Office-Based Anesthesia
An office-based anesthetic is defined as an anesthetic that is performed in an outpatient venue (office, procedure room) that is not accredited as either an ambulatory surgery center (ASC) or as a hospital (Hausman LM, Rosenblatt MA. Office-based anesthesia. In: Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Ortega R, Stock MC, eds. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins; 2013:860–875). Along with providing safe anesthesia to patients (healthy to medically challenged) undergoing increasingly complex procedures, anesthesia professionals must understand office safety and policy, legal and financial issues such as antitrust laws, and billing and collection issues. A challenge to office-based practitioners is that presently there is little or no training in office-based anesthesia (OBA) within the standard anesthesia residency program.
I. Brief Historical Perspective of Office-Based Anesthesia
Over the past several decades, as a result of both surgical and anesthetic advances the surgical experience has changed (laparoscopic techniques, fast onset and offset anesthetics), lending increasing numbers of procedures to be suitable for performance in outpatient venues.
During the 1970s, <10% of all surgical and diagnostic procedures were performed on an ambulatory basis, and virtually all were performed in hospitals. By 1987, approximately 40% of all procedures were performed as ambulatory. The vast majority of plastic surgical procedures are performed on an ambulatory basis, and many are performed in private offices.
II. Advantages and Disadvantages (Table 31-1)
Table 31-1 Advantages and Disadvantages of Office-Based Anesthesia | ||
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III. Office Safety
Injuries and deaths occurring in offices are often multifactorial in their causation (including overdosages of local anesthetics, prolonged surgery with occult blood loss, accumulation of multiple anesthetics, hypovolemia, arterial hypoxemia, and the use of reversal drugs with short half-lives).
Both the Anesthesia Patient Safety Foundation and the American Society of Anesthesiologists (ASA) have emerged as leaders in the field of OBA safety and have advocated that the quality of care in an office-based practice be no less than that of a hospital or ASC.
Reports of morbidity and mortality within office-based practices vary dramatically.
The challenge of acquiring accurate morbidity and mortality data for OBA is complicated by the fact that many offices are not required to report adverse events.
There are reported cases of injuries to patients in offices resulting from obsolete and malfunctioning anesthesia machines, as well as resulting from alarms that have not been serviced or are not functioning properly (Table 31-2).
The ASA has created guidelines for defining obsolete anesthesia machines.
Table 31-2 Causes of Injury in the Office | |
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IV. Patient Selection
Before presenting for an office-based procedure, the patient must be medically optimized. The patient should have a preoperative history and physical examination recorded within 30 days, all pertinent laboratory tests performed, and any medically indicated specialist consultation(s) done.
Patient selection for OBA is a controversial topic. The ideal patient for an office-based procedure has an ASA physical status of 1 or 2. The ASA also has developed recommendations regarding patient selection.
When determining whether a patient is suitable for OBA, it is important to realize that the location is often remote and the anesthesiologist may be unable to get assistance if it is required. Therefore, anticipated anesthetic problems must be avoided (Table 31-3).
Obesity and Obstructive Sleep Apnea. It is estimated that 60% to 90% of all patients with obstructive sleep apnea (OSA) are obese. The majority of the patients with OSA have not been formally diagnosed. There may be failure to intubate the trachea or ventilate the lungs, they may have respiratory distress soon after tracheal extubation, or they
may experience respiratory arrest with preoperative sedation or postoperative analgesia. These patients tend to be exquisitely sensitive to the respiratory depressant effects of even small dosages of sedation or analgesics.
Pulmonary embolism from deep vein thrombosis is a significant cause of perioperative morbidity and mortality from office-based surgical procedures.
Table 31-3 Characteristics of Patients Who May not be Good Candidates for Office-Based Procedures | ||
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V. Surgeon Selection
The relationship between the surgeon and anesthesiologist must be one of mutual trust and understanding. There have been cases reported of surgeons performing procedures for which they have little or no training.
A system should be in place for monitoring continuing medical education as well as peer review and performance improvement for both surgeons and anesthesiologists (Table 31-4).
Table 31-4 Sentinel Events that Should Trigger a Chart Review and be Presented at a Performance Improvement Quality Assurance Meeting | |
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VI. Office Selection and Requirements
The office needs to be appropriately equipped and stocked to perform general anesthesia (Table 31-5). All equipment described in the ASA algorithm for management of the difficultRelated posts:
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