to do these patients in an outpatient setting, conflicts arise for sure."
Dr. Daley says it's wise to evaluate borderline patients on a case-by-
case basis, examining the patient, the comorbidities and the procedure.
A patient may have hypertension and diabetes and be moderately
obese, but if his blood pressure is under control and he's had no recent
hospital admissions, it's probably safe for him to undergo a 90-minute
shoulder arthroscopy. "If you can check off those boxes and if this guy
is in a good state of health," says Dr. Daley, "he's probably fine for the
procedure."
This same patient, however, would probably not be a good candidate
for an outpatient spine case, says Dr. Daley. Sleep apnea, which Dr.
Daley calls "one of the biggest risk factors you see," changes everything.
"Those are the ones you're more hesitant about. You have to know how
you're going to control post-op pain and if the patient is using his posi-
tive airway pressure device."
Another factor pushing cases to outpatient settings is the increasing
number of private-pay patients. If patients have a say in where their sur-
gery is to be held, they'll no doubt weigh the impact their choice has on
their wallets: a $200 co-pay at the surgery center is easier to swallow
than a $2,000 co-pay at the hospital. What's clear in talking to caregivers
is that you can't lose sight of the patient's safety when deciding whether
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O C T O B E R 2 0 1 5 | O U T P A T I E N TS U R G E R Y. N E T
Placement of the endotracheal tube could stimulate bronchospasm in an asthmatic.
The Coumadin should not be an issue if the international normalized ratio (INR) is nor-
malized before surgery. However, if it is not normalized then it may increase the patient's
risk of substantial bleeding during surgery — especially from an area where no tourni-
quet can be applied.
— Vince Kasper, MD
Dr. Kasper (vincent.kasper@gmail.com) is the director of regional anesthesia at United
Anesthesia Services in the Philadelphia area.
