Normal protocol or unsafe practice?

[UAbio9301]

Advertisement - Members don't see this ad

A facility that I work at (Partner in a private practice) has decided to launch a Navigational Bronchoscopy Program in the interim future. Roughly speaking, the procedure requires GETA with high PEEP, full paralysis, TIVA (due to longer procedure and exposure of proceduralist to circuit), coordination with pulmonologist for biopsy of pulmonary nodules. However, the administration did not involve the anesthesia department in the planning of the launch. Little to no consideration was placed on risk assessment, logistical constraints and the remote location relative to where our anesthesiologists are typically busy providing care to OR patients.

Many of our partners, including the site chief, insist that the procedures be done in the OR due to it being a thoracic procedure with far from mild potential complications, and transporting s patient on an elevator would be required, if done in a non-OR setting. Yes, it is re-assuring that a critical care physician would be doing the procedure, but shouldn't the overall judgement of the anesthesiologist take precedence over any other facility reason? The rebuttal was Joint Commission guidelines be followed, and none of the ORs are currently equipped for negative pressure. However, many bronchoscopies are done in this facility without negative pressure, on higher risk patients. Let me re-emphasize that these are elective procedures.

Would anyone be in the wrong for refusing to do the procedure outside of the OR unless it is medically necessary to NOT be performed in an OR suite?

 

[coffeebythelake]

A facility that I work at (Partner in a private practice) has decided to launch a Navigational Bronchoscopy Program in the interim future. Roughly speaking, the procedure requires GETA with high PEEP, full paralysis, TIVA (due to longer procedure and exposure of proceduralist to circuit), coordination with pulmonologist for biopsy of pulmonary nodules. However, the administration did not involve the anesthesia department in the planning of the launch. Little to no consideration was placed on risk assessment, logistical constraints and the remote location relative to where our anesthesiologists are typically busy providing care to OR patients.

Many of our partners, including the site chief, insist that the procedures be done in the OR due to it being a thoracic procedure with far from mild potential complications, and transporting s patient on an elevator would be required, if done in a non-OR setting. Yes, it is re-assuring that a critical care physician would be doing the procedure, but shouldn't the overall judgement of the anesthesiologist take precedence over any other facility reason? The rebuttal was Joint Commission guidelines be followed, and none of the ORs are currently equipped for negative pressure. However, many bronchoscopies are done in this facility without negative pressure, on higher risk patients. Let me re-emphasize that these are elective procedures.

Would anyone be in the wrong for refusing to do the procedure outside of the OR unless it is medically necessary to NOT be performed in an OR suite?

Lymph node biopsies? What exactly are you worried about? "High peep" like 10? Bleeding risk tend to be low compared to interventional pulm procedures. Why would you need to rush from the procedure room to the OR? You think you might need to Crack the chest?🙀 thats basically zero risk of that.

Presumably there is some risk stratification that takes place? Unless i'm missing something this is pretty normally done in a procedure room +/-offsite. We do them next to our gi lab

From an operational and logistic perspective i would be more worried about an anesthesiologist covering this plus some other site at the same time.

 

[abolt18]

We do these robotic bronchscopy cases every day in Endo (down the hall from the ORs, but definitely not IN the OR) 10 of peep, large ETT, inhaled anesthetic, zero issues. Very boring stuff. Occasionally they ask for a breath hold so they can do a spin with the fluoro/CT to sync the imaging better with the machine.

 

[UAbio9301]

Lymph node biopsies? What exactly are you worried about? "High peep" like 10? Bleeding risk tend to be low compared to interventional pulm procedures. Why would you need to rush from the procedure room to the OR? You think you might need to Crack the chest?🙀 thats basically zero risk of that.

Presumably there is some risk stratification that takes place? Unless i'm missing something this is pretty normally done in a procedure room +/-offsite. We do them next to our gi lab

From an operational and logistic perspective i would be more worried about an anesthesiologist covering this plus some other site at the same time.

They are not lymph node biopsies, they are targeting peripheral lesions in the lung parenchyma through a robotic bronchoscope.

 

[coffeebythelake]

They are not lymph node biopsies, they are targeting peripheral lesions in the lung parenchyma through a robotic bronchoscope.

Ok so what is your concern? Still biopsy. Still low risk for bleeding. If they cause a ptx multiple people in the room can put in a chest tube? Not sure how doing it in OR would be superior?

 

[UAbio9301]

We do these robotic bronchscopy cases every day in Endo (down the hall from the ORs, but definitely not IN the OR) 10 of peep, large ETT, inhaled anesthetic, zero issues. Very boring stuff. Occasionally they ask for a breath hold so they can do a spin with the fluoro/CT to sync the imaging better with the machine.

The room they have designated to do these procedures is on a different floor and isn't a short walk (or run) to if there is an ACLS event and the anesthesiologist responsible is managing a pediatric induction or dealing with a PACU event. It is fine if that anesthesiologist is solely responsible, but the coverage requirement will almost always require that anesthesiologist to be responsible for OR cases AND non-OR concurrently.

 

[coffeebythelake]

coverage requirement will almost always require that anesthesiologist to be responsible for OR cases AND non-OR concurrently.

This is the only real potential issue. And there is a simple solution. You just pointed it out.

 

[UAbio9301]

Ok so what is your concern?

Tension pnuemothorax, major vascular injury, iatrogenic mediastinal injury, iatrogenic bronchopleural fistula, just to name a few. Those risks (while rare) are statistically more likely with a provider performing a novel procedure. Those concerns, superimposed on facility limitations and remote location of this suite would make me very nervous if I were responsible for other anesthetics nowhere near this suite.

 

[UscGhost]

Tension pnuemothorax, major vascular injury, iatrogenic mediastinal injury, iatrogenic bronchopleural fistula, just to name a few. Those risks (while rare) are statistically more likely with a provider performing a novel procedure. Those concerns, superimposed on facility limitations and remote location of this suite would make me very nervous if I were responsible for other anesthetics nowhere near this suite.

While true. If you do those in the OR, is there going to be a thoracic surgeon available to handle them anyway?

Otherwise its going to be the pulmonologist placing an emergency chest tube....dont need an OR for that

 

[psychbender]

Tension pnuemothorax, major vascular injury, iatrogenic mediastinal injury, iatrogenic bronchopleural fistula, just to name a few. Those risks (while rare) are statistically more likely with a provider performing a novel procedure. Those concerns, superimposed on facility limitations and remote location of this suite would make me very nervous if I were responsible for other anesthetics nowhere near this suite.

So make that a solo physician site. Directing remote sites plus main OR is asinine.

These cases are real basic and uneventful, though. PTX risk is a little higher than the usual bronch when they go after those distal lesions, but otherwise risks are very similar. If you would have been fine covering a regular bronch with EBUS at that location, you should be fine doing these.

 

[UAbio9301]

While true. If you do those in the OR, is there going to be a thoracic surgeon available to handle them anyway?

Otherwise its going to be the pulmonologist placing an emergency chest tube....dont need an OR for that

More of my concerns are the logistical, facility specific limitation. This is a community hospital with 1 anesthesia tech.

They will have to be transferred (most O2 dependent at baseline) to an elevator and another long walk to the PACU.

Most pneumothoraxes don't develop until post procedure. What happens if your patient is in the PACU, develops a hemodynamically significant pneumothorax and the pulmonologist has already started the next procedure, but you are tied up with a difficult intubation or intra-operative event?

 

[abolt18]

More of my concerns are the logistical, facility specific limitation. This is a community hospital with 1 anesthesia tech.

They will have to be transferred (most O2 dependent at baseline) to an elevator and another long walk to the PACU.

Most pneumothoraxes don't develop until post procedure. What happens if your patient is in the PACU, develops a hemodynamically significant pneumothorax and the pulmonologist has already started the next procedure, but you are tied up with a difficult intubation or intra-operative event?

Every one gets a bedside chest X-ray before we leave the Endo suite and the pulmonologist looks at it immediately. PTX? Chest tube. If it's normal but they have significant concern due to the location of the lesion, they may order a 2-view to be done between PACU and phase 2.

 

[CopaceticOne]

More of my concerns are the logistical, facility specific limitation. This is a community hospital with 1 anesthesia tech.

They will have to be transferred (most O2 dependent at baseline) to an elevator and another long walk to the PACU.

Most pneumothoraxes don't develop until post procedure. What happens if your patient is in the PACU, develops a hemodynamically significant pneumothorax and the pulmonologist has already started the next procedure, but you are tied up with a difficult intubation or intra-operative event?

It takes time to clean the room, turn over equipment, upload the next set of patient info into the robot.

We do these every day on a different floor than the ORs. I do a TIVA & keep them paralyzed, PEEP 10-12 depending on what the pulm doc asks for. After the robot part, our docs do the EBUS fun for getting the node samples. Then wake up, elevator ride and hallway trip to the PACU.

These are waaaaay easier than something like a case with neuromonitoring. No need to make a mountain out of a molehill.

 

[coolforschool]

It takes time to clean the room, turn over equipment, upload the next set of patient info into the robot.

We do these every day on a different floor than the ORs. I do a TIVA & keep them paralyzed, PEEP 10-12 depending on what the pulm doc asks for. After the robot part, our docs do the EBUS fun for getting the node samples. Then wake up, elevator ride and hallway trip to the PACU.

These are waaaaay easier than something like a case with neuromonitoring. No need to make a mountain out of a molehill.

Mostly agreed. These are usually the easiest cases of the day (8.0-8.5 tube, TIVA, PEEP 10). We do 4-6 daily with a busy interventional pulm service.

That being said, there are valid considerations as our pulmonologists are very good, but occasionally we get some very bad things that happen in there (cerebral air/stroke, PA biopsy, hemorrhage, etc.), probably 1-2% rate of serious complications. PTX rate is around 5-10% but not a big deal since they’ll happily do a pigtail in PACU, and we have a ton of support around.

I imagine the complication rates will be higher for a place just starting to do these.

 

[painquestions8989]

PTX rate is around 5-10% but not a big deal since they’ll happily do a pigtail in PACU, and we have a ton of support around.

Anyone who is nonchalant about stats like these must have lots of support and experienced personnel. At a smaller community center when the patient is crashing and nobody has any idea what to do, I can understand OP's concerns.

 

[nycitygas]

These can easily and safely done in the bronch suite

 

[coolforschool]

Anyone who is nonchalant about stats like these must have lots of support and experienced personnel. At a smaller community center when the patient is crashing and nobody has any idea what to do, I can understand OP's concerns.

We’re a quaternary care center, and most of us are cardiac trained. So, yes and yes.

 

[coffeebythelake]

Anyone who is nonchalant about stats like these must have lots of support and experienced personnel. At a smaller community center when the patient is crashing and nobody has any idea what to do, I can understand OP's concerns.

If the proceduralist isn't skilled then maybe doing it in a community hospital isn't thr place for them.

 

[abolt18]

Anyone who is nonchalant about stats like these must have lots of support and experienced personnel. At a smaller community center when the patient is crashing and nobody has any idea what to do, I can understand OP's concerns.

Pneumothorax =/= tension pneumothorax. I'd suspect the incidence of "crashing" patients after this is MUCH lower than that 3-5% because the PTX is identified long before there's and hemodynamic compromise.

 

[PpfSuxTube]

Anyone who is nonchalant about stats like these must have lots of support and experienced personnel. At a smaller community center when the patient is crashing and nobody has any idea what to do, I can understand OP's concerns.

Well you seem to be describing 2 separate entities. Anywhere doing guided bronch biopsies in an official rolled out program isnt exactly a place where "nobody has any idea what to do" is it?


I would just do the case. Its not some random guy doing the procedure. Its a critical care trained pulmonologist equally invested in the patients airway and lungs as you are if not more... for me thats possibly the safest scenario even more so that having a thoracic surgeon available who couldn't intubate his foot into his sock

 

[FiO2@21]

More of my concerns are the logistical, facility specific limitation. This is a community hospital with 1 anesthesia tech.

They will have to be transferred (most O2 dependent at baseline) to an elevator and another long walk to the PACU.

Most pneumothoraxes don't develop until post procedure. What happens if your patient is in the PACU, develops a hemodynamically significant pneumothorax and the pulmonologist has already started the next procedure, but you are tied up with a difficult intubation or intra-operative event?

OP, we had this exact thing happen. Tension PTX in PACU which was also far away from the pulmonologist and the anesthesiologist who were already in their next case in the endo suite.

A separate anesthesiologist who was running the board needled him. This was at a community center and the response in PACU was chaotic with a rapid being called, people who didn't know what the case was yelling at him to intubate before he needled, etc. So, very community. Pt did fine.

I'm now trying to imagine the cases being done at the closer ORs vs the endo suite. Perhaps the pulmonologist would have heard what was happening and left their case to help? The rest of the complications you listed would require someone like CVTS. This particular facility of ours would not have such a surgeon immediately available every moment to help, I suspect yours doesn't either.

I agree I would not direct a CRNA/AA and instead assign a physician to be in that room while you're first starting out, or ever. If your group runs too lean to accommodate that then I agree distance may be an issue but your facility may argue that this is your problem and not theirs.

Good luck!

 

[coffeebythelake]

OP, we had this exact thing happen. Tension PTX in PACU which was also far away from the pulmonologist and the anesthesiologist who were already in their next case in the endo suite.

A separate anesthesiologist who was running the board needled him. This was at a community center and the response in PACU was chaotic with a rapid being called, people who didn't know what the case was yelling at him to intubate before he needled, etc. So, very community. Pt did fine.

I'm now trying to imagine the cases being done at the closer ORs vs the endo suite. Perhaps the pulmonologist would have heard what was happening and left their case to help? The rest of the complications you listed would require someone like CVTS. This particular facility of ours would not have such a surgeon immediately available every moment to help, I suspect yours doesn't either.

I agree I would not direct a CRNA/AA and instead assign a physician to be in that room while you're first starting out, or ever. If your group runs too lean to accommodate that then I agree distance may be an issue but your facility may argue that this is your problem and not theirs.

Good luck!

Seems like the chaos in pacu was a combination of inexperience and inadequate hand off