Would you do this case?

[Agast]

Thanks for the input and healthy discussion. I personally ended up cancelling the case, telling the director he should be a main OR case for a lot of the concerns already stated. Wasn't comfortable without a day of surgery potassium either. They weren't too happy. But then again we have a history of doing sketchy cases on ASA 3.5-4s and our exemption criteria feels non-existent. I felt it necessary to somewhat draw the line. I'm a new attending (11 months out of residency) so it makes these decisions a little harder.

This was mainly to provide insight into peoples' reasoning for cancelling cases; IMO one of the hardest things we do.

Are you affected by the surge over there? If something happened to this man would he have an ICU bed?

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[ChiDO]

From an ortho perspective, what do you think of the surgeon's ban on brachial plexus block for this scope / adhesiolysis/ manipulation? What kinda pain relief have you gotten when you do local infiltration? Do you use exparel in your practice?

Not sure why he didn't want a block, unless he wanted immediate rom and therapy. 🤔Seems unreasonable to say no to any type of block.

We do blocks on everyone. Lots of our sports guys do continue on-q pumps. Lots of scalene on shoulder. FI for my THAs. Add+ipack+genicular for TKAs.

We use Exparel at asc only.

 

[DrOwnage]

Decent surge, but still have beds available in the ICU. This surgeon is pretty unreasonable and one of the least favorites. I believe he had a bad outcome from an ISB, that's the only reason I would think he avoids them.

 

[Reveler]

People are doing geniculars for TKAs?

 

[Robotic Wis-Hipple]

Aside from active chest pain, SOB, or acute illness I’m not really sure you can create a less appropriate ASC case.

Pt is large, BMI 38 is pretty damn close to ASC exclusion IMO. I imagine some do exclude at 35 (though yes, if you do that you have few pts these days). CKD. And extremely premature CAD. Why do I care that he’s been fine for “x” years since his stents? His coronaries tried to kill him at 26-27yo, he’s still an obese poorly controlled diabetic, he’s had stents at some point though we know nothing of his antiplatelet requirement though I’m sure he was told to hold them if he’s on them (and I’d imagine he is or
should be on them). Then you’re handcuffed with no block? GTFO.

The reason to do this case in an ASC begins and ends with the facility fee.

 

[abolt18]

Thanks for the input and healthy discussion. I personally ended up cancelling the case, telling the director he should be a main OR case for a lot of the concerns already stated. Wasn't comfortable without a day of surgery potassium either. They weren't too happy. But then again we have a history of doing sketchy cases on ASA 3.5-4s and our exemption criteria feels non-existent. I felt it necessary to somewhat draw the line. I'm a new attending (11 months out of residency) so it makes these decisions a little harder.

This was mainly to provide insight into peoples' reasoning for cancelling cases; IMO one of the hardest things we do.

Did you talk to the partner that approved him in the first place? Curious what (s)he had to say.

 

[Aether2000]

Absolutely not. Needs repeat labs, and I need to see the echo or cardiac cath reports myself. I never trust a cardiologist assessment since not infrequently they say ok for surgery but followup for another echo and cardiac cath immediately after surgery....yeah right....

 

[coffeebythelake]

Aside from active chest pain, SOB, or acute illness I’m not really sure you can create a less appropriate ASC case.

Pt is large, BMI 38 is pretty damn close to ASC exclusion IMO.

That BMI is a midwestern medium. Our ASC exclusion criteria is BMI of 45 or above.

 

[abolt18]

That BMI is a midwestern medium. Our ASC exclusion criteria is BMI of 45 or above.

Ours is 50... But the ASC is connected to the hospital. (Separate building connected by hallway)

 

[nimbus]

Thanks for the input and healthy discussion. I personally ended up cancelling the case, telling the director he should be a main OR case for a lot of the concerns already stated. Wasn't comfortable without a day of surgery potassium either. They weren't too happy. But then again we have a history of doing sketchy cases on ASA 3.5-4s and our exemption criteria feels non-existent. I felt it necessary to somewhat draw the line. I'm a new attending (11 months out of residency) so it makes these decisions a little harder.

This was mainly to provide insight into peoples' reasoning for cancelling cases; IMO one of the hardest things we do.

Good job!

It’s not that hard if you ask yourself, “would I want this operation at a freestanding surgery center if I was this patient with these conditions?”

 

[abolt18]

Absolutely not. Needs repeat labs, and I need to see the echo or cardiac cath reports myself. I never trust a cardiologist assessment since not infrequently they say ok for surgery but followup for another echo and cardiac cath immediately after surgery....yeah right....

Few weeks ago I had a patient coming for lumpectomy who also happened to have active chest pain with < 4 METS. She saw a cardiologist the week before the scheduled surgery. Patient says "the cardiologist said i was okay to have surgery". Problem is, the cardiologist also scheduled her for a chemical stress test and an echo in a month...

His clinic note was incomplete without any assessment/plan filled out. I called the cardiologist and he didn't have recollection of the details of the clinic visit. So i asked him to get her stress test and echo moved up sooner, so as to not delay surgery a whole month, and cancelled the case.

To make matters worse, she had made it through our anesthesia pre-op clinic.

 

[nimbus]

Absolutely not. Needs repeat labs, and I need to see the echo or cardiac cath reports myself. I never trust a cardiologist assessment since not infrequently they say ok for surgery but followup for another echo and cardiac cath immediately after surgery....yeah right....

I’ve seen this too. Mind boggling.

 

[caligas]

Obese, insulin dependent DM, ESRD, CAD, OSA, HTN.

if things go south, you can not defend, you did the right thing and partner who cleared needs feedback

 

[Mman]

Obese, insulin dependent DM, ESRD, CAD, OSA, HTN.

if things go south, you can not defend, you did the right thing and partner who cleared needs feedback

to be fair it really isn't that obese. It's probably close to median BMI for me. Also not ESRD, it's CKD. Also nice that it isn't in the beach chair position and is a surgery that you can get away with no narcotics with a nice block.

I can understand how some people are going to cancel and make it be done at hospital, although that somewhat depends on how remote your surgery center is, although if I did it at the hospital I would do the exact same anesthetic. It's not like I'm putting an art line in or making them be a postop admission. I'd imagine a patient like this has a 99% chance of doing great and going home same day without difficulty.

 

[Southpaw]

to be fair it really isn't that obese. It's probably close to median BMI for me. Also not ESRD, it's CKD. Also nice that it isn't in the beach chair position and is a surgery that you can get away with no narcotics with a nice block.

I can understand how some people are going to cancel and make it be done at hospital, although that somewhat depends on how remote your surgery center is, although if I did it at the hospital I would do the exact same anesthetic. It's not like I'm putting an art line in or making them be a postop admission. I'd imagine a patient like this has a 99% chance of doing great and going home same day without difficulty.

Many ASCs are dinged, or black marked, during accreditation/reaccreditation if their rate of transfer for admission is high. In my experience many of my higher up admins aren't any more excited than I am about extremely loose ASC exemption criteria. Can the case be done in the ASC? Sure. Is your anesthesia any different ASC vs hospital? No. Is that the point? Absolutely not. You can take all of the heart and renal stuff out of the picture and simply consider OSA/no ISB/intra and post-op narcs. Unless your surgeons are spectacular at local it's a bad idea to take a shoulder surgery patient with OSA who isn't compliant with CPAP (not sure if this patient is) and load them up with narcs and send them out the door. Not uncommon to see post op O2 sats in these patients in the low 90s with difficulty getting them off O2. Send him home? Transfer? Admit for CPAP and continuous pulse oximetry?

Let's say you do an ISB and box the phrenic. Now you've got a OSA with questionable CPAP compliance, BMI 38 (agree this isn't that high) sitting in PACU saying he can't catch his breath/take a deep breath/sat'ing in the low 90s/high 80s on O2. Are you going to admit/transfer now?

The point is your decision to admit post-operatively often doesn't declare itself until post op. Now you're asking your ASC nursing staff to hang around another hour waiting on an ambulance and it's kept you there late also. MEANWHILE, your otho surgeon is long gone and getting started on the back 9 on the golf course before you even leave the building.

ASC exemption criteria are meant to set ASCs up for success while not being overly restrictive. The idea of 'well my anesthesia won't be any different in the hospital' or 'I'll make this work >90% of the time' isn't really the point in my opinion.

 

[dannyboy1]

Many ASCs are dinged, or black marked, during accreditation/reaccreditation if their rate of transfer for admission is high. In my experience many of my higher up admins aren't any more excited than I am about extremely loose ASC exemption criteria. Can the case be done in the ASC? Sure. Is your anesthesia any different ASC vs hospital? No. Is that the point? Absolutely not. You can take all of the heart and renal stuff out of the picture and simply consider OSA/no ISB/intra and post-op narcs. Unless your surgeons are spectacular at local it's a bad idea to take a shoulder surgery patient with OSA who isn't compliant with CPAP (not sure if this patient is) and load them up with narcs and send them out the door. Not uncommon to see post op O2 sats in these patients in the low 90s with difficulty getting them off O2. Send him home? Transfer? Admit for CPAP and continuous pulse oximetry?

Let's say you do an ISB and box the phrenic. Now you've got a OSA with questionable CPAP compliance, BMI 38 (agree this isn't that high) sitting in PACU saying he can't catch his breath/take a deep breath/sat'ing in the low 90s/high 80s on O2. Are you going to admit/transfer now?

The point is your decision to admit post-operatively often doesn't declare itself until post op. Now you're asking your ASC nursing staff to hang around another hour waiting on an ambulance and it's kept you there late also. MEANWHILE, your otho surgeon is long gone and getting started on the back 9 on the golf course before you even leave the building.

ASC exemption criteria are meant to set ASCs up for success while not being overly restrictive. The idea of 'well my anesthesia won't be any different in the hospital' or 'I'll make this work >90% of the time' isn't really the point in my opinion.

So we agree that it won’t change the anesthetic and relative risk. The only question is do I piss of the orthopod or the asc admin if we have to transfer? Guess it depends on the surgeon/admins in question…..

 

[Southpaw]

So we agree that it won’t change the anesthetic and relative risk. The only question is do I piss of the orthopod or the asc admin if we have to transfer? Guess it depends on the surgeon/admins in question…..

I'd say that the idea of doing a case knowing there's a decent chance you may need to transfer, knowing what you already knew about the patient pre-op, isn't doing that patient any service whatsoever. If you did the case in the hospital he may simply need a longer PACU course, but eventually is good to go home, which isn't typically the case in an ASC. Once you make a decision to transfer the deal is done, even if the patient seems fine to go home by the time he gets to the hospital.

 

[coffeebythelake]

Many ASCs are dinged, or black marked, during accreditation/reaccreditation if their rate of transfer for admission is high. In my experience many of my higher up admins aren't any more excited than I am about extremely loose ASC exemption criteria. Can the case be done in the ASC? Sure. Is your anesthesia any different ASC vs hospital? No. Is that the point? Absolutely not. You can take all of the heart and renal stuff out of the picture and simply consider OSA/no ISB/intra and post-op narcs. Unless your surgeons are spectacular at local it's a bad idea to take a shoulder surgery patient with OSA who isn't compliant with CPAP (not sure if this patient is) and load them up with narcs and send them out the door. Not uncommon to see post op O2 sats in these patients in the low 90s with difficulty getting them off O2. Send him home? Transfer? Admit for CPAP and continuous pulse oximetry?

Let's say you do an ISB and box the phrenic. Now you've got a OSA with questionable CPAP compliance, BMI 38 (agree this isn't that high) sitting in PACU saying he can't catch his breath/take a deep breath/sat'ing in the low 90s/high 80s on O2. Are you going to admit/transfer now?

The point is your decision to admit post-operatively often doesn't declare itself until post op. Now you're asking your ASC nursing staff to hang around another hour waiting on an ambulance and it's kept you there late also. MEANWHILE, your otho surgeon is long gone and getting started on the back 9 on the golf course before you even leave the building.

ASC exemption criteria are meant to set ASCs up for success while not being overly restrictive. The idea of 'well my anesthesia won't be any different in the hospital' or 'I'll make this work >90% of the time' isn't really the point in my opinion.

What does the ASA say about ASC criteria? I imagine it isn't just up to individual ASC to set it up without guidance

 

[anbuitachi]

You are at a surgery center on a Friday doing ortho cases with one room scheduled. You are about to start the first case and the nurse mentions something about the 2nd patient being “sick.”

You did not have access to patients histories the night before. You decide to go to the front desk and ask for the next patients binder. You see a paper with your partner ok’ing the patient for surgery when he was asked to review the chart yesterday. You read into the chart.

The case is a left shoulder scope with lysis of adhesions and capsular release + manipulation in lateral positioning with bean bag. The case is scheduled for 85 minutes.

The patient is 38 year old with a BMI of 38, had a CABG in 2009 + history of stents. HTN (couple of meds), HLD, Type 2 diabetes on 3 meds and a decent amount of insulin. OSA, creatinine of 3 (GFR 21), on the renal transplantation list at a local hospital. Has a K of 5.6 4 days ago. Other labs okish. EKG with non specific delay and some non specific changes. No echo on file. Cardiologist note saying patient ok for surgery.

Small surgery center without many things besides ultrasound and macgrath. Light staff that day due to the light schedule and no partners there.

Do you proceed with the case or cancel before the patient arrives?

how is this guys exercise tolerance? running marathons?

 

[coffeebythelake]

So we agree that it won’t change the anesthetic and relative risk. The only question is do I piss of the orthopod or the asc admin if we have to transfer? Guess it depends on the surgeon/admins in question…..

More importantly, I want everyone on the same page. The patient needs to understand his risk might be higher for whatever reason (OSA, cardiac, etc). And the surgeon won't pretend to be surprised if you had to admit thr patient afterwards.

 

[Katheudontas parateroumen]

With only the information stated I would say no. I need another K for sure. 5.6 is heading into the moderate range already. Although it’s probably chronic, if for some reason I’d have to give him Sux for like a larngyspasm there’s risk of increasing into above 6 which would be concerning for anyone. I’d like to see that value ~5 or less. Next I’d have to assume with all his CV comorbidities what’s his exercise tolerance and how well controlled. That’s most important. Next is I’d have to assume his OSA on CPAP is well tolerated. Since surgeon doesn’t want a block this makes it into a primary opioid based which certainly increases risk of respiratory complications. I would be ok doing this case at the hospital under GA. But at this point, there are too many assumptions to be made that’ll have to delay the case as it’s already second start to be done at ASC.

 

[Robotic Wis-Hipple]

That BMI is a midwestern medium. Our ASC exclusion criteria is BMI of 45 or above.

I agree. But if you were designing an ASC with efficiency and optimal safety in mind would you set your fictional ASC BMI exclusion criteria at 45? I doubt it. I’d say 40 sounds good, this is simply less feasible financially anymore so BMI keeps getting moved up.

In the main hospital this is a simple case. But that’s not the point. The guys risk isn’t zero.

 

[Urzuz]

Let’s be clear — this guy isn’t going to die on the table. He’s been revascularized so that should make you feel better. His BMI really isn’t that high. Yes he has CKD which increases the chance of morbidity associated with any procedure he’s going to undergo, but that in it of itself isn’t going to happen in the immediate perioperative period.

IMO the biggest thing this guy is at risk for at the ASC is developing hypoxemia postop from too much pain medication/anesthesia. Why a surgeon wouldn’t want a block for any shoulder surgery is beyond me, other than them being impatient and wanting to get out of the hospital 10 minutes earlier. Here’s the question: if he was good with an ISB would you feel comfortable doing the case? I would. I’m almost certain that most surgeons, even those that “don’t like blocks” would be agreeable to having their patient get a block if the choice was block+operate or no block+cancel. You are a consultant physician — talk to the surgeon, present your issues, and explain to him why you want to treat this guy differently than a run-of-the-mill ASA 1 shoulder scope and why a block is critical to his management. If he still says no, then you cancel.

 

[vector2]

Let’s be clear — this guy isn’t going to die on the table. He’s been revascularized so that should make you feel better.

He was revascularized in 2009. What's the 10 yr patency rate for SVGs.....especially in someone with CKD 4 and poorly controlled DM...

 

[Mman]

Let's say you do an ISB and box the phrenic. Now you've got a OSA with questionable CPAP compliance, BMI 38 (agree this isn't that high) sitting in PACU saying he can't catch his breath/take a deep breath/sat'ing in the low 90s/high 80s on O2. Are you going to admit/transfer now?

The point is your decision to admit post-operatively often doesn't declare itself until post op. Now you're asking your ASC nursing staff to hang around another hour waiting on an ambulance and it's kept you there late also.

I personally recall zero instances of someone with a BMI of 38 and OSA needing postop admission from an interscalene block. Never seen it happen. Now could it happen? Sure, theoretically. But it's usually the COPD cripples that are at risk from phrenic nerve paralysis, not the people who breathe just fine but obstruct when they sleep.

Also this was a Friday morning case. It's not like you would need to be there 10 hours postop trying to figure out how to manage the patient.

 

[Urzuz]

He was revascularized in 2009. What's the 10 yr patency rate for SVGs.....especially in someone with CKD 4 and poorly controlled DM...

I didn’t see when his CABG was, so your point is well taken. That being said, as long as he can walk up a flight of stairs, he will be fine — with a block in place, the amount of stress on his heart will be negligible . A 1.5 hour shoulder scope under GA+block produces little to no stimulation. You won’t gain anything by doing this case in a hospital like some people are suggesting — this case this won’t need an admission if you do it right.

 

[Arch Guillotti]

I personally recall zero instances of someone with a BMI of 38 and OSA needing postop admission from an interscalene block. Never seen it happen. Now could it happen? Sure, theoretically.

I have seen it once. Except that the patient was on bipap already so he went home anyway.

 

[dabears505]

One thing especially when you are starting our, you can always find a different job if you get let go for canceling cases. But that lawsuit or bad outcome will always be with you til you die. When something bad happens, it's not just monetary and a nuisance dealing with lawyers, it's guilt that you caused someone harm til you die.

 

[Southpaw]

I personally recall zero instances of someone with a BMI of 38 and OSA needing postop admission from an interscalene block. Never seen it happen. Now could it happen? Sure, theoretically. But it's usually the COPD cripples that are at risk from phrenic nerve paralysis, not the people who breathe just fine but obstruct when they sleep.

The rate of getting the phrenic after an ISB is near 100% and not dependent on COPD or any other co-morbidity. I've had 1 patient require admission post-op from an ISB.

 

[Mman]

The rate of getting the phrenic after an ISB is near 100% and not dependent on COPD or any other co-morbidity. I've had 1 patient require admission post-op from an ISB.

I know it is 100%. What I am saying is that unless you are a terrible COPD patient you almost always tolerate it just fine. I've done more than 1000 interscalene blocks and never had it be clinically significant in an OSA patient. I have seen it been significant in a COPD patient requiring intubation.

It isn't the COPD that makes you get the phrenic nerve, it is the COPD that makes the patient not tolerate the phrenic nerve being blocked. OSA is not nearly as big of an issue with the phrenic nerve. Narcotics are far more worrisome for OSA patients.

 

[Southpaw]

I know it is 100%. What I am saying is that unless you are a terrible COPD patient you almost always tolerate it just fine. I've done more than 1000 interscalene blocks and never had it be clinically significant in an OSA patient. I have seen it been significant in a COPD patient requiring intubation.

It isn't the COPD that makes you get the phrenic nerve, it is the COPD that makes the patient not tolerate the phrenic nerve being blocked. OSA is not nearly as big of an issue with the phrenic nerve. Narcotics are far more worrisome for OSA patients.

What you said was 'it's usually the COPD cripples that are at risk from phrenic nerve paralysis'. I responded to that.

What you meant was 'it's usually the COPD cripples that are at risk from the sequelae of phrenic nerve paralysis'.

I don't count my blocks so no idea how many I've done. I've been in practice > 10 years though so I've done plenty. It is indeed rare to require admission from SOB after an ISB. It's kind of a moot point though as the OP's surgeon seemed adamant his patient not have one.

 

[Mman]

What you said was 'it's usually the COPD cripples that are at risk from phrenic nerve paralysis'. I responded to that.

actually you responded as if I had said the COPD cripples were at risk OF phrenic nerve paralysis, not from it. The word "from" implied I was referring to the sequelae.

I will stop being pedantic but my clinical point stands, simply having a BMI of 38 does not place someone at high risk of pulmonary complication from ISB and would certainly not get me to expect them to require postop admission or monitoring.

 

[Southpaw]

I will stop being pedantic but my clinical point stands, simply having a BMI of 38 does not place someone at high risk of pulmonary complication from ISB and would certainly not get me to expect them to require postop admission or monitoring.

There is nothing I posted that disputes that. BMI 38 isn't high these days. I imagine BMI 38 is fine for most all ASCs.

Let's say you do an ISB and box the phrenic. Now you've got a OSA with questionable CPAP compliance, BMI 38 (agree this isn't that high) sitting in PACU saying he can't catch his breath/take a deep breath/sat'ing in the low 90s/high 80s on O2. Are you going to admit/transfer now?

 

[GassYous]

There is nothing I posted that disputes that. BMI 38 isn't high these days. I imagine BMI 38 is fine for most all ASCs.

It is sad that we think like this
I legitimately get excited when my patient is under 100 kg

 

[Barleycorn]

This was mainly to provide insight into peoples' reasoning for cancelling cases; IMO one of the hardest things we do.

Extremely hard to do, especially when starting out. Look the surgeon in the eye and give them the black and white reasons why you wont do the case.

At the end of the day it's your license and your kids food on the table.

If the patient aspirates/has chest pain/keeps desatting in the PACU in a surgery center, the surgeon will be long gone and your only help will be the secretary and the a nurse who thinks the pulse ox is the call light.

 

[kidthor]

One thing especially when you are starting our, you can always find a different job if you get let go for canceling cases. But that lawsuit or bad outcome will always be with you til you die. When something bad happens, it's not just monetary and a nuisance dealing with lawyers, it's guilt that you caused someone harm til you die.

Exactly - if you are being pushed to do risky things at your current job, then it's not a good job. If you as the perioperative expert recommend that patient safety isn't optimal (or even halfway reasonable), then don't do it. They can fire you tomorrow and you'll be able to find a better job in short order.

 

[kidthor]

Many ASCs are dinged, or black marked, during accreditation/reaccreditation if their rate of transfer for admission is high. In my experience many of my higher up admins aren't any more excited than I am about extremely loose ASC exemption criteria. Can the case be done in the ASC? Sure. Is your anesthesia any different ASC vs hospital? No. Is that the point? Absolutely not. You can take all of the heart and renal stuff out of the picture and simply consider OSA/no ISB/intra and post-op narcs. Unless your surgeons are spectacular at local it's a bad idea to take a shoulder surgery patient with OSA who isn't compliant with CPAP (not sure if this patient is) and load them up with narcs and send them out the door. Not uncommon to see post op O2 sats in these patients in the low 90s with difficulty getting them off O2. Send him home? Transfer? Admit for CPAP and continuous pulse oximetry?

Let's say you do an ISB and box the phrenic. Now you've got a OSA with questionable CPAP compliance, BMI 38 (agree this isn't that high) sitting in PACU saying he can't catch his breath/take a deep breath/sat'ing in the low 90s/high 80s on O2. Are you going to admit/transfer now?

The point is your decision to admit post-operatively often doesn't declare itself until post op. Now you're asking your ASC nursing staff to hang around another hour waiting on an ambulance and it's kept you there late also. MEANWHILE, your otho surgeon is long gone and getting started on the back 9 on the golf course before you even leave the building.

ASC exemption criteria are meant to set ASCs up for success while not being overly restrictive. The idea of 'well my anesthesia won't be any different in the hospital' or 'I'll make this work >90% of the time' isn't really the point in my opinion.

I totally agree. The getting the patient through the OR part here is going to be easy for a competent anesthesiologist. The post-op course is absolutely the challenge. This sort of patient will need to be admitted some percent of the time for post op questions, and the optics to everyone else make it look like it was YOUR fault. I'm sure the admins and surgeons will say you overnarcotized, your block was bad, you gave too much fluid, the BP wasn't perfect, the preop workup was inadequate... or that you should have cancelled the patient if this was going to happen. While blaming you for cancelling prospectively the next time. They want to have their cake and eat it too.

The best scenario is as Southpaw said - have effective agreed-upon restriction criteria that keeps these decisions out of your hands and prevents such patients from hitting the door. That way you can keep the patients safe without being pressured to accept a bunch of risk in these uncomfortable grey areas. If the ASC criteria is a free for all then you'll de facto be allowing in patients that from a safety perspective shouldn't be there.

 

[Hoya11]

I totally agree. The getting the patient through the OR part here is going to be easy for a competent anesthesiologist. The post-op course is absolutely the challenge. This sort of patient will need to be admitted some percent of the time for post op questions, and the optics to everyone else make it look like it was YOUR fault. I'm sure the admins and surgeons will say you overnarcotized, your block was bad, you gave too much fluid, the BP wasn't perfect, the preop workup was inadequate... or that you should have cancelled the patient if this was going to happen. While blaming you for cancelling prospectively the next time. They want to have their cake and eat it too.

The best scenario is as Southpaw said - have effective agreed-upon restriction criteria that keeps these decisions out of your hands and prevents such patients from hitting the door. That way you can keep the patients safe without being pressured to accept a bunch of risk in these uncomfortable grey areas. If the ASC criteria is a free for all then you'll de facto be allowing in patients that from a safety perspective shouldn't be there.

what criteria would you suggest that would have screened out this patient?

 

[coffeebythelake]

Aside from active chest pain, SOB, or acute illness I’m not really sure you can create a less appropriate ASC case.

If the patient had active chest pain, active shortness of breath, or acute illness.. he would be inappropriate for elective ortho case no matter where he goes. ASC or hospital

 

[CaliCatheter]

Knowing orthopods, if he/she was told the case is cancelled and needs to go to the main OR we do it today with an ISB, im guessing he picks the latter.

Were the stents before or after the CABG?

 

[Robotic Wis-Hipple]

If the patient had active chest pain, active shortness of breath, or acute illness.. he would be inappropriate for elective ortho case no matter where he goes. ASC or hospital

Um…. Yes.

 

[Robotic Wis-Hipple]

what criteria would you suggest that would have screened out this patient?

This is a good question.

BMI alone - no
Hx of CABG/PCI? - No, especially with a cards note attached
CKD? - no

But the physician screening IMO was a tad rubber stamp-y. The whole picture and the no block together make this a suboptimal ASC case IMO. Sure it can be done, many here would do it and 97% of the time that guy gets out of the ASC by early afternoon. But just because we can doesn’t mean we should. At some point we’ve got to do what’s in the best interest for all involved not just the most efficient or profitable.

This guy has multiple risk factors and has poor CV protoplasm. If anything happens or he requires transfer/admit the number of TPS reports and people lining up to second guess your decision will be plentiful. You can’t always do the CYA cancelectomy, but this is one where I would.

I just think ASC patients should read like an ASC patient. And this one doesn’t to me.

 

[GassYous]

There's just so many ways for the case to go bad. Not worth it. No block request means the surgeon is slow and sucks. The fast ones don't care especially. It's just not happening.

 

[DrOwnage]

No block request means the surgeon is slow and sucks. The fast ones don't care especially. It's just not happening.

It's impressive how right you are just from the little info I gave you.

 

[NICMAN]

So we agree that it won’t change the anesthetic and relative risk. The only question is do I piss of the orthopod or the asc admin if we have to transfer? Guess it depends on the surgeon/admins in question…..

A CRNA only looks at the intraop management, a physician looks at the pre, intra, and post-op management. I often call patients personally to look into pre-op work up if they are borderline. I have the surgeons order labs or additional work up as needed including TTE (though usually the reason to order a TTE is sufficient to move a case).

Post-op there are several management options available in a hospital that are not available in a freestanding ASC—including primarily the capacity to admit. I have had a couple of caths—stenting after ASC cases in renal failure patients in my short career so to say “so you are saying you wouldn’t do anything differently” rests heavily on the assumption that anesthetic care won’t need to be modified in any way. It is the kind of fallacious circular reasoning that gets people in trouble…

it also helps when you have surgeons who give a flying canole who take pride in their work who I would be proud to have work on my own family members. Such surgeons usually don’t bring these train wrecks to our ASC.

 

[PlayToWin]

Decent surge, but still have beds available in the ICU. This surgeon is pretty unreasonable and one of the least favorites. I believe he had a bad outcome from an ISB, that's the only reason I would think he avoids them.

I’m guessing he wouldn’t stop doing shoulder scopes if he had a bad outcome from his technique or patient related factor

 

[deleted697127]

A CRNA only looks at the intraop management, a physician looks at the pre, intra, and post-op management. I often call patients personally to look into pre-op work up if they are borderline. I have the surgeons order labs or additional work up as needed including TTE (though usually the reason to order a TTE is sufficient to move a case).

Post-op there are several management options available in a hospital that are not available in a freestanding ASC—including primarily the capacity to admit. I have had a couple of caths—stenting after ASC cases in renal failure patients in my short career so to say “so you are saying you wouldn’t do anything differently” rests heavily on the assumption that anesthetic care won’t need to be modified in any way. It is the kind of fallacious circular reasoning that gets people in trouble…

it also helps when you have surgeons who give a flying canole who take pride in their work who I would be proud to have work on my own family members. Such surgeons usually don’t bring these train wrecks to our ASC.

What surgery and what time frame are you talking about post op that the patients needed Cath’s post op?

 

[Velefunt]

There's just so many ways for the case to go bad. Not worth it. No block request means the surgeon is slow and sucks. The fast ones don't care especially. It's just not happening.

Interesting, it's the complete opposite where I work. The slow surgeons are slow and nothing we do impacts their life in terms of getting out on time.

It's our fast efficient surgeons who consistently complain that the 5 minutes it takes to do the whole block process x5+ cases adds another 25+ minutes to their day when they could have been out 25+ minutes earlier.

They're fast because they want to maximize their daily case counts and still get out early.

 

[NICMAN]

What surgery and what time frame are you talking about post op that the patients needed Cath’s post op?

Intra-Op MI for STEMI.
Cyctoscopies. This was at a different ASC connected with the hospital and really was an “outpatient optional” block of rooms with no specific exclusion criteria (other than routine optimization) next to the main OR at a big Level 1 trauma center.

They pulled the scope and I called a code stemi. One had an LAD aneurysm 3 cm large. The cardiologist never saw anything like it. ESRD Pt with normal labs, dialysed day before with a good functional status of 8 METS or so…

it is a numbers game. It is best to make the odds be in your favor.

 

[NICMAN]

Interesting, it's the complete opposite where I work. The slow surgeons are slow and nothing we do impacts their life in terms of getting out on time.

It's our fast efficient surgeons who consistently complain that the 5 minutes it takes to do the whole block process x5+ cases adds another 25+ minutes to their day when they could have been out 25+ minutes earlier.

They're fast because they want to maximize their daily case counts and still get out early.

Have the surgeon mark the patients 2 ahead of schedule and block in the pre-op area. Boom! Happy surgeons and patients.