Preparing for Adverse Events When Performing Office-based Procedures

The procedures with the highest risk of airway compromise among laryngeal office-based procedures are vocal fold biopsy, vocal fold injection, transnasal laser ablation of the vocal folds, and transnasal esophagoscopy, because they are the most stimulating to both the patient and laryngeal tissues, Dr. Daniero said. The overall complication rate is extremely low, however.

Pharmacology-related emergencies can also occur. “Allergic reactions to topical or locally injected medication, an improper mixture of lidocaine or epinephrine, or interactions with a patient’s home medications can lead to serious consequences,” Dr. Sigari said. Given all of this, a surgeon should keep in mind that the same adverse events that occur in the operative theater, such as an electrocautery-related fire or burns, wrong surgery site, and inadvertent injury to non-involved limbs or other body parts, could occur in office—even if the chance is rare.

Changes in heart rate and blood pressure during a procedure can increase a patient’s risk of a cardiovascular event, such as MI or stroke, Dr. Daniero added. The fluctuations in heart rate and blood pressure are nearly identical to those that occur upon induction of general anesthesia (Laryngoscope. 2012;122:1331-1334; Ann Otol Rhinol Laryngol. 2012;121:714-718).

Melin Tan-Geller, MD, a laryngologist at Montefiore Health System in Bronx, N.Y., pointed out that something as simple as a patient fainting can be an adverse event. “Making patients comfortable enough to undergo a procedure while they are awake and aware can be challenging as well,” she said. “Patients must be able to sit still for the duration of the procedure and remain calm.” Patients may need to be coached through a procedure to make them as comfortable as possible.

In addition, because local anesthetics are the primary source for patient comfort, take care to avoid toxicity, which could manifest in cardiac events.

Evaluating Risk Level

Proper patient selection and risk stratification is the single most effective method to avoid adverse events in a clinic. This process includes reviewing a patient’s medical history before scheduling him or her for an in-office procedure. “Screen individuals with significant comorbidities or anxiety regarding procedural intervention, as well as patients with abnormal anatomy or a high body-mass index,” Dr. Sigari said. Keep in mind that candidates for in-office procedures might not have been seen or cleared by a primary physician and could therefore be at risk for an undiagnosed or under-managed comorbidity.

Clarification of specific roles may be the most important part of handling an emergency situation and can begin during a mock critical event. —James J. Daniero, MD, MS

Dr. Daniero pointed out that a patient who cannot tolerate a diagnostic flexible laryngoscopy will likely have difficulty with any unsedated procedure. “The hemodynamic changes in this setting would likely be more extreme and place the patient at higher risk,” he said. Furthermore, patients with significant cardiac disease may be managed in the controlled setting of the operating room with the help of an anesthesiologist, rather than in the clinic with limited acute care options. Taking a pre-procedure set of vital signs and/or using continuous monitoring can help screen patients who may not be safe to undergo a procedure at the time. Following this procedure can help the physician identify an undiagnosed, poorly controlled hypertensive patient.