Acdf

[apma77]

67 yr old male w cardiac stents (has cardiac clearance w good fxn), DM, but severe sleep apnea and non-compliant with cpap (threw away machine cause it was not comfortable to wear) coming in for 2 level ACDF at outpatient center. 300 lbs..6'0

do you do this case or turf to hospital?? any anesthesia pearls when doing this case in outpatient setting??

 

[Bertelman]

67 yr old male w cardiac stents (has cardiac clearance w good fxn), DM, but severe sleep apnea and non-compliant with cpap (threw away machine cause it was not comfortable to wear) coming in for 2 level ACDF at outpatient center. 300 lbs..6'0

do you do this case or turf to hospital?? any anesthesia pearls when doing this case in outpatient setting??

When were the stents placed? Still on Plavix, or did he throw those away, too? Any symptoms?

What defines "severe OSA"? The somnography or his wife?

I'm guessing this outpt center is attached to a bigger hospital if you are tackling ant spine cases. That provides a relief for his potential post-op OSA and prolonged PACU stay, which at this point is my biggest concern.

 

[ssmallz]

Turf to hospital. ACDF + noncompliant OSA = overnight on a monitored bed for me

 

[apma77]

not so easy to turf cases to hospital when theres tremendous pressure in PP to do cases at ASC...most patients with epidemic obesity nowadays one has to assume have OSA so cant turf all OSA to hospital

 

[Bertelman]

not so easy to turf cases to hospital when theres tremendous pressure in PP to do cases at ASC...most patients with epidemic obesity nowadays one has to assume have OSA so cant turf all OSA to hospital

So then present this to them as a patient that would consume more than their share in the way of staff resources in the post-op period. This one patient could burden nurses, docs and the coveted short discharge times, throwing off the entire day.

Or just pull the "this isn't good care" trump card.

 

[bostonblaz]

I had a somewhat similar case but he didn't have the stent history. When I was asked a week before if they could do it I said yes if he was done as the first case of the day. It takes our guy 2 hours to do the case so he was in recovery at 10. That way he can stay as long as we need so when we shut the lights at 430 he either is walking out the door hours before or packed into a ambulet and sent to the local hospital. He did totally fine and was discharged by noon. Blaz

 

[Mman]

not so easy to turf cases to hospital when theres tremendous pressure in PP to do cases at ASC...most patients with epidemic obesity nowadays one has to assume have OSA so cant turf all OSA to hospital

You can't turf them all, but you can the guy with diagnosed sleep apnea who admits complete noncompliance with CPAP and doesn't even have a CPAP machine to use tonight.

I can see if he winks and nods and says he wears it everynight. But ACDF could have potential for neck swelling postop and you already know he obstructs his airway.

This patient is a mandatory overnight stay with continuous pulse ox and monitoring solely from his body habitus and diagnosed/untreated sleep apnea. If he's never been diagnosed officially, that's a different story. Might be the same outcome, but when the diagnosis and lack of treatment are already documented on the chart you gotta cover your butt.

 

[doctor712]

Hi gang,

Just a quick curious question, much is being made of the "untreated" and non-compliant OSA. What's the difference if he was a diagnosed (polysomnography) with OSA and was compliant, and his lack of compliance?

That is, how does his compliance/or not, change your anesthetic plan? Is this an airway issue only (he's harder or less to intubate etc) because he's compliant or not, OR, is this more of an issue with pulmonary hypertension and other physiology that may along with OSA?

Just wondering what compliant or not, when someone has been formally diagnosed, has to do with things here. Does everything have to do with him obstructing at home post-op because he's non-compliant, or are the comments specific to a "better tuned up patient" that is compliant? both from physio and obstructive points of view.

Interesting, thanks in advance!!!

D712

 

[Mman]

My primary concern is postop obstruction of his airway. If he has already been diagnosed with sleep apnea and is not treated, we KNOW that he obstructs his airway and drop his sats in his sleep at baseline. So in a perfect world he's already desatting overnight. Now we are going to give him an anesthetic and narcotic pain medicines which will further alter his CO2 response curve and send him home unmonitored. So now instead of waking up when he desats a little and starting to breath again, he'll desat much further because of the narcotics in his system. How much further? Don't know. Don't want to know.

If he was compliant with his CPAP and would wear it overnight postop, the risk of postop respiratory failure is likely exceedingly low. But if he doesn't, it's much higher.


The issues of chronic treatment and pulmonary hypertension and this and that are all relevant, but less important to me than him dropping dead from an obstructed airway in his sleep.

 

[Bertelman]

In addition, if he is compliant that means he can bring his device in for PACU. If he tossed it, that is not an option. Since this is at a surgicenter, we cannot simply request an RT and BiPAP in PACU.

 

[doctor712]

My primary concern is postop obstruction of his airway. If he has already been diagnosed with sleep apnea and is not treated, we KNOW that he obstructs his airway and drop his sats in his sleep at baseline. So in a perfect world he's already desatting overnight. Now we are going to give him an anesthetic and narcotic pain medicines which will further alter his CO2 response curve and send him home unmonitored. So now instead of waking up when he desats a little and starting to breath again, he'll desat much further because of the narcotics in his system. How much further? Don't know. Don't want to know.

If he was compliant with his CPAP and would wear it overnight postop, the risk of postop respiratory failure is likely exceedingly low. But if he doesn't, it's much higher.


The issues of chronic treatment and pulmonary hypertension and this and that are all relevant, but less important to me than him dropping dead from an obstructed airway in his sleep.

MMan,

Thanks for the reply, I missed the outpatient center part and thought he'd be in the hospital for a while. Regardless, I understand your post-op point, whether 2 or 5 days post-op. Really appreciate the deets. :thumb up:

D712

 

[apma77]

patient was advised to see sleep doc and be prescribed his CPAP again and bring it into PACU and do this as first case of day and observe patient til the door closes at 5pm...if hes not doing ok will transfer to hospital...but this "deal" was made w surgeon beforehand

 

[ssmallz]

not so easy to turf cases to hospital when theres tremendous pressure in PP to do cases at ASC...most patients with epidemic obesity nowadays one has to assume have OSA so cant turf all OSA to hospital

It may not be easy but I'm sick of feeling like we need to put our *****es on the line because some surgeon doesn't appreciate the risks of his/her pts all in the name of keeping the surgeon happy. Do any other docs do the same for us? NO. I don't mind helping out to move things along and bending the rules when you can but I draw the line at pt safety. When it really truly affects pt safety, we need to draw the line because some lawyer certainly will.

 

[Mman]

It may not be easy but I'm sick of feeling like we need to put our *****es on the line because some surgeon doesn't appreciate the risks of his/her pts all in the name of keeping the surgeon happy. Do any other docs do the same for us? NO. I don't mind helping out to move things along and bending the rules when you can but I draw the line at pt safety. When it really truly affects pt safety, we need to draw the line because some lawyer certainly will.

I agree. I believe part of my job isn't trying to cancel cases, but it's trying find a safe way to get the case done. If I can't figure out a way to do it safely, it shouldn't be done (for elective cases). Safety is relative when dealing with emergencies.

 

[urge]

67 yr old male w cardiac stents (has cardiac clearance w good fxn), DM, but severe sleep apnea and non-compliant with cpap (threw away machine cause it was not comfortable to wear) coming in for 2 level ACDF at outpatient center. 300 lbs..6'0

do you do this case or turf to hospital?? any anesthesia pearls when doing this case in outpatient setting??

I'm sure you can do it, but I would try to turf to hosp. Case goes well: nobody cares & they'll keep bringing sicker patients. Case goes bad: everybody becomes a Monday morning quarterback. What do you stand to gain from doing this case?

 

[urge]

not so easy to turf cases to hospital when theres tremendous pressure in PP to do cases at ASC...most patients with epidemic obesity nowadays one has to assume have OSA so cant turf all OSA to hospital

Does your ASC have rules like no ASA 3's?

 

[Mman]

Does your ASC have rules like no ASA 3's?

that would seem a bit over the top if you ask me. We have a few hard and fast rules, but ASA status isn't one of them. I mean a guy with stents in his heart can have a carpal tunnel at the ASC with no problem.

 

[cincincyreds]

67 yr old male w cardiac stents (has cardiac clearance w good fxn), DM, but severe sleep apnea and non-compliant with cpap (threw away machine cause it was not comfortable to wear) coming in for 2 level ACDF at outpatient center. 300 lbs..6'0

do you do this case or turf to hospital?? any anesthesia pearls when doing this case in outpatient setting??

I'm assuming ACDF is anterior cervical disc fusion. This is the exact reason I work at a hospital and not an outpatient center. What if the patient dies in the middle of the night from airway obstruction. Who do you think the family's lawyer is going to go after? The surgeon, or you? You would have to be insane for doing this at an outpatient center and then sending the patient home in my eyes. First, for the care of the patient. Second, for litigation. Sure I could make double at an outpatient center, but I feel doing this isn't a license for murder.

 

[seinfeld]

Does your ASC have rules like no ASA 3's?

If I did not do ASA 3 at an outpt center i wouldnt be doing many cases. Most of our cysto's are asa 3 or 4. I think it needs to be decided on a case by case basis.

Our outpt centers have overnight beds but even so this guy sounds like he will need in hospital coverage at least for 23 hours mainly because i am concerned about narcotics in a non-compliant OSA patient.