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JOIN THE DISCUSSION - TOP  If you answered "yes" to any of these questions, or would like to share with other professionals a comment or opinion on a topic related to ambulatory anesthesia then please "Join the Discussion". Your question, reply or comment will be published in the next available issue of SAMBA TALKS. Include your name (or initials), email address, city, and state, if you would like these published. Please note that because of the high volume of questions we receive, there is often a delay of 1 to 2 months before publication. SAMBA Talks will include all discussion questions we receive considered of interest to the membership at large. We will endeavor to publish a response to at least one of these questions. The response will be from experts in the field, and from those willing to express a view on a particular topic, backed by experience and/or published evidence. Where email addresses are published, those individuals have indicated their interest in discussing the published questions. Questions and responses from previous months are now available at the eNewsletter Discussion Archive. If you have any comments regarding the previous questions, please submit them to SAMBA Discussion, and they will be published here next month. Please note: The information presented in the replies below does not represent SAMBA policy. The replies are solely the opinions of the individuals who wrote them.
Question 1: We perform anesthesia for colonoscopies using propofol and regard this as general anesthesia. However, ASA guidelines seem to indicate that end-tidal CO2 monitoring is a standard of care for general anesthesia. Do you regard end-tidal CO2 monitoring a standard of care for colonoscopy with propofol? -- From: John Booth, Richmond, VA (booth006@mac.com) Reply 1 We believe it is absolutely the standard of care to monitor end-tidal CO2 during a colonoscopy using propofol or any deep sedation. Anesthesia vigilance should be the same whether a procedure is done in the operating room or out of the operating room and whether general anesthesia or MAC is performed. Monitoring for any anesthetic should include EKG, blood pressure, pulse oximetry, and capnography. There are several companies making low-priced portable pulse oximeters and capnographs. To not use these monitors is indefensible. -- From: David S. Rapkin, M.D., Richmond Hts, OH Reply 2 It is correct to call patients who are asleep with propofol for colonoscopies as having general anesthesia- that's what most folk are doing. It is not sedation, since the patients are not "responding purposefully to painful stimuli {ASA Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia, 2004}. Also, "If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required." {ASA Position on Monitored Anesthesia Care, 2005}. This definition is not dependent on which drug/s are used, or what the procedure is, but only on the state that the patient reaches. Calling this state "sedation” also does not change the fact that it is general anesthesia If the patient is under general anesthesia, all relevant ASA guidelines apply. In the ASA Standards for Basic Anesthesia Monitoring (2005), under Ventilation: we find: "Every patient receiving general anesthesia shall have the adequacy of ventilation continually evaluated. Qualitative clinical signs such as chest excursion, observation of the reservoir breathing bag and auscultation of breath sounds are useful. Continual monitoring for the presence of expired carbon dioxide shall be performed unless invalidated by the nature of the patient, procedure or equipment." So the requirement is “shall" (have to) unless it's 'not possible'. I do regard end-tidal CO2 monitoring as the standard of care for colonoscopy with propofol, and for all such GAs with propofol, anywhere we give it. -- From: Beverly K. Philip, M.D., Boston, Massachusetts Reply 3 I agree and would like to add that sedation to the point of GA is not needed for patient comfort & safe conduct of colonoscopy/EGD. Whether it stems from our end, by telling the gastroenterologist that their patient will be completely asleep for the procedure or from their end where they have guaranteed to their patient that they will be asleep - whichever - it has created a potentially unsafe environment. Maybe it's a NYC paranoia, but both of the gastroenterologists that I work with and I tell our patients that they will NOT be asleep, they will hear us talking but they will be comfortable. Patients tell me afterwards that they were more awake this time but that it was fine. I would advise offices that perform endoscopy with sedation and do not choose to use ETCO2 monitoring to provide only light sedation. -- From: Melinda Mingus, M.D., Manhattan, NY
What guidelines are ASCs following regarding sleep apnea patients? Specifically for mild and moderate sleep apnea patients having peripheral surgery, how long post surgery do they remain in the ASC? -- From: Richard F. Gargiulo, M.D. (Rgargiulo@virtua.org) Reply I would refer you to the ASA practice guidelines on this topic for which I have attached the link below. Hope this helps. www.asahq.org/publicationsAndServices/sleepapnea103105.pdf
Question 1: What is the general consensus for fluid replacement during tumescent liposuction on healthy individuals? -- From: Jean White, M.D., Atlanta, GA (jeanwhite@mac.com)
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