Ambulatory Airway Management: Safety, Strategy, and Standards in the Outpatient Setting.

Discharge Criteria and Complications After Ambulatory Surgery

I n recent years, the emphasis in providing surgical services has undergone remarkable change. Previously, patients undergoing surgical procedures remained in a hospital for many days after the operation. In 1994, 66% of all elective operations in the United States were performed on an outpatient basis (1). More complex ambulatory procedures are being performed on sicker patients (2). With the increased emphasis on early discharge after surgery and anesthesia, it is important to identify criteria that can be used to determine when patients can safely go home under the care of a friend or relative. In this article, we review current knowledge regarding the assessment of home-readiness after ambulatory surgery and discuss potential complications and appropriate treatment regimens.

Obesity, obstructive sleep apnoea, and diabetes mellitus: anaesthetic implications

Ambulatory surgery is on the rise, with an unmet need for optimum pain control in ambulatory surgery centers worldwide. It is important that there is a proportionate increase in the availability of acute pain-management services to match the rapid rise of clinical patient load with pain issues in the ambulatory surgery setting. Focus on ambulatory pain control with its special challenges is vital to achieve optimum pain control and prevent morbidity and mortality. Management of perioperative pain in the ambulatory surgery setting is becoming increasingly complex, and requires the employment of a multimodal approach and interventions facilitated by ambulatory surgery pain specialists, which is a new concept. A focused ambulatory pain specialist on site at each ambulatory surgery center, in addition to providing safe anesthesia, could intervene early once problematic pain issues are recognized, thus preventing emergency room visits, as well as readmissions for uncontrolled pain. This paper reviews methods of acute-pain management in the ambulatory setting with risk stratification, the utilization of multimodal interventions, including pharmacological and nonpharmacological options, opioids, nonopioids, and various routes with the goal of preventing delayed discharge and unexpected hospital admissions after ambulatory surgery. Continued research and investigation in the area of pain management with outcome studies in acute surgically inflicted pain in patients with underlying chronic pain treated with opioids and the pattern and predictive factors for pain in the ambulatory surgical setting is needed.

Mandate for Accreditation in Plastic Surgery Ambulatory/Outpatient Clinics

Ambulatory surgery numbers are rising in the United States at a rapid pace. Between 1996 and 2006, procedures carried out in free-standing surgical centers rose by 300 %. Airway management is a key factor in time management, patient safety, and cost-effectiveness. For the anesthesiologist practicing in a free-standing or office-based unit, patient selection and preparation for all eventualities are essential. A combination of traditional skills and advances in technology and anesthetic research are discussed to outline what we believe is a guide to safe anesthetic practice and airway management in the ambulatory setting. Pre-assessment of the patient, the management of the uncomplicated airway, and management of the anticipated and unanticipated difficult airway are discussed in this article.

BackgroundPatients undergoing ambulatory surgery under general anesthesia experience considerable levels of postoperative nausea and vomiting (N/V) after their discharge. However, those complications have not been thoroughly investigated in hand surgery patients yet. We investigated factors associated with postoperative N/V in patients undergoing an ambulatory hand surgery under general anesthesia and determined whether patients' satisfaction with this setting is associated with postoperative N/V levels.MethodsWe prospectively evaluated 200 consecutive patients who underwent ambulatory hand surgeries under general anesthesia to assess their postoperative N/V visual analogue scale (VAS) levels during the first 24 hours after surgery and their satisfaction with an ambulatory surgery setting. Potential predictors of postoperative N/V were; age, sex, body mass index, smoking behavior, a history of postoperative N/V after previous anesthesia or motion sickness, preoperative anxiety level and the duration time of anesthesia. We conducted multivariate analyses to identify factors associated with postoperative N/V levels. We also conducted multivariate logistic regression analyses to determine whether the N/V levels are associated with the patients' satisfaction with this setting. Here, potential predictors for satisfaction were sex, age, postoperative pain and N/V.ResultsPostoperative N/V were associated with a non-smoking history, a history of motion sickness and a high level of preoperative anxiety. Twenty-two patients (11%) were dissatisfied with the ambulatory setting and this dissatisfaction was independently associated with moderate (VAS 4-7) and high (VAS 8-10) levels of postoperative N/V and with a high level (VAS 8-10) of postoperative pain.ConclusionsAlthough most of the patients were satisfied with the ambulatory surgery setting, moderate to high levels of N/V were associated with dissatisfaction of patients with this setting, suggesting a need for better identifying and managing those patients at risk. The information regarding risk factors for N/V could help in preoperative patient consultation regarding an ambulatory hand surgery under general anesthesia.

Introduction Hospital clinical pharmacy practice in the UK has developed beyond traditional boundaries of ward-based inpatient services. Royal Pharmaceutical Society Hospital Pharmacy Standards recommend pharmacy team members are integrated into multidisciplinary teams across the organisation to ensure safe and appropriate medicines use whatever the setting1. Pharmacy professionals provide pharmaceutical care and specialist services in outpatient and ambulatory settings and through participation in multidisciplinary team (MDT) meetings. Within the outpatient setting, research typically focusses on single outpatient clinics within specific disciplines, little evidence describes the overall contribution to patient care across whole pharmacy services2. Aim To describe the scope of clinical pharmacy services occurring beyond traditional ward-based services in a tertiary hospital; including quantification of outpatient clinics and MDT meetings provided by pharmacy professionals. Methods The Deputy Chief Pharmacist invited clinical Principal Pharmacists to participate in semi-structured interviews exploring the scope of “non-traditional” services across the Trust during March 2023. Non-traditional services were defined as direct clinical care outside of ward-based inpatient clinical pharmacy services. Indirect clinical care activities such as guideline writing, drug expenditure and governance activities were excluded. Inpatient board rounds/ward rounds and any service not currently provided due to vacancy were excluded. Participants were asked to quantify services provided, advise who provided the services and to describe contributions provided by the pharmacy team. The study was deemed service evaluation and ethical approval waived. Results 100% invited pharmacists participated. Pharmacists attended and contributed to over 150 MDT meetings monthly across 24 sub-specialities; 80% were for outpatients. In tertiary/quaternary services, these frequently covered patients beyond local geography. MDT meetings were typically attended by specialist, principal or consultant pharmacists. Common contributions included: provision of pro-active advice/responding to queries; medicines optimisation; monitoring; income or compliance assurance; prescribing/deprescribing. Specialist pharmacists provided 80-100 outpatient clinic sessions across 17 sub-specialities through a mix of face-to-face and virtual appointments, advanced pharmacy technicians provided on-treatment and counselling clinics. Activities included: initiation, monitoring, adjustment and cessation of medicines; patient counselling and MDT referral. Medicines prescribed were typically high cost, complex and higher risk. Pharmacists prescribed and clinically verified homecare medicines and provided ongoing annual review of outpatient medicines, including prescribing/deprescribing. Teams described medicines reconciliation and counselling in ambulatory haematology settings, off-site units and infusion suites. The team organised, optimised and provided advice and counselling for patients requiring antimicrobial therapies at home. Clinical pharmacists and pharmacy technicians provided medicines information to patients, internal and external healthcare professionals. Discussion/Conclusion This study provides evidence of the broad scope of clinical pharmacy practice beyond the boundaries of traditional ward-based services in a tertiary teaching hospital. This study was limited to a single organisation, specific clinical pharmacy activities and outcomes of these services were not fully quantified. Formal collation of clinical pharmacy activities within “non-traditional” outpatient and ambulatory settings is limited because activity data collection forms in hospital pharmacy are typically validated in traditional ward-based pharmacy services. We recommend further studies to validate activity collection tools to benchmark the activities of clinical pharmacy professionals providing services in outpatient and ambulatory settings both within and between hospital Trusts.

Impact of Index Surgical Care Setting on Perioperative Outcomes and Cost Following Penile Prosthesis Surgery

ObjectiveTo review and analyze the airway and anesthesia management methods for patients who underwent endoscopic closure of tracheoesophageal fistula (TEF) and to summarize the experience of intraoperative airway management.MethodWe searched the anesthesia information system of the First Affiliated Hospital of Nanjing Medical University for anesthesia cases of TEF from July 2020 to July 2023 and obtained a total of 34 anesthesia records for endoscopic TEF occlusion. The intraoperative airway management methods and vital signs were recorded, and the patients’ disease course and follow-up records were analyzed and summarized.ResultsThe airway management strategies used for TEF occlusion patients included nasal catheter oxygen (NCO, n = 5), high-flow nasal cannula oxygen therapy (HFNC, n = 4) and tracheal intubation (TI, n = 25). The patients who underwent tracheal intubation with an inner diameter of 5.5 mm had stable hemodynamics and oxygenation status during surgery, while intravenous anesthesia without intubation could not effectively inhibit the stress response caused by occluder implantation, which could easily cause hemodynamic fluctuations, hypoxemia, and carbon dioxide accumulation. Compared with those in the TI group, the NCO group and the HFNC group had significantly longer surgical times, and the satisfaction score of the endoscopists was significantly lower. In addition, two patients in the NCO group experienced postoperative hypoxemia.ConclusionDuring the anesthesia process for TEF occlusions, a tracheal catheter with an inner diameter of 5.5 mm can provide a safe and effective airway management method.

The purpose of this review is to discuss current practices and changes in the field of ambulatory anesthesia, in both hospital and ambulatory surgery center settings. New trends in ambulatory settings are discussed and a review of the most current and comprehensive guidelines for the care of ambulatory patients with comorbid conditions such as postoperative nausea and vomiting (PONV), obstructive sleep apnea and diabetes mellitus are reviewed. Future direction and challenges to the field are highlighted. Ambulatory anesthesia continues to be in high demand for many reasons; patients and surgeons want their surgical procedures to be swift, involve minimal postoperative pain, have a transient recovery time, and avoid an admission to the hospital. Factors that have made this possible for patients are improved surgical equipment, volatile anesthetic improvement, ultrasound-guided regional techniques, non-narcotic adjuncts for pain control, and the minimization of PONV. The decrease in time spent in a hospital also decreases the risk of wound infection, minimizes missed days from work, and is a socioeconomically favorable model, when possible. Recently proposed strategies which will allow surgeons and anesthesiologists to continue to meet the growing demand for a majority of surgical cases being same-day include pharmacotherapies with less undesirable side-effects, integration of ultrasound-guided regional techniques, and preoperative evaluations in appropriate candidates via a telephone call the night prior to surgery. Multidisciplinary communication amongst caregivers continues to make ambulatory settings efficient, safe, and socioeconomically favorable.It is also important to note the future impact that healthcare reform will have specifically on ambulatory anesthesia. The enactment of the Patient Protection and Affordable Care Act of 2010 will allow 32 million more people to gain access to preventive services that will require anesthesia such as screening colonoscopies. With this projected increase in the demand for anesthesia services nationwide comes the analysis of its financial feasibility. Some early data looking at endoscopist-administered sedation conclude that it offers higher patient satisfaction, there were less adverse effects than anesthesiologist-administered sedation, and is economically advantageous. This and future retrospective studies will help to guide healthcare policymakers and physicians to come to a conclusion about providing ambulatory services for these millions of patients. Ambulatory anesthesia's popularity continues to rise and anesthetic techniques will continue to morph and adapt to the needs of patients seeking ambulatory surgery. Alterations in already existing medications are promising as these modifications allow for quicker recovery from anesthesia or minimization of the already known undesirable side-effects. PONV, pain, obstructive sleep apnea, and chronic comorbidities (hypertension, cardiac disease, and diabetes mellitus) are perioperative concerns in ambulatory settings as more patients are safely being treated in ambulatory settings. Regional anesthesia stands out as a modality that has multiple advantages to general anesthesia, providing a minimal recovery period and a decrease in postanesthesia care unit stay. The implementation of the Affordable Healthcare Act specifically affects ambulatory settings as the demand and need for patients to have screening procedures with anesthesia. The question remains what the best strategy is to meet the needs of our future patients while preserving economically feasibility within an already strained healthcare system.

Background and Objectives: Airway management and ventilation during laryngotracheal surgery represent some of the most challenging tasks in anesthesiology. The shared airway between the surgeon and anesthesiologist requires continuous coordination to ensure optimal oxygenation while maintaining an unobstructed surgical field. Materials and Methods: This narrative review is based on a comprehensive literature search of PubMed, Embase, Scopus, and Google Scholar, covering all publications from inception to 30 June 2025. The literature search was performed using a defined Boolean strategy and explicit inclusion/exclusion criteria, focusing on adult human subjects. The search included combinations of the terms “laryngotracheal surgery,” “airway management,” “ventilation strategies,” “jet ventilation,” “Tritube,” and “Flow Controlled Ventilation.” Only English-language studies focused on human subjects were included. Results: Traditional ventilation strategies, such as apneic oxygenation and jet ventilation, remain widely used but present limitations in terms of gas exchange efficiency, risk of barotrauma, and surgical interference. In recent years, new devices and ventilation modes—particularly the Tritube® combined with Flow-Controlled Ventilation—have emerged as promising alternatives. These approaches allow continuous ventilation with minimal airway diameter, improving surgical access and patient safety. FCV’s potential to optimize gas exchange and reduce mechanical power is physiologically compelling, but its supporting evidence remains limited and heterogeneous, primarily consisting of small, single-center studies and case series. Conclusions: Optimal airway and ventilation management in laryngotracheal surgery requires individualized planning, technical expertise, and close interdisciplinary communication. This approach must integrate objective neuromuscular monitoring to ensure patient safety and include a comprehensive strategy for safe postoperative airway management and extubation. While emerging technologies have significantly expanded available options, their successful application depends on training, experience, and appropriate case selection. Further high-quality clinical studies are needed to standardize protocols and validate long-term outcomes of these innovative ventilation strategies.

Breast reconstruction remains an important part of a patient's journey after the diagnosis of breast carcinoma and treatment with mastectomy. Although inpatient immediate breast reconstruction has been described, there is a paucity information about whether similar procedures are performed in the ambulatory setting. The authors sought to investigate rates and patterns for delayed and immediate breast reconstruction in the ambulatory surgery setting using nationally representative data from 2016 to 2019. Using the Nationwide Ambulatory Surgery Sample database, we identified patients with an International Statistical Classification of Disease and Related Health Problems, Tenth Revision, procedure code for breast reconstruction. Demographic and clinical characteristics were recorded for each encounter of breast reconstruction, and linear regression and logistic regression were used to assess for trends and disparities. National weighted estimates for ambulatory breast reconstruction increased by 15.6% from 89 237 in 2016 to 103 134 in 2019, resulting in 377 109 procedures during the study period. Inflation-adjusted total charges for ambulatory breast reconstruction were $14 billion between 2016 and 2019, or 1.7% of overall charges for ambulatory surgery. Immediate reconstruction was performed in 34.7% (95% CI, 33.4%-36.1%) of cases and increased by 46.9% from 26 930 in 2016 to 39 559 in 2019. Racial disparities were observed in access, comorbidities, and spending. Our findings indicate a moderate increase in ambulatory breast reconstruction with a substantial growth in the performance of immediate breast reconstruction in the ambulatory setting.

See Article, p 699 GLINDA: Are you ready now? DOROTHY: Yes… GLINDA: Then close your eyes, and tap your heels together three times. And think to yourself -- "There's no place like home; there's no place like home; there's no place like home." DOROTHY: There's no place like home. There's no place like home. There's no place like home. There's no place like home. —The Wizard of Oz (1939) Noel Langley, Florence Ryerson, and Edgar Allen Woolf The concept of multimodal postoperative recovery programs—commonly referred to as enhanced recovery after surgery (ERAS) programs or "fast-track surgery"—was first proposed by Kehlet and Wilmore1 more than 20 years ago, when it was recognized that isolated, single clinical interventions were inadequate in addressing the problem of multifactorial perioperative complications and morbidity. Although simple in principle, collective experience and reported data during the interim 20 years have observed relatively slow progress in disseminating, implementing, and sustaining ERAS programs.2,3 This can likely be partly explained by the requirement for multidisciplinary collaboration, as well as cultural and organizational factors that frequently impede fundamental change in traditional patient care.2,3 Furthermore, the initial protocols for open colonic surgery included only a few essential principles of ERAS, whereas, the advent of more multifaceted and complicated ERAS programs and protocols have hampered implementation.2 From the contemporary perspective, the main issue still to resolve with ERAS programs is how to make further progress in achieving the ultimate goal of a risk-free surgical procedure.2 Thus future ERAS strategies should include a shift away from the conventional endpoints of early recovery and shortened length of stay to place more emphasis instead on mitigating postdischarge problems.2,4 However, at least in the United States, there are major health care policy changes that mandate continued attention on postoperative early recovery and reduced length of stay. No matter what the postoperative priorities, fundamentally transforming the traditional structures and processes of surgical and anesthetic care can indeed be challenging. Fortunately, there are innovators paving the way. In this issue of Anesthesia & Analgesia, Tokita et al5 provide a comprehensive description of a very innovative migration of complex cancer surgery from the hospital setting to an ambulatory extended recovery (AXR) setting of the Josie Robertson Surgery Center (JRSC) at Memorial Sloan Kettering Cancer Center (MSKCC). A key first question is "What is ambulatory extended recovery after surgery?" In 2003, the International Association for Ambulatory Surgery (IAAS) provided very pertinent, international consensus-based terminology (Figure 1).6 The IAAS has also made the following fundamental functional distinction:7Figure 1.: Basic terminology related to surgical encounter timeframes and synonyms.6 True ambulatory surgery is where patients are admitted, operated on, and discharged during the time frame of 1 working day (6–8 hours). There is no overnight facility stay. Ambulatory surgery with extended recovery is where patients are admitted, operated on, and stay for 1 night postoperatively with an overall stay up to 23 hours. To fully realize the potential expansion of ambulatory surgery, one must first understand the definition and current limitations of the different types of ambulatory surgery facilities. An ambulatory surgery center (ASC) is a freestanding facility that typically performs surgical procedures that do not require overnight stay. An ASC is not required to be associated with a hospital. An ambulatory surgery facility, which is not associated with a hospital, can perform surgical procedures stipulated on the current US Centers for Medicare & Medicaid Services (CMS) ASC covered procedures list. However, such an independent ASC cannot perform any procedures on the current Medicare inpatient-only (MIO) list (Figure 2). This significantly differs from a hospital outpatient department (HOPD), which is 100% owned by a hospital and is not limited in its procedural scope. Hospital-owned facilities can perform ambulatory surgery within the hospital, in a facility attached to the hospital, or in a facility physically separated from the hospital. In the United States, an HOPD is reimbursed at a markedly higher rate by CMS than an independent ASC. There are other significant differences between an independent ASC and an HOPD (Figure 2).8–10Figure 2.: Characteristics of an independent ASC versus a HOPD as defined by the US CMS.8–10 ASC indicates ambulatory surgery center; CMS, Centers for Medicare & Medicaid Services; HOPD, hospital outpatient department.Tokita et al5 accordingly note that organizationally, (a) the JRSC is part of the MSKCC and operates as a hospital-associated outpatient clinic; (b) the JRSC is attached to the Memorial Hospital ambulatory license; and (c) all JRSC staff are employed at MSKCC. These specific organizational aspects of the JRSC might make its AXR model neither feasible nor appropriate in a conventional ASC—particularly from a financial perspective. According to US CMS Rule 42 C.F.R. §412.3(e), a hospital admission is classified as inpatient if the surgical procedure is on the MIO list, or if the provider expects that the hospital stay will cross 2 midnights. If a surgical procedure on its MIO list is performed in an outpatient setting or with postoperative observation status (minimum of 8 hours, but <24 hours), CMS might refuse to reimburse for the procedure. If a surgery is not on its MIO list, CMS will only reimburse for postoperative inpatient status if clinical documentation can justify the need for a greater than 2 midnight stay.11,12 Importantly, a documented comprehensive preoperative patient assessment, which applies objective, well-defined clinical criteria for recommending postoperative inpatient versus outpatient status,13 can validly and compliantly be provided by a Perioperative Medicine program and clinic.14 The initial, major challenge at MSKCC was thus identifying the types of surgical procedures—with historical average inpatient hospital stays of 2–4 days—that with suitable patient selection and management, could be safely discharged home after a single overnight stay.5 While technically qualifying as ambulatory or outpatient procedures from a regulatory standpoint and payer perspective, Tokita et al5 distinguish these more complex, short-stay, AXR procedures from conventional outpatient procedures after which the patient recovers and is discharged home in a few hours. Here again, a Perioperative Medicine program and clinic can play a very important role in implementing patient selection criteria and undertaking needed medical optimization for an AXR procedure.15,16 The MSKCC leadership and other organizational stakeholders were guided by a set of principles and a series of related questions in developing the JRSC, which are not only illustrative but also vital for other entities pursuing any such pioneering health care delivery model:5 How can we become national leaders in delivering high-quality and cost-effective day and short-stay surgery? How can we maximally standardize processes and procedures? How do we continually assess progress to innovate and improve? How can we apply new technology to streamline processes and allow staff to focus on patients? What are the optimal roles for nurses and advanced practice providers within this short-stay environment? Most importantly, how can we ensure that the needs and experience of the patient and their loved ones are considered and prioritized in everything we do? With more extensive surgical procedures being performed in an ambulatory setting, it is necessary that patient safety is not jeopardized. The ERAS principles that allowed the migration of these surgical procedures to the outpatient setting must still be applied. This would reduce unplanned hospital transfers from the ambulatory facility, as well as mitigate emergency department visits and acute care hospital readmission after discharge. These adverse outcomes might negate the cost-effectiveness of moving the surgical procedures to the outpatient setting. Future studies should investigate approaches to identify and manage postdischarge complications. This could be achieved with real-time electronic symptom monitoring systems similar to the one used by Tokita et al.5 In addition, such electronic systems can provide patient self-management advice that could reduce unnecessary emergency department visits. These systems could also directly assess patient-reported outcomes. Such monitoring would also allow identify the timeline of complications and classify them as medical versus surgical, and determine approaches toward preventing them. Medical complications can be addressed through modifying patient selection criteria and perioperative management. In contrast, surgical complications can be addressed through reassessment of perioperative care, as well as surgical technique and expertise. In summary, there has been a continued, and likely future sustained expansion of the number of ASCs and the number of procedures performed in ASCs, particularly in the United States but also worldwide.17–19 As insightfully observed by Philip,10 such outpatient surgery has been a success in the United States because of 2 important reasons: (1) a focus on efficiency, quality, and cost of care and (2) a focus on the patient and the role of humanism in medicine. The pioneering work of Simon and colleagues in creating the JRSC at MSKCC exemplifies these 2 fundamental tenets of health care value and humanism.5 Nevertheless, in order for AXR to achieve its ultimate yet still potential positive health care impact, it must be financially sustainable in an ASC setting. At least in the United States, this will require major, progressive changes to current CMS regulations and reimbursement. DISCLOSURES Name: Thomas R. Vetter, MD, MPH. Contribution: This author helped write and revise the manuscript. Name: Girish P. Joshi, MBBS, MD, FFARCSI. Contribution: This author helped write and revise the manuscript. This manuscript was handled by: Jean-Francois Pittet, MD.

Airway assessment and management are cornerstones of anaesthesia, yet airway complications remain an important source of morbidity. We performed a before-and-after evaluation of a collaborative intervention to improve adherence to airway assessment and management guidelines in patients scheduled for surgery under general anaesthesia. A prospective, multicentre before-and-after evaluation of a collaborative intervention. Collaborative intervention to improve adherence to airway assessment and management guidelines in patients scheduled for surgery under general anaesthesia. Data were collected on 21 consecutive days before and after the intervention. Anaesthetists with staff or residency positions at 22 hospitals. Patients aged 18 years or older undergoing nonemergency surgery were recruited. Establishing a learning network that included local leaders, meetings to share experiences and knowledge, interactive sessions and provision of printed materials on airway assessment and management. Clinical airway management for general anaesthesia was provided by the anaesthetists participating in the study. Outcomes were the completion of airway assessment at the preanaesthetic visit, rates of unanticipated difficult airway, algorithm adherence and related airway complications. The study included 3753 patients (1947 preintervention and 1806 postintervention). The percentage of patients with a complete airway assessment increased from 25.1% preintervention to 48.4% postintervention (P <0.001). The incidences of unanticipated difficult airway were 4.1% before the intervention and 3% after it (P = 0.433). Rates of adherence to the algorithms for anticipated and unanticipated difficult airway management were similar in the two periods. The incidences of related adverse events were also similar. The collaborative intervention was effective in improving airway assessment but not in changing difficult airway management practices.