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A significant number of respondents say they're trying to avoid or decrease the use of opioids with patients in general, and especially with obese patients. That, too, is important, says Dr. Sinha. "People need to be aware of the interaction between obesity and narcotics, and sleep apnea, especially," he says. "Opioids suppress the respirato- ry drive not just when patients are in our care, but also after they leave our care. We may be asked why we would let somebody with sleep apnea get narcotics after they leave our care." On a related point, Dr. Sinha strongly recommends implementing stricter discharge criteria for morbidly obese patients who've been given any kind of opioid or sedative — something only a small frac- tion of our respondents say they've done. "You need to be able to show that any potential respiratory depressive effects have worn off and that it's OK for that patient to be taken off the monitor and go home," says Dr. Sinha. For heavier patients, that may require extra time in the PACU, he acknowledges, which can be a sticking point. The answer? "Maybe instead of having them in a bed, put them in a chair," he suggests. "That way they're a little more awake. Maybe have them go to the restroom, so they ambulate a little bit. You want to make sure they don't desaturate or show any symptoms of suboptimal respiratory drive." Even if that requires extra recovery time. Empathy matters The Harford County Ambulatory Surgery Center in Edgewood, Md., recently raised its BMI limit from 43 to 45, as long as no other signifi- cant comorbidities are present, but many patients still end up over the limit, says nurse administrator Kim Merrill, RN, BSN. Even if they don't start out that way. "We do a lot of workers' compensation orthopedic cases, and it sometimes takes months and months to get authorizations," says Ms. 5 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • O C T O B E R 2 0 1 6