- ASA Status
- Expected Blood Loss
- Obstructive Sleep Apnea
- Cardiac Disease
- Pulmonary Disease
- Malignant Hyperthermia
- Difficult Airway
- Pediatric Considerations
A significant factor in assuring good patient outcome at Ambulatory Surgical Centers is proper patient selection. SSC exclusion criteria are not as restrictive as other freestanding ASCs because of its commitment to resident education and its access to resources shared with the Bramhall inpatient services.
Caveat #1: there are no respiratory therapy, x-ray, blood bank, or laboratory services immediately available to SSC patients.
Caveat #2: almost all ophthalmologic cases must be done at SSC because the Bramhall unit is no longer equipped for complex ophthalmologic surgeries. After hours surgeries at SSC are always eye surgeries.
The following guidelines have been developed to assist in proper patient selection.
ADULTS with ASA > 3 (severe systemic disease that is a constant threat to life) and
INFANTS AND CHILDREN with ASA >2 (severe systemic disease) will be considered for the Scarborough Surgery Center only following an anesthesia evaluation at the PREP Clinic, Brighton Medical Center Campus.
Since no blood bank services are positioned at SSC caution is needed when scheduling intra-abdominal procedures with the potential for heavy blood loss. No blood products are stored at SSC.
- Patients with BMI> 50 generally will not be booked at the SSC
- Patients with BMI<53 whose procedures are performed with "local" or "Local/MAC" and minimal sedation may be considered after PREP assessment.
- Patients >350 lbs. will be booked for a PREP assessment, even if BMI < 50, to determine appropriateness for the SSC
Patients are excluded if:
- signs and symptoms of OSA persist despite treatment (ie any A-fib, tachyarrhythmias, daytime somnolence, uncontrolled HTN).
- CPAP treatment abandoned by patient and no re-evaluation performed that justifies non-CPAP treatment.
- no CPAP unit at home to bring to SSC (since there are no CPAP units or respiratory techs at SSC).
- uncertain that a responsible adult will be monitoring them at home.
- other co-morbidities (such as COPD, asthma, angina, HTN and CHF) are poorly controlled.
- known OSA plus a history of difficult intubation.
- Typically excluded if have OSA and BMI >39 and invasive surgery planned.
If excluded, then PCP (or sleep medicine) involvement is necessary before SSC booking. Failing that, schedule at Bramhall.
Coronary Disease: Patients excluded with untreated or inadequately treated coronary disease. Included in this group are patients with unstable angina (new onset with frequency>3/day, chronic stable angina which has increased in frequency, and angina at rest).
Heart Failure patients excluded if not fully treated and stable.
Pacemakers and AICD: Patients whose surgery must be performed with cautery require evaluation at the PREP clinic and AICD reprogramming on the day of surgery. The use of bipolar cautery is acceptable without PREP evaluation.
Asthma: Patients excluded if under poor control and if general anesthesia is required. In this category are patients actively wheezing despite inhaler therapy.
Regional anesthetics can be offered as long as the surgeon understands that nothing more than a block with light sedation will be provided.
COPD: Patients are typically excluded if they are
- oxygen dependent or known CO2 retainers,
- short of breath at rest or with conversation or with < 1/2 flight exertion. and
- general anesthesia is required.
(known or high risk) permitted but requires PREP consultation.
or clinical features which suggest that airway management could be a problem--and could interfere with anesthesia availability to other rooms:
requires PREP consultation and probable exclusion from SSC.
are not appropriate patients for SSC under any circumstances due to equipment limitations.
No tonsils on children under 3 years (because overnight observation for sleep disordered breathing is required)
No known or suspected difficult airways (SSC lacks necessary equipment)
No tonsils on obese children with known OSA and a BMI greater than 35.
NEONATE OBSERVATION REQUIREMENTS:
All prematures (born <37 weeks) under 52 weeks gestational age receiving general anesthesia will be monitored for apnea/bradycardia for a minimum of 12 hours following completion of the procedure or last observed apnea/bradycardia episode. At this time, all ex-premies are transferred to Barbara Bush Children’s Hospital for observation.
All term infants under one month of age receiving anesthesia will be observed and monitored for apnea/bradycardia for a minimum of 4 hours following procedure completion. If apnea/bradycardia observed then a minimum observation period of 12 hours from the last episode is required. Transfer to BBCH would be arranged.