Would you do this case?

[DrOwnage]

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?

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[dannyboy1]

He had a cabg 12 years ago at age 26?
In any event, hard to cancel a case for cardiac reasons when there is a cardiology note clearing them. Would prefer to do it under ISB/sedation, but could do GA if needed. Would definitely need a day of surgery potassium.

 

[DrOwnage]

Yes.

 

[dchz]

Well, did the cardiologist comment on the current status of his coronary arteries?
If they are patent then I don't see any MEDICAL reason why I can't do the case.

But logistical reasons would be the fact that this is a surgery center with limited staff on a friday.

 

[woopedazz]

This is my regular patient. So I voted yes with an ISB, art line, GA.... but, if that's considered "overkill" or "not the usual practice" at the surgical centre I'd probably rebook for in-hours as that triggers my spider sense.

 

[drmwvr]

This is my regular patient. ISB, art line, GA.

In an ASC?

 

[DrOwnage]

No cath info. No art line equipment. This surgeon doesn’t allow interscalene blocks. Only adductors. In a small 2 OR ASC. The question isn’t if the patient should have surgery. It’s if they should have it at a non-hospital SC.

 

[woopedazz]

In an ASC?

Yeah edited. I agree

 

[woopedazz]

No cath info. No art line equipment. This surgeon doesn’t allow interscalene blocks. Only adductors.

Then I'd say no. I'm not a baller like some others.

 

[dabears505]

Why is someone with ckd stage 3 on a transplant list?

 

[NICMAN]

This patient is not a candidate for surgery at the large ortho center where I am the medical director.

Send to the main OR. Do it there with A-line monitoring and day-of labs.

 

[NICMAN]

The ASC will have to “eat” the cost of an ambulance ride for admission or have crappy metrics of ED visits post-op in the likely scenario that things don’t go perfectly.

 

[BobLoblaw78]

So much missing information. Any chest pain or neuropathy? Activity level? Was the stent in the last year or two? I want to know those things regardless of whether I think the case needs to go elsewhere.

I would at least give my partner a call and ask what else he found and why he cleared it. Hopefully he had better information, if not, you at least know more about his methods.

 

[vector2]

No chance. Esp if the surgeon doesn't like ISB + a minimalist technique. I mean, you're gonna do GA on this familial hyperlipidemia ESRD fatty with OSA who prolly has diabetic gastroparesis too? At an ASC? Pass.

 

[coffeebythelake]

Are his medical problems "fixed"? Get a potassium level. Assuming everything is optimized, i would probably do the case. Middle of line ASA3 case. It's a small ASC but you still have regular PACU monitoring. GA tube, have some phenylephrine in line. Do you think this patient has medical issues that will significantly increase thr likelihood of an unanticipated hospital admission? The big question that needs to be asked is what do you have in the main hospital that you do not have in the ASC.

 

[GassYous]

cancel do it at the main

 

[sevo00]

No for ASC. Def at hospital

 

[nimbus]

The big question that needs to be asked is what do you have in the main hospital that you do not have in the ASC.

A cardiologist and a Cath lab.

 

[coffeebythelake]

A cardiologist and a Cath lab.

😅

And what if this patient had a recent cath that showed widely patent grafts and minimal other coronary disease? I mean context here is more important than the actual medical diagnosis on his chart.

 

[zizzer]

Nothing in this history rules out the case under GA for me, but if he had HF symptoms without a TTE, angina, a nonreassuring airway exam, or concerning enough K or glucose, I would decline at the ASC.

 

[vector2]

Are his medical problems "fixed"? Get a potassium level. Assuming everything is optimized, i would probably do the case. Middle of line ASA3 case. It's a small ASC but you still have regular PACU monitoring. GA tube, have some phenylephrine in line. Do you think this patient has medical issues that will significantly increase thr likelihood of an unanticipated hospital admission? The big question that needs to be asked is what do you have in the main hospital that you do not have in the ASC.

Presumably the main hospital has istats, aline if you need one, plenty of norepi and/or vasopressin in the pyxis, bipap machines with a respiratory therapist, real PACU nurses used to these ASA 3.5's, and more availability of backup whether it be other anesthesiologists or consultants.

You gain so little by doing this case at an ASC (especially without an ISB) but you have so much to lose. Yes, 97 times out of 100 nothing will happen but "can probably get away with it" is a terrible way to triage totally elective ambulatory cases.

 

[DirtDocMD]

He needs to be done at a hospital.

So, 5/10 years on his stents?? Any caths since then??

Your partner who ok’ed this needs a slap upside the head. A patient with a (seriously)higher probability of post-op complications deserves a facility that can DEAL with those complications.

 

[abolt18]

Why is someone with ckd stage 3 on a transplant list?

CKD 4. OP said GFR in the 20s.

 

[Barleycorn]

As someone who does a lot of surgery center, absolutely no.

OSA worsened by post op narcs because of no regional necessitating post op monitoring

No invasive hemodynamic monitoring

No backup for possible difficult airway

No way to check labs

Pick one. The times I've done cases like these Ive regretted it or felt like I got away with something.

 

[abolt18]

Nope.

 

[dabears505]

CKD 4. OP said GFR in the 20s.

My bad.

 

[secretasianman]

Not a good idea. Wouldn't risk winging it.

 

[PlayToWin]

The ASC will have to “eat” the cost of an ambulance ride for admission or have crappy metrics of ED visits post-op in the likely scenario that things don’t go perfectly.

I used to work at a surgi centers where we routinely did cases like this. They didn’t give a sh! t if patient had a LvAD and as anesthesiologist who had the privilege of. billing these private patients were supposed to be magicians and fix any issues that occurred. Needless to say, we had a decent amount of post op transfers and luckily no deaths.
I remember this one ortho would do 6 shoulders scopes and 7 knees by 3 pm….all works man comp.
400 lb patients in beach chair ( max was 350lb on that chair). really shady stuff in that place .
They sold and we lost the contract
Glad I don’t go there anymore.

 

[Velefunt]

If you aren't deliberately withholding some "gotcha" type important medical history, then yes, the CV note presumes this patient has been diligent with his CV followup and other appropriate maintenance/compliance with medical therapies given he's made it onto the transplant list and maintained his "standing" on the list. I then assume he's optimized.

GA-LMA

I'd be my most charming and convincing self to get the patient a brachial plexus block, but it's not a hard stop. ERAS oral pre-med with acetaminophen and gabapentin. Small intermittent titrated doses of fentanyl if the block doesn't happen.

 

[drmwvr]

If you aren't deliberately withholding some "gotcha" type important medical history, then yes, the CV note presumes this patient has been diligent with his CV followup and other appropriate maintenance/compliance with medical therapies given he's made it onto the transplant list and maintained his "standing" on the list. I then assume he's optimized.

GA-LMA

I'd be my most charming and convincing self to get the patient a brachial plexus block, but it's not a hard stop. ERAS oral pre-med with acetaminophen and gabapentin. Small intermittent titrated doses of fentanyl if the block doesn't happen.

dam...obese - and - IDDM - and - on his side with a bean bag squishing his guts.....whatever you'd say about the rest of his history, odds are against his tolerating an aspiration well...just....why?

 

[Reveler]

dam...obese - and - IDDM - and - on his side with a bean bag squishing his guts.....whatever you'd say about the rest of his history, odds are against his tolerating an aspiration well...just....why?

Yea, only pre-meds I'm giving this guy are IV, including reglan and famotidine

 

[GaseousClay]

No small surgery center I’ve seen will be capable of drawing a stat K+ so postpone to main OR

 

[namethatsmell]

ER doc reading your forum...and really glad to see most folks telling the surgeon they're not gonna play "hold my beer."

Thanks to covid many ERs/hospitals are simply maxed out right now. I've had 34/35 of beds in my ER taken up by patients boarding waiting for beds upstairs to open...leaving us 1 monitored bed to see the average of ~95pts who check into the ED on a given day. We're seeing patients double-stacked in the hallways and turned the ED conference room into more makeshift spots to see pts in chairs. I've done joint reductions and sewn lacs in the waiting room because there's no where to see pts. RN staffing shortage is it's own disaster.

Anyway, right about now isn't the time we're looking to add to our dumpster fire by having to play turbo-mode human tetris and find a way to physically accommodate a tubed train wreck from an ASC into the overflowing ER...and try to keep the patient alive with nurses we don't have and being tied up trying to transfer the patient to an available ICU bed that doesn't exist.

So yeah thanks to all who are cancelling the cases/sending them to the main OR.

Sincerely,

All the ER docs

 

[GassYous]

What are you going on about?

 

[coffeebythelake]

ER doc reading your forum...and really glad to see most folks telling the surgeon they're not gonna play "hold my beer."

Thanks to covid many ERs/hospitals are simply maxed out right now. I've had 34/35 of beds in my ER taken up by patients boarding waiting for beds upstairs to open...leaving us 1 monitored bed to see the average of ~95pts who check into the ED on a given day. We're seeing patients double-stacked in the hallways and turned the ED conference room into more makeshift spots to see pts in chairs. I've done joint reductions and sewn lacs in the waiting room because there's no where to see pts. RN staffing shortage is it's own disaster.

Anyway, right about now isn't the time we're looking to add to our dumpster fire by having to play turbo-mode human tetris and find a way to physically accommodate a tubed train wreck from an ASC into the overflowing ER...and try to keep the patient alive with nurses we don't have and being tied up trying to transfer the patient to an available ICU bed that doesn't exist.

So yeah thanks to all who are cancelling the cases/sending them to the main OR.

Sincerely,

All the ER docs

Honestly I don't think this scenario presented by the OP is meant to include the added problems of the covid disaster that is happening right now. In parts of the country where covid is inudating thr hospitals, elective surgeries such as the case here would almost certainly be held off regardless of whether it is booked for ASC or main hospital ORs. Medical staff and resources are retasked to ICUs etc

 

[Impromptu]

General anesthesia with an LMA would likely be adequate at a surgery center. As others have said, context is key here, so there are a thousand things that could change this scenario. At my location a cardiology clearance note typically means that he is medically optimized. Asymptomatic non-specific changes on EKGs do not warrant cancelling surgery. If he was on dialysis, then he would have been dialyzed the day prior. He would need a day of surgery K+. Patients with OSA bring their CPAP machines, which are needed maybe 5-10% of the time in the surgery center. Most shoulder surgeons are pretty decent at their intraoperative local anesthetic for these types of cases.

Preoperatively I would give PO acetaminophen, gabapentin, reglan, and pepcid. Due to his CAD I would also give 2 mg IV midazolam for anxiolysis. I would preoxygenate well. Induction would consist of fentanyl, lidocaine, and propofol. If he has a normal mouth with all of his teeth, then LMAs can be used fine in the lateral position. I would keep him spontaneously breathing. Phenylephrine would be my choice for a pressor if needed.

The risk of him needing to be admitted to a hospital afterward is minimal.

 

[woopedazz]

No way I'm giving this OSA, etc guy midazolam last thing on a Friday.

 

[Mman]

No way I'm giving this OSA, etc guy midazolam last thing on a Friday.

2nd case of the day on a Friday morning and he is 38 years old. Pretty sure the versed will be OK. But that's about the only thing I'd give him preop except for a nice brachial plexus block to ensure he requires no narcotics at any point.

 

[dchz]

Contrarian hat on*

If this pt didn't have the previous CABG. are you ok with this case being done?

 

[Hoya11]

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?

the only real concern here in my mind is the CAD history at such a young age and the stability of his cardiac revascularization...

the other stuff is just typical fat guy stuff..

if he had good exercise tolerance, a normal EF, and a cardiac note saying all is good with CABG/stents - i would do it.

you can make the argument that any case is safer in a hospital - theres blood, theres backup airway stuff, others docs, cath lab, bypass machines

but unless i think there is a real world chance the patient is going to need that intervention, im going to just do the case

why would now be the time this guy is going to have a coronary event? hes been good for years, hes going to be in lateral position - so many concerns of beach chair fluid shifts are gone, hes going to be given high fio2 and have a controlled airway, most likely additional BP meds from me to optimize HR and BP, and a ISB to negate sympathetic stimulation - from what i am given here i see no reason not to proceed.

 

[Planktonmd]

No cath info. No art line equipment. This surgeon doesn’t allow interscalene blocks. Only adductors. In a small 2 OR ASC. The question isn’t if the patient should have surgery. It’s if they should have it at a non-hospital SC.

If the surgeon is not going to allow you to control this patient's post-op pain appropriately then this patient does not belong at the ASC.
A patient with OSA and uncertain coronary status deserves effective pain control.

 

[Aheadbyacentury]

If the surgeon is not going to allow you to control this patient's post-op pain appropriately then this patient does not belong at the ASC.
A patient with OSA and uncertain coronary status deserves effective pain control.

Unless you are planning to send him to the ER.. Do the case!! I wouldnt even repeat a potassium.

 

[ChiDO]

Surprise surprise, anesthesia cancelling a Friday case so they can get on the golf course earlier!

So what that the patient is a nightmare.. Just hit the green "go" button on the anesthesia machine and play sudoku. If the patient doesn't so well in pacu, doesn't matter, I'll be on the lake already.. So what's the big deal?!

Joking aside, We have a great anesthesia team in our physician owned asc and hospital. They will review all charts that are suspect and will let us know to move to the big institution if warranted.

I'd be upset if they were cleared by anesthesia earlier in the week and then you decide to cancel without any changes to their health. But, I haven't seen that happen at our places unless patients health status changed.. New onset ekg changes, bad labs, chest pain.

 

[vector2]

Surprise surprise, anesthesia cancelling a Friday case so they can get on the golf course earlier!

So what that the patient is a nightmare.. Just hit the green "go" button on the anesthesia machine and play sudoku. If the patient doesn't so well in pacu, doesn't matter, I'll be on the lake already.. So what's the big deal?!

Joking aside, We have a great anesthesia team in our physician owned asc and hospital. They will review all charts that are suspect and will let us know to move to the big institution if warranted.

I'd be upset if they were cleared by anesthesia earlier in the week and then you decide to cancel without any changes to their health. But, I haven't seen that happen at our places unless patients health status changed.. New onset ekg changes, bad labs, chest pain.

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?

 

[sevo00]

If the surgeon doesn’t “allow” an ISB, then I won’t allow him to do this case at an ASC. Stay in your lane and Don’t tell me how to do my anesthetic

 

[Southpaw]

OSA (CPAP compliant?)
CABG at age of 26
ESRD, K of 5.6 4 days ago (doesn't say dialysis dependent)
BMI?

Just want to say that if you're doing these in an ASC then 1) your medical director failed you and 2) you have essentially no ASC exemption criteria.

No ISB at an ASC? GTFO

 

[Southpaw]

I'd be upset if they were cleared by anesthesia earlier in the week and then you decide to cancel without any changes to their health. But, I haven't seen that happen at our places unless patients health status changed.. New onset ekg changes, bad labs, chest pain.

My guess if that if one of your partners was potentially setting you up for failure they'd at least call you to run it by you.

 

[DrOwnage]

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.

 

[coffeebythelake]

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.

You did what you felt was appropriate. I agree cancelling cases is one of the most difficult things we have to do.

 

[kidthor]

This case is representative of scope creep at ASCs (pun included). This patient is not ASC material and exposes the patient and the OR staff to risk. Sure, it'll go well 96 out of 100 times but what about the expected 4% of badness? It's not worth the risk to do this at an ASC that is resourced and optimized for healthier patients.