Girish P. Joshi, MB, BS, MD, FFARCSI Professor of Anesthesiology and Pain Management Director of Perioperative Medicine and Ambulatory Anesthesia Patient Selection For Ambulatory Surgery: Can Any Patient Be an Outpatient? THE UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS Conflict Of Interests • None O u t l i n e • Describe the concerns of ambulatory surgery in challenging patients • Understand the approach to determining patient selection for ambulatory surgery • Justify appropriate selection of challenging adult patients scheduled for ambulatory surgery – Sick, elderly, obese, OSA, diabetes mellitus, cardiac implantable electronic devices Reengineering in Surgical Paradigm • In the US, ~ 70% surgical procedures performed on an outpatient basis • Improvements in surgical and anesthetic techniques make more procedures possible in outpatient setting • Complex surgical procedures are increasingly performed on complex patients Source: Intellimarker. Ambulatory Surgical Centers Financial & Operational Benchmarking Study. Fifth Edition. VMG Health, July 2010 (67). In an ambulatory setting, patient selection influences perioperative outcome. Patient Selection Influences Perioperative Outcome • Delayed discharge home • Reduced efficiency of the ASC • Unplanned hospital admission • Increased post-discharge complications • Unplanned readmission • Patient/family dissatisfaction Joshi, Girish, MB, BS, MD, FFARCSI Patient Selection for Ambulatory Surgery
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THE UNIVERSITY OF TEXAS Conflict Of Interests … Assessment & Identification of Comorbid Conditions [OSA, Hypoventilation, Cardiovascular, Difficult airway, DM] Comorbid Conditions
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Girish P. Joshi, MB, BS, MD, FFARCSI Professor of Anesthesiology and Pain Management
Director of Perioperative Medicine and Ambulatory Anesthesia
Patient Selection For Ambulatory Surgery: Can Any Patient Be an Outpatient?
THE UNIVERSITY OF TEXAS
SOUTHWESTERN MEDICAL CENTER
AT DALLAS
Conflict Of Interests
• None
O u t l i n e
• Describe the concerns of ambulatory surgery in challenging patients
• Understand the approach to determining patient selection for ambulatory surgery
• Justify appropriate selection of challenging adult patients scheduled for ambulatory surgery – Sick, elderly, obese, OSA, diabetes mellitus, cardiac
implantable electronic devices
Reengineering in Surgical Paradigm
• In the US, ~ 70% surgical procedures performed on an outpatient basis
• Improvements in surgical and anesthetic techniques make more procedures possible in outpatient setting
• Complex surgical procedures are increasingly performed on complex patients
Joshi GP, et al: Anesth Analg 2013; 117: 1082-91 * Joshi GP, et al: Anesth Analg 2012; 115: 1060-8
BMI 40-50 kg/m2 BMI>50 kg/m2
Follow SAMBA-OSA Recommendations *
Joshi, Girish, MB, BS, MD, FFARCSI Patient Selection for Ambulatory Surgery
OSA Patients
For Ambulatory Surgery
• Scientific literature on safety and perioperative management of OSA patients is sparse and of limited quality
Anesthesiology 2014; 120:268-86
ASA-Scoring System For OSA Patients
A. Severity of OSA (0-3 pts) B. Invasiveness of surgery/anesthesia (0-3 pts) C. Requirements for postoperative opioids (0-3 pts) • Overall score (0-6): A + greater of B or C
– Score ≥4 increased risk from OSA – Score 5 or 6 significantly increased risk from OSA
Not suitable for ambulatory surgery
• Intra-abdominal and upper airway surgery are not suitable for ambulatory surgery
Anesthesiology 2014; 120:268-86
Joshi GP et al: Anesth Analg 2012; 115: 1060–8
SAMBA-OSA Systematic Review
• No difference in complications between OSA and non-OSA patients undergoing ambulatory surgery
• Most studies used standardized, protocolized approach to patient care – Emphasis on preoperative diagnosis – Emphasis on use of non-opioid analgesics to
minimize opioid use – Emphasis on postoperative care particularly
use of CPAP after discharge Joshi GP et al: Anesth Analg 2012; 115: 1060–8
Selection of a OSA Patient For Ambulatory Surgery
Patient With Known OSA Patient With Presumptive
Diagnosis of OSA
Optimized Comorbid Conditions
AND Able to use CPAP after
discharge
Patients With Non-optimized
Comorbid Conditions
Optimized Co-morbid Conditions
AND Postoperative opioids can be limited by using non-
opioid analgesic techniques
Not Suitable For Ambulatory Surgery,
may benefit from diagnosis and treatment
Proceed With Ambulatory Surgery
Proceed With Ambulatory Surgery
Joshi GP et al: Anesth Analg 2012; 115: 1060-8
No guidance can be provided for airway surgery
Joshi, Girish, MB, BS, MD, FFARCSI Patient Selection for Ambulatory Surgery
Surgery For OSA in An Ambulatory Setting
• Systematic review of 18 studies (2160 patients) • No deaths or major catastrophic events • Overall adverse event rate = 5.3% • Respiratory complications = 1.5%
– Majority were O2 desaturations, and were not clinically significant
• Readmission rate 0.4% • OSA surgery performed on an outpatient basis
is generally safe • Exceptions: tongue base surgery, high AHI,
• Analysis of the National Survey of Ambulatory Surgery
• No increase in airway surgery over a decade
• Unplanned readmission rate <4%
• No mortality or serious complications
• Minor complications: 9% Mahboubu H et al: JAMA Otolaryngol Head Neck Surg 2013; 139: 28-31
Diabetic Patients
For Ambulatory Surgery
Glycemic Control Guidelines
Is there a preoperative blood glucose level above which one should postpone elective surgery?
• No evidence that any particular blood glucose level is harmful for outpatients
• First step in decision making: assess for significant complications of hyperglycemia such as severe dehydration, ketoacidosis, and hyperosmolar non-ketotic states
• Postpone surgery of these conditions are present
Preoperative Blood Glucose Level
• Good long-term control: proceed with surgery
• Poor long-term control: consider comorbidities
and risks of surgical complications (e.g.,
delayed wound healing and wound infection)
• Decision to proceed made in conjunction with
the surgeon
Joshi, Girish, MB, BS, MD, FFARCSI Patient Selection for Ambulatory Surgery
Proceed After BGL Correction or Correct BGL in the Operating Room
• Rapid correction of BGL not necessary
• Timing of BGL correction based upon available time in the preop period duration of surgery
Patients With Cardiac Disease
For Ambulatory Surgery
Stepwise approach to perioperative cardiac assessment for CAD.Colors correspond to the Classes of Recommendations in Table 1.
Gupta PK, et al: Circulation 2011; 124: 381-7; http://www.surgicalriskcalculator.com
ACS NSQIP: Surgical Risk Calculator
http://www.riskcalculator.facs.org
1/4/15 6:54 PMPatient Information - ACS Risk Calculator
Page 1 of 2http://www.riskcalculator.facs.org/PatientInfo/PatientInfo
Height (in)
Weight (lbs)
Risk Calculator Homepage About FAQ ACS Website ACS NSQIPWebsite
Enter Patient and Surgical Information
Procedure 49525 - Repair inguinal hernia, sliding, any age Clear
Begin by entering the procedure name or CPT code. One or more procedures willappear below the procedure box. You will need to click on the desired procedure toproperly select it. You may also search using two words (or two partial words) by
placing a ‘+’ in between, for example: “cholecystectomy+cholangiography”
Reset All Selections
Are there other potential appropriatetreatment options?
Other SurgicalOptions
Other Non-operative options None
Please enter as much of the following information as you can to receive the bestrisk estimates.
A rough estimate will still be generated if you cannot provide all of the informationbelow.
Age Group 65-74 years Diabetes Oral
Sex MaleHypertension requiring
medication Yes
Functional status Independent Previous cardiac event No
Emergency case NoCongestive heart failure
in 30 days prior tosurgery
No
ASA class III - Severe systemic disease
Wound class Clean Dyspnea None
Steroid use for chroniccondition No
Current smoker within 1year No
Ascites within 30 daysprior to surgery No History of severe COPD No
Systemic sepsis within48 hours prior to
surgeryNone Dialysis No
Acute Renal Failure No
Ventilator dependent NoBMI Calculation:
66
Disseminated cancer No 270
1/4/15 6:54 PM- ACS Risk Calculator
Page 1 of 2http://www.riskcalculator.facs.org/Outcome
0% (Better) 100% (Worse)
Risk Calculator Homepage About FAQ ACS Website ACS NSQIP Website