Dr. Tan-Geller noted that patients who have a coagulopathy or are taking blood-thinning medications will be more prone to uncontrollable bleeding and may not make good candidates for in-office procedures, because bleeding may be more difficult to control in an office setting, depending upon the available equipment.
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August 2015Taking Precautions
The manner in which a therapy is delivered in office to an awake patient is quite different that that used in a hospital setting. “Physicians wishing to transition therapies to an in-office setting should seek the advice [of] or shadow another physician who has already performed these procedures in-office,” Dr. Sigari said. “Physicians need to be very aware of their own limits and be willing to abort a procedure before it progresses on a downward spiral toward an adverse event.”
To better ensure a seamless procedure, Dr. Sigari insists on having the proper equipment on hand. “Although one of the goals of an in-office procedure is to reduce cost, the upfront equipment cost can be significant,” he said. “But having the proper equipment to perform a procedure will allow you to complete it quickly and safely.” This might require more scopes, surgical instrumentation, and monitors. Additionally, consider purchasing patient monitoring equipment, such as pulse oximetry devices, heart rate monitors, and blood pressure monitors.
If oral or intravenous sedation is used, it is necessary to monitor oxygen saturation and heart rate, Dr. DelGaudio added.
For laryngeal procedures, adequate topical anesthetic—usually lidocaine or pontocaine—and various methods to deliver the medication to the involved procedure site can reduce the likelihood of laryngospasm, Dr. Daniero said. Associated equipment might include a flexible drip catheter, Abraham cannula, or nebulizer.
Dealing with Adverse Events
Although proper safety equipment is mandated in a hospital or ambulatory surgery center, there are no mandates for minimal equipment in an office setting. Physicians who wish to perform office procedures should have a crash cart on the premises, including a resuscitation cart for cardiopulmonary resuscitation, in the unlikely event of a severe airway or cardiac emergency. Consider partnering with a local hospital or ambulatory surgery center to develop a cart equipped with technologies that can be used to handle basic emergencies. All clinic staff should know where equipment and emergency medications are located. Maintain the cart and its contents, and routinely check inventory for expired or missing medications.
A bag-mask ventilation kit with supplemental oxygen nearby, intubation kit, intravenous access kit, suctioning supplies, cauterization equipment, and medical code supplies are critical to ensure safety during laryngeal office-based procedures.