Archive November 2017 XVIII, No. 11

Anesthesia Alert: Who's Unsafe for Outpatient Surgery?

Certain patients shouldn't get past your anesthesia gatekeepers.

Perry Ruspantine

Perry Ruspantine, CRNA, APRN


difficult airways SIGNS OF TROUBLE Several factors suggest potential difficult airways, which should be a red flag for any freestanding surgery center.

As more and more complex procedures find their way into outpatient facilities, it's crucial for your anesthesia providers to determine which patients are appropriate for same-day surgery — and which are not. But how do they do it? As you'll see, there's no foolproof way to determine who's a good candidate for outpatient surgery.

Most of us are familiar with the ASA scores, but they really don't measure operative risk (see "ASA Scores Don't Measure Operative Risk"). Keep in mind that all outpatient facilities are not created equal. A patient who may not be a candidate for office-based surgery may be fine in a surgery center. And a patient who may not be a candidate for a freestanding ASC may be fine in a hospital-based outpatient center.

Here are some red flags and considerations when it comes to patient selection:

  • Age (But physiologic age is more important than chronological age.)
  • Abnormalities of major organ systems
  • Expected difficult airways, based on Mallampati score, recessed chin, major overbite, small mouth or large tongue
  • Morbid obesity (greater than 40 BMI)
  • Obstructive sleep apnea with continuous positive airway pressure (CPAP)
  • Previous adverse events with anesthesia, including malignant hyperthermia and pseudocholinesterase deficiency
  • Current medications that may adversely affect anesthetic choices or outcomes
  • Smoking or a history of alcohol or drug abuse (We shouldn't hesitate to ask patients if they use street drugs, and if so, what and how often.)
  • Psychological status (Some patients need general anesthesia, because they get extremely claustrophobic if their faces are covered.)
  • Support system (If needed, is someone available to care for them at home?)
  • Coagulation (Is there a risk of DVT or pulmonary embolism?)

Carefully review lab tests, with particular focus on known underlying conditions. Women of childbearing age should have HCG levels tested, but most lab studies are not necessary, and the practice of getting an EKG on everyone, regardless of condition, has fallen by the wayside.

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