Surgery Center Case

[seinfeld]

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Doing my thing at outpt center and get a call from the PAT nurse regarding a patient scheduled for later in the week.

60 something women, hx of chronic UTI and requiring ureteroscopy and stent change. Nurse asks me if she is OK for outpt center. I review her chart

9 months ago during after her first stenting she developed severe sepsis and flash pulmonary edema 3 days postop. 6 months ago she did the same thing. Both times she was reintubated either in Pacu or on the floor. Hx also significant for mild/moderate Aortic Stenosis with Mean gradient of 15 Pk of 30. DM, HTN, EF 30%. Last cardiology consult during that admission blammed introp fluid management in a pt with diasytolic dysfunction as the cause.

I punted her to cardiology (has not seen since her last hospitlization) and back to the main hospital. Anyone out there who would do her at the outpt center? it is just a stent change after all.

BTW when i spoke with the pt, he/she was suprised anyone would consider doing it at an outpt center.

 

[Jeff05]

clearly they would blame fluid management.
how about blaming the obvious uro-SIRS/sepsis we see after many simple GU procedures. between her AS and diastolic dysfunction and systolic dysfunction this patient is preload dependent. any decrease in svr/venous return and she slides down the starling curve and goes into failure.

in this case, i don't think that third time is the charm. i would have her go to a hospital with a good PACU and SICU.

 

[Masseter Spasm]

Why would any surgeon familiar with this patient's history try to schedule it at an ASC? A patient requiring ICU admission twice in the preceding year following a routine stent placement/removal should not have the same procedure done at the ASC. This patient may require a level of care that will be quickly exhausted at the ASC. It is also in the ASC's best interest to defer care for this patient, because if the patient requires transfer to a hospital this could be considered a reportable incident to local, regional, national accrediting agencies.

 

[Planktonmd]

The question is:
If you send her to the hospital is she going to stay overnight or be done as an outpatient then discharged home?
I am assuming that she is not going to remain hospitalized unless something goes wrong immediately post-op, so what's the difference between discharging her home form the hospital or from the ASC?
The fact that in the past she had urosepsis does not automatically make her surgery contraindicated at an ASC.

 

[Jeff05]

the fact that she may have urosepsis may be seen as a contraindication. i would schedule her in a large hospital and see how she does. if she's stable after hanging out in the pacu for 2-4 hours post-op, she can go home.

 

[siednarb]

Whenever the words "It's Just a...." become your justification for doing something that you know in your gut you shouldn't do, you are asking for trouble.

 

[Planktonmd]

the fact that she may have urosepsis may be seen as a contraindication. i would schedule her in a large hospital and see how she does. if she's stable after hanging out in the pacu for 2-4 hours post-op, she can go home.

Who said that she has Urosepsis?
We were only told that she HAD a possible urosepsis a few months ago.
And why wait 2-4 hours in PACU?
What happens in 2-4 hours that could not happen in, let's say, 5 hours or 1 hour?
And why is that thing that is going to happen in 2-4 hours can only happen at a "large hospital"?