Let’s look at a case study which highlights a specific risk of general anesthesia at a freestanding surgery center or a surgeon’s office operating room:
The patient is a 66-year-old woman admitted for a facelift, neck lift, and blepharoplasties. The surgery is scheduled for 8 hours, and will be conducted in a private operating room adjacent to a plastic surgeon’s office. The patient has preoperative medical clearance from her internist. Her only medical problems are hyperlipidemia and stable asthma. She has no history of cardiac problems. Her weight is 80 kg, and her BMI=29. Her ECG and preoperative labs are normal.
The anesthesiologist meets the patient prior to the surgery, reviews the chart, and examines the patient. The assessment is ASA II, and the plan is general endotracheal anesthesia. The anesthesiologist’s informed consent includes the common risks of sleepiness, pain, nausea, and sore throat postoperatively. He explains that the risks of serious complications related to the heart, the lungs, or the brain are not zero, but that the risks are close to zero. The patient consents.
The patient enters the operating room at 0730 hours. The anesthetic consists of midazolam 2 mg IV as a premed, induction with propofol 200 mg IV, fentanyl 100 micrograms IV, and rocuronium 40 mg IV. The trachea is intubated, and anesthesia is maintained with 1-1.5% sevoflurane, 50% nitrous oxide, a propofol infusion at 50 mcg/kg/min, and intermittent boluses of fentanyl.
The surgery concludes at 1630 hours. The surgeon wraps the face in several layers of gauze bandages, and the anesthesiologist discontinues the anesthetic drugs. The patient eventually begins bucking on the breathing tube, and the tube is removed. The anesthesiologist and the operating room nurse transport the patient to the PACU (Post Anesthesia Care Unit), where the patient is connected to the standard monitors of pulse oximetry, ECG, blood pressure, and temperature. Four liters/min of oxygen are administered intranasally. The initial vital signs are an oxygen saturation of 95%, heart rate of 90, respiratory rate of 24, and blood pressure of 140/88.
The PACU nurse’s name is Gloria, and she is new to this surgical facility. Her last job was as a home health nurse for a registry company. The anesthesiologist has never met her before. The anesthesiologist gives a detailed sign out to the PACU nurse, transferring care to her. He orders fentanyl 50 mcg IV as needed for postoperative pain, and labetalol 10 mg IV as need to maintain the blood pressure less than 140 systolic and 90 diastolic.
Twenty minutes later, the anesthesiologist physically leaves the facility. He signs out to the plastic surgeon, who remains in his office across the hall to do paperwork.
Thirty minutes later, the anesthesiologist receives a cell phone call from the plastic surgeon. The patient is having difficulty breathing, the oxygen saturation is less than 80%, the blood pressure is elevated at 170/100, and there is a facial hematoma developing in the right cheek which is inhibiting the patient’s ability to breathe. The anesthesiologist is alarmed. He instructs the surgeon to call 911, and says he will return to the site immediately. Traffic is heavy at rush hour and it takes him 30 minutes before he arrives. The paramedics are onsite, the patient has been reintubated, and the patient is being transported to a nearby hospital. In the days that follow, the patient does not reawaken. A neurologic consult and an EEG confirm the diagnosis of anoxic brain damage.
This is every anesthesia provider’s nightmare. What went wrong?
A number of things went wrong, and the primary issue was the absence of an experienced acute care doctor on site when this patient began to decompensate. The interval history after the anesthesiologist left the facility was as follows:
The patient began to moan and complain that her face hurt. Her blood pressure increased to 165/100. The nurse treated her with two doses of 50 mcg of IV fentanyl. The patient became increasingly somnolent, began to snore and obstruct her airway, and her oxygen saturation dropped to 88%. The elevated blood pressure went untreated. The nurse turned the nasal oxygen up to 6 liters/minute and called the plastic surgeon. The plastic surgeon arrived on scene, and unsuccessfully tried to improve the patient’s airway, but the oxygen saturation dropped to 70%. The snoring first increased in amplitude and then converted to total airway obstruction. The blood pressure climbed to 165/100, and surgeon noted that the patient’s right cheek was swollen, adding to the airway obstruction. The oxygen saturation dropped further to 60%. The surgeon ordered an amp of Narcan IV to reverse the fentanyl, but neither he nor the nurse knew where the Narcan was stored. They telephoned the anesthesiologist and then they called 911. By the time the nurse found the Narcan, the oxygen saturation had been below 80% for over five minutes. She injected the Narcan IV, and the patient still did not wake up. Paramedics arrived five minutes later, and were able to intubate the trachea on the third attempt. The oxygen saturation then climbed to 100%, and they transported the patient to the hospital.
Can this scenario occur? Yes? Have variations on this theme occurred? Yes. Based on my experience as an expert witness, expert reviewer, and quality assurance committee member for many years, this scenario is representative of several cases I’m aware of. The common thread is a perioperative patient with an airway, breathing, or circulation disaster when there was no anesthesiologist present.
An increasing number of surgeries are being conducted utilizing general anesthesia in freestanding surgery centers or physician offices. Advances in anesthesia pharmacology, monitoring, training, and pain control enable safe anesthesia care in many locations remote from an acute care hospital. Today, one of every ten surgeries is performed in a doctor’s office.
Freestanding surgery centers and office-based operating rooms are islands without intensive care units, laboratories, rapid response teams, respiratory therapy departments, arterial blood gas measurements, or emergency rooms. The reservoir for assistance when an acute complication arises isn’t deep. PACU medical care is typically safe when a physician anesthesiologist is on site and available for consultation. For the last case of each day, the anesthesiologist must utilize judgment in deciding when to leave the facility.
PACU complications are not rare. For inpatients and outpatients combined, the PACU complication rate was 24% in a prospective study of more than 18,000 consecutive admissions to the PACU. The most frequent events were nausea and vomiting (9.8%), the need for upper airway support (6.8%), and hypotension (2.7%). From1985 to 1989, 7.1% of the 1175 anesthesia-related malpractice claims in the United States were attributed to PACU events. The most serious adverse outcomes were due to airway, respiratory, and cardiovascular complications.
In a freestanding operating room suite where general anesthesia is performed, it’s critical that before the final anesthesiologist departs, all patients must be awake with stable vital signs and free of airway, breathing, or cardiac problems. The anesthesiologist needs to evaluate when it’s safe to leave.
I’ve personally performed over 7,000 general anesthetics in freestanding surgery centers and office operating rooms. General anesthesia in freestanding facilities can be very, very safe, but the complication rate in ambulatory surgery centers is not zero. In a study by Fleisher et al, for patients > 65 years of age the incidence of death in an ambulatory surgery center was calculated to be 2.3 per 100,000 outpatient procedures. The number of patients admitted to a hospital within 7 days of outpatient surgery was 9.08 per 1000 outpatient procedures performed at a physician’s office, and 8.41 per 1000 outpatient procedures performed at an ambulatory surgery center. Advanced age, a previous inpatient hospital admission within the past 6 months, surgical location at a physician’s office or an outpatient facility, and the invasiveness of the surgery were the risk factors for an increased risk of hospital admission or death within 7 days of surgery at an outpatient facility.
What should have happened in the case study above?
The anesthesiologist was responsible for the patient and any complications until the patient was discharged from the PACU. Every facility will typically have a policy mandating that an anesthesiologist remains on site after a general anesthetic until a patient is medically discharged. What does “medically discharged” mean? It does not mean that the anesthesiologist must stay until the patient is wheeled out the door to their ride home. Medically discharged means the patient is: 1) awake and oriented to time and place, 2) able to maintain their airway without any device or assistance, and 3) pain is reasonably controlled with oral medications, 4) nausea is reasonably controlled, 5) there is no bleeding or surgical complication, 6) the vital signs are within normal limits, and 7) an adult is present to accompany the patient home.
I’d advise this guideline: You, the anesthesiologist, should not depart until you’re able to have meaningful conversation with your final patient in the PACU, confirming that the patient is awake, free of airway or breathing problems, and appears ready to resume their recovery after the surgery center. It’s within the standard of care to sign out to the surgeon at this point, but realize that the surgeon is not an expert in airway management or acute care management. The surgeon is not a substitute for an anesthesiologist.
What about the PACU nurse in this case study? All PACU nurses are not equal. PACU nurses are required to have ACLS (Advanced Cardiac Life Support) certification, but some nurses are inexperienced and cannot manage complications they’ve never seen before. An anesthesiologist needs to have a sense for the experience and competency of the nurse before he decides to depart. If you’ve never met your PACU nurse previously, I’d recommend you query her regarding her last job(s) and her comfort zone managing an PACU patient alone.
What about CRNA (Certified Registered Nurse Anesthetist) readers of this website? A solitary freestanding operating room is not typically staffed by an anesthesia care team, which would necessitate both a CRNA and an attending physician anesthesiologist care for one patient. If the solitary freestanding operating room is located in an opt-out state and the lone anesthesia provider is a CRNA, then the discussion regarding physician anesthesiologists in the case study applies to the CRNA.
The moral of this column? Don’t get caught on the other end of a traffic snarl while the patient you just anesthetized is hypoxic in the PACU. You worked hard to keep your patient alive and safe throughout the operating room course, but your job isn’t finished until your patient is wheeled out the door to their ride home after their time in the PACU. When you’re on site at the surgery suite, your patient is safe. When you’re not on site, there are no guarantees. You pay your own malpractice insurance, and I know you want to avoid a bad outcome for both your patient’s wellbeing and for your own.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
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