Ambulatory Anesthesia, An Issue of Anesthesiology Clinics (The Clinics: Surgery)

204 Pages·2010·4.87 MB·English

by  Peter S.A. Glass MD

AmbulatoryAnesthesia
Foreword
Ambulatory Anesthesia
LeeA.Fleisher,MD
ConsultingEditor
Overthepast40years,therehasbeenamarkedincreaseinthepercentageofpatients
havingsurgeryinanambulatorysetting. Thishasbeentheresultofmultiplefactors,
includingthedevelopmentofnewanestheticandanalgesicagents,newsurgicaltech-
niquesandtechnology,andanincreaseddesiretoreducecostsandimprovepatient
convenience.Thisissuecontainsaseriesofarticleshighlightingsomeoftheimportant
questions related to delivery of ambulatory care and means of measuring and
improving outcomes. It also highlights some of the issues related to a growing area
ofambulatorypractice—theoffice-basedsetting.
AsGuestEditorforthisissue,IamfortunatetohavePeterStanleyAbrahamGlass,
MB, ChB, Professor and Chairman, Department of Anesthesiology at Stony Brook
UniversityMedicalCenter.Hehasauthored96originalarticlesand40bookchapters.
He has conducted many funded investigations related to delivery of anesthesia and
analgesiaintheoutpatientsetting.HehasbeenPresidentoftheSocietyforIntravenous
AnesthesiaandisanactivememberandcurrentlySecretaryoftheSocietyforAmbula-
toryAnesthesia.Givenhisresearch,education,andleadershiproles,hehasbeenable
toassembleanoutstandinggroupofcontributorstothisissueofAnesthesiologyClinics.
LeeA. Fleisher,MD
University ofPennsylvaniaSchool ofMedicine
3400Spruce Street,Dulles 680
Philadelphia, PA19104,USA
E-mail address:
[email protected]
AnesthesiologyClin28(2010)xiii
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AmbulatoryAnesthesia
Preface
PeterS.A.Glass,MB,ChB
GuestEditor
This issueof Anesthesiology Clinics isdevoted to ambulatory and office-based anes-
thesia.Outpatient/ambulatoryorsame-daysurgeryisnotreallynew.JamesNicolldocu-
mented the successful administration of 8,988 ambulatory anesthetics in England in
a 10-year period from 1899 to 1908. Ralph Waters opened an outpatient facility in
1918inSiouxCity,Iowa.Thesuccessesofanesthesiaandsurgeryledtoagreatertrend
toward hospitalization. Despite occasional publications in the surgical literature, there
was little organized effort to pursue outpatient surgery and anesthesia until the
1960s.In1962,theUniversityofCalifornia,LosAngeles,openedanoutpatientsurgical
clinic within the hospital. In 1966, George Washington University Hospital opened its
ambulatory surgical facility, and in 1970, Reed and Ford opened the Surgicenter in
Phoenix, Arizona, the first ambulatory surgery center (ASC) that was not affiliated
with an acute care hospital. Freestanding ASCs grew from 459 in 1985 to 1,381 in
1990. In 1974, national societies dedicated to the field began to appear. In 1984, the
SocietyforAmbulatoryAnesthesiawasorganizedasthefirstandonlyspecialtysociety
withintheAmericanSocietyofAnesthesiologistsdedicatedtoambulatoryanesthesia.
Overthepastmorethan40years,ambulatorysurgeryanditsextensionintotheoffice
has grown to approximately 70% of all surgical procedures performed in the United
States.Therehavebeenseveraldriversthathavefacilitatedthisconversionfrominpa-
tient to outpatient surgery. These include enhanced quality of patient care with
increasing patient satisfaction, financial incentives, pharmacologic and technical
advancesinanesthesia,and,lastly,majortechnicaladvancesinsurgicalprocedures.
Probablythemostsignificantofthesedrivershasbeenacombinationofeconomic
advantagescoupledwithimprovedqualityofcareandpatientsatisfactionthatambu-
latorysurgeryprovided.Inthe1960sand1970s,therewasgreatpressureonsurgical
bedcapacityandanationalcrytoreducehealthcarespending.Severalstudieshave
comparedsurgicalprocedures(suchassimplecataractextractionandcholecystec-
tomy)doneinahospitalwiththosedoneinanASC.Alldemonstratedlittledifference
inadverseoutcomes(largelyalowerrateofinfectioninanASC)withgreaterpatient
satisfaction. Enhanced patient satisfaction was improved by the far better efficiency
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xvi Preface
obtainedwithinanASC.Thisgreaterefficiencyalsowasimportantindrivingdownthe
costoftheepisodeofcare.AstudyperformedbyBlueShield/BlueCrossin1977esti-
matedthataprocedureperformedinanASCcost47%lessthanifperformedwithin
thehospital.Asthecostofcarewasreducedandpatientsatisfactionimproved,Medi-
care began increasing the number of procedures covered in ASCs. Private insurers
encouragedthistrendandinthe1990s,Medicareactuallycutbackonreimbursement
for a number of procedures that were performed in a hospital. This site of service
differentialhasbecomethenormforprivateandgovernmentinsurers,therebysolid-
ifyingtheroleofambulatorysurgery.Thegrowthofambulatorysurgeryhasnotbeen
universal, with many European countries having 10% or fewer surgeries done on
asame-daybasis.
Atthesametimethateconomicincentiveswereatwork,thereweresimultaneous
advancesindrugsavailabletoanesthesiologiststoprovideanesthesiathatenabled
rapid recovery of patients from anesthesia. In addition, more effective drugs for the
treatmentofpainandanesthesiasideeffects,suchaspostoperativenauseaandvom-
iting (PONV), were being released. Propofol probably has had the most significant
impact on ambulatory anesthesia. As an induction and a maintenance agent, it
enhanced the speed and quality of recovery. Probably the quality of recovery by
creating awake patients without the feeling of a hangover and a marked reduction
in the incidence of PONV (and the possible reduction in postoperative pain) played
asignificantroleintheacceptabilitybypatientsofhavingtheirsurgeryonanambula-
torybasis.Theintroductionofpropofolalsoledtotheenormousgrowthofproviding
moderate and deep sedation for minimally invasive or less-invasive surgeries and
procedures done under local or regional anesthesia. Although sedation may seem
aneasierandsafertechniquethangeneralanesthesia,reviewoftheMedicaredata-
baseaswellasstateauditshaveshownthisisnottrue.Performingsafeandeffective
deepsedationisanimportantskillthatanesthesiaprovidersneedtoacquiretoworkin
anASCenvironment.DrsHessionandJoshiprovidethescienceandartofsedation.
Atthesametime,short-actinganalgesics(fentanyl,alfentanil,andremifentanil)and
neuromuscular blockers (atracurium, vecuronium, cisatracurium, and mivacurium)
were introduced, making it easier for anesthesiologists to provide intense analgesia
and profound neuromuscular blockade yet allowing patients to wake up within
minutesandleavetheASCfortheirownhomewithinanhourofcompletingasurgical
procedure. This ability to titrate anesthetic drugs more precisely was enhanced by
increasing knowledge of drug interactions during anesthesia and the development
ofbrainfunctionmonitors.
As PONV was recognized as the most undesirable side effect of anesthesia,
a greater effort was made in understanding its pathophysiology; at the same time,
new drugs with fewer side effects became available (serotonin-3 antagonists). In
this issue, one of the leaders in the field of PONV, Dr Gan and colleagues, provide
areviewoftheseadvancesandcurrentmanagementofPONV.
Themanagement ofpostoperativepainpresented anequalchallengetoinsuring
the growth of ambulatory surgery. Again, increasing knowledge of pain pathophysi-
ology, concepts of multimodal analgesia, and new compounds all contributed in
makingsurethatpatientshadadequatepaincontrolpostoperatively.Amajorleader
inthefieldofpostoperativepainmanagementhasbeenDrWhite.InthisissueofAnes-
thesiologyClinics,heandDrElvir-Lazoprovideanoverviewofcurrentknowledgeon
howbesttomanagepostoperativepainintheambulatoryenvironment.
In line with the increasing knowledge of multimodal analgesia, an increasing
interestinregionalanalgesiaoccurred.Technologicaladvancesinultrasoundimaging
further stimulated increasing use of regional anesthesia. At the same time, the
Preface xvii
advantagesandsafetyofcontinuousregionalcathetersforpatientsdischargedhome
becameevident.SwensonandcolleaguesandJacobandcolleaguespresent2excel-
lent articles that bring readers up to date with the use of regional anesthesia, ultra-
sound,andcathetersforregionalanesthesiablockade.
Another technological advance that has had a major impact on the practice of
ambulatoryanesthesiaistheadventofthelaryngealmaskairway.Althoughitsdevel-
opment probably did not add to the actual growth of ambulatory surgery, it had
a significant impact on how anesthesia is practiced in this environment as well as
helpingtominimizepostoperativesorethroat.DrsLubaandCutterprovideacomplete
overviewoflaryngealmaskairwayspresentlyavailabletoanesthesiapractitioners.
Probably the largest population that has embraced ambulatory surgery is
doctors working with children. The whole concept of reduced anxiety, efficient
care, and rapid return to a friendly environment makes ambulatory surgery ideal
for pediatric patients. They present their own challenges for care in an ASC.
Drs Collins and Everett provide an excellent review of how to take care of pedi-
atric patients for ambulatory anesthesia.
As rapidly as the practice of anesthesia has changed to enhance ambulatory
surgery, so has technology within surgery. Endoscopic equipment advances have
almost paralleled the growth in ambulatory surgical volume. Advances in imaging,
catheters, and minimally invasive techniques have combined to move procedures
that were done in a hospital setting followed by days of recovery in a hospital bed
toanambulatoryenvironmentwithrecoveryathome.
ASCsgrewinnumber,size,andcomplexity.Tothisend,greatemphasishasbeen
placed on effective management of ASCs so that they can continue to provide the
advantages that were evident in their initial evolution. Although ASCs are a social-
based business, they still lend themselves well to management principles as Six
Sigma or Toyota’s lean production system. Drs Merrill and Laur provide readers
with an excellent approach (based on their own ASC) to providing highly effective
managementinthisenvironment.
Withtheincreasingmovetoambulatorysurgery,patientswerenolongeravailable
tobeseenbyananesthesia provider theevening before surgery.Similarly,patients
whoweretobeadmittedtothehospitalpostsurgerywerealsobeingadmittedonly
on the morning of surgery. This led to the need for an alternative method of seeing
patientsandoptimizingthembeforesurgeryandanesthesia.Thepreoperativeclinic
wasestablishedtoaccommodatethisrole.Aspreoperativeclinicsevolved,theques-
tionofwhatpreoperativework-upwasreallyneededbegantobeasked.Incorporated
inthisquestionwaswhoneededtobeseenandwhatpreoperativetestingwasappro-
priate. Several articles appeared demonstrating that patients received excessive
preoperative testing and that for some procedures (eg, lens extraction), no testing,
eveninthesickestofpatients,isrequired.Howmuchtestingforambulatorypatients
is needed is not yet fully resolved. Dr Richman provides the most recent evidence
availabletoanswerthisquestion.
Astimepasses,olddiseasesbecomemoreprominentasknowledgeoftheircause
and impact becomes more evident. A classic example of this is obstructive sleep
apnea(OSA).ThepublicationoftheAmericanSocietyofAnesthesiologistsguidelines
on the management of OSA generated much concern and consternation as to how
thesepatientsweretobeevaluatedpreoperativelyandhowtheyweretobemanaged
intraoperatively.Thisstimulatedincreasingresearchinthisarea.FrancesChungand
hergroupinTorontohavepublishedextensivelyandcontributedsignificantnewinfor-
mationonOSAandanesthesia.Weareluckytohavehergroupprovideanupdateon
OSAandanestheticmanagement.
xviii Preface
WiththesuccessofambulatorysurgerywithinASCs,practitionersbegantopush
theenvelopefurtherbyperforminglow-riskprocedureswithinanofficesetting.Thisis
now the fastest growing market within ambulatory surgery. This environment has
created the greatest challenge to anesthesia providers for a variety of reasons. Not
only is the physical space limited, but also anesthesia equipment is rarely available
andneedstobebroughtontothepremiseseachtimesurgeryisscheduled;expecta-
tionsofsurgeonsandpatientsare high.Inaddition,manystates havenotyetregu-
latedoffice-basedsurgeryandanesthesia,thusstandardsvaryconsiderablyacross
sites. Already, several disasters occurring with office-based surgery have been
exposedinthelaypress.Thus,itisimportantthatanesthesiaproviderscontemplating
providing anesthesia in an office setting familiarize themselves with the pitfalls and
minimum standards promulgated by the American Society of Anesthesiologists.
DrsKurrekandTwerskyhavebeenleadersincreatingthesestandardsandprovide
readers with an excellent overview of what is needed in setting up an office-based
anesthesiologypractice,whereas DrAhmadprovidesmanypractical approachesin
providinganesthesiacareinanofficesetting.
Peter S.A.Glass, MB,ChB
Departmentof Anesthesiology
School ofMedicine
SUNY StonyBrook
HSC Level4,Room 060
StonyBrook,NY 11794-8480, USA
E-mail address:
[email protected]
AmbulatoryAnesthesia
Contents
Foreword:AmbulatoryAnesthesia xiii
LeeA.Fleisher
Preface xv
PeterS.A.Glass
AmbulatorySurgery:HowMuchTestingDoWeNeed? 185
DeborahC.Richman
Ambulatorysurgerycurrentlyrepresentsmorethantwothirdsofsurgeries
performed.Itisconsideredlow-risksurgeryandpatientsexpecttobedis-
chargedhomesafelyandcomfortablythesameday.Morethan30yearsof
evidencesupportstheideathatpreoperativeassessmentisbestdoneby
afocusedhistoryandphysical,andonlyminimal,selective,furtherlabora-
toryinvestigations.Costsareoptimizedbythisapproachandoutcomes
havenotbeenshowntobeadverselyaffected,possiblyevenimproved,
with less harm inflicted by additional testing. This article focuses on
whatisappropriatetestingforambulatorysurgerypatients.
ObstructiveSleepApnea:PreoperativeAssessment 199
EdwinSeetandFrancesChung
Obstructive sleep apnea is the most prevalent breathing disturbance in
sleep.Itislinkedtoahostofpreexistingmedicalconditions,andassoci-
atedwithpoorerpostoperativeoutcomes.Screeningandvigilanceduring
thepreoperativeassessmentidentifiespatientsathighriskofobstructive
sleepapnea.Furtherdiagnostictestsmaybeperformed,andplanscanbe
made for tailored intraoperative care. The STOP and the STOP-Bang
questionnairesareusefulscreeningtools.Patientswithaknowndiagnosis
ofobstructivesleepapneashouldbeseeninthepreoperativeclinic,where
riskstratificationandoptimizationmaybedonebeforesurgery.Thisreview
articlepresentsfunctionalalgorithmsfortheperioperativemanagementof
obstructivesleepapneabasedonlimitedclinicalevidence,andacollation
ofexpertknowledgeandpractices.Theserecommendationsmaybeused
toassisttheanesthesiologistindecision-makingwhenmanagingthepa-
tientwithobstructivesleepapnea.
PostoperativePainManagementAfterAmbulatorySurgery:RoleofMultimodal
Analgesia 217
OfeliaLoaniElvir-LazoandPaulF.White
Multimodal(orbalanced)analgesiarepresentsanincreasinglypopularap-
proachtopreventingpostoperativepain.Theapproachinvolvesadminis-
tering a combination of opioid and nonopioid analgesics. Nonopioid
viii Contents
analgesicsareincreasinglybeingusedasadjuvantsbefore,during,andaf-
ter surgery to facilitate the recovery process after ambulatory surgery.
Early studies evaluating approaches to facilitating the recovery process
havedemonstratedthattheuseofmultimodalanalgesictechniquescan
improveearlyrecoveryaswellasotherclinicallymeaningfuloutcomesaf-
ter ambulatory surgery. The potential beneficial effects of local anes-
thetics, NSAIDs, and gabapentanioids in improving perioperative
outcomescontinuetobeinvestigated.
UpdateontheManagementofPostoperativeNauseaandVomiting
andPostdischargeNauseaandVomitinginAmbulatorySurgery 225
TinaP.LeandTongJooGan
Postoperative nausea and vomiting (PONV) continues to be one of the
mostcommoncomplaintsfollowingsurgery,occurringinmorethan30%
of surgeries, or as high as 70% to 80% in certain high-risk populations
withoutprophylaxis.The5-hydroxytryptaminetype3(5-HT )receptoran-
3
tagonistscontinuetobethemainstayofantiemetictherapy,butnewerap-
proaches, such as neurokinin-1 antagonists, a longer-acting serotonin
receptor antagonist, multimodal management, and novel techniques for
managinghigh-riskpatientsaregainingprominence.Therelatedproblem
ofpostdischargenauseaandvomiting(PDNV)hasreceivedincreasingat-
tentionfromhealthcareproviders.TheissuesofPONVandPDNVarees-
peciallysignificantinthecontextofambulatorysurgeries,whichcomprise
morethan60%ofthecombined56.4millionambulatoryandinpatientsur-
geryvisitsintheUnitedStates.Becauseoftherelativelybriefperiodthat
ambulatorypatientsspendinhealthcarefacilities,itisparticularlyimpor-
tanttopreventandtreatPONVandPDNVswiftlyandeffectively.
RoleofRegionalAnesthesiaintheAmbulatoryEnvironment 251
AdamK.Jacob,MichaelT.Walsh,andJohnA.Dilger
Theuseoflocalanestheticsinambulatorysurgeryoffersmultiplebenefitsin
linewiththegoalsofmodern-dayoutpatientsurgery.Avarietyofregional
techniquescanbeusedforawidespectrumofprocedures;allareshown
toreducepostproceduralpain;reducetheshort-termneedforopiatemed-
ications;reduceadverseeffects,suchasnauseaandvomiting;andreduce
thetimetodismissalcomparedwithpatientswhodonotreceiveregional
techniques. Growth in ambulatory procedures will likely continue to rise
with future advances in surgical techniques, changes in reimbursement,
andtheevolutionofclinicalpathwaysthatincludesuperior,sustainedpost-
operativeanalgesia.Anticipatingthesechangesinpractice,theroleof,and
demandfor,regionalanesthesiainoutpatientsurgerywillcontinuetogrow.
AmbulatoryAnesthesiaandRegionalCatheters:WhenandHow 267
JeffreyD.Swenson,GloriaS.Cheng,DeborahA.Axelrod,
andJenniferJ.Davis
Severalclinicaltrialshavedemonstratedthesuperiorityofcontinuouspe-
ripheral nerve block compared with traditional opioid-based analgesia.
Theabilitytoprovidesafeandeffectivecontinuousperipheralnerveblock
Contents ix
athomeisanattractivealternativetoopioid-basedanalgesiawithitsre-
lated side effects. In this article, the practical issues related to catheter
use in the ambulatory setting are discussed. Techniques for catheter
placement, infusion regimens, patient education, and complications are
subjecttomanyinstitutionalpreferences.Inthisreview,specialemphasis
isplacedonevidence-basedtechniques.
Sedation:NotQuiteThatSimple 281
PeterM.HessionandGirishP.Joshi
Thenumberofdiagnosticandtherapeuticinterventionsperformedunder
sedationisgrowingrapidly.Whileprovidingpatientswithanimprovedex-
periencesecondarytoanxiolysis,analgesia,andamnesia,sedationalso
putsthematriskforassociatedcardiorespiratoryandothercomplications.
Several medications are available for sedation, all of which have unique
advantages and disadvantages. The combination of patient characteris-
tics,proceduralfactors,andsideeffectsassociatedwitheachmedication
placeseachpatientatriskandtherefore,vigilanceduringsedationcannot
be overemphasized. Due vigilance includes proper monitoring, training,
staffing,andequipment,allofwhichareessentialtothesafedeliveryof
sedation.
SupraglotticAirwayDevicesintheAmbulatorySetting 295
KatarzynaLubaandThomasW.Cutter
Supraglotticairwaydevices(SGAs)offercertainadvantagesoverendotra-
chealintubation,makingthemparticularlywellsuitedforthespecificde-
mands of outpatient anesthesia. Patients may tolerate the placement
andmaintenanceofanSGAatalowerdoseofanestheticthanthatneeded
foranendotrachealtube;neuromuscularblockingagentsarerarelyneces-
saryforairwaymanagementwithanSGA;theincidenceofairwaymorbid-
ity is lower with SGAs than with endotracheal tubes; and SGAs may
facilitatefasterrecoveryandearlierdischargeofpatients.Twolimitations
ofSGAsareincompleteprotectionagainstaspirationofgastriccontents
and inadequate delivery of positive pressure ventilation. Newer variants
oftheoriginallaryngealmaskairway,theLMAClassic(LMANorthAmer-
ica,Inc),aswellasanarrayofotherrecentlydevelopedSGAs,aimtoad-
dress these limitations. Their utility and safety in specific patient
populations (eg, the morbidly obese)and duringcertain procedures (eg,
laparoscopicsurgery)remaintobedetermined.
ChallengesinPediatricAmbulatoryAnesthesia:KidsareDifferent 315
CoreyE.CollinsandLucindaL.Everett
Thecareofthechildhavingambulatorysurgerypresentsaspecificsetof
challengestotheanesthesiaprovider.Thisreviewfocusesonareasofclin-
icaldistinctionthatsupporttheadditionalattentionchildrenoftenrequire,
andonclinicalcontroversiesthatrequireproviderstohaveup-to-datein-
formationtoguidepracticeandaddressparentalconcerns.Theseinclude
perioperativerisk;obstructivesleepapnea;obesity;postoperativenausea
x Contents
andvomiting;neurocognitiveoutcomes;andspecificconcernsregarding
commonear,nose,andthroatprocedures.
ManagementbyOutcomes:EfficiencyandOperationalSuccessintheAmbulatory
SurgeryCenter 329
DouglasG.MerrillandJohnJ.Laur
Qualityofcareandserviceinhealthcarecanbenefitfromtheuseofalgo-
rithm-drivencare(standardwork)thatintegratesliteratureassessmentand
analysisoflocaloutcomeandprocessdatatoeliminateunnecessaryvar-
iationthatcauseserrorandwaste.Effectivemanagementofanambulatory
surgerycenterrequiresthatleadershipemphasizeconstantimprovement
intheprocessesofcaretoachievemaximumpatientsafetyandsatisfac-
tion, delivered with highest efficiency. Process improvement may be
achievedbysimplemeasurementalone(theHawthorneeffect).However,
asshowninthisarticle,theauthorshavesuccessfullyusedtheimplemen-
tation of regular measurement and open discussion of patients’ clinical
outcomesandotheroperationalmetricstofocusactivesystemsimprove-
mentprojectsinambulatorysurgerycenters,withexcellentresults.
Office-BasedAnesthesia:HowtoStartanOffice-BasedPractice 353
MattM.KurrekandRebeccaS.Twersky
Ambulatory,office-basedanesthesia(OBA)hasexperiencedanexponen-
tialgrowthinthelastdecade,andispopularamongpatientsandhealth
careprovidersalike.About17%to24%ofallelectiveambulatoryproce-
duresintheUnitedStatesarecurrentlybeingperformedinanoffice-based
setting. Special considerations must be made when comparing OBA to
ahospitalsetting,particularlywithrespecttofacilityandenvironment,ad-
ministration,andaccreditation.Increasingregulationwillensurethatpa-
tient safety remains the primary focus. In the meantime, the anesthesia
provider must take adequate steps to ensure that the quality of care in
OBAiscomparabletothatinahospital.
OfficeBased IsMyAnestheticCareAnyDifferent?AssessmentandManagement 369
ShireenAhmad
Office-basedanesthesia(OBA)isauniqueandchallengingvenue,and,al-
thoughtheclinicaloutcomeshavenotbeenevaluatedextensively,existing
data indicate a need for increased regulation and additional education.
OutcomesinOBAcanbeimprovedbyeducationnotonlyofanesthesiol-
ogistsbutalsoofsurgeons,proceduralists,andnursingstaff.Legislators
mustbeeducatedsothatappropriateregulationsareinstitutedgoverning
thepracticeofoffice-basedsurgeryandthelaypublicmustbeeducated
to make wise, informed decisions about choice of surgery location. The
leadership of societies, along with support from the membership, must
play a key role in this educational process; only then can OBA become
assafeastheanesthesiacareintraditionalvenues.
Index 385
Ambulatory Surgery:
How Much Testing
Do We Need?
Deborah C. Richman, MBChB,FFA(SA)a,b,*
KEYWORDS
(cid:2)Preoperative (cid:2)Laboratory (cid:2) Testing (cid:2) Ambulatory
(cid:2)Surgery (cid:2) Assessment
Preoperative testing is done to predict risk, alter management, and improve
outcomes.Ifthisis thepremise, theneach testneedstobeconsideredwithoneor
allofthesethreeaimsinmind.
Currently more than two thirds of surgeries in the United States are done on an
ambulatorybasis.Apfelbaumpredictsthegrowthofambulatorysurgeriestobeclose
to80%ofallsurgeries1intheUnitedStateswithinthenextcoupleofyears.
Patientselectionisamajorfactorinrunningasuccessfulambulatorysurgeryunit
with good patient outcomes. Different models of ambulatory surgery centers have
different selection criteria. Some may offer full-service anesthesia and physically be
partofthemainhospitalmakingadmissionapossibility,aspartoftheprocess.Others
maynot wanttheinefficiency offiber-optic intubation forthedifficult intubation and
screen these patients out. Still others are free standing and admission is not an
acceptableoption,ratheracomplicationandcontinuousqualityimprovementfactor;
consequentlytheyhavestricterselectioncriteriaforappropriatepatients.
Traditionally,preoperativetestinghasbeenpartofthescreeningprocessforappro-
priatepreoperativecareandselection.Preoperativetestingcoststhiscountryanesti-
mated$18billionannually.Ambulatorysurgeryisbydefinitionlow-risksurgery2and
patients,whoareusuallyAmericanSocietyofAnesthesiologists(ASA)physicalstatus
1or2,expecttobedischargedhomesafely.MortalityriskinASA1and2patientsis
0.06% to 0.08% and 0.27% to 0.4%3–5 in all surgeries, much lower in this low-risk
category.
a Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY
117948480,USA
b Preoperative Services, c/o Department of Anesthesiology, Stony Brook University Medical
Center,StonyBrook,NY117948480,USA
* Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY
117948480.
Emailaddress:[email protected]
AnesthesiologyClin28(2010)185 197
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