Ambulatory anesthesia is used for surgical procedures where the patient does not need to stay overnight in the hospital. The same anesthetics that are used in the operating room setting are used in the ambulatory setting, including general, regional and local anesthetics. Sedation anesthetics are also given in the ambulatory setting. This issue will cover best practices and procedures for perioperative care, regional anesthesia, pediatric anesthesia, administering office anesthesia, and more.
Front Cover 1
Ambulatory
2
copyright
3
Contributors 4
Contents 8
Anesthesiology Clinics
14
Foreword
16
Preface
18
Perioperative Management of Co-Morbidities 24
Perioperative Evaluation and Management of Cardiac Disease in the Ambulatory Surgery Setting 26
Key points 26
Introduction 26
Hypertension 27
Functional capacity 27
Coronary artery disease 27
Heart failure 28
Coronary stents 29
Cardiovascular implantable electronic devices: pacemakers and implantable cardioverter defibrillators 29
Aortic stenosis 30
Prosthetic heart valves 31
Preoperative testing 32
Perioperative medical management 32
Prophylaxis for infective endocarditis 32
Putting it all together: a stepwise practical approach for ambulatory surgery 33
Preoperative cardiac evaluation on the horizon 35
References 35
Perioperative Consideration of Obstructive Sleep Apnea in Ambulatory Surgery 38
Key points 38
Introduction 38
Risk factors and pathophysiology 39
Diagnostic criteria of OSA 39
Methods for perioperative screening for OSA 39
Preoperative evaluation of the patient with suspected or diagnosed OSA for ambulatory surgery 39
Outcome of patients with OSA undergoing ambulatory surgery 41
Perioperative care of patients with OSA for ambulatory surgery 41
Postoperative disposition and unplanned admission after ambulatory surgery 42
Summary 43
References 43
Management of Diabetes Medications for Patients Undergoing Ambulatory Surgery 46
Key points 46
Preoperative inquiries 46
Medications for Type 2 Diabetes Mellitus 46
Insulin 47
Insulin Pumps 47
Hypoglycemia 47
Significance of diabetes in surgical outpatients 49
Glycemic Disturbances 49
Evidence for Glucose Control in Critical Care and Surgical Patients 49
Perioperative management of diabetes medications 49
Insulin Dosing 49
Day prior to surgery 49
Day of surgery 51
Correction doses of insulin 52
Insulin pumps 52
Oral Medications 52
Anesthesia care 53
Scheduling 53
Glucose Measurement 54
Abnormal Blood Glucose Values 54
Postoperative Care 54
References 54
Regional Anesthesia 58
Peripheral Nerve Blocks for Ambulatory Surgery 60
Key points 60
Introduction 60
Upper extremity PNBs 63
Interscalene Block 63
Supraclavicular Block 65
Infraclavicular Block 65
Axillary Block 67
Lower extremity PNBs 67
Femoral Nerve Block 68
Sciatic Nerve Block 68
Summary 69
References 69
Neuraxial Anesthesia for Outpatients 76
Key points 76
Introduction 76
Selection of agents 76
Epidural anesthesia 79
Selection of agents 83
Side effects 84
Summary 87
References 87
Anesthesia for Procedures 90
Anesthesia for Ambulatory Diagnostic and Therapeutic Radiology Procedures 92
Key points 92
Introduction 92
Contrast 93
Other contrast media 93
MRI 93
Magnet Safety 93
Anesthetic Considerations for MRI 93
Monitoring/patient access 95
Ear safety 96
Interventional radiology 96
Radiation Safety 96
Anesthetic considerations for interventional radiology 97
Anesthetic 97
Monitoring/Equipment 98
Procedures 98
Postprocedure care 100
Summary 100
References 100
Ambulatory Anesthesia for the Cardiac Catheterization and Electrophysiology Laboratories 102
Key points 102
Introduction 102
Consultation: a multidisciplinary approach 102
General strategies for the ambulatory anesthesiologist 103
Higher risk procedures in the ambulatory surgery setting 103
Complex Catheter Ablation 103
Lead Extractions for Cardiovascular Implantable Electronic Devices 104
Transcatheter aortic valve replacement 105
Radiation safety 105
Summary 106
References 106
Nonoperating Room Anesthesia for the Gastrointestinal Endoscopy Suite 108
Key points 108
The patients 109
The procedures 109
Anesthesia techniques for GI endoscopy 110
Preanesthesia preparation for the GI endoscopy suite 111
Anesthetic technique 111
Postanesthesia care 113
An increasing role for anesthesia in the GI endoscopy suite of the future 113
References 114
Chronic Pain 116
Key points 116
Introduction 116
History of interventional pain management 116
Anesthesia techniques in off-site locations 117
Interventional pain-relieving procedures 117
Complications related to anesthetic techniques in interventional pain procedures 123
Airway Compromise 123
Disinhibition and Agitation 123
Predisposition to Neural Injury 124
Summary 128
References 128
Pediatric Ambulatory Anesthesia 132
Key points 132
Introduction 132
Patient selection 133
Upper Respiratory Infection 133
Apnea Risk in Infants 134
Sleep Apnea and Tonsillectomy 135
Cardiac Risk 135
Undiagnosed Weakness or Hypotonia 136
MH 136
Hyperkalemic cardiac arrest 136
PRIS 137
Preoperative Pregnancy Testing 137
Preoperative management 137
Nonpharmacological Anxiolysis 137
Clowns and magicians 137
Audiovisual material and games 139
Humor and verbal methods 139
Intraoperative management 139
Intubation Without Neuromuscular Blockade: Remifentanil 139
Pain Management for Circumcision 141
Acetaminophen: Rectal Dosing 141
Summary 143
References 143
Initial Results from the National Anesthesia Clinical Outcomes Registry and Overview of Office-Based Anesthesia 152
Key points 152
Introduction 152
Administrative and safety issues 153
Literature Review 153
Accreditation and Other Administrative Issues 155
Facility, Patient, and Procedure Selection 156
Data analysis from the Anesthesia Quality Institute 158
Future direction of OBA 163
References 163
Airway Management 166
Key points 166
Introduction 166
Lessons learned from recent studies 167
The Fourth National Audit Project of the United Kingdom 167
2013 Update: ASA Difficult Airway Algorithm 169
The SGA: When Might It Fail? 170
Videolaryngoscopes: Glottic View Versus Successful Intubation 170
Airway assessment 174
Developing an Airway Strategy 175
SGA Tips for Success 176
VL: Tips for Success 177
Anesthetic emergence and extubation 177
The Bailey Maneuver 177
Emergency equipment 179
Summary 181
References 181
New Medications and Techniques in Ambulatory Anesthesia 184
Key points 184
Introduction 184
Novel sedative-hypnotics drugs and delivery systems 185
Propofol Formulations 185
Alternate Propofol Emulsion Formulations 185
Ampofol 185
IDD-D Propofol 2% 185
AM149 186
Propofol-Lipuro 1% and 2% 186
Albumin emulsions 187
Nonemulsion Formulations 187
Propofol cyclodextrin formulation 187
Micelle formulations 188
Propofol Prodrugs (Fospropofol, HX0969w) 188
SEDASYS System 189
Benzodiazepine Receptor Agonists 190
PF0713 190
Remimazolam (CNS 7056) 190
AZD 3043 (previously named TD-4756) 190
JM-1232 (-) (MR04A3) 191
Etomidate Derivatives 191
Methoxycarbonyl etomidate 192
Cyclopropyl MOC etomidate 192
MOC-carboetomidate 193
Other Class 193
Melatonin 193
Novel neuromuscular blocking/reversal agents 193
Gantacurium (GW280430A) 194
CW 002 194
Sugammadex 194
Novel analgesics and analgesic delivery systems 194
Kappa-Opioid Agonists 195
CR665 (JNJ-38488502) 196
CR845 196
Local Anesthetics 197
EXPAREL (bupivacaine liposome injectable suspension 1.3%) 197
SABER-Bupivacaine 199
Nonintravenous formulations of fentanyl 199
Summary 200
References 200
Postop Issues/Care/Discharge 208
Postoperative Issues 210
Key points 210
Postanesthetic recovery 210
Discharge scoring system 211
Fast-Tracking 211
Discharge from Ambulatory Surgical Unit 212
Discharge After Regional Anesthesia 212
Postdischarge Instructions 214
Summary 215
References 215
Acute Pain Management 218
Key points 218
Introduction 218
Identify: risk stratification, preprocedural planning 220
Implement: MMA, regional anesthesia 220
Implement: MMA, pharmacotherapy 222
Implement: nonpharmacologic techniques 223
Intervene: recovery room rescue 223
Summary 223
References 224
Long-Acting Serotonin Antagonist (Palonosetron) and the NK-1 Receptor Antagonists 228
Key points 228
Introduction 228
Risk factor identification 229
Pharmacologic intervention 229
Palonesetron 231
Aprepritant, Casopitant, Rolapitant 231
Clinical evidence of efficacies 232
Palonosetron 232
Neurokinin Receptor Antagonist 234
Summary 236
References 236
Administrative Issues 240
Scheduling of Procedures and Staff in an Ambulatory Surgery Center 242
Key points 242
Introduction 242
Basic definitions 243
Systems for procedure scheduling 243
Using utilization to assign or time 247
Prediction of procedure duration 247
Categories of OR delays 249
Summary 251
References 251
Practice Management/Role of the Medical Director 254
Key points 254
Introduction 254
History and development of the ambulatory surgery medical director 255
Management by outcomes and process improvement 256
Care pathway development: reducing error and improving quality by reducing variation 261
Summary 261
References 263
Appendix 1 Example of a multidisciplinary algorithm of care resulting from a safety event 263
Surgical Team 263
Anesthesia Team 264
Pre-operative/Recovery Nurse 265
Legal Aspects of Ambulatory Anesthesia 266
Key points 266
Practice-related legal issues 266
Professional Liability 266
Patient selection 267
Informed consent 267
Professional association standards 268
Regulatory Considerations 268
CMS conditions for coverage 268
State law requirements 269
Kickbacks 269
Stark and physician self-referrals 270
Contracts 271
Ownership-related legal issues 271
Federal Antikickback Statute Restrictions on Ownership 271
Stark Law Considerations 272
State Law Requirements 273
Requirements that referring physicians perform the services themselves 273
Disclosure or sunshine requirements 273
Summary 273
References 273
Accreditation of Ambulatory Facilities 276
Key points 276
Introduction 276
Accrediting organizations 277
Deemed status 278
Ambulatory facility regulation by states 279
Quality reporting and outcomes 280
References 281
Anesthesia Information Management Systems in the Ambulatory Setting 284
Key points 284
Benefits 285
Medical Record Review 285
Support Links (Information Buttons) 286
Organization of Information 286
Automatic Transfer of Vital Signs 286
Legibility 287
AIMS is Integrated with the EHR 288
Decision Support 288
Menus 289
Compliance 290
Icons Communicate Patient Status 291
Registries 292
Summary of benefits 293
Challenges 294
Report Management 294
Forest-for-the-trees Dilemma 294
Garbage In, Garbage Out 294
Short Cases Require an Experienced AIMS User 294
Device Integration 294
Support and Downtimes 295
Alerts After the Fact 295
Workstation Reliability and Availability 296
Cost 296
Medicolegal Concerns 298
The future 299
Standardization 299
Access and Portability in a Health Information Exchange 299
Wireless Monitoring and Integration 299
Mobile Technology 299
Summary 300
References 300
Quality Management and Registries 302
Key points 302
Why quality management is important and how to do it 302
External resources and registries 305
What data to collect 307
How to use QM data 308
Summary 310
References 310
Index 312
The Four Ps: Place, Procedure, Personnel, and Patient
Jeffrey L. Apfelbaum, MDjapfelbaum@dacc.uchicago.edu, Department of Anesthesia and Critical Care, Pritzker School of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 4028, Chicago, IL 60637, USA
Thomas W. Cutter, MD, MAEdtcutter@dacc.uchicago.edu, Department of Anesthesia and Critical Care, Pritzker School of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 4028, Chicago, IL 60637, USA
Jeffrey L. Apfelbaum, MD, Editor
Thomas W. Cutter, MD, MAEd, Editor
Patient ingress
As with all anesthetics, perioperative management may be divided into preoperative, intraoperative, and postoperative management. Preoperatively, one of the things that makes the practice of ambulatory anesthesia unique is the appropriate selection of patients. Most ambulatory anesthesiologists have encountered the patient who is deemed an inappropriate candidate because of his or her comorbidities. A question often asked of experienced ambulatory practitioners is whether there is a checklist or the like that can be applied to determine appropriate patients for the outpatient setting. This checklist might include answers to questions such as, “what is the maximum body mass index; should I care for a patient with a difficult airway; is a spinal anesthetic appropriate; are patients with an implantable cardiac defibrillator (ICD) acceptable?” There is potential value in creating such a checklist for the anesthesia provider and the proceduralist, but there are potential problems as well. To uniformly refuse service to all individuals with a given condition likely unduly limits access and does not allow the facility to take full advantage of its potential. Rather than a checklist that limits itself to just one aspect, it is best to recognize that it is not just the patient selection process that is important, but one must also consider the providers, the procedure, and the facility (place), taking into account the comorbidities of the patient, the skillsets of and access to providers, the procedure itself, and the availability of equipment in, and the location of, the facility.
Facilities (place) where ambulatory anesthesia is practiced include hospitals, where there can be a designated suite of operating rooms for these cases or where they can be interspersed throughout the larger operating room suite. Alternatively, there can be a separate dedicated building where ambulatory procedures are performed, referred to as an “on-campus” setting. Outpatient procedures can also be performed in a freestanding surgicenter located some distance away from a major hospital. The final location is that of the office, which is probably the ne plus ultra of ambulatory anesthesia. Obviously, each of these settings has its advantages and limitations in terms of its ability to care for the more complex patient because of the available personnel and equipment and the proximity to other facilities for support or even transfer.
The number of providers and their level of training also impact the selection process. The skillset of the ancillary staff is important, especially when it comes to postanesthesia care. Having a receptionist with no medical training who also serves as the individual who monitors the patient after the procedure limits the complexity of both the procedure and the anesthetic technique. Having two trained and capable postanesthesia care unit nurses may mean that more complex procedures and anesthetics may be performed. Having an anesthesia technician may provide more equipment support so more sophisticated techniques (eg, fiberoptic bronchoscopy) may be available. Thus, the caliber and quantity of primary and support personnel influence the selection process.
The procedure is clearly an important part of the equation. In the 1990s, criteria for an acceptable procedure included minimal blood loss/fluid shift, duration of less than 90 minutes with simple equipment, minimal postoperative care, and minimal pain able to be treated with oral medications.1 In the twenty-first century, the requirement is merely that the patient be able to go home the same day or, in some settings, within 23 hours. There really are no hard and fast rules that can be applied to distinguish an ambulatory procedure from an inpatient procedure other than the ability to safely go home the same day. When an anesthesiologist can provide an anesthetic from which the patient should be able to recover within a few hours, the limiting feature becomes the postoperative care associated with the procedure.
The final factor in the equation is the patient. Some may believe that only American Society of Anesthesiologists physical status class 1 or 2 patients should be cared for in an ambulatory setting, but this fails to take into account the impact of the place, the procedure, and the personnel. For example, a patient with obstructive sleep apnea can safely receive a lower extremity regional anesthetic with intravenous sedation and analgesia in many ambulatory facilities. There is little if any evidence that an otherwise healthy patient with a body mass index above a certain level is at increased risk for an ambulatory procedure, but there is the caveat that the operative table must be able to support the weight. While some may be loathe to care for a patient with an ICD in an office-based practice or a surgicenter, performing a procedure for this patient in an on-campus or integrated facility may be entirely appropriate. Thus, one must look at a variety of factors and integrate them into a meaningful whole to determine the appropriateness of admission to an ambulatory setting. Figs. 1 and 2 illustrate this principle, where a patient with an ICD is acceptable in an on-campus setting but not in an office setting.
Fig. 1 Patient, providers, procedure, and place all overlap: proceed. CST, certified surgical technician; MD, medical doctor; OR operating room; PACU, postanesthesia care unit; RN, registered nurse.
Fig. 2 Patient, providers, procedure, and place do not all overlap: do not proceed.
Patient egress
The defining aspect of an ambulatory anesthetic is the patient’s ability to safely and comfortably leave the facility the same day. There are at least four sequelae to consider that are dependent on the anesthesiologist’s preoperative, intraoperative, and postoperative management. While these will be dealt with in greater detail in other articles, they can be summarized to provide an overall recommendation for perioperative management. These “barriers” to discharge include pain, postoperative nausea and vomiting, excessive sedation, and significant pathophysiologic derangements.
Pain is regarded as the most common and most important adverse postoperative outcome.2–4 Multimodal therapy using low-dose opioids, nonsteroidal anti-inflammatory drugs, and regional anesthesia serves to mitigate this. Postoperative nausea and vomiting can likely be regarded as the second most significant impediment and is also amenable to a multimodal approach, both to avoid the problem and to treat it. Excessive sedation also results in delayed discharge,5 so preoperative and intraoperative sedative-hypnotics and intraoperative and postoperative opioids should be used judiciously. Morbid events, such as cardiac ischemia, hyperglycemia, cerebral vascular accident, or persistent hypotension, may also delay discharge, but the preoperative selection process and overall perioperative management should minimize this. Managing to avoid the sequelae of these comorbidities and other “complications” is of paramount importance to ensure a safe and timely discharge to home.
For this issue of Anesthesiology Clinics, our authors have detailed many of the clinical and logistical perioperative ambulatory anesthesia concerns that may lead to suboptimal outcomes and offer ways to manage them. We have also included articles on the administrative aspect of the practice of ambulatory anesthesia, since quite often it is the anesthesiologist who serves as the medical director and administrative go-to person in the facility. We finish with a glimpse of the future, including articles on the electronic medical record and the application of quality assurance registries in the ambulatory domain. We hope to provide a relatively broad overview of the practice of ambulatory anesthesia while also yielding a deeper understanding of some of the more common or pressing issues.
Summary
The bottom line is that proper preoperative selection and preparation and the application of certain intraoperative techniques will best ensure that those who walk in to an ambulatory surgery facility will be able to walk out the same day.
References
1. White, P. F., Song, D. New criteria for fast-tracking after outpatient anesthesia: a comparison with the modified Aldrete's scoring system. Anesth Analg. 1999; 88:1069–1072.
2. Macario, A., Weinger, M., Truong, P., et al. Which clinical anesthesia outcomes are both common and important to avoid? The...
| Erscheint lt. Verlag | 9.8.2014 |
|---|---|
| Sprache | englisch |
| Themenwelt | Medizin / Pharmazie ► Gesundheitsfachberufe |
| Medizin / Pharmazie ► Medizinische Fachgebiete ► Anästhesie | |
| ISBN-10 | 0-323-29934-2 / 0323299342 |
| ISBN-13 | 978-0-323-29934-3 / 9780323299343 |
| Haben Sie eine Frage zum Produkt? |
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