Central Line
Episode Number: 135
Episode Title: Subspecialty: Society for Ambulatory Anesthesia
Recorded: June 2024
(SOUNDBITE OF MUSIC)
VOICE OVER:
Welcome to ASA’s Central
Line, the official podcast series of the American Society of Anesthesiologists,
edited by Dr. Adam Striker.
DR. STRIKER:
Welcome to Central Line. I'm your editor and host, Doctor Adam Striker.
Today, I'm joined by my colleague, Dr. Steven Butz, who happens to be president
of SAMBA, the Society for Ambulatory Anesthesia, along with a couple other
colleagues, Drs. Victor Davila and Thomas Durick. Today we're going to discuss
some common perioperative myths and misconceptions that have percolated through
time, maybe a potpourri of topics. We thought this would be an interesting way
to tackle a few items as it relates to specifically ambulatory anesthesia, and
try something a little different today. So I'm looking forward to this
conversation, and I just want to thank all of our guests for joining us today.
I'd like to start by asking each of you to introduce yourself to our listeners
and tell us a little bit about your practice and your role with SAMBA.
DR. STEVEN BUTZ:
Sure. Thanks for having us, Adam. My name is Steven Butz. I am the
immediate past president of SAMBA. I actually just relinquished my president
role in May, but I am a pediatric anesthesiologist in Milwaukee. I run the
Children's Wisconsin Ambulatory Surgery Center, and like I said, I am just
recently coming off being president with SAMBA.
DR. VICTOR DAVILA:
My name is Victor Davila. I am an anesthesiologist at Ohio State
University Medical Center. I do, obviously ambulatory anesthesia, and I'm the
treasurer for the Society for Ambulatory Anesthesia/ But also have a
significant amount of my time spent as an intensivist in the critical care
unit. And it's a pleasure to be here.
DR. TOM DURICK:
And I'm Tom Derrick. I'm an anesthesiologist, along with Victor at Ohio
State. I'm relatively new to academics. I spent 30 years in private practice
before coming to academics. Most of the time over the last two decades, I spent
exclusively in ambulatory surgery centers, and I am currently our anesthesia
clinical operations director for Outpatient Care New Albany, which is one of
two and the first surgery center that Ohio State built and now runs. And I'm
currently the chairman of SAMBA’s Performance Measures Committee, which, with
Doctor Davila's help, we're morphing into more than just the Performance
Measures Committee, but we're adding a lot more value measurement, cost
measurement, and analysis for anesthesiologists.
DR. STRIKER:
Excellent. Well, thanks to all of you for joining us. Why don't we start
off the conversation with Doctor Butz. And Dr. Butz, we're going to talk a
little bit about some common perioperative myths today, but let's have you give
just a little bit of an overview to our listeners on why that's important. What
kind of price is paid when healthcare professionals, but particularly anesthesiologists,
are not only exposed to lore but perhaps succumbed to it? And what kind of
concerns should we be aware of when we're not getting perhaps the most
accurate, up to date information?
DR. BUTZ:
You know, that's a great question. Just because I feel like
anesthesiologists a lot of times spend a lot of their practice fairly solo. You
know, we don't have a lot of interaction with our colleagues. And when we do,
it's a quick, hey, how do I take care of this problem? And you just get a lot
of word-of-mouth education. You know, certainly with today's access to online
things, it's out there. But a lot of times when you're getting that quick
curbside consult, it gives a big opportunity to kind of perpetuate these myths
that either people picked up in their training or something that they may have, like glanced or overheard.
Um, and these things kind of just perpetuate themselves, you know? And right or
wrong, it happens a lot. You know, sometimes it's a great way to transmit
information, but sometimes you get the wrong information in your hands and you
might not necessarily recognize it. So this was something that came up in our
annual meeting, and we actually did a whole panel on it. And it was one of those
ones I think went over really well. Everybody in the audience, I think, heard
something familiar that either they were right or wrong about, and I think it
was a great learning moment for a lot of people in the audience.
DR. STRIKER:
When I think back to things that I learned in training, that ultimately
changed over time, I think myths or misconceptions we used to carry with us
were based on our teaching that just hadn't gotten up to date, but one new
variable in today's society that that wasn't present when any of us were
training or at least wasn't as prevalent -- the idea of social media or a
plethora of online information. You probably have a really good perspective on
how that plays into the misconception. Whereas before it might have just been,
for lack of a better term, may have been a passive misunderstanding. Whereas
now, how much does do those avenues weigh in on almost more of an active
misunderstanding that we have to contend with?
DR. BUTZ:
Well, you know, I don't think any one of us has not run into a patient
who's, you know, been to visit Dr. Google. I mean, there's a lot of times that
patients bring things up, like, I'll have someone and perhaps say, well, my
kid's got red hair, so you're going to give, you know, more pain medicines,
right, or they're going to wake up crazy. So there's a lot of stuff that's out
there that's kind of right. Or at least you can figure out where they've heard
or what's going on with it. But a lot of times I find that some of these either
urban legends or these kind of myths that go on that are presented to you are
presented in a setting where you're on the spot to answer right away. And I
don't know that everybody is either 100% prepared or if it's just easier to
say, oh yeah, I agree, and let's move on because I'm running late and let's
hurry up with this case and it doesn't really matter. But it is harder to take
that step back and either really look at what the latest literature is on a
topic, or to really get a consult with someone who would be knowledgeable,
either in your department or in your group. But sometimes I feel like we're
having to do this on the fly, and I think it perpetuates it a little more,
especially when you know someone's had a similar procedure, like patients who
come in for things sequentially and they're like, well, the last anesthesiologist
told me this. So then you're kind of like, caught over that barrel of, you
don't want to throw your colleague under the bus, but it might not necessarily
be right. So you kind of have to mold the way you're saying it. So there's a
lot of finessing with this, and it really helps to come from a strong point of
view of knowing the actual facts and really what this is on, and being able to
dismiss people or reassure them or whatever it takes to kind of say, no, this
is safe. This is why I'm doing it. And this is what the latest or the most
recent teachings say.
DR. STRIKER:
Well, let's tackle a few myths. The first one I want to talk about is
Hypercarbia versus Hypocarbia. Dr. Davilla, you've worked on this topic and why
don't you go ahead and maybe introduce this a little bit to our audience. Not
obviously what Hypercarbia is, but why this is an issue and what new findings
or new information we should probably be a little more abreast of.
DR. DAVILA:
Sure, I wish I was going to say new information. It's more information
that has kind of been rediscovered multiple times. It gets discovered about
once every decade or two since the beginning of when people started doing
anesthetics. The basic idea is that hypercarbia is something that should be
avoided. And when I was a resident, I remember vaguely getting instructions,
you know, to keep somebody, for example, end tidal CO2 between, you know, 32
and 35 or 30 to 35, you know, with the idea that you're compensating for an end
tidal CO2. Uh, so end tidal CO2 to the pao2 and, you know, to kind of keep them
under that 40 so that you didn't allow the patient to get hypercarbia. And, um,
like I said, every couple of decades or two, we kind of discover that that's a
bad idea. It's been discovered a couple of different ways. But in a nutshell,
whenever you make somebody alkalinic or give them a respiratory alkalosis. that's
not something that, you know, a lot of the tissues and a lot of the things in
the human body are really designed to kind of compensate for. And so what ends
up happening is that you have some cardiovascular changes, including, you know,
decreased inotropy, decreased perfusion. It also becomes harder for the blood
to kind of release that oxygen, which everybody's familiar with. So it holds on
to the oxygen better. The cells kind of get to wave at the oxygen as it goes
by. Uh, and then you end up with just a general decrease in the oxygen delivery
to many tissues. That in and of itself is probably not a great thing. But where
you see a lot of these effects is actually in the central nervous system and
specifically the brain, which is obviously a pretty oxygen hungry organ. And so
what you end up seeing is that you have this kind of cognitive dysfunction
that's pretty common, and it's been pretty well described in several different
contexts related to making patients alkalemic, in other words, breathing them
down. And so it's probably a better idea to keep somebody slightly hypercarbic
with an end tidal CO2 in the high 30s, maybe 40 or so, and kind of allow for
the patient to be slightly ossidemic because it's hard to know exactly what
it's going to be unless you have a blood gas. But it's better to be slightly
acidemic than slightly alkalimic.
And, you know, you can actually see there have been, for example, there
was this one study that I really liked where they took people that like to go
mountaineering. They took these people that can climb a big mountain. So
they're pretty healthy at baseline. And they had them climb this big mountain.
And there's two basic types of people. As the oxygen levels decrease, there are
people that just kind of breathe normally, and there's people that tend to
hyperventilate as a way of kind of compensating for this kind of lack of
oxygen. And what they found was that this hyperventilation actually led to
measurable cognitive decline for, you know, several days afterwards in these
completely healthy population. And so you can imagine in some patients, for
example, especially some of our older patients, where you have this idea that
people keep kicking around, this kind of grandma has never been the same when
she ever since she went to surgery. And there's increasing evidence to say that
a lot of this has to do with just changes in oxygen delivery to the brain. So
in a nutshell, that's the basic idea that you probably should make your
patients more hypercarbia than you typically do, or that many people typically
do, and that will actually lead to other changes in your ventilatory mechanics,
or allows for other changes in ventilatory mechanics that are probably good for
the patient also, but that are slightly different from the topic of hyper
versus hypo carbia.
DR. STRIKER:
Comment just briefly about the ambulatory setting versus a more acute
inpatient setting.
DR. DAVILA:
So with this particular issue, in the ambulatory setting, you'll see, for
example, just patients having, you know, a little bit less delirium when they
wake up, probably, you know, kind of makes it a little bit easier to get them
out of the PACU if they have a slightly easier time. Um, there's not a lot of
hard data related to decreased PACU, length of stay and those kinds of issues.
But I will say that as these things are improved, you have just generally
speaking, better outcomes with these patients. When we think of somebody having
a difficult time getting perfusion to their head, we think of this as a an
issue where if they don't have a stroke, they're okay. And I would argue that,
you know, just kind of generalized slightly decreased oxygen delivery is not
great for getting patients up and out and reactive and just kind of with it
when they get out of surgery. And at least anecdotally, it definitely makes a
difference in patients that I've taken care of.
DR. STRIKER:
Well, I do have some more myths that I want to discuss with all of you,
including one concept that I think has got to be at the top of the list of the
most misunderstood concept in anesthesiology. So please stay with us through a
short patient safety break.
(SOUNDBITE OF MUSIC)
DR. JEFF GREEN:
Hi, this is Dr. Jeff Green with the ASA patient safety editorial board.
Communication gaps during patient handoffs in the perioperative setting
increase the risk of patient harm. While electronic tools can improve
communication and patient safety during handoffs, low tech strategies can go a
long way toward ensuring continuity of care and accurate information exchange.
These include standardized checklists and templates, as well as patient safety
communication techniques such as read back, repeat back, and other closed loop
approaches. Formalized structured templates ensure that key information is
communicated to all personnel involved in care transitions, such as for or to
PACU or to ICU transfers. For shift changes in the OR, a less formal and more
portable three by five note card with key safety information can be handed to
the clinician, assuming care of the patient. With both approaches, face to face
communication between providers is essential for a safe handoff. There is no
one size fits all strategy to safe handoffs, but adopting a standardized
process may improve patient outcomes.
VOICE OVER:
For more patient safety content, visit ashq.org/patientsafety.
DR. STRIKER:
Well, we're back discussing myths misconceptions with our distinguished
panel of ambulatory anesthesiologists and SAMBA members. Dr. Durick, I want to
turn to you to talk about Mac, because I think Mac is got to be one of the most
misunderstood concepts widely out there. If you don't mind, let's talk a little
bit about the concept. Maybe a brief overview of what Mac truly is. A little
bit about what your work entails on this topic and what we should know about
Mac, especially as it pertains to ambulatory surgery centers.
DR. DURICK:
Thank you. Adam. As I mentioned, I spent over two decades in private
practice running surgery centers besides just working in them. So I was able to
see the implications of billing something as a mac versus a general where it
didn't affect the facility billing, but it definitely affects the anesthesia
billing. So first and foremost, the best anesthetic--people think Mac is better
or it's not as good in ambulatory surgery center—the best anesthetic is the
safest anesthetic for your patient in your hands for that patient at that time.
So what I'm trying to do is, besides have people think safety first, is to
realize that there are just constant threats to our ability to practice and
most importantly, get paid for that practice. Dr. Harter put that out there and
his Monday Morning Outreach. It was about eight weeks ago, I believe was on
April 15th. We was talking about how some of the insurance companies are no
longer going to pay for the physical status modifiers. And we all know that the
higher the ASA physical status on a patient, the more risk it is for the
patient and for us to care for that patient. So there were several states where
Blue Cross Blue Shield is opting out. They're going to follow Medicare's lead
on that. Aetna says they're following through. So one of my big initiatives and
it's been this way for 30 plus years, is to make sure we get paid for the work
we do. I don't want to see the anesthesiologists taking a medical legal risk
and not getting reimbursed for that risk they take.
So the definition of Mac varies depending on who you're looking at. The
ASA basically defines Mac, it says it's a specific anesthesia service performed
by qualified anesthesia provider for a diagnostic or therapeutic procedure. And
it goes on to say it's not just actual anesthetic itself. You still have to do
pre anesthetic evaluation, optimize care, do post doc. But you also always have
to prepare for whatever degree of anesthesia and sedation. You are always
prepared for a conversion to a general anesthetic. All the risks still go
through there. And Mac, they say, is varying levels of sedation, awareness,
analgesia and anxiolysis in there. When you look at Medicare's definition of of
Mac, it says it's the intraoperative monitoring by a physician or a qualified
anesthesia practitioner of monitoring the patient's vital signs. And again, in
anticipation for the need for an administration of a general anesthetic and
managing the adverse reactions to the surgical procedure. What I find
interesting is their definition still says giving PO medications like atropine,
Demerol or Valium. And I don't think that that is very common in this time
frame. And then if you look at the insurance company's definition of Mac, it it
basically says it's a continuation of care. It's a continuum of degrees of
sedation to where you are trying to keep a patient from either having
recollection, having knowledge, or responding to painful stimuli throughout the
surgical procedure. But again, it has to be done by a qualified physician or under
the medical direction of a physician or an anesthesia care provider.
So to get those wonky definitions out of the way, the biggest threat to
us is we have to remember how we get paid when we're doing nerve blocks. When I
started at Ohio State, there was a myth. It was a genuine myth that if I did a
block in the operating room, I could not get paid for it. And I still have
talked to colleagues over the last 30 years who still believe that. And that is
inherently untrue. When you look at the Medicare's National Correct Coding
Initiative, which they put out every year, which tells you exactly how you bill
for things. It says that the block can be done before, during or after the
anesthetic. And I think the one thing that people forget and that one thing
that we are trying to push in the facilities where I work is you should have in
the note by the surgeon and the operative note that they are requesting
assistance with post-op pain management. The insurance companies pay the
surgeon and the surgical team as part of their global coverage to manage the
post-op pain. We think a post-op pain in the first 24, maybe 48, 72 hours of
putting a catheter in, but you have to get the surgeon's assistance. So more
and more insurance companies will deny your block if the surgeon's note does
not say, I requested a sentence with this post-op pain management.
And the last thing I want to make sure people understand that if you're
doing an epidural or you're doing a nerve block, the type of anesthesia has to
be either a general and when you're doing a nerve block, it can be a spinal, an
epidural, or a general. But that anesthetic should not be dependent on whether
your nerve block or your epidural work. So if you are doing a nerve block and
you're billing for a mac, most of the time the insurance company is going to
deny you the nerve block because that is your primary anesthetic.
And the last thing is, I've seen people say, well, then I'll just say I'm
doing a general with the natural airway, which is great, which most of the
times we're doing. But Medicare has the seven components for how to get paid
for medical direction. And number three says that you personally participate in
the most demanding aspects, including, if applicable, induction and emergence.
The real don't have an induction in Mac. It's a continuum, but a general
anesthetic has an induction. If you're using an EMR, there is an actual point
where you must click induction. And to be able to bill for that, to be able to
bill for the general, the anesthesiologist must be present during that
induction. So you can't have it both ways. You can't say, I'm going to do a
general with the natural airway, but I don't need to go in the room because
it's really a mac. If you are following the letter of the law, if you're going
to pass your audits when CMS, Joint Commission, AAAC, quad ASF, whoever comes
through there and does your chart reviews, they need to see that you were
present. You're checking that box that you were present during inductions to
make sure that you can get paid for your block.
DR. STRIKER:
Okay, so what should the average anesthesiologist out there practicing in
an ambulatory surgery center, what would be the takeaway here? What should they
do when they listen to this podcast? What would be the one thing you'd suggest
to them?
DR. DURICK:
The biggest thing that I would suggest is two things is one, that they
learn that you can do the block before or during the case. So that is a myth.
If you do the block after the patient's asleep, you've gotten consent. You're
doing an ultrasound guided regional anesthetic. You can still get paid for that
block. But again, if you are billing it as a mac or a regional anesthetic with
a mac, you will not get paid for that block. You can still bill for it, but you
will not get paid for that block. It is considered your primary method of
anesthetic. So the biggest takeaway is that the anesthetic is not dependent
upon your block. If I'm doing the interscalene block for a shoulder
reconstruction, I'm doing a general anesthetic with an LMA, and I'm doing a
block for post on pain management. I make sure my surgeon has that inherently
in their note. Every shoulder we do, we're going to do a block. It's in their
note. I've asked anesthesia for assistance for post-op pain management. So
number one I've checked that box. And two is that the adequacy of the
anesthetic is not required that my block has to work. Now we hope that it
always works. And if we're using ultrasound guidance it should always work. But
it's not dependent upon that. That is basically your take home message is that
if I'm doing an AV fistula and I'm doing it under a block and a block doesn't
work, well, then that's my primary anesthetic. So as long as your block is not
your primary anesthetic and you can still bill for a general with the induction
and you are present, that's a take home message. Just make sure you're billing
correctly and that you're billing to the letter of the correct coding
initiatives for Medicare.
DR. STRIKER:
Should we be correcting individuals, not not in even necessarily anesthesiologists or
anesthetists about the term of Mac, because it is used a lot, I think, as a
surrogate for IV sedation or mild sedation. And I feel like it's a term that
it's just made it into the lexicon of a lot of perioperative personnel. Ignoring
the ramifications of that, does that contribute to a lot of the
misunderstanding or just the misunderstanding of anesthesiologists?
DR. DURICK:
I really think it does, and that's well said, because again, all of the
different governing bodies, including the ASA, they do state that Mac is a
continuum, a mac for a ten minute cataract is different than a mac for an hour
and a half difficult, tortuous colon or an upper endoscopy. It is that
continuum. What does not change is that an anesthesia provider has to be
present during that anesthetic, and that we are continuously vigilant and ready
and prepared to do a general anesthetic and to treat any of those physiologic
aberrations that might happen because of the sedation, because of the
procedure, because of the surgery. So Mac is that continuum. Mac for a cataract
can go south quickly if they're pulling on the eye, and all of a sudden that
patient Brady's down or heaven forbid, has no pulse. You know, suddenly we have
to be there to quickly interact with that. The conscious sedation or monitored
sedation, the guidelines by the ASA should be followed by every place where
sedation is given that if you have to do an airway maneuver, you have now gone
beyond the definition of moderate sedation. Moderate sedation states that the
patient is able to respond to verbal stimuli, not painful stimuli, but verbal
stimuli. Whether it's a thumbs up, give me an okay sign, say yes, I'm doing
okay. But they also do not need any assistance in maintaining a patent airway.
So if you're doing a colonoscopy and there's no anesthesia personnel in the
room, and all of a sudden they're doing a jaw lift because the patient's desaturating,
they've gone beyond moderate sedation. They're now either into a mac or a
general anesthetic with or without a natural airway. So part of what we as
anesthesiologists have to do, having the oversight anywhere sedation is giving
in a building where we work, is make sure we're educating our non anesthesia
providers, our nurses and our proceduralists what is safe sedation and where
they should draw the line.
DR. STRIKER:
Well, there's a couple other misconceptions that I'd like to talk about
with Dr. Buta. One is involving preoperative evaluations and ones involving
allergic reactions. And so, Dr. Butz, do you mind talking a little bit about
the myth regarding preoperative evaluations to start?
DR. BUTZ:
Absolutely. And actually I'm kind of stepping in for one of our SAMBA
members, Ken Cummings. What he was talking about was the recent CMS change
about ambulatory surgery not needing a 30-day HMP. That's always been kind of
like that golden rule going forward with surgery that, you know, where's the
30-day HMP. Can't do the case without the HMP. So really what research has
shown is that in a healthy ambulatory patient that the HMP made no difference
to outcomes. And different literature actually showed that doing routine
preoperative testing actually increases morbidity and mortality to patients by
basically flagging false positives that get chased down the rabbit hole. So a
lot of these things, you know, what we've always hold is always holy going
forward is that we had to have these was actually completely wrong. And if you
are at an ambulatory surgery center, you don't need a 30-day hmp anymore,
according to the Centers of Medicare and Medicaid Services. Now, of course,
your own policies might overrule that, but it's something definitely worth
looking into and something that is absolutely true.
DR. STRIKER:
That is certainly, um, good information to have. Over the years, I've
been involved with so many cases that have been delayed, if not canceled,
because of that particular issue. And so it's at the very least, it's nice to
see that it's being looked at in a more a more definitive manner on what the
real benefits or downsides are of something like that.
DR. BUTZ:
Right? And absolutely, it's only for ambulatory surgery. It's not for
even outpatients done in the hospital setting. So that's where the setting
really matters in this case.
DR. STRIKER:
Gotcha. Well, I know you want to talk about allergic reactions or I
should say allergies and medicine more specifically.
DR. BUTZ:
Yes. Out of almost everything in this panel, this is the one that really
rang the truest to me for the conundrums I come through on a daily basis. And
this is something, um, that was presented by Jamie Hyman out of Yale. And one
of the things that you always hear about, or you see, like a patient who has
either an egg allergy and then you get flagged in your EMR that you can't give
propofol. So what's the deal with that? Um, part of this is taking a step back
to really look at what an allergy is. You know, our immune system is a great
thing that protects us. But what the immune system is best about identifying is
either big proteins or really long chain carbohydrates. So small molecules
really are invisible to it to the most part. So in keeping that in mind going
forward, it'll help make a little bit of this clear. So looking at propofol,
the thing that people always talk about like oh well there's lecithin in it,
it's got to be eggs. So yes, propofol is an alkyl phenol that is the active
drug. And what it's in is that emulsion that's made up of soybean oil, purified
egg lecithin and glycerol. So you're like, okay, so what's the deal? The
problem is, is egg allergy is to the protein that's in the egg white, not the
lecithin that's contained within the egg yolk. So again, having an egg allergy
for a large like 99% of the people isn't from what is in propofol.
The other thing that you see is soybean. So again, the allergy and
soybean is going to be the protein that's in the soybean. Remember what I said.
This is an emulsion made of soybean oil. So what they've done is they've also
refined the oil. So there's no proteins in it. And again oils usually aren't
something that our immune system sees. So again a soybean allergy would not
cross over with a propofol allergy.
And then the last thing that you see is every now and then you'll see
like a peanut allergy to say, oh, do we need to avoid propofol just because
they're allergic to everything kind of stuff. And again, the peanut allergens
are part of the prolamin superfamily, which is what most of where the allergies
for that come in. And none of those are in propofol.
So again, if you've got an egg, a soybean or a peanut allergy, you're
safe with propofol. And that was even backed up in a study that looked at
patients who had an allergy under anesthesia, and they didn't know what it was
from. So in investigating 153 of these patients, they only found that four of
them were diagnosed with a propofol allergy.
And out of the four that actually had an allergy to propofol, none had an
egg, soy, or peanut allergy. And then they did the reverse of this. And they
looked at patients who had egg, soy, and peanut allergies, and they looked to
see if they had any reaction to getting propofol. And in 171 anesthetics, none
of those nearly 100 patients who had the food allergies had any reaction to
propofol. So it kind of bears out in that study of not a huge one but looking
at it pretty closely.
One of the other things you see this is usually when you're prepping the
case like, oh, patient has an iodine allergy. We can't use Betadine. So a
patient with an iodine allergy can't get a Betadine prop. So what do you do
with that? And again if you really think about it and iodine allergy you can't
really be allergic to the element of iodine. It's too small to get recognized.
And it's something that is an essential element to live. So you can't be
allergic to that any more than you can be allergic to iron, say, because irons
in your hemoglobin. The other one that you see is the seafood allergy. You
know, is that something that's going to cross-react with Betadine because the
iodine in it, and really the things that cause seafood allergies are the
proteins that are in the sea foods.
And those are things like parvalbumin collagen, tropomyosin, enolase. So
all these things are not things that are going to be found in our preps.
The other thing that's probably bigger than all of them is penicillin
allergies. You know, you always see particularly in pediatrics. Oh patient has
an amoxicillin allergy. What do we use. Can we give cefazolin or do we have to
move over to clindamycin. So the thing to remember with this is that out of all
the penicillin allergies, trying to find an Ige mediated allergy to beta
lactams is incredibly rare, that there's an allergy to the beta lactam core.
What it's related to is the R1 group that's on here. And penicillin and
cefazolin have different R groups. So there is zero cross-reactivity to that.
And that by patients limiting that it basically denies them of the superior
cover of cefazolin than clindamycin for their preoperative antibiotics when
that's indicated.
And that kind of brings up another bad problem when you get into EMRs is
when someone gets a penicillin allergy into their EMR, it is literally like an
act of God to get that removed. One of the things that I've learned recently is
that in our hospital, the pharmacy department will actually work to remove this
from patients. But it takes a lot to do because there are so many databases
that this perpetuates. It's not just like in your local EMR, but it goes to the
local pharmacies and it goes to doctor's offices, and it's all over the place
to really be able to stamp down and get that allergy removed is really hard.
And even the more difficult part with this is that the things that go into a
true allergic reaction is going to be that Ige mediated response to allergen
things like just getting a rash or breaking out aren't allergies that most of
those are just side effects of the drug, which frequently happens with, you
know, amoxicillin with morphine. It's like they're not allergies, they're just
histamine releases or something that's a different mediated allergy. So having
that conversation with the patient not to dismiss them, but to actually try and
educate them and say, actually amoxicillin, this is a side effect from it,
particularly the longer you take it or the more often you take it, but it's not
a true allergy. And so being able to give the patient the right drug is
something that can be hard to do. And I think a lot of people just kind of like
throw up their arms because there's so many roadblocks in the way. But the
right thing is to give the right drug to the right patient for the right
purpose.
DR. STRIKER:
Well stated. You you brought up a number of issues, but one thing I do
want to specifically ask as an example, pertaining to propofol. Individuals,
even including myself a number of years ago that were reticent to give propofol
to someone that had the egg allergy, not necessarily because of the science,
but because of the drug insert. That specifically said, it is a
contraindication. And as practitioners, we're nervous about giving a drug and
having some untoward issue and then having it looked back upon as it could have
been contributory, even if you know that that probably wasn't the causative
agent of any kind of problem. And I feel like in recent years the amount of,
um, investigative work done by all of our colleagues and putting it in the
literature has pretty much nullified that concern. So my first question is, A
do you think that's true, that from a medical legal perspective, that the
amount of evidence out there pretty much has made that concern moot point? And
number two, is that the kind of work that as clinicians, we are left to have to
do to combat misinformation or outdated information included in a drug insert
so as to, as you stated, give the right drug to the right patient?
DR. BUTZ:
You know that, again, that's so multi-layered, but I'm glad you brought
it up because actually the insert for propofol differs by country. So where you
might see, you know, propofol in Europe versus the United States or like
different countries in Europe, it may or may not have that egg warning to it.
The egg warning came from our FDA making it go in there. So that's where it
gets into the more difficult parts of getting to the true source of where this
comes from and how you do it. I think very forcefully, we vindicated egg
allergies from being an issue with propofol use in our literature. And so
trying to spread that and trying to get that out is very important. Um, you
know, you'll see that a lot with some black box warnings that really changed
the way we use medications, like what came up with codeine. But you really have
to know what's in there, where it came from, and basically who's in control of
this and what the plus minuses are either way.
DR. STRIKER:
Yeah, it's such important work because you do not want to deprive someone
from any kind of agent that you think is going to benefit them in any way,
simply because of technicalities, if you will, a technicality not related to
the science.
DR. BUTZ:
Correct. Correct.
DR. STRIKER:
Well, this has been a great discussion, and I, I do want to take the
opportunity to ask all of you a little bit about the SAMBA organization. We've
been trying to focus a few of our podcast episodes this year on subspecialty
societies, and I'm sure everybody listening, or at least most, are familiar
with SAMBA as the organization, but maybe not necessarily the work
specifically. And maybe there's other things you'd like our listeners to know
about the organization. So why don't each one of you talk a little bit about
the organization, or just give your thoughts or things that you'd like our
audience to know? Let's start with Dr. Davila.
DR. DAVILA:
Sure. So SAMBA has been doing a lot of work, and it has for years, to try
to make sure that we are a very responsive organization to our membership. And
we, I think, do an excellent job as an organization of kind of providing a one
stop shop for ambulatory anesthesiologists, providing information related to
regional anesthetics. You know, the kind of egress technologies that are that
are coming, going and evolving. And it's a small enough organization that you
still get to meet and speak to all the people that are, you know, doing all the
actual research. You get to meet some of the leaders in the field and walk
around at our conference and, and really get a good opportunity to kind of
discuss things. And I feel like our members are extraordinarily knowledgeable
and always inform the way that our organization kind of faces the world and
tries to put out guidelines and information that really help move the
subspecialty of ambulatory anesthesiology forward. It's truly an organization
that I've found extraordinarily helpful, uh, in my practice, and I'm very
grateful to.
DR. STRIKER:
Dr. Durick, how about you?
DR. DURICK:
As a newer member to SAMBA again, I spent 30 years in private practice
and most of the time I was solo. So for almost 20 of those years I was truly
not part of a group. So when your meeting funds are limited, you know, I didn't
focus on some of those bigger meetings and talk about misconceptions or myths.
I always felt, oh, well, SAMBA didn't pertain to me. It's a bunch of academic
people just talking about research. Absolutely the the opposite. What impressed
me the most the last 3 or 4 years now that I've been a part of samba, it's the
passion. The people at these meetings are absolutely passionate about improving
the quality of care, improving patient outcomes, and improving the ability for
us as providers to do a better job. So it was that passion. And just like Dr.
Davila said, when you're walking around, people will come up to you and they
will ask you questions, especially if you present it. And with my niche, with
the financial side of it, I got a lot of questions about that. It's the chance
to interact with people who share your passion, but then want to take that
message home to wherever they work. Small group, large academic practice, huge
private practice. It does not matter. It's that passion to those people that
want to make everything better, safer, more efficient, not just for our
patients, but for each other. That's what impresses me the most about SAMBA.
DR. STRIKER:
And Dr. Butz, let's leave the last word with you.
DR. BUTZ:
I have to say, hearing what you know, Tom and Vic said just really makes
me feel so good because I've been involved with this organization for a long
time, for like almost 20 years now. And that's exactly what I like to hear from
it. You know, we have a saying that everybody does ambulatory surgery, but not
everybody does ambulatory anesthesia. I think that we try and tell people how
to do things well. It's something that when you come from our meetings, I've
been involved with organizing our meetings for the last few years, and it's
always been my goal to actually give people useful knowledge to come home from.
I think that when you see something, you see the people who are on the
forefront of making it work and are really solving your day-to-day problems.
And this goes for, you know, again, not just academics, but like Tom was
saying, like the private practitioners who might not have access to this stuff
otherwise or might just think that, oh, I don't care what you know, all the
academics think we're not writing papers on whatever the solubility of the
newest anesthetic agent is, but this is actually really a nuts and bolts kind
of thing of how do you do your job? How do you do it? Well, how do you avoid
the pitfalls in the road as they come up? And really, how do I become a better
provider?
DR. STRIKER:
Well said all of you. This has been a great conversation. I certainly
hope we get the opportunity to do this again because we just scratched the
surface on so many topics. But Dr,. Davila, Dr. Durick, Dr. Butz, thank you so
much for joining us today and sharing not only your insights and expertise, but
your time.
DR. DAVILA:
Thank you very much.
DR. BUTZ:
Yeah, thank you so much for having us.
DR. DURICK:
Yeah. We really appreciate the opportunity.
DR. STRIKER:
Wonderful. Well, for those of you that are listening, hope you enjoyed
today's podcast. If you want to learn more about SAMBA, please check out the
website at sambahq.org. Check out our catalog of previous episodes and tell a
colleague about the podcast if you find it interesting. And don't hesitate to
leave a review on your favorite podcast platform and certainly join us again
next time. Take care.
(SOUNDBITE OF MUSIC)
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