BackTable / ENT / Article
Anesthetic Protocol In Office-Based Rhinologic Procedures
Wasiq Nadeem • Oct 20, 2021 • 164 hits
Office-Based Rhinologic procedures are a great tool to treat patients with chronic rhinitis, chronic rhinosinusitis, eustachian tube dysfunction, or nasal valve insufficiency who have either failed medical therapy or are not good surgical candidates. A proper anesthetic protocol for office-based rhinology is essential in ensuring patient comfort and minimizing complications that can arise from improper anesthetic administration, including side effects, improper administration, and comorbidity considerations. Dr. Scott Fortune highlights his anesthetic protocol on the Backtable ENT podcast with significant importance attributed to pre-procedure planning, dosing, and techniques for anesthesia administration in rhinologic procedures.
We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• Pre-procedure planning and debriefing with the team involved in the office-based rhinologic procedure is essential to ensure everyone has reviewed the patient file, is comfortable with the procedure, and all questions are answered
• Adequate review of the patient’s chart and history is vital to review any possible anesthetic contraindications and make appropriate changes as needed.
• Dr. Scott Fortune’s oral anesthetic protocol pre-procedure includes a combination of Acetaminophen (500 mg), Promethazine (12.5 mg), and Triazolam (0.125 mg). Prescriptions are filled beforehand and medications are administered the day of procedure to ensure proper dosing.
• Topical and procedural anesthesia includes topical 1:15,000 epinephrine with 1% lidocaine initially, followed by topical 1:1,000 epinephrine with 4% lidocaine in the procedure room, and finally with an injection of 1:200,000 epinephrine with 1% lidocaine. This is done with pulse oximetry and cardiac monitoring.
Table of Contents
(1) Pre-Procedure Planning and Debriefing for Office-Based Rhinologic Procedures
(2) Oral Anesthesia Protocol for Office-Based Rhinologic Procedures
(3) Topical and Procedural Anesthesia in Office-Based Rhinologic Procedures
Pre-Procedure Planning and Debriefing for Office-Based Rhinologic Procedures
Dr. Fortune discusses the importance of a good anesthetic protocol for office-based rhinologic procedures and highlights that the better the anesthesia, the smoother the procedure. He breaks down pre-procedure planning into three main needs that need to be addressed: (1) patient comfort, (2) staff comfort, and (3) patient chart review as a team with importance to patient medical problems and medications. He describes how each one of these should be addressed prior to the procedure to ensure a safe procedure in which all members of the team, including the patient, are comfortable throughout.
[Ashley Agan MD]
Well, let's get into the anesthesia protocol because I think that's the part that I think about the most and worry about the most. When I do any in-office procedure, the handful that I've done, I feel like that's the part where you really need to take the most time and make sure all of that is good and goes well because then the success of the procedure all stems from that setup in my mind. I don't know. Can you talk about that?
[Scott Fortune MD]
Yes, you're exactly right. For office-based rhinology, the anesthesia is the whole procedure. The better you have the patient anesthetized, the smoother things are going to go for you. The anesthesia has three needs - the first being the patient. The patient's got to be comfortable because the last thing you want is for the patient to walk out and say, "Wow, that doctor really hurt me.” If a patient is pleased, he's going to tell five friends, but a patient with bad experiences tells ten friends. Things can go wrong right out of the gate if you don't have a good anesthesia plan in place.
The other need is for the staff. If the staff senses that the patient's uncomfortable, the staff gets distracted and your procedure will not go smoothly. Then the anesthesia protocol is important for you too. I mentioned that the otolaryngologist is the captain of the team here, and if you're not comfortable, then everyone else takes their cue from you. That includes the patient. The patients, even with little sedation, know what's going on. They can see if you're sweaty, you're uncomfortable, if your staff. The anesthesia has got to be good for everybody. It's got to be good for the patient, good for the staff and good for the surgeon.
The next consideration about that is to consider the anesthesia before the procedure. How we handle that is we have a debriefing the day before our office procedures are scheduled and we go through the patients and we say, "We have Patient X tomorrow and their list of medical problems include some sleep apnea or some whatever and their medications are these." These are important things to consider before you get in the room with the patient. Part of the anesthesia, I would say, is having some monitoring on hand. If you got to give any little bit of sedation, you need at least a pulse ox and a pulse monitor.
We have evolved into having a little Welch Allyn unit. It's not very large and it was pretty inexpensive, but it will cycle blood pressure, pulse. It has a little plethysmography part which will capture the respiratory rate. It does a continuous saturation and the nice thing is, at the end, it will give you a little printout and you can scan that into your chart as a record that you monitored the patient which is helpful too. Most otolaryngologists already have this no matter what setting they're practicing in, but you need to make sure you got a crash guard. If your patient has to be sedated and you need some airway equipment, the time to find out that you don't have that is not when you're standing there with a patient who needs that. Before you do this, you need to give some thought to your rescue equipment, make sure that's set and that's all part of your anesthesia protocol.
Once we've run through that debriefing, we set a plan for the next day. Once again, make sure you know your state laws. What we're doing in Tennessee is considered level one anesthesia. It's really a procedure under local anesthesia with just a little added sedative. We don't require any extra certification from the state, but in some states you may, so make sure you know your state rules on this. Our oral medications that we give to the patients on the day of the procedure are administered about an hour ahead of time. We found that's the optimum time to get these medicines in and to have their effect.
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Oral Anesthesia Protocol for Office-Based Rhinologic Procedures
Dr. Fortune continues to discuss his oral anesthetic protocol prior to the procedure. He speaks to a proper combination of analgesia and sedation, while using medications that also contain cough suppressing and antiemetic properties which can aid in preventing procedural discomfort in office-based rhinology. Dr. Fortune’s oral anesthetic protocol, which is administered an hour prior to the procedure, starts with 500 mg of Acetaminophen, 12.5 mg of Promethazine, and 0.125 mg of Triazolam. Promethazine has both antiemetic and cough suppressing side benefits. Triazolam is used due to its anxiolytic and short acting properties vs. a longer acting counterpart such as Diazepam which can cause sedation for longer than intended. If patients are taking other sedating medications, a lower dose of Triazolam can be used. In case of emergencies, flumazenil can be used as a benzodiazepine reversal agent in your crash cart.
[Scott Fortune MD]
First we give acetaminophen. That's 500 mgs. That's your analgesic. We use promethazine. We use 12.5 mgs. We like that because it gives a little bit of sedation, but promethazine has two really important other side benefits. One, it's a cough suppressant, right? Think about your cough syrups, Phenergan with codeine, right? It prevents that coughing thing that office-based patients can get going and the second thing it does is it's an antiemetic. It prevents them from getting nauseated. If you've ever done anything in your office that people become vasovagal, they get the vapors and the promethazine we find just smooths all that problem out.
Then the other sedative that we use and it's an anxiolytic, it's triazolam. It's a very short-acting benzodiazepine which is important because you can control it. When we first started doing these, we used diazepam. That's Valium. It's a long-acting benzo and we found that there was just too much variability. Some people would be falling out on the side of the wheelchair when we rolled them over the procedure room and others would be nothing happened and everywhere in between and it was just too variable. We didn't get a reliable effect of that sedative. We switched after a site visit to using triazolam and we're much more satisfied with the anxiolytic effects and just a little bit of sedation that that supplied. That works on that-
[Ashley Agan MD]
What's the dosing on that?
[Scott Fortune MD]
I'm sorry, the dose of the triazolam that we use is 0.125. Just a little safety tip, we have the patients fill the prescriptions, but bring them to our office and we administer the medicines. The reason I bring this up is we've had it happen twice that a patient showed up to our office with triazolam 0.25 mgs, twice the dose that we prescribed. You definitely want to be aware of something like that. Pharmacists sometimes will fill ... If you write for two tablets of 0.125, they'll just give you one tablet of 0.25 if they don't have the dose you prescribed, at least in our state.
We always check the medications, make sure they're the right dose. We administer them in the office. We have a nurse and either a second nurse or one of our mid-levels who verify the medicines, check the patient's vital signs before we administer any medication and give the medications an hour before the procedure begins.
[Gopi Shah MD]
Who are the patients that maybe can't ... Are there patients who can't do this three-medication cocktail? Are there any patients that you worry about, "Hey, I don't know if I want to do the anxiolytic and the promethazine"? Ever have patients like that or is this protocol pretty standard for most, 95% of the time, this is what it is? Did you have to veer off I guess?
[Scott Fortune MD]
Yeah, we have patients that either choose not to do it or that we advise against it. It's usually the ones that are having less done. If they're just having cryoablation or radiofrequency and nothing else, that's one situation or another situation that comes up sometimes is that they don't have family or friends or anyone that can drive them to and from the office. As soon as they get a sedative, they have to have a driver. It's even a little risky I would say to rely on a medical taxi to take that patient home because the taxi drivers really aren't qualified to do any sort of assessment if something happens in the car on the way home, but yes, there are times when we don't use that oral protocol. We will still give them the acetaminophen, but if they're not having much done or they're uncomfortable with a little bit of sedation or they don't have a driver, we'll skip that part of the anesthesia protocol.
[Ashley Agan MD]
Another question I had for you Scott is what about those patients that are obese or severe OSA? Are those better to then just do in the OR or do they also do okay with this protocol in your office, or, "Hey, we just do the Tylenol and we still get them in the office because even general anesthesia can be complex, riskier for these patients as well"?
[Scott Fortune MD]
These are all important points. That's the reason we do the debriefing the day before is to go over things like this and the one for sure that you want to be anticipating a problem with is a sleep apnea patient. Typically, what we'll do with those is, let's say they're on some other medicines that concern us like a lot of people in Tennessee are on gabapentin or Lyrica or other sedative-type medicines. What we'll do for that patient is instead of giving them a whole tablet of the 0.125, we might just give them a half. In our crash cart, we do have a benzodiazepine-reversing agent. We have the flumazenil and I've never had to use it, but I feel comfortable that it's there in case I find myself in a situation where someone's too sedated, I can use that medication to reverse that effect.
That is exactly why we don't use narcotics. Our anesthesiology colleagues tell us that mishaps with medications more often than not involve narcotics. There's much more of a safety margin with the benzodiazepines, especially if you're using a short-acting one and a low dose. That's another reason we like triazolam, those two reasons. I wouldn't definitely not recommend using diazepam in a sleep apnea patient. Now, because if nothing happens in your office, the effect of that medication is going to last for hours after you release that patient home. That's where things can happen once they leave your office. The triazolam is short enough acting that by the time they've had the medication on board an hour before the procedure and have gotten through there 30 minutes of the procedure and then we observe them for another 20 or 30 minutes afterwards, most of the medication effect is gone by then. It's that short acting. The triazolam gives you a good margin of safety.
Another one that a lot of people use is lorazepam. That's Ativan. It's a little bit longer acting. If you're going to use that, I would definitely recommend you go with the lower end of 0.25 or 0.5 of that one. I would not use 1 mg. I think that's too much and it will last too long, but you bring up a good point, so yeah.
Topical and Procedural Anesthesia in Office-Based Rhinologic Procedures
Dr. Fortune continues to discuss the final part of his anesthetic protocol for office-based rhinology which includes topical anesthetic as well as injected anesthetic, which begins 15 minutes ahead of the procedure start time. Dr. Fortune will have the patients bring Afrin, which is squirted into their nose as they enter the procedure room. This is followed by topical anesthesia using cotton, initially with 1% lidocaine with 1:15,000 epinephrine which is enough for basic endoscopies. For office-based rhinologic procedures, more anesthetic is required and is then followed by topical 4% lidocaine with 1:1,000 epinephrine. After 10 minutes, 1% of lidocaine with 1:200,000 epinephrine is injected for the final part of the anesthetic protocol with no more than 4-6 mL total injected including both sides. Adequate monitoring should be done using pulse oximetry and cardiac monitoring to assess for signs of systemic epinephrine absorption with a lower volume of injected anesthetic used in patients with a cardiac history or other contraindications.
[Gopi Shah MD]
The patients come in and you've given the medicines and now take us through the ... I assume there's some topical anesthesia preparation. What do you do for that?
[Scott Fortune MD]
Yeah, so the first phase was the oral sedation, which we've covered pretty well, but the second phase is the topical anesthesia. The first step of that is just what you normally use for any scope procedure in your office. We had to change that a little bit too for the pandemic. It used to be sprayed. Now it's all about cotton. Our topical gets applied by the nurse on some cotton fibers in their nose in the holding room before we move over to the procedure room. The topical begins about 15 minutes before the scheduled time, so about 15 minutes before we want to start.
Let's say our first procedure of the day is going to be 7:30. About 7:15, we're going to go into the pre-procedure room and we're going to apply the cotton. For us, the topical that we use for scopes is 1% lidocaine with 1:15,000 epi and that's a mixture we started with a long time ago and we just stuck with it. It's pretty good for basic endoscopy. That alone would not be enough to do any of these office based rhinology procedures. The second part of the topical starts when the patient gets in the procedure room. That's when the physician enters and we'll start placing pledges.
What we use is a 1:1 mixture of 4% lidocaine light again, and 1:1,000 epinephrine. That is a potent epinephrine which is another reason you want to have that monitor handy, that pulse ox or that little Welch Allyn unit that I was referring to earlier. Most are going to tolerate this pretty well because you've pre-decongested them with your regular topical solution. We actually have the patient bring some Afrin too. Right when they go into the procedure room, we'll squirt their nose with Afrin and that's another way to get some decongestion which prevents the systemic absorption of the epinephrine.
Once we have the second round of the topical in the nose, we'll wait about 10 minutes and then we'll start the third phase of the anesthesia which is the injections. Our injection is 1% lidocaine with 1:200,000 epinephrine and we like that because it gives good vasoconstriction and it gives excellent anesthesia, but it doesn't give palpitations. The epi is just a little bit more dilute in that injection and so the patient doesn't feel as if their heart's racing. If I've seen one thing that patients complain of depending on your local, it's the palpitations. They definitely feel the 1:100,000 I've never seen pulse rates get above 90 or 100 once I inject, but the patient's definitely noticed it. When we changed to 1:200,000, all that went away.
[Ashley Agan MD]
I guess you're debriefing the day before along with the OSA and the sedation, your cardiac patients, so like hypertension, coronary artery disease may play a role and any changes of your topical injections or whether or not you decide to keep them in the office versus go to the OR, would you say?
[Scott Fortune MD]
Yes, that's true. Those with cardiac history, we're going to stay on the low end of injection. Typically, for what I'm doing, I don't need more than anywhere from 4 to 6 mLs of injection total. That includes both sides. That usually keeps you below a threshold where any cardiac events might happen, but if you've got a patient with a pretty serious cardiac history and then they're a risk for general anesthesia and you want to do this in your office. I might recommend you have that monitor unit because at least the Welch Allyn thing at least you have one lead of ECG tracing on that. The sedative protocol we talked about is not so much that the patients are completely out. If they're failing something, they can tell you.
Dr. Scott Fortune
Dr. Scott Fortune is a practicing physician with Allergy & ENT Associates in Nashville, Tennesee.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2021, March 16). Ep. 18 – Office Based Rhinology [Audio podcast]. Retrieved from https://www.backtable.com
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