BMI Reference tool
Click BMI Tool for full details.
In Summary, EBP BMI recommendations:
-If OSA or presumed OSA, then follow SAMBA-OSA recommendations with STOP-BANG. STOP-BANG 5+ =high risk= moderate/severe OSA=increased rate of perioperative/respiratory complications, critical care admission, and a 1 in 4 chance of having an adverse event.
-If able to use CPAP (if diagnosis OSA) after surgery.
Preoperative Medications to hold or Continue for Surgery
Click Preoperative Medication Protocol for current protocol on either to HOLD or CONTINUE medications. In summary, EBP recommendations are to seek Prescriber input on blood thinners/anticoagulants/antiplatelets.
Also, seek recommendations on need to modify doses of the following:
Insulin, Naltrexone, Suboxone, Subutex, and medications related to Cardiac Stent Management.
Click Evidence Table for full details of EBP recommendations, or Click Quick Guide for a summary.
Preoperative patient selection criteria for anesthesia services
Click Preop Screening Protocol for full details. In Summary, EBP
Preoperative Patient Selection recommendations:
In general, CIEDs (Pacemakers or ICDs) are not appropriate for OBS/ ASC setting. (There are exceptions-See protocol)
In general, a blood glucose of 400 and above is an indication to postpone surgery until it is lowered (not by anesthesia intervention) or cancellation.
In general, High Blood Pressure (SBP 180>, DBP 110> is an indication to postpone surgery until it is lowered (not by anesthesia intervention) or cancellation.
In general, postpone surgery for patients who arrive for day of surgery with:
Fasting (NPO) Guidelines
• Clear liquids
-Stop 2 hours prior to procedure
• Breast milk
Stop 4 hours prior to procedure
• Infant formula
Stop 6 hours prior to procedure
• Nonhuman milk
Stop 6 hours prior to procedure
• Light meal**
Stop 6 hours prior to procedure
**Per ASA 2017 Fasting Guideline. Click Here to see Guideline.
Click Here to see Guideline Summary.
Cardiac Implantable Electronic Device: (CIED) Recommendations
1. Click Preop Screening Protocol for EBP Recommendations on CIED Patient Selection.
2. Click Decision-Making Tool for a Quick Guide on Magnet versus Reprogram
3. Click ICD Considerations Tool for a Quick Guide on Proceeding with Surgery for Patients with ICD.
Elective Surgery Recommendations on PPE During COVID-19
Please see our latest PPE recommendations while at facilities during COVID-19 pandemic here.
In summary, please contact us to coordinate time/location on where to deliver your PPE for facility use.
Our current recommendation is to wear an N-95 (or equivalent) and eye protection during all times of anesthesia delivery to patients.
Managing patients receiving an endotracheal tube or LMA will necessitate use of extra PPE. Not all facilities contracted with our group have implemented these extra PPE precautions, which is why we are offering to supply our anesthesia providers a standardized PPE kit for free. As elective surgeries during this time period of pandemic increases, please contact us to coordinate delivery of a standardized PPE kit.
Recommendations For Anesthesia Services requiring Intubation (ETT/LMA) During COVID-19:
1. Modified Rapid Sequence Intubation:
a. Preoxygenate patient with 100% FiO2 by allowing patient to breathe spontaneously with anesthesia circuit mask for at least 2 minutes.
b. Do not apply positive pressure ventilation to preoxygenate but rather follow step a. above.
2. After Intubation, attach HME filter directly to ETT/LMA, then attach anesthesia circuit. Keep HME filter while patient intubated.
3. Upon Extubation, dispose of ETT while removing HME filter. Apply HME filter to anesthesia circuit mask while providing supplemental oxygen. Transfer patient to recovery with surgical mask on patient (nasal cannula under) or oxygen face mask.
Anesthesia Patient Safety Foundation
Risk Stratification tools
Perioperative Cardiac Risk Indexes/
1. ACS NSQIP Surgical Risk Calculator
2. ASC NSQIP Surgical Risk MICA Excel Calculator
3. Revised Cardiac Risk Index (RCRI) Calculator
4. STOP-BANG Calculator
5. 24-Hour CIED Technical Support Contacts
Cardiac Implantable Electronic Device: (CIED) TOOLS
1. Click Here to see an example of a Chest x-ray which can identify device type, leads, and manufacturer. This Chest x-ray shows 3 leads:
Right atrial lead
Right ventricular lead: Shocking Coil (thicker,denser radio-opaque distal portion of lead)
*Note: This thicker, denser distal coil is not seen in a strictly pacemaker device.
Coronary Sinus lead: Suggests Re-synchronization therapy for low ejection fraction
*Note: Chest x-ray provides most information needed for an emergency scenario, however, it does not provide key information on:
A. Whether patient is pacemaker dependent
B. Battery life (minimum 3 months battery life recommended)
C. Placement of leads (Recommended no sooner than 3 months prior to elective surgery as this is critical window of dislodgement)
For these reasons, an interrogation report is indicated prior to elective surgery.
2. Click Here to see an example of a 12-EKG which can help identify CIED function, underlying rhythm
CORONAVIRUS (covid-19) UPDATES
03/15/2020: UPDATE: All facilities contracted with our facility remain open. Our team will update in real-time as news develop.
03/17/2020: UPDATE: Our facility in Laurel, MD has announced cancellation of all anesthesia services for the remainder of March, and all of April until further notice. This is the only facility so far to close anesthesia services due to COVID-19 precautions. Thank you for your patience and understanding during these difficult times. We will update accordingly.
03/25/2020: UPDATE: Our facility in National Harbor region has announced cancellation of all anesthesia services for the remainder of Maryland and April until further notice.
05/09/2020: UPDATE: In preparation for upcoming reopening of facilities to elective surgery, please read anesthesia recommendations here.
09/01/2020: UPDATE: We will continue to mail N-95's (or equivalent) on an as needed basis to independent contractors when facilities are unable to provide one for anesthesia providers. Please email VECRNA@gmail.com to have N-95's mailed to you free of charge.
11/05/2020: UPDATE: Hi CRNAs we launched a CRNA Referral Bonus Program. Please see link to learn more about how you can earn $200 for referring a CRNA to us.
05/19/2021: UPDATE: Our Anesthesia Services has expanded to 41 sites during COVID. Some of you are working for us full-time and some PRN. Please contact us to receive your COVID 19 PPE kits as employee and patient safety is essential.
07/19/2021: UPDATE: As our anesthesia team has increased to 27 CRNAs, please remember to send copies of COVID vaccination records to VECRNA@gmail.com. Welcome all CRNAs who have joined recently. Once COVID passes, we will ensure to resume our annual employee parties so we can network and catch up. Thank you for your expert anesthesia services.
12/05/2021: UPDATE: A COVID variant called Omicron has spread to the DMV region and we anticipate an exponential rise in COVID cases, which means potential facility closures mid-December. If you have obtained your COVID vaccine booster, please email copies to VECRNA@gmail.com We will keep you posted on closures.
01/02/2022: UPDATE: Happy new year! We are noting increased case cancellations due to COVID, but not facility cancellations so far. Anticipate early dismissals from facilities as COVID transmission rises. No worries, you will still receive your 8-hr guarantee. Sincerest thanks to frontline healthcare workers for all that you do. Thank you for teaming with Visurraga Enterprises LLC during 2021.