Anesthetic Protocol In Office-Based Rhinologic Procedures

[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.

[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.