PATIENT SELECTION

PREOPERATIVE MEDICATIONS

PREOPERATIVE PREPARATION

PREOPERATIVE EVALUATION: History and Physical - TOP

The ambulatory surgery center my group covers has a policy that all surgical patients have a current history and physical prior to their procedure. Some of the podiatrists at the center have requested that the histories and physicals on their patients be performed by the anesthesiologists rather than sending them to a primary care doc. Would we be offering a valuable and convenient service to these patients or opening Pandora's Box in terms of added medical legal liability?

-- From John Martucci, M.D., Downer's Grove, IL

REPLY:

Yes.

The big question is why would you want to do this? A surgical H&P has to include a description of the surgical site and indications for surgery. As an anesthesiologist I'm not interested in writing that note! I'm not sure that you can get paid for both this note and not have it be part of the Pre-Op note that you need to write. Lastly, if you start acting as the primary care doc on this, you assume responsibility for following up on any abnormalities identified.

Why not get a brief note from the patient's PCP- even a recent clinic not would suffice. The facility may be able to declare that the note from the anesthesiologist qualifies as an H&P as well as the pre-anesthesia note, but I would still be careful that this declaration does not attach an unwanted duty to follow-up on the patient.

-- From Alan P. Marco, M.D., M.M.M., Toledo, Ohio

REPLY:

There may be significant conflict of interest/legal issues with Medicare in that one cannot supervise an anesthetic/ perform an anesthetic as well as perform the Primary History and Physical. I was in private practice briefly approx one year ago. The Medicare laws were reasons cited to stop performing the preoperative H&P as well as the anesthetic. Our podiatric colleagues will just have to send their patients for H&Ps to the primary physician or the ASC will have to have another individual available that will not have anesthetic duties as the primary concern.

-- From Andrew Herlich, D.M.D., M.D., Philadelphia, PA

REPLY:

In Michigan, we performed the H&Ps as a service to our non-physician colleagues and their patients. One does have to dust off the old physical diagnosis skills from med school and internship, but it's like riding a bike. Do make sure that you bill for the service.

-- From Thomas W. Cutter, M.D., M.A.Ed., Chicago , IL

PREOPERATIVE EVALUATION: Pre-Op Lab Requirements - TOP

What are your guidelines for pre-op lab requirements in the freestanding surgery center?

-- From Diana McDaniel, R.N., M.S.N., Evansville, IN

REPLY:

Preoperative laboratory tests in the freestanding surgery center should be the same as those used anywhere that elective surgery with anesthesia is performed. The ASA has developed a Practice Advisory for Preanesthesia Evaluation (last amended in 2003; available at http://www.asahq.org/publicationsAndServices/preeval.pdf) which applies the same recommendations to general anesthesia, regional anesthesia and moderate to deep sedation, for elective surgical and non-surgical procedures. They do not supply different recommendations for different anesthetizing locations.

Help in determining which tests to order can be obtained in the Practice Advisory mentioned above. This Advisory emphasizes that routine tests are not medically necessary, but tests should be performed on a selective basis, taking into consideration such factors as the patient's age, type and severity of pre-existing illnesses, and magnitude of the proposed procedure. Examples of indications for certain tests are included in the Advisory. Of course, any legal requirements in your region must be known and complied with.

-- Anonymous

PREOPERATIVE EVALUATION: Pregnancy Testing - TOP

Is pregnancy testing necessary for EGD/Colonoscopy on female patients?

-- From Mahendra Shah, M.D., Trenton, NJ

REPLY:

The practice of routine preoperative testing has been under constant review and revision with current practice tending toward more focused testing driven by the patient's coexisting physiologic disease states, and how information gained would alter the course of an anesthetic. The question becomes in early term pregnancy how would a positive pregnancy test change the management of the anesthetic? In our literature, there is currently no scientific data to support that any anesthetic drug can harm an early human pregnancy. Furthermore, the ASA Committee on Ethics has written that the "State of pregnancy is very personal information that belongs to the patient, and it does not alter her right to proceed with anesthesia and surgery if she so desires. Therefore, pregnancy testing should be offered to patients but should not be required by physicians unless there is a compelling medical reason to know whether the patient is pregnant." They continue, "The Committee on Ethics maintains that a blanket policy of non-consented testing for pregnancy cannot be ethically justified. Beyond not being ethical, it also may not be legal to test a patient for pregnancy without her consent."(1) So, if the provider or patient has a high index of suspicion then pregnancy testing should be offered, but as to being necessary or routine, the current scientific and ethical evidence would not support that opinion.

References:
(1) Palmer, S., Jackson, S. "What's New in Ethics, Hot Issues in Legally Sensitive Times", American Society of Anesthesiologists Newsletter, Oct 2003, Number 10, Volume 67,

-- From John Frenzel, M.D., Houston, TX

PATIENT SELECTION: Age - TOP

Youngest Appropriate Age

I work in an outpatient unit that is connected by a bridge to a hospital that has no pediatrics or pediatricians. The local pediatric surgeon has just adopted us to do all of his elective surgical cases. What is the youngest appropriate age to care for non-premature infants for ambulatory procedures in this setting in order to minimize the risk of peri-anesthetic complications (apnea)?

-- Anonymous

REPLY:

Apnea risk is one of the concerns in ambulatory care of infants, but there is little evidence regarding the risk in healthy term infants. Selection of the procedure is also important; if pain can be managed with local/regional or non-opioid analgesia postoperatively then there can be greater comfort with doing the procedure on an outpatient basis. Many facilities will do healthy term infants for relatively minor procedures (hernia repair, circumcision, etc) on an outpatient basis but as a first morning case and with a somewhat longer period of observation in the facility - 4 hours being an arbitrary number often chosen (Everett LL. How young is the youngest infant for outpatient surgery? in Fleisher, L, ed: Evidence-Based Practice of Anesthesiology; Saunders, Philadelphia, 2004; pp. 419-23.) This also generally does not apply to higher risk populations such as infants with pyloric stenosis.
As the question notes, risk is higher in former premature infants, and has been stratified by Cote (Cote CJ, et al Anesthesiology 1995;82:809-21). Many facilities choose cutoff between 46 and 60 weeks postconceptual ages, or, to simplify, use 6 months post-delivery at any postconceptual age. Anemia or ongoing apnea may extend the risk.

Other concerns include experience of the anesthesia provider, age-specific competency of the nursing and other support staff, and the availability of appropriate equipment. Staff should be PALS-trained and there must be a transfer agreement in place with a facility which could accept pediatric patients. Several studies suggest some increased anesthetic risk in patients under 1 year of age (Morray JP et al. Anesthesiology 2000;93:6-14). The American Academy of Pediatrics Section on Anesthesiology has developed guidelines for the pediatric perioperative anesthesia environment (Pediatrics 1999;103:512-5) which have been echoed by the ASA (http://www.asahq.org/clinical/PediatricAnesthesia.pdf) and Society for Pediatric Anesthesia (http://www.pedsanesthesia.org/policyprovision.html). A basic component of these is the suggestion that each facility delineate what patient ages, populations, and procedures they will undertake. It also recommends that the facility define patients they consider at increased risk, and that those patients be cared for by a pediatric anesthesiologist.

-- From Lucy Everett, M.D., Seattle, WA

PATIENT SELECTION: Pregnancy - TOP

I work at a free-standing surgery center across from a medical center. Recently, a surgeon wanted to schedule an I & D of a breast abscess on a pregnant patient scheduled for an elective c-section in a few days. I was hesitant because of the risk of inducing labor, but more importantly, fetal distress. Is it wise to do this at a free-standing ASC? Should continuous fetal monitoring be utilized in this situation? If monitoring is used, is it incumbent to have the availability for an immediate c-section should problems arise? Are there any limitations on what procedures and when they can be performed as an out-patient on the pregnant patient?

-- From Steven Spiro, M.D., Mission Hills, CA

REPLY:

I think your hesitation about doing this case at your center was understandable. The risk of inducing labor is fairly high in the third trimester, for pelvic and uterine surgery, due to close proximity to the uterus. Even though breast surgery is a little remote from the uterus - the surgical procedure, site of surgery, and the patient's underlying condition have been shown to be associated with a higher incidence of abortion in the first trimester, labor in the third trimester, IUGR, and perinatal mortality.

It is probably not a good idea to operate on a pregnant patient, in the third trimester, at an ambulatory facility without obstetric back-up. Ideally, a labor and delivery nurse, midwife, or an obstetrician should be available intraoperatively to monitor fetal heart tones (FHTs) and uterine contractions. Normally, I & D of a breast abscess is a quick procedure and establishment of FHT monitoring/uterine contraction monitoring may take some time. Therefore, such monitoring may not be practical in this setting. However, as a general guideline, such monitoring should be instituted in all kinds of surgery, if technically possible. Post-operatively, the recommendation is to monitor for FHTs and uterine contractions for at least 24 hours.

Yes, FHTs should be monitored continuously intraoperatively, if technically feasible, and postoperatively.

Obviously, monitoring and any detection of fetal decelerations (late or variable) will necessitate immediate delivery. Facility and personnel to institute immediate delivery of the baby should be available on site. It may not be wise to rush the patient across the street to the medical center for delivery of a compromised fetus for both, safety issues and medico-legal reasons.

Each medical facility should adhere to their institutional regulations regarding surgery for the pregnant patient. Below are some general guidelines, modified from the references mentioned below and adapted for the ambulatory setting:

1. Avoid surgery during pregnancy, if possible.
2. Avoid surgery during first trimester (organogenesis) - high risk for abortion and congenital anomalies. Postpone surgery until second trimester, if possible.
3. Avoid surgery during third trimester - high risk for inducing labor. Postpone surgery until postpartum period, if possible.
4. Preoperative evaluation of patient by obstetrician.
5. Preoperative counselling of patient by anesthesiologist and obstetrician, especially regarding possible effects on fetus from agents and techniques used.
6. A thorough, preoperative airway examination by the anesthesia care team - risk of difficult tracheal intubation is almost 8 times higher in the pregnant patient. A difficult airway cart must be readily stocked and available on site.
7. Prophylaxis against pulmonary aspiration - use of non-particulate antacid, H2 antagonist, and metoclopramide (barring, no contraindications such as bowel surgery).
8. Avoid general anesthesia. Use regional or local anesthesia, if possible - paracervical blocks are contraindicated in a patient with a viable fetus.
9. If general anesthesia has to be used, avoid high concentration of nitrous oxide for a prolonged period of time. It may reduce uterine blood flow (animal studies). It is recommended to add a volatile agent to offset the uterine vasospasm associated with nitrous oxide. The volatile agent also reduces myometrial irritability and may prevent premature induction of labor. Use preoxygenation, rapid sequence induction/intubation, and cricoid pressure.
10. Consider tocolysis, especially in second trimester and third trimester. All tocolytics have cardiovascular adverse effects which should be weighed against the possible benefits of preventing premature labor.
11. Left uterine displacement should be maintained perioperatively (preop, intraop, and postop) in second and third trimester.
12. Monitor for FHTs and uterine contractions intraoperatively, if technically feasible, and postoperatively under proper supervision (labor and delivery nurse, midwife, or obstetrician). Transvaginal probes are available to allow monitoring during abdominal or pelvic surgery. Neuraxial analgesia may mask the pain associated with uterine contractions - therefore, monitoring uterine contractions post-operatively is essential. If necessary, tocolysis can be instituted expeditiously.
13. Maintain homeostasis (normal blood glucose, normal oxygenation, normal blood pressure, and normal carbon dioxide).
14. Document FHTs preoperatively, intraoperatively - if possible, and post-operatively.
15. Have an obstetric back-up (equipment and personnel) on site for monitoring and facilitating delivery - vaginal or cesarean.
16. Prophylax against venous thrombosis.

Good references for this topic include:

1. Nonobstetric surgery during pregnancy by Sheila Cohen, M. D. in David Chestnut's Obstetric Anesthesia, Principles and Practice, 2nd edition.
2. Anesthesia for the obstetric patient for non-obstetric surgery by Joy Hawkins, M. D. in IARS Review Course Lectures, 1997 series.

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

Should pregnant patients receive anesthesia (general, Bier blocks, axillary blocks) for surgery in free-standing ASC's? Would doing digital or wrist blocks place any risk on the ASC?

-- Anonymous

REPLY:

In general, pregnant patients in the third trimester should not receive general or regional anesthesia in ASCs, as the risks of preterm labor and/or fetal distress require the immediate availability of obstetrical and neonatal back-up which is not possible in the majority of ASCs. Only in the very unusual situation that an ASC is within the immediate vicinity of an obstetrical unit, and the appropriate personnel are immediately available, would I consider it appropriate to do these patients in an ASC.

In the first trimester, all non-emergency surgery should be avoided. There is an increased risk of teratogenicity during this trimester, and there may be an increased risk of spontaneous abortion. If an ASC commonly deals with emergency surgery, then pregnant patients in the first trimester may be acceptable candidates.... if the center is ready to also deal with the possibility of a spontaneous abortion.

The situation with anesthesia for surgery at an ASC during the second trimester is less clear-cut. Typically, surgery which cannot be postponed until after delivery is performed during this trimester, as it is considered to be the period during which the combined risks of teratogenicity, preterm labor and fetal distress are lowest. However, obstetrical consultation should be available to assess the need for tocolytic therapy if preterm labor develops, especially in the last part of this trimester. As well, fetal heart rate monitoring is generally recommended after ~16 weeks gestation, and obstetrical personnel should be available to help interpret the results and manage the patient(s) if abnormalities are detected.

Keeping the above in mind, for the majority of ASCs it is probably most practical to simply avoid providing anesthesia (general, Bier blocks, or axillary blocks) for all pregnant patients. However, if one chooses to provide anesthesia to these patients, preoperative consultation with an obstetrician is imperative.

Even digital or wrist blocks may put the ASC at an increased risk. If a toxic reaction (eg. seizure) from an inadvertent intravenous injection occurs, the "full stomach'' considerations and airway changes of the pregnant patient can make the management of such a reaction more difficult than usual. As well, two and not just one patient may be adversely effected by such an event. However, the possibility of an inadvertent intravenous injection from these blocks is very small, and an ASC may decide that the possibility is small enough that it is willing to allow these blocks in pregnant patients. If so, I would suggest that an anesthesiologist should be immediately available in case such a reaction occurs; policies be established which include the precautions which should be taken for pregnant patients, such as left uterine displacement after ~ 20 weeks gestation; and supplemental sedation be avoided, due to the unknown teratogenic effects of these drugs and their potential enhanced potency in the pregnant patient.

-- Anonymous

REPLY:

I feel compelled to add one caveat to the comments on operating on pregnant patients in an ASC or surgical hospital. When fetal monitoring is indicated, one needs to have the staff with the demonstrated and documented competency as well as the equipment. Most ASC's can have the monitors but probably would not have the lawyer-proof staff in the unlikely event that the pregnancy became a problem. For that reason we do not do any pregnant patients at our facility.

-- From Lou Freeman M.D., Fresno, CA

 PATIENT SELECTION : Duration of Procedure - TOP

We do a significant number of cosmetic surgeries at our ambulatory surgery center. Some of these operations last well over six hours. We are currently considering limiting the length of surgery that can be performed without an automatic overnight admission for observation. Are there any guidelines or recommendations currently available to assist in this decision process?

-- From C.C., M.D., Tampa, FL

REPLY:

As you so correctly indicate, many cosmetic surgery procedures can last several hours, and many/most are scheduled as same-day procedures. Unfortunately there are no guidelines or recommendations I am aware of regarding the upper limit of surgical duration which is appropriate for same-day surgery. Although there is evidence in the literature suggesting that longer surgery is associated with both an increased duration of PACU stay and an increased risk of unanticipated overnight admission after ambulatory surgery, these studies provide no information to help formulate specific length-of-procedure guidelines.
I assume you are already tailoring your anesthetic to optimize recovery from these prolonged ambulatory anesthetics. It may also be a good idea to schedule them first thing in the morning to optimize the availability of recovery area nurses and other support personnel at the conclusion of the procedures. I would recommend that you collect data regarding the length of surgery and the duration of postoperative stay and frequency of overnight admission at your center, and make any decisions regarding the maximum length of surgery based on this information.

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

PATIENT SELECTION: Type of Procedure - TOP

Thyroidectomies - TOP

I am an anesthesiologist in New Orleans at an outpatient center. A surgeon in the group where I work is starting to do thyroid surgery there. This includes both subtotal and total thyroidectomies where the patient goes home the same day (not a 23 hr. stay). What are your views on outpatient thyroid surgery?

-- From D.M., New Orleans, LA

REPLY:

I can't let pass this chance to give you my opinion about this topic. The most important risk of this surgical procedure is that it takes place in a tissue too close to the upper airway. There is an unavoidable risk of postsurgical edema, and moreover, the high risk of postsurgical hemorrhage is always present. In my modest opinion, these problems are seen in approximately 2% - 3% of cases, but when they occur, they place the patient at high risk because both can result in serious respiratory problems and lead to death. For all of above, I consider that this surgical procedure shouldn't be included in a same day surgery program.

-- From Enrique Conde Gareca, M.D., Santa Cruz de la Sierra, Bolivia

REPLY:

This is an interesting issue. Two head and neck surgeons at the institution where I work had differing opinions on whether partial thyroidectomy could be done as an outpatient. One saw no problem with the procedure, the other was concerned about the late development of a hematoma with the potential for airway compromise. The latter surgeon had had a recent case of need for urgent neck exploration in a postoperative partial thyroidectomy.

Both surgeons were adamant that total thyroidectomy patients should not be discharged home because of the very real risk of postoperative life-threatening hypocalcemia due to inadvertent parathyroidectomy at the time of the procedure.

Overall this would suggest that same day surgery on the thyroid is potentially risky and will eventually lead to out-of-hospital loss of airway and maybe life. I would encourage your surgeon to seek the opinions of his colleagues at other centers.

-- From P. H. N., Houston, TX


Vaginal Hysterectomies - TOP

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

Plastic Surgery - Multiple Procedures - TOP

I work with a Plastic Surgeonwho 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

REPLY:

This question raises several office surgery safety issues including the length of surgery, performance of combination procedures, large volume liposuction, and transfer of a patient from an office to hospital for treatment.

There are a number of studies that show that combination surgical procedures and extended length of surgery can result in poorer outcomes. Hughes, in the Anesthetic Surgery Journal March 2001, found when liposuction was combined with abdominoplasty the mortality was one in 3,281 procedures-a rate 14 times greater than that for lipoplasty alone. In 2000, the Florida Board of Medicine limited office procedures to 8 hours and in February 2004 the Board of Medicine enacted an emergency ban on combination of liposuction and abdominoplasty following an unusually high number of deaths that occurred subsequent to combination procedures. The American Society of Plastic Surgeons' recommendation in Procedures for the Office Based Surgery Setting is that the overall duration of procedures should be completed in six hours (Plastic and Reconstructed Surgery, 110:1337, 2002).

There have been a number of reports regarding fatal outcomes following liposuction. The American Society of Plastic Surgeons issued a Practice Advisory on liposuction in March 2003, which defined large volume of liposuction as that which exceeds 5000cc of total aspirate. It recommends that these procedures should only be performed in an Acute Care Hospital or in a facility that is accredited or licensed. The Advisory also states that large volume liposuction combined with other procedures has resulted in "serious complications and such combinations should be avoided.

Finally, in the State of Florida any transfer of a patient from an office to a hospital for treatment requires that an Office Surgery Incident Report be filed. We analyze these reports and have published an article in the Archives of Surgery in September 2003, which showed a ten times higher rate a death following office surgery than when similar procedures were performed in an Ambulatory Surgery Center. Subsequent analysis of these reports have indicated that the incidence of injury and death in Florida have declined following the implementation of rules that contain limitations on the time of surgery, the volume of liposuction, and in some cases the performing combination of procedures.

-- From Hector Vila, Jr., M.D., Tampa, FL

Total Knee Replacement - TOP

We are a small Ambulatory Surgery Center in Ft. Myers, Florida. Recently a surgeon requested time to do a total knee replacement (TKR) here. He said that this was done routinely in many places. I could not verify that with my literature search. To me it seemed in the experimental stages, requiring continuous infusion pumps, etc. Do you have any data, position, or opinion on doing TKRs in an ambulatory setting? We have no facilities to neither give blood nor provide prolonged pain control.

-- From Paul DeLeeuw, M.D., Ft. Myers, FL

REPLY:

First, Medicare will not reimburse for a total joint in an ambulatory setting. The other third party payors (e.g., Blue Cross / Blue Shield, Aetna, etc.) will, but the determining factors become the cost of the prosthesis, physical status of the patient, and (of course) postoperative analgesia care of the patient.

I have discussed this topic with many of our orthopedic surgeons, and we are first going to do a unicompartmental minimally invasive knee arthroplasty in our centers. These patients routinely go home on the first postoperative day from the hospital (with a psoas compartment catheter in place) and do very well. The reimbursement for the center would be reasonable, and we could do the procedure for about one half the cost of doing it in the hospital, which should be attractive the insurance company.

Also, we are fortunate to have a rehabilitation facility down the street from our center, and many of our patients are already going there after their total joint replacements (performed as inpatient surgery). I have in-serviced the staff at that rehabilitation facility, and have sent a few patients there after other procedures with nerve block catheters in place. This practice is permissible (from a reimbursement standpoint), since it is an admission "down," and not "up" to a higher level of care. It is illegal to admit to a higher level of care from an ambulatory setting.

The blood loss associated with a total knee replacement is surely a concern, since most ambulatory centers do not have protocols in place for transfusions. This is why I think it reasonable to start with a unicompartmental knee arthroplasty first thing in the morning, with both a psoas compartment catheter and a single shot sciatic block in place.

For these patients, in order to minimize symptom variability (especially PONV), I preferentially use propofol as a total intravenous anesthetic. Avoiding volatile agents can decrease PONV, as well as unplanned admissions. Propofol in my experience allows for faster emergence and decreases nursing interventions in the PACU thereby increasing nursing efficiency. The combination of propofol with the stated nerve blocks allows for patients to return to baseline cognitive function sooner in PACU which pleases both the patient and loved ones caring for patient. When I use nerve blocks (especially continuous nerve blocks) and total intravenous anesthesia with propofol, I also avoid intraoperative midazolam and narcotics, in order to facilitate all of the above.

After observing the patient in the recovery unit for a few hours, the patient can either be sent home if they have an appropriate caregiver, or to an assisted-care facility if necessary.

One cannot underestimate the critical importance of patient selection in this process.

-- From Don Siwek, M.D., Sarasota, FL

Laparoscopic Gastric Banding - TOP

Does anyone think that laparoscopic gastric banding is an acceptable procedure for a freestanding outpatient facility?

-- From Gerald Kranis, M.D., Miami, FL

REPLY:

Our group of 27 anesthesiologists has cared for 5500 bariatric patients over 5 years through 2003; 3000 were done in a full service 400+ bed hospital and 2000 at Fresno Surgery Center which is actually a 20 bed hospital. FSC has monitored beds in private rooms but no formal ICU. The vast majority of the procedures are laparoscopic gastric bypasses. The average LOS is 2 days. The transfer rate is extremely low and those transfers have not been for primary respiratory problems. None of the 2000 patients has required ventilatory support beyond very occasional CPAP.

Of the 2000 cases at FSC, I did 580 and 2 partners did 850 between them. We intubate under GA and SCH and need the difficult airway cart 1-2 times per year. We have concluded that BMI alone is not a limiting factor. The largest BMI was 85 and we routinely do patients with BMI's from 60-70. There are some co-morbid conditions that cause us to refer a patient to the larger institution. We assume that all patients have OSA and treat them accordingly. Most problems occur during the surgeon's learning curve (first hundred cases) and when the anesthesiologist is wedded to deep anesthesia with longer duration drugs. Extubation occurs only when patient can lift head, responds to commands and has appropriate VC. Average operating times are under 2 hours.

There are two procedures that have been discussed as outpatient procedures. They are the laparoscopic Roux-en Y gastric bypass (L-RYGB) and laparoscopic adjustable gastric banding (LAGB).

The L-RYGB procedure is the most accepted procedure by bariatric surgeons for weight loss. It is not generally considered an outpatient procedure. A series of 1000 outpatient L-RYGB's was recently presented. At first glance this series seems amazing but the "outpatient" stays included a 23 hour observation admission, which makes an actual LOS of 1-2 days depending on when one starts the 23 hour clock.

On the other hand, the LAGB is less invasive and could be done as an outpatient case with a number of caveats and considerations. The recent ASBS Meeting included a series of 700 LAGB's done as outpatients. While this operation does not involve bowel anastomoses, it is a major laparoscopic abdominal operation with its own set of complications such as esophageal injury.

Whatever procedure is done, it must be remembered that these are morbidly obese patients with a very high proportion having OSA and other co-morbid factors. Therefore the selection of anesthetic agents, technique and post-op analgesics is critical to safety and success. Our experience with obese patients has made us comfortable doing many as outpatients but it is still somewhat controversial and some centers still put these patients into an ICU setting overnight.

Our surgeons (three separate groups) all say that the LAGB is OK as an outpatient but it is not the best operation for obesity. They have also observed that the band was originally marketed to dedicated bariatric surgeons without overwhelming acceptance. It is now being marketed to the wider population of general surgeons who may not have the experience to furnish the required long-term support required in a bariatric program.

-- From Lou Freeman, M.D., Fresno, CA

PREOPERATIVE MEDICATIONS: Lithium - TOP

A woman has been on lithium for 10 years. Her mother states that she cannot be off it for more than 3 days, but her surgeon requests that she be off it for 2 weeks. What is the safe time frame to be off this medication before surgery?

-- From L.S., Louisiana

REPLY:

While the surgeon should be commended for taking a conservative course, this may a case of "mother knows best". Although some authorities recommend discontinuing lithium for 2 weeks before ECT because it may interfere with the therapeutic effectiveness of the ECT, and increase the incidence and severity of memory loss, I am aware of no literature which supports discontinuing the drug before elective surgery. Indeed, for the patient with a severe manic-depressive disorder, maintaining the drug may be critical in preventing life-threatening actions potentially associated with relapse into a manic state.

Nevertheless, there are several considerations which one must be aware of when providing anesthesia to patients receiving lithium therapy: potential prolongation of neuromuscular blockade (established for succinylcholine and pancuronium; not studied for the newer agents); possible potentiation of the action of sedative/hypnotics (established for barbiturates and diazepam; not studied for propofol, midazolam, or other newer agents); potential cardiac arrhythmias and conduction abnormalities (documented in lithium toxicity; one case report of atropine-resistant bradycardia during anesthesia with propofol and fentanyl); and the possibility of hypothyroidism and nephrogenic diabetes insipidus precipitated by the lithium therapy.

In the case described above, I would suggest that these anesthetic considerations be discussed with the mother so that she is aware of the importance of the situation, and then the mother's opinion of the maximum duration her daughter can have the lithium discontinued before surgery should be followed. (Manic-depressive patients themselves are notoriously unreliable in assessing their own need for therapy and should not be relied upon to make this decision).

-- From D.D., Houston, TX  

PREOPERATIVE PREPARATION: Body Jewelry - TOP

What do you do about body jewelry? I've always had patients remove tongue rings and nose rings because they're in our field. But patients frequently object strongly to eyebrow rings and naval rings being removed. Historically, we've always said electrocautery and burns are an issue. But is this really true?

-- From David S. Rapkin, M.D., Richmond Heights, OH

REPLY:

This is an increasingly common problem. Our head of ambulatory anesthesia, Dr. Sivashankaran, does not think that electrocautery-induced burns are an issue. Another colleague, Dr. Mark Boswell, notes that the risk of a burn applies only to electrocautery applied "near" the jewelry. He suggests that the decision about removal be left to the surgeon and that this be documented. Dr. Boswell also says that tongue jewelry should come out.

It appears that there are at least 3 distinct problems here. Firstly, there is the risk of tissue burn. Jewelry may provide an alternate path to ground for electrocautery units. Although newer units have ground-referenced generators that should prevent burns, manufacturers of electrosurgery systems continue to advocate for removal of all jewelry. Certainly, if jewelry is to be retained, electrocautery should not be used in close proximity. Secondly, there is the risk that jewelry may become snagged on bedding or other items, causing damage to tissue or to the jewelry itself. Third, oral jewelry and piercings can impede airway management - there seems to be a consensus that these decorations should be removed before surgery.

It would be interesting to know what the policy is in different institutions.

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

PREOPERATIVE PREPARATION: Pediatric Patient - TOP

I am a consultant who assists physicians in the development of freestanding ambulatory surgical centers throughout the US. Overall, the licensing requirements tend to be fairly uniform with one exception; there is a tremendous disparity among health department offices regarding requirements for emergency medications and equipment relative to the age of the anticipated patient population-- specifically, pediatric patients.

Most recently we were apprised by one agency official that a pediatric patient is defined as 18 years of age and younger and that in order to treat patients 14 years of age and older (which was our licensing request) the group would still be required to provide "pediatric defibrillator paddles, pediatric emergency medications (unit doses), special resuscitative equipment, pediatric surgical instrumentation and pediatric stretchers." In many other states 14 is considered the cut off for these items, and in some instances it is as low as age 12. Only a few states actually have written codes defining the specific qualifications of a pediatric patient.

Are there any published guidelines from professional organizations, specifically related to anesthesia or peri-operative emergencies, which I can use successfully in dealing with these agencies to provide some level of consistency? I would appreciate any comments and recommendations you may offer.

-- From Mary Parker, Los Angeles, CA

REPLY:

The American Society of Anesthesiologists has published a document, "Pediatric Anesthesia Practice Recommendations", which is found at: http://www.asahq.org/clinical/PediatricAnesthesia.pdf.

In that document, there is a section on equipment and drugs. The requirements for medications and equipment should be based on the age of the patient that is expected to be treated.

-- From Lance Lichtor, M.D., Iowa City, IA

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