Is my patient a candidate for an outpatient procedure?

Today, many operations and diagnostic procedures are performed in outpatient centers, and modern, short-acting anesthetics facilitate quick recovery and early discharge.

However, some patients may not be appropriate candidates for outpatient procedures if they are at increased risk for anesthesia complications due to significant underlying health problems.

This decision must be individualized. The same patient might be an appropriate outpatient candidate for a minor, superficial procedure with local anesthesia and minimal or moderate sedation, but might be at risk for unplanned admission to the hospital if the surgical procedure is more invasive or requires general anesthesia.

Here are general guidelines listing medical conditions that typically require a procedure to be performed in a hospital rather than an outpatient center. At the discretion of the anesthesiologist, these may be waived under appropriate circumstances or for minor procedures.

• – Anemia or coagulopathy that might require transfusion
• – Cardiovascular disease, severe or symptomatic:
  • – Aortic stenosis
  • – Arrhythmia
  • – Cardiomyopathy with reduced LVEF (less than 40 percent)
  • – Carotid artery disease
  • – Congestive heart failure
  • – Coronary artery disease
  • – History of complex congenital heart disease
  • – Pulmonary hypertension
  • – Valvular disease
• – Chronic pain syndrome, opioid dependence
• – Epilepsy or seizure disorder, if not well controlled
• – Liver disease, severe: Model for End-Stage Liver Disease (MELD) score greater than 10
• – Morbid obesity, with BMI greater than 40
• – Musculoskeletal disease: Myasthenia gravis, muscular dystrophy (if procedure requires general anesthesia)
• – Obstructive sleep apnea, moderate or severe (airway procedures, laparoscopic surgery, or upper abdominal surgery)
• – Pregnancy: Termination of pregnancy is not advised in an outpatient facility if gestational age is greater than 16 weeks
• – Pulmonary disease:
  • – Severe COPD
  • – Pulmonary fibrosis

Additional preoperative blood or urine testing is at the discretion of the admitting surgeon, the referring physician, or the anesthesiologist. Urine pregnancy testing is automatically ordered on admission for female patients of potential child-bearing age. Any patient who is qualified to sign her own consent may elect to waive the pregnancy test.

The best assurance of a good postoperative outcome is that the patient is in optimal condition prior to surgery, as determined by the patient’s internist or cardiologist. The purpose of preoperative evaluation is to assure that no further diagnostic testing or medical therapy is necessary to optimize the patient. Our goals are to identify patients who cannot increase cardiac
output in response to metabolic demands after major surgery, or who are at risk for cardiac complications despite optimal medical management.

Please refer to the ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.

Major risk factors for cardiac complications after non-cardiac surgery include:

• – Prior MI
• – History of CHF
• – Peripheral arterial disease, including a history of stroke or TIA
• – Diabetes
• – Chronic renal disease
• – Abnormal EKG

High-risk and intermediate-risk operations include:

• – Aortic surgery
• – Lower extremity revascularization
• – Thoracic surgery
• – Kidney transplantation
• – Major head-and-neck surgery
• – Operations where major blood loss and/or fluid shifts may be anticipated (general surgery, gynecology, orthopedics, urology)

The following tests may be indicated. Please see below for more information:

• – Chest X-ray
• – EKG
• – Non-invasive cardiac testing
• – Pacemaker or ICD evaluation
• – Pulmonary function testing
• – Sleep study

Indicated only for patients with known pathology, congestive heart failure, or recent pneumonia.

Men over the age of 50 and women over the age of 60 should have a 12-lead EKG if one has not been performed in the past year. A patient of any age with cardiopulmonary disease, renal disease, hypertension, or diabetes, should also have a preoperative EKG performed close to the date of the procedure. Please send a copy of the EKG, with interpretation, along with a prior EKG if available.

If the EKG is abnormal, or shows significant change from prior EKGs, the patient’s internist or cardiologist should determine the need for any additional assessment of cardiac functional status or coronary artery disease.

No further work-up is indicated for patients with good functional capacity, who can generate an activity level of greater than 7 METS or tolerate a heart rate of 130 or more without symptoms.

Non-invasive stress testing, including assessment of ventricular function, may be indicated for patients who:

• – Experience angina or dyspnea on exertion
• – Have risk factors for coronary artery disease
• – Have risk factors for CHF exacerbation
• – Have had no diagnostic stress testing within the past 2 years, or appear clinically worse than when previously tested.

Patients who have poor exercise tolerance, or for whom exercise tolerance cannot be assessed, should undergo non-invasive stress testing if:

• – No stress test has been performed in the past 2 years
• – The planned surgery is high-risk or intermediate-risk
• – They have at least one risk factor for postoperative cardiac complications.

If a patient has had a previously abnormal stress test, and has poor exercise tolerance, cardiologist evaluation is indicated to optimize risk reduction.

In the presence of valvular heart disease or pulmonary hypertension, the patient’s internist or cardiologist should reassess the severity of disease and address any evidence of progression since the previous evaluation.

Patients with pacemakers should have an evaluation of settings and battery function within 6 months of the procedure.

A patient with an implanted defibrillator (ICD) or a cardiac resynchronization therapy (CRT) device should have the device checked within 3 months of the procedure.

Patients who are scheduled for lung resection or other major thoracic surgery should have preoperative pulmonary function testing, but it is not indicated for most other procedures.

Sleep study:

If a patient has received a sleep study, please send the results with the patient’s other records. Otherwise, a “STOP-BANG” questionnaire assessment of sleep apnea is sufficient.

Drinking Water

Guidelines for Adults and Teenagers:
Adults and teenagers over the age of 12 may have solid foods and dairy products until 8 hours before their scheduled arrival time at the hospital or surgery center. Alcoholic beverages should be avoided within 8 hours of the scheduled arrival time.

Clear liquids – NOT milk or dairy products – are actively encouraged until 2 hours before the time the patient is scheduled to arrive at the hospital or surgery center.

Clear, see-through liquids include:

• – Water
• – Clear fruit juices such as apple juice and white cranberry juice
• – Plain tea or black coffee (NO milk or creamer)
• – Clear, electrolyte-replenishing drinks such as Pedialyte, Gatorade, or Powerade (NOT yogurt or pulp-containing “smoothies”)
• – Ensure Clear or Boost Breeze (NOT the milkshake varieties)

Certain procedures may require special preoperative fasting instructions. If the patient receives separate instructions from the surgeon or the physician performing the procedure, those should be followed carefully. For example, patients undergoing colonoscopy, bariatric (obesity) surgery, or colorectal surgery may be instructed to be on a clear liquid diet for a day or more prior to surgery. Please contact the surgeon’s office with specific questions.

Here is a table to explain the timing of when to stop oral intake. The patient should look for the scheduled arrival time, and when to stop eating solid food. We encourage patients to continue to drink clear liquids as they wish until 2 hours before arriving at the hospital or surgery center.

Most medications should be taken on the patient’s usual schedule the day before the scheduled procedure. We recommend that patients not take most oral medications within 8 hours of their scheduled arrival time, because many medications can cause stomach irritation or nausea if taken without food. Many medications are available in IV form, and can be given during or after anesthesia when necessary.

This question becomes more complicated for antihypertensive medications, anticoagulants, antiplatelet therapy, and pain medications.

Nearly all the medications commonly used for general anesthesia and sedation have the effect of lowering blood pressure and reducing sympathetic tone; some of them depress cardiac function as well. Common medications include propofol, fentanyl, midazolam, and the inhaled fluorinated ethers such as sevoflurane and desflurane. For this reason, caution should be used in telling patients to take all antihypertensive medications on the morning of surgery, as significant hypotension may result during anesthesia.

Beta blockers: Consensus opinion from the ACC/AHA in 2014 advises that patients who are already on beta blockers should continue to take them during the perioperative period. However, initiating beta blockade shortly before noncardiac surgery was associated with fewer nonfatal MIs but a higher rate of stroke, death, hypotension, and bradycardia. We advise patients to take their usual dose of a beta blocker on the morning of surgery with a sip of water.

ARBs and ACE inhibitors: A recent large prospective cohort study found that patients who did not take ARBs or ACE inhibitors in the 24 hours before noncardiac surgery were less likely to suffer
intraoperative hypotension and the primary composite outcome of all-cause death, stroke, or myocardial injury. Unless a patient’s hypertension is difficult to control, it may be best to withhold ARBs and ACE inhibitors within 12-24 hours of a procedure under anesthesia.

Diuretics: If the patient is taking a diuretic for treatment of hypertension, consider holding the diuretic on the morning of surgery to avoid dehydration while the patient is NPO. However, if the patient has severe liver disease or congestive heart failure, it may be best to continue diuretic therapy.

The surgeon or the physician performing the procedure often requests that anticoagulants or antiplatelet therapy be discontinued for several days to a week in advance of surgery. If you feel that it is not in your patient’s best interest to hold these medications, it is best to discuss this with the surgeon in advance.

Often, low-dose aspirin can be continued throughout the perioperative period without increasing the risk of bleeding for many routine procedures, and it may protect the patency of drug-eluting coronary stents. However, in some circumstances such as intracranial surgery, the risk of bleeding may be unacceptable.

In a 2016 update on dual antiplatelet therapy, ACC/AHA guidelines advise: “Decisions about the timing of surgery and whether to discontinue DAPT after coronary stent implantation are best individualized. Such decisions involve weighing the surgical procedure and the risks of delaying the procedure, the risks of ischemia and stent thrombosis, and the risk and consequences of bleeding. Given the complexity of these considerations, decisions are best determined by a consensus of the surgeon, anesthesiologist, cardiologist, and patient.”

Patients who are on opioid treatment for acute or chronic pain may be advised to take their medications with a sip of water up to two hours before the time of surgery. Fentanyl patches may be used per the patient’s routine; it is helpful for the patient or family to make a note of the time and date of placement, and inform the anesthesia team. Patients with severe opioid dependence, especially those who are taking Suboxone (buprenorphine and naloxone) or methadone as maintenance therapy, should be referred for a Pre-surgical Pain Medicine consultation, as postoperative pain management in these patients presents special challenges.

Our Pain Centers warmly welcome new patient referrals. We offer consultation services for patients with challenging pain conditions, whether the pain is acute or chronic. We also offer consultation services for patients with chronic pain conditions who need to undergo surgery, so that the plans for their care by physician anesthesiologists who specialize in pain medicine may be coordinated before, during, and after their procedures.