Issues in ambulatory anesthesia

Published on 07/02/2015 by admin

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Last modified 07/02/2015

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Issues in ambulatory anesthesia

Brian P. McGlinch, MD

A substantial majority of surgical and invasive medical procedures in the United States are performed in ambulatory settings, from which discharge immediately following or within 24 h of the procedure is expected. Financial incentives have encouraged the performance of surgical procedures outside the inpatient or hospital setting, resulting in adoption of this practice model. Advances in surgical technology (e.g., robotic surgery) have contributed to an increasing number of procedures performed with improved patient safety, less blood loss, and minimal postoperative discomfort. Anesthetic management approaches utilizing regional anesthesia, new anesthetic agents, and multimodal therapies for treating pain and postoperative nausea and vomiting (PONV) have improved the reliability of postprocedure discharges to home. Along with the conduct of anesthesia, the anesthesia provider’s role in the ambulatory setting is crucial for ensuring patient safety and practice efficiency.

Patient screening and evaluation

For patients to safely undergo invasive procedures in a nonhospital environment, underlying medical conditions must be identified, evaluated, and stabilized prior to the scheduled procedure. There are no contraindications for patients with significant but stable underlying disease (i.e., American Society of Anesthesiologists, [ASA] physical status categories 3 and 4) to undergo an invasive procedure or operation in an ambulatory setting if the procedure is unlikely to exacerbate the underlying condition or conditions. In 2002, the ASA issued a practice advisory indicating that preoperative testing, particularly laboratory studies, does not significantly improve the preoperative preparation nor significantly alter perioperative management decisions unless indicated by symptoms, clinical findings, or preexisting conditions that warrant evaluation. There is no evidence that perioperative adverse outcomes are influenced when preoperative evaluations are eliminated in healthy or medically stable patients.

A preoperative telephone interview with the patient can often determine the presence and stability of significant underlying diseases (e.g., angina, chronic obstructive pulmonary disease) or special anesthetic concerns (e.g., latex allergy, malignant hyperthermia, obstructive sleep apnea [OSA], a history of difficult intubations) meriting further preoperative evaluation or scheduling considerations. If the intended procedure could impact the stability of a patient’s underlying condition or conditions, a more extensive evaluation can and should be performed before the day of surgery. The telephone interview also provides an opportunity for confirming with the patient the arrival time, place, and directions, as well as a review of preoperative fasting recommendations. This simple intervention reduces day-of-surgery delays and cancellations.

Preoperative fasting is a common issue that must be addressed in any setting in which sedation or anesthesia is anticipated because it influences practice efficiency. The ASA recommends the interval between ingestion and sedation or anesthesia be 2 h for clear fluids, 4 h for breast milk, and 6 h for nonhuman milk and solid food. In most circumstances, preoperative overnight fasting of both food and water has been abandoned prior to elective surgical procedures. Ingestion of clear fluids up until 2 h prior to receiving sedation or anesthesia in patients without risk for aspiration of gastric contents (e.g., no gastroesophageal reflux disease, bowel obstruction) improves patient comfort while preventing dehydration.

OSA is a common diagnosis (9% of middle-aged women, 24% of middle-aged men) of such importance to anesthesia practice that the ASA issued a practice guideline addressing this condition. At this time, there is insufficient evidence to recommend one particular anesthetic technique over another. However, OSA is negatively impacted by the use of intravenously administered sedative and hypnotic agents, as well as inhaled anesthetic agents. Postprocedure recovery and respiratory monitoring warrant significantly longer observation periods in both the inpatient and outpatient settings. The ASA guidelines recommend that, compared with patients without OSA, those with OSA be monitored for 7 h after the last episode of airway obstruction or hypoxemia while breathing room air and for 3 h longer on room air before being discharged to home. These guidelines functionally result in patients with OSA being admitted for overnight or 23-h observation in most cases of untreated OSA or for patients who are noncompliant with recommended continuous positive airway pressure therapy for OSA, as prescribed by the patient’s treating physician. The presence of OSA should not automatically preclude a particular patient from being considered for an ambulatory procedure. However, consideration must be made for the potential implications for airway management and postoperative monitoring for even the most routine procedural interventions.

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