The assumption in this chapter is that office-based anesthesia (OBA) is distinct from outpatient anesthesia in a freestanding surgery facility. OBA is used in many medical specialties, including most dental subspecialties, dermatology, plastic surgery, ophthalmology, otolaryngology, and gynecology. The procedures described in this chapter are but a small sampling of the ways in which anesthesia is used in medical/dental offices. Anesthesiologists who carry out anesthetic procedures in the office setting may be sole practitioners or part of a group of anesthesiologists who have a “division” or rotation devoted to OBA. Although anesthesia practiced in an office carries the same risks, burdens of responsibility, and skill requirements as in a fully equipped surgical center, in the office setting, the anesthesiologist may be expected to arrange for the oxygen supply, suction, monitoring, and emergency equipment. They may even bring a portable anesthesia machine with them from site to site. This unique challenge for the anesthesia provider includes working with personnel unfamiliar with anesthesia concerns, converting the office into a facility appropriate for anesthesia, selecting appropriate patients, providing safe and effective anesthesia/analgesia, and properly preparing and recovering the patients.

Many states have laws listing strict requirements for medical facilities where anesthesia is provided for surgical procedures. Some states have regulations based on the type of surgical procedure performed. Others regulate and credential the facility based on the type of anesthesia used (i.e., GA, iv, local). Still others base regulations on the type of facility itself. In California, for example, dental offices are regulated differently than medical offices. For many years, the California Dental Board has regulated anesthesia in the dental or oral surgery office by credentialing the anesthesia provider and/or the office facility itself. An oral surgeon, dentist, or physician issued a GA permit by the Dental Board goes through a credentialing process by one or two examiners that includes direct observation of an anesthesia case, demonstration of emergency drills, and examination of required monitoring and resuscitation equipment on site. The permit allows the holder to provide GA in any dental office. The Dental Board also issues “Conscious Sedation” permits to those dental practitioners who qualify and want to use this technique. Physicians in California wishing to have iv sedation or general anesthesia available in their office must first be accredited as a surgery center by one of several agencies providing this service such as AAAHC.org.

In the office setting, the anesthesia provider may or may not have the use of an anesthesia machine or other sophisticated equipment that is readily available in a surgical center. In some respects, however, this setting is analogous to other out-of-OR locations. The ASA Guidelines for Nonoperating Room Anesthetizing Locations1 covers all types of out-of-OR facilities, and these recommendations should be followed. Appropriate monitoring—including pulse oximetry, ECG, and BP—is required. Many portable monitors have ETCO₂ monitoring capability, which may be useful for the spontaneously ventilating, sedated patient. A precordial stethoscope is quite useful for monitoring respirations, especially in the dental patient, in whom airway obstruction is a frequent occurrence during the procedure. Also in accordance with the ASA guidelines, full resuscitation equipment, an adequate source of O₂ (and backup O₂), a functioning suction, adequate lighting and electrical outlets (with backup battery source), and a telephone with immediate access to a hospital ER also must be available. In the credentialed medical (nondental) facility, these items are required to be on site. In the dental facility, they may or may not be present. It is the responsibility of the anesthesia provider to make sure these items are available in the medical or dental facility before administering an anesthetic.

Typically, the anesthetic techniques in the office setting can range from conscious sedation, deep iv sedation to general anesthesia with intubation. The type of procedure, the patient’s clinical status, and the surgeon or dentist’s
preference all contribute to the decision of which technique is best for that particular situation. In the pediatric patient having dental restoration work, “conscious sedation” is not adequate because most often the dental restoration required is very extensive and will likely take several hours to accomplish. In this situation, general anesthesia with nasal intubation (or oral intubation if nasal intubation is not possible) is usually the best choice of anesthetic technique. In the patient having dental implant placement, minimal or moderate sedation may be all that is required. The oral surgeon may require the patient’s cooperation at times during the procedure. The patient undergoing full face laser resurfacing will most likely require deep sedation or general anesthesia because this procedure can be quite painful. However, because sedation is a continuum, the anesthesia provider must be prepared to rescue any patient receiving any sedation in the office (see Continuum of Depth of Sedation, ASA Guidelines).

As in all medical facilities, the patient’s safety is of paramount importance. In the office setting, the ability to achieve a successful outcome is dependent first of all on appropriate patient selection. The patients presenting for OBA will fall into several categories, depending on the procedure and the patient’s age and medical condition. An “appropriate patient” can be an ASA 1 or 2 patient. They may even be an ASA 3, if: (a) their medical problems are stable and well controlled with medication, and (b) the office procedure itself will not pose an undue risk to them.

In a medical or dental office, often there is no separate recovery area designated as such. It is common practice for the patient to be recovered by the anesthesiologist in the treatment room until they can open their eyes and maintain an adequate airway without assistance. At that point, any iv or monitors that may have been used can be removed. If it is a pediatric patient, the parents may be brought into the room, although recovery remains under the supervision of the anesthesiologist. Office anesthesia patients can be discharged when they are well oriented, their pain and nausea are controlled, and they have a responsible adult to accompany them. They may still feel drowsy, but this should not prevent them from being able to walk with assistance.

Discharge instructions regarding appropriate postop activities should be given to the responsible adult with the patient. Generally, patients are asked to adhere to the following instructions upon discharge:

The anesthesiologist also should give the responsible party (parent, friend, other relative) his/her pager or cell phone number in the event they need to contact the anesthesiologist after patient discharge.

Description: A variety of medical devices have been approved for use to improve skin concerns, such as wrinkles, precancerous skin lesions (actinic keratoses), discoloration, acne scars, traumatic scars, and sagging skin. In the mid-1990s laser resurfacing using the fully ablative CO₂ laser was very popular. This procedure yielded wonderful results, but extensive heat from this procedure caused some undesirable side effects such as scarring or pigmentation problems, prompting the industry to develop the cooler and more conservative resurfacing tool using the erbium laser. Less than a decade later, a novel fractionated laser resurfacing device was developed that removed only a fraction of the skin in a pattern reminiscent of pixels in newspaper print. Certainly, the risks and side effects were reduced compared to the older technology, though this more conservative approach rendered a more modest improvement of skin concerns. Further research led to the development of nonablative technologies such as radiofrequency/ ultrasound/nonlaser light-based devices, most of which resulted in better side effect profiles and positive outcomes. Although the holy grail of devices would render a no-down-time, painless procedure void of negative effects, the search for such continues to elude us. Meanwhile, physicians who perform these procedures should encourage patients to opt for office-based anesthesia and thus make the experience a more pleasant one for all involved.

Because some devices deliver a tremendous amount of heat to the skin surface, ablating both the epidermis and a portion of the dermis, nerve blocks and local anesthetic infiltration are often inadequate, thus requiring either iv sedation or GA. Facial nerve blocks may be performed to supplement iv sedation. After a Betadine® prep, anesthetic eye drops are used, followed by the insertion of protective corneal shields. The treatment then begins with one or more passes performed at various energy levels.

Usual preop diagnosis: Wrinkles, precancerous skin lesions (actinic keratoses), acne scars, and traumatic scars.