Appropriate use of SCDs in outpatient surgery

I'm attempting to find research/protocols on the appropriateness of using sequential compression devices on outpatients in order to prevent deep vein thrombosis. The length of the surgery appears to be a deciding factor.

Started by: Jan Bahle (Other) at December 1, 2011 (12:50 pm)

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Our facility puts SCD's on all patients, for every surgical procedure. The exceptions are if they are under 18, or a Surgeon requests them not be used. It is better to use them on to many people than not enough. We also participate in the recycle program which cuts down on cost as well as waste.

Mark B. (OR Manager/Supervisor) at December 9, 2011 (7:53 pm)

With respect to the discussion on preventing DVTs by using Sequential Compression Devices, there are comments that refer to the length and complexity of surgery, and the type/depth/length of anesthesia. In these contexts, please be aware of the following regulatory requirements for reimbursement under the Code of Federal Regulations (CFR) for procedures that are performed in the outpatient setting, specifically in Ambulatory Surgery Centers (Title 42 of the Code, or 42 CFR), under Section 416.65 (b), that: (1) Covered surgical procedures are limited to those that do not generally exceed (i) a total of 90 minutes operating time; and (ii) a total of 4 hours recovery or convalescent time. (2) If the covered surgical procedures require anesthesia, the anesthesia must be (i) local or regional anesthesia; or (ii) general anesthesia of 90 minutes or less duration. (3) Covered surgical procedures may not be of a type that (i) generally result in extensive blood loss; (ii) require major or prolonged invasion of body cavities; (iii) directly involve major blood vessels; or (iv) are generally emergency or life-threatening in nature.

The regulations focus on safer practices. We suggest that discussions on preventing DVT include these limitations, i.e., total time for procedures and anesthesia. There are no federal regulations for office procedures, although some states may have licensing requirements for this and/or include this under a physician"™s medical license. These comments are exclusive of accrediting agencies"™ requirements.

The regulatory information can be found at the web site for the Electronic Code of Federal Regulations under Title 42 (Public Health). The exact URL for the quoted regulations is: http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid= e487c154fb0a16835f77591584edc8ef&rgn=div8&view=text&node= 42:3.0.1.1.3.4.1.3&idno=42 .

Bruce B. Ettinger, MD, MPH
Los Angeles County Department of Public Health
Health Facilities Licensing and Certification Programs

bruce ettinger (Administrator/Director/Manager/Owner/Exec. Officer) at December 9, 2011 (1:59 pm)

We use SCD's for all laparoscopy procedures, hx of DVT's or PE, and any case of 1 hour or longer. We also have a unit that is sent home with patients if they will be non-ambulatory for a couple of days.

Pat S. (Director, Surgical Services/Director of Nursing) at December 6, 2011 (10:33 am)

All of our blog readers should know that Dr. Friedberg"™s book is the bible in my office, and I will not hire an anesthesiologist unless he reads parts of his book and is willing or able to justify to me why he should NOT be using Dr. Friedberg"™s methods.

So far everybody that has tried his methods adapts to them well. If I am able to do 8 hour cases and send them home one hour after the end of the case it is because of Dr. Friedberg.

More importantly, my conscience rests easier because it is safer. Four years & 1,200 procedures later, not one single deep vein thrombosis or pulmonary embolus.

Ricardo L. Rodriguez MD
Board Certified Plastic Surgeon
1300 Bellona Avenue
Baltimore, Maryland 21093
410-494-8100

Barry Friedberg (Anesthesiologist/Nurse Anesthetist) at December 4, 2011 (3:37 pm)

Date Published: February 2009

Lethal Pulmonary Embolisms Are Avoidable

Congratulations to Keyes, et al(1), on their recent publication identifying pulmonary embolism as the leading cause of mortality in office-based abdominoplasty. Unfortunately, mortality from hospital-based abdominoplasty, not infrequently combined with hysterectomy, was not reported and, very likely, equals (or exceeds) on an annual rate the 23 deaths reported for the 5 years in their study. All abdominoplasty, as well as all cosmetic, deaths regardless of their operative location should be reported.(2)

In 2005, the late Dr. Ann Lofsky wrote that "immobility associated with general anesthesia is a significant risk factor for thromboembolism," and that "newer techniques for intravenous sedation that include the use of propofol drips, often in combination with other drugs, have made it possible to perform lengthy or extensive surgeries without general anesthesia and without the loss of the patient's airway protective reftexes."(3)

Dr. Lofsky was referring to propofol ketamine (PK) technique(4) which, in addition to essentially eliminating the risk of death from pulmonary embolism, is also devoid of triggering agents for malignant hyperthermia(MH). After the recent MH tragedy in Florida in an otherwise healthy 18 year-old woman, it is time to re-evaluate the routine use of general anesthesia in cosmetic surgery.

Independent of the extent of the dissection, abdominoplasty is an extra-peritoneal procedure. Despite commonly held beliefs, lengthy experience with PK has demonstrated that imbrication of the rectus abdominis sheath does not require profound muscle relaxation, but merely adequate local analgesia. PK does not demand perfection from the surgeon with local analgesia but merely persistence.

Unlike the common practice of administering local anesthesia under general anesthesia, local anesthesia in the dissociative model (i.e. diazepam ketamine or PK) provides reproducible preemptive analgesia. This eliminates the perceived need for muscle relaxants, enables patients to retain native muscle tone during surgery, and rapidly ambulate after surgery.

I have provided PK sedation for all cosmetic surgeries, including abdominoplasty, for more than 16 years for more than 4,000 patients of more than 100 different surgeons. There have been no fatal pulmonary embolisms, aspirations, pneumothorax,' or other airway misadventures. Also, there have been no hospitalizations for unmanageable postop pain or postoperative nausea and vomiting (PONV).

Readers interested in more specific information may find the clinical pathway on the home page of www.cosmeticsurgeryanesthesia.com.

References:

1. Keyes, GR, Singer R, Iverson, R, et al.: Mortality in Outpatient Surgery. Plast Reconst Surg 122:245, 2008.

2. Friedberg BL: Preface in Anesthesia in Cosmetic Surgery, Cambridge University Press, New York, xviii, 2007.

3. Lofsky AS: Deep venous thrombosis and pulmonary embolism in plastic surgery office procedures. The Doctors"™ Company Newsletter, Napa, CA, 2005
http://www.thedoctors.com/risk/specialty/anesthesiology/J4254.asp

4. Friedberg BL: Propofol-ketamine technique, dissociative anesthesia for office surgery: a five-year review of 1,264 cases. Aesth Plast Surg 23:70,1999.

Barry L. Friedberg, M.D.
Assistant Professor of Anesthesia
Volunteer Faculty
Keck School of Medicine
University of Southern California
Los Angeles, CA

Barry Friedberg (Anesthesiologist/Nurse Anesthetist) at December 4, 2011 (2:22 pm)

Date Published: February 2009

Lethal Pulmonary Embolisms Are Avoidable

Congratulations to Keyes, et al(1), on their recent publication identifying pulmonary embolism as the leading cause of mortality in office-based abdominoplasty. Unfortunately, mortality from hospital-based abdominoplasty, not infrequently combined with hysterectomy, was not reported and, very likely, equals (or exceeds) on an annual rate the 23 deaths reported for the 5 years in their study. All abdominoplasty, as well as all cosmetic, deaths regardless of their operative location should be reported.(2)

In 2005, the late Dr. Ann Lofsky wrote that "immobility associated with general anesthesia is a significant risk factor for thromboembolism," and that "newer techniques for intravenous sedation that include the use of propofol drips, often in combination with other drugs, have made it possible to perform lengthy or extensive surgeries without general anesthesia and without the loss of the patient's airway protective reftexes."(3)

Dr. Lofsky was referring to propofol ketamine (PK) technique(4) which, in addition to essentially eliminating the risk of death from pulmonary embolism, is also devoid of triggering agents for malignant hyperthermia(MH). After the recent MH tragedy in Florida in an otherwise healthy 18 year-old woman, it is time to re-evaluate the routine use of general anesthesia in cosmetic surgery.

Independent of the extent of the dissection, abdominoplasty is an extra-peritoneal procedure. Despite commonly held beliefs, lengthy experience with PK has demonstrated that imbrication of the rectus abdominis sheath does not require profound muscle relaxation, but merely adequate local analgesia. PK does not demand perfection from the surgeon with local analgesia but merely persistence.

Unlike the common practice of administering local anesthesia under general anesthesia, local anesthesia in the dissociative model (i.e. diazepam ketamine or PK) provides reproducible preemptive analgesia. This eliminates the perceived need for muscle relaxants, enables patients to retain native muscle tone during surgery, and rapidly ambulate after surgery.

I have provided PK sedation for all cosmetic surgeries, including abdominoplasty, for more than 16 years for more than 4,000 patients of more than 100 different surgeons. There have been no fatal pulmonary embolisms, aspirations, pneumothorax,' or other airway misadventures. Also, there have been no hospitalizations for unmanageable postop pain or postoperative nausea and vomiting (PONV).

Readers interested in more specific information may find the clinical pathway on the home page of www.cosmeticsurgeryanesthesia.com.

References:

1. Keyes, GR, Singer R, Iverson, R, et al.: Mortality in Outpatient Surgery. Plast Reconst Surg 122:245, 2008.

2. Friedberg BL: Preface in Anesthesia in Cosmetic Surgery, Cambridge University Press, New York, xviii, 2007.

3. Lofsky AS: Deep venous thrombosis and pulmonary embolism in plastic surgery office procedures. The Doctors"™ Company Newsletter, Napa, CA, 2005
http://www.thedoctors.com/risk/specialty/anesthesiology/J4254.asp

4. Friedberg BL: Propofol-ketamine technique, dissociative anesthesia for office surgery: a five-year review of 1,264 cases. Aesth Plast Surg 23:70,1999.

Barry L. Friedberg, M.D.
Founder & President, Goldilocks Anesthesia Foundation

Barry Friedberg (Anesthesiologist/Nurse Anesthetist) at December 4, 2011 (2:20 pm) [last edited on December 4, 2011 (2:22 pm)]

I request SEDS on people who have a history on thrombosis regardless of the length of the procedure. We also use SEDS on procedures lasting over 2 hours. Paul G. CRNA

Paul G. (Anesthesiologist/Nurse Anesthetist) at December 4, 2011 (11:53 am)

Length of surgery is only ONE of the deciding factors determining the use of mechanical devices. Patients must be evaluated for other risk factors that are also key in identifying Moderate to High-Risk Patients. There are a variety of guidelines and recommendations including the ACCP, AORN and the Caprini Risk Assessment. However, keep in mind that with the trend toward shorter stays and more complicated surgeries in outpatient settings, the risks for DVT simply do not stop once a patient leaves a facility. According to a UMass Medical School"™s "Best Practices""Preventing deep vein thrombosis and pulmonary embolism," once patients return home, they may be even less mobile than they were in the facility. Of 57 patients studied, 13 developed DVT during the six weeks after surgery, despite having shown no signs of this complaint while in the facility.

Sending patients home with a DVT compression device and SCDs has proven to prevent DVT and save lives.

M. Farrow (Other) at December 2, 2011 (4:33 pm)

I thought the AAAASF guidelines were for cases 1 hour or longer, or maybe that is not necessarily the automatic sequentials, just either pneumatic boots, TED stockings, or ace bandages.

Susan G. (Other) at December 2, 2011 (12:32 pm)

We use SCD's on every patient having General Anesthesia ...the length of the surgery is not a factor.

Lorraine G. (Administrator/Director/Manager/Owner/Exec. Officer) at December 2, 2011 (10:26 am)

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