the surgical repair of the bleed. You cannot properly evaluate one of these patients without the lab. These cases should not be done at the ASC.

-- Douglas B. Mayers, MD, PhD, Cleveland, OH

REPLY 2

I agree with Doug Mayers comments. Caveat being, if there is a rebleed in the PACU, it is probably safer for that person to be treated immediately in the operating room of the ASC rather than to try and transport. Typically, these patients are still somewhat mentally impaired from their anesthetic and may not have full capacity to protect their airway. Therefore, attempting to transfer them is probably more risky than treating them immediately in the ASC. However, rebleeds that are actively bleeding and that have not been appropriately worked up (blood tests, etc) are best treated at a hospital that is equipped with all necessary ancillary support.

-- Paul Krakovitz, MD, Cleveland, OH

REPLY 3

I agree with the all the comments that have already been made. For the patient who bleeds in the immediate post-operative period, that case is probably most effectively handled at the site the surgery took place. These patients can certainly have unstable airways and transportation to another facility might put them at undue risk.

For the patient who typically bleeds several days after the operation, then I do agree that this should be handled at a hospital that has the ability to perform lab testing, to give blood products and would be better equipped to handle a potentially very critically ill patient.

-- Chris Discolo, MD, Cleveland, OH

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

QUESTION 1

I am an anesthesiologist at an ASC in Washington State. I am looking for post-operative guidelines on interscalene blocks to give to patients upon discharge so they know what is normal and what should cause concern. Do you have any such form or know where I can get one?

-- Mary Fischer, WA. (mfischer@yakasc.com)

QUESTION 2

I'm looking for some guidelines for managing insulin preoperatively, in the free-standing, outpatient setting. Do such recommendations occur within our literature, or within the endocrinology literature? Considering "sweet is better" is really no longer a viable option...

-- M. Herman, M.D. (franz16@comcast.net)

QUESTION 3

I work at a free standing outpatient surgery center (not connected to a hospital /no lab/ no overnight rooms). One of our ENT Surgeons has requested privileges to perform Para Thyroidectomy's. We are concerned about discharging the patient within the same day as well as inability to monitor labs, and potential airway complications. Any opinions would be welcome.

-- JM, CRNA, Houston, TX

QUESTION 4

This issue comes up almost weekly at the Ambulatory Surgery Center in our VA hospital. Many of our patients admit to cocaine use. I am sure there are many who deny it too. Our policy has been to urine test every patient who admits to use when having his or her preop evaluation. If the urine test is positive for cocaine, the surgery is cancelled. For marijuana, we go ahead and do the case. I would like to know what my colleagues do. We have been criticized for this policy because we are probably missing as many (+) tests due to the general unreliability of these patients. Thanks.

--Dana N Wiener MD, Durham, NC

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