Spectrum Off-Campus Practice Site Page

Generations /InterMed ASC NEW
Maine Center for Reproductive Health

Maine Eye Center
Mercy Hospital NEW
Ortho Associates

Plastic & Hand  
Portland Endoscopy Center  UPDATED
Scarborough Surgery Center
NEW

Plastic & Hand


Anesthesiology Exclusion Criteria for WADSC
Revised /updated Mar 2, 2006


1. Patients exceeding 300 lbs. (table limit) or with a Body Mass Index 37-40 will be done at Plastic and Hand Surgical Associates discretionarily following an anesthesia evaluation. Patients with BMI over 40 will not be done at P&H with one specific exception - those hand cases that can be done under straight local in the event of block failure. Morbid obesity is defined as BMI>37. A weight vs. height nomogram will be provided.

2. Patients 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 rest angina). 

3. Patients with pacemakers and AICD's whose surgery cannot be performed without a Bovie (use of a bipolar is acceptable). 

4. Asthmatics under no or poor control to receive general anesthesia. In this category are patients actively wheezing despite inhaler therapy. Regional anesthetics can be performed as long as the surgeon understands that nothing more than a block will be offered.

5. Sleep apnea patients who use a positive pressure breathing device (i.e. nasal CPAP). Patients with BMI over 40 will not be done at P&H with one specific exception - those hand cases (CTR) that can be done under straight local in the event of block failure. No sedation or Xanax.

6. COPD patients who are oxygen dependent or known CO2 retainers. In addition patients short of breath at rest, or with 1 flight of stairs (or equivalent exertion).

7. Pediatric patients under the age of seven.

8. Patients with known or high risk of Malignant Hyperthermia.


Q/A Policies 11/03 (Siegle) rev. 6/04

1)  OBESITY POLICY reiterated. Absolute upper limit is 300 lbs (table limit). BMI upper limit is 40, with occasional anesthesiologist discretionary exception. BMI pts. 37-40 need to be cleared by anesthesiologist (at least a "drive by"). 
Regarding any exceptions made for BMI >40 pts., I urge you to only make exceptions for cases which will involve regional anesthesia, and where the case can be performed under straight local should the block fail. Carpel tunnel release, for example,  might fall into this category whereas a palmar fasciectomy would not.
  Also, if one is performing a"drive by" but will not be doing the case, please try to contact the individual who will do the case to make sure they are in agreement.
"Drive-by" evaluations will be done between cases. Please try to be flexible.

2) Paravertebral blocks. They have worked extremely well here for breast cases (performed by CH). I would encourage others to learn the technique. Charlie would be happy to "mentor" others at MMC.

3) Ax blocks vs General for endo carpal tunnel:    Time from entering the OR to discharge is the same (82 min.),  but actual OR time is much less for GA cases. Pts. ultimately more comfortable following blocks. P&H has no preference. Decision is between pt. and anesthesiologist (unless surgeon has a preference in a particular situation).  

4) We may have to undergo some sort of peer review for P+H to retain their certification. Any suggestions? I'll keep you posted.

5)  Whoever works on Wednesdays, please drain liquid from the CO2 canister.

6)  Please make sure  you fill in and sign the machine/gas check list daily, and turn off machines at the end of the day.

7)  Please continue to use anti-nausea triple therapy on GA cases. I reviewed a years worth of N/V data and came to the conclusion that the individual with the best results (not me) used phenergan 6.25mg.. I would suggest therefore, reglan, decadron, and phenergan intraop, and save zofran for recovery room rescue.

8) Preop antibiotics: PACU nurse will try to administer in preop prior to going to OR, time & IV placement permitting. Probably won't happen on 1st case of day.


 

Orthopedic Associates

A. BMI Restrictions
B. Hip Replacements, Minimally Invasive NEW
C. Regional Blocks

 

Patients >40 BMI @ OA

Mary Neal, September 9, 2004

OA patients >40 BMI must be seen and evaluated (fill out a pink sheet).

Only patients who are otherwise healthy and have normal airways should be accepted for surgery at OA.

If the patient is not disease free (no hypertension, CAD, DM, smoker, PVD etc.) or the airway assessment is anything beside a Class I, with 4cm mouth opening and FROM of the neck, the patient should be referred to an alternative facility for anesthetic and surgical care.

 


MIS Hip Anesthesia Protocol NEW
      Minimally Invasive Surgery

Rob Hubbs, M.D. 3/30/08


Preop:
* These patients are carefully selected to be good outpatient candidates. Typically they are relatively young and are very healthy.
* Usually given Oxycontin 10 mg, Tylenol 1000 mg, Celebrex 200 mg, Lyrica 75 mg, Ancef 1 gm

Intraop:
* Positioning - lateral with Ax roll
* GA with ETT - surgeon requires muscle relaxation until closing begins
* Avoid nitrous oxide to lessen risk of PONV - these patients have to progress quickly to walking in PACU 
* Upper body Bair Hugger
* PONV prophylaxis - at a minimum dexamethasone 4 mg & dolasetron 12.5 mg - additional agents as indicated
* Pain control - usual requirement is approximately 1.4 mg of hydromorphone. Fentanyl for induction - usually 100 mcg
* IVFluids - usually about 2 L intraop - no foley placed but with EBL this hasn't been a problem. If anything, patients seem to run dry
* Reverse muscle relaxants normally

Postop:
* Most receive: Tylenol 1000 mg, oxycodone 10 mg, hydromorphone PRN, Ancef 1 gm
* 3 of 7 patients have had delayed voiding in PACU. All 3 were catheterized. At least 1 had >/= 400 cc's of urine in bladder. I am trying to get a protocol together to address this issue, but it's in the works. Dr. Babikian and Paul Evans are well aware of this issue.

Other average info on first 6 patients at OA:
* Total IVFluids (intraop and PACU): 3400 cc
* Total Oral fluids: 1000 cc
* OR EBL: 500 cc
* PACU Drain output: 400 cc
* PACU urine output (no foley): 400 cc
* Intraop hydromorphone: 1.4 mg
* Postop hydromorphone: 0.6 mg
* Total OR time: 129 minutes
* Total PACU time 340 minutes


 

Maine Center for Reproductive Health 

Download by clicking: The Manual (pdf format, 700K)
Denise LaRue, MD updated 5/16/06

This practice site has closed


 

Scarborough Surgery Center  (SSC)

Emergency Eye Case at SSC
Unexpected Blood Loss: Summary of Resources NEW

 

A. Emergency Eye Case Information 

Robert Ascanio, Oct. 2007

This information is intended primarily to assist those who do not regularly rotate to SSC, but may be called there in the event of an emergency eye case.

  -Best entry point for docs is the side entry just across from the physician's parking lot.
  -Entry to SSC requires ID badge for all entry points inside and out of the facility.
 
-Locker rooms located on basement level.
  -A spare blue bell key and Anesthesia office key is located in the lock box mounted on
the side of the blue bell in OR room # 1. Lockbox combo is (xxxx)  (Same as combo to MMC Main Campus Anesthesia Office).
  -Code carts and MH carts are located in the core area.
  -If you are here doing a case after-hours or on weekends/holidays THERE IS NO
CAFETERIA SERVICE. Plan accordingly.
-Pyxis machines are in Pre-op as well as OR rooms. You will have to set your Pyxis password first (same as Maine Med) in order to access drugs in the pyxis machines here. 

********************

B. Unexpected Blood Loss @ SSC; Summary of Resources NEW

Marjorie Humeniuk, October  2009 

In case of unexpected large-volume blood loss in Day-Surgery cases at SSC, the following information may be helpful:

Emergency Laparotomy Case Cart:

-in the inner core across from room 9 
-includes large bin filled with supplies for us.
-contains IV fluids, 2 hespan, bloodsets and supplies to start a large bore IV. 
-also contains appropriate tubes for lab work such as coags, type & cross, and ABGs. 
-All of this is checked daily to avoid outdating 
-list of contents that can be scanned quickly so you can see what's in there.

Pressors & Resuscitation Drugs:

-Emergency drips, such as dopamine and epinephrine can be found in the code cart. 
-Plum pump tubing is with the drips.
-The fastest way to get a pump is to send someone to Pedi post op, there is one in every cubby.
Anesthesia Workroom: on the cart with the circuits, 2nd shelf from the top, front and center.
    *fluid warmer
    *high flow infusion sets for the warmer
    *more hespan and bloodsets

Emergency Transfusion Protocol:

-currently being revised/condensed; for now:
-4 units of O D-negative RBCs stored in the NorDx refrigerator.
-If you need to use the uncrossmatched blood, the Blood Bank needs to be called directly at 662-2121, Do not call NorDx. 
-an order must be placed in the hospital computer system, ASAP.
-specimen needs to be collected and sent to the Blood Bank ASAP. 
-the blood will be released immediately regardless of the specimen
-the NorDx courier will deliver the blood
-STAT ABGs, Coag panels must be sent to Bramhall by courier.