How to Manage Complications in the Outpatient Setting

How to Manage
Complications in the
Outpatient Setting
Michael L. Schwartz, MD, RVT, FACS
Division Chief Vascular Surgery Nyack Hospital
Division Chief Vascular Surgery Good Samaritan Hospital
Complications in the Office
• Facility complications
• Fire
• Equipment failure
• Power outage
• Anesthesia Issues
• Procedural Complications
QuickTime™ and a
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hink!…What are your contingencies?…Be prepared!
Implications of Off-site
Surgery
•No blood bank
•No ventilators
•No ICU care
•Low manpower
•Advanced
equipment may not
be available.
What’s at Risk?
• Patient risk
• 10 fold increase in risk of adverse
outcomes including death in the office
setting (Vila, Soto, Cantor, Arch Surg. 2003;138:991-995)
• Reputation risk
• Referring physicians
• Prospective patients
• Accreditation risk
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Accreditation Risk
American Association of
Ambulatory Surgery
Facilities
Accreditation Association
for Ambulatory Health Care
Joint Commission
Reportable incidents to the
accreditation agency
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Office based surgery is very
scrutinized
Any patient death within 30 days
Wrong patient or wrong site surgery
Any “serious or life threatening
event”
Any hospital transfer
Any hospital admission within 72
hours of the procedure
Sign a transfer agreement
with your hospital
• Written agreement between
an ASC and a local Medicareparticipating hospital to accept
any emergency from the ASC
• Required in 30 states anyway
• Make sure you’re on staff at
the transfer hospital - you
want to deal with your own
complication
Do not be a cowboy in
your outpatient center to
avoid complications
• How to be a cowboy…
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Poor patient selection
Trying to push the envelope
Persevering when you should abandon
the procedure
Not being prepared to handle a
complication
Delaying transfer in trying to salvage
the complication
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Specific Scenarios
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These are our management protocols
Make your own based on your specific situation
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Distance from transfer hospital
What is your staffing? (nurses/assts)
Is anesthesia present?
What is your personal experience?
Do you have required equipment?
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Is your C-arm up to snuff?
Varicose Vein Complications
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Bleeding complication
Junction thrombus at
sapheno-femoral
junction. (Hingorani/Ascher)
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Lovenox / 1 week
follow-up then reevaluate
Long term A/C?
pending U/S
followup
Central Access
Complications
• Case selection
• Potentially devastating
• Use ultrasound guidance to
minimize complications
• Don’t persist!!
• Diagnose with C-Arm
• Stabilize the pneumothorax
for transfer, have a pigtail
available
Dialysis Access
Complications
• Vein rupture (AVF)
• Anastamosis
rupture
• Pulmonary
embolism
• Arterial embolism
#@!%
Vein Rupture
• In many cases it’s expected
(BAM) limited controlled
extravasation.
• Moderate extravasation Balloon occlude and pressure
• Covered stent?
• Occlude the access and bring
back for OR revision another
time
Anastamosis Rupture
• More difficult to compress
• Covered stent useful
• May require closure of
AVG
• Transfer only if continued
expansion after closure
Pulmonary Embolism
• Common but most asymptomatic
• Can be confused with CHF/systemic
problems
• Large AVF vs. AVG (clot burden
small)
• Declot first before treating outflow
• Use TPA in addition to declot
• Asymptomatic, but…cumulative effect
for repeat treatments
Arterial Embolism
• Usually occur during
arterial plug
dislodgement
• Use Fogarty OTW
catheter
• Plug is resistant to tPA
• May require OR
treatment
Peripheral Intervention Complications
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Patient Selection
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TASC A iliac
TASC A and B fem pop
Avoid TASC C and D
Hospitals have some
advantages
Complications in an O/P
center can be lethal for iliac
lesions
Long SFA occlusions take too
long
What to avoid?
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Patients to avoid
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Significant medical comorbidities
Poorly cooperative
Lesions to avoid
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Heavily calcified
Single vessel runoff
Anastamotic vein graft lesions
No Renals, aortas or carotids
Peripheral Interventions
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Access Site Thrombosis
Access Site Bleeds
Arterial Perforations
Distal Embolization
Arterial/Stent Thrombosis
Access site thrombosis
• Access Site Thrombosis (T/F to OR)
• Closure device complications (T/F to
OR)
Access site bleeds
• Use Angioseal (patient
selection)
• Observe for 2 hours post
• Don’t clog RR
• Small hematoma, US
compression
• Large hematoma (T/F)
Arterial Perforation
• More common with age / DM
• Can tamponade with balloon
inflation
• If significant extravasation,
covered stent ($)
• Observe for 2 hours, if any
instability ...transfer.
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Distal Embolization
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Tough to manage in center
Avoid single vessel runoff
OTW Fogarty technique
T/F if symptomatic
Elective if asymptomatic
Arterial or Stent Thrombosis
• Consider lysis
• We have no Angiojet
• If symptomatic arrange T/F
while brief attempt at
recanalization
• Set a time limit!
In Conclusion....
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The office is a terrible place to have a complication
Dangerous for the patient
Dangerous for your business
Good initial case selection is the key to success
Have a policy on how to deal with each complication
Have the equipment (pigtails/cov stents/OTW Fogartys)
Not a sin to deal with a complication safely in the
hospital.
Thank You