Office-based Anesthesia Research Articles

Literature Review for Office-Based Anesthesia.

Literature Review for Office-Based Anesthesia.

Anesthesiologist’s Manual of Surgical Procedures, 5th ed.

This hardcover reference textbook has 1720 pages, and according to the preface, functions as, “an easily accessible source of clinically relevant information about a wide variety of both common and not-so-common surgical procedures.” This is the 5th edition, updated and revised by the authors, the majority of which are from California, and the primary author’s home institution is Stanford University Medical Center. New to this edition are video content accessible via www.YouTube.com and full electronic access through www.inkling.com as well as the use of their app for portable devices available in Apple’s App Store and on Google Play for Android users. The authors acknowledge the limitations of using publicly available video content, but we appreciated the inclusion of this material as we believe it will streamline the ability of the readers to find another venue for reviewing a particular procedure. As seen in the previous edition, the textbook is divided into 15 sections organized in an anatomically top-down approach starting with neurosurgery, ophthalmic, otolaryngology, and ending with out-of-operative room procedures, office-based anesthesia, and emergency procedures for the anesthesiologist. Not surprisingly, the content of many sections is unchanged from the previous edition; however, references in the form of “suggested readings” listed after all chapters, and many individual procedures have been updated and revised. This was clearly evident and appreciated in the trauma surgery chapter with double the references from the previous edition including, for example, recent changes to advanced trauma life support and the impact of antiplatelet drugs on trauma outcomes. The most significant additions were found in the sections of pediatric surgery and out-of-operating room procedures. One new chapter is on pediatric bariatric surgery with several recent references reflecting the relatively new and increasing challenges to the anesthesia provider. For this edition, management of the difficult airway and anticoagulation guidelines for neuraxial procedures were added to the appendices. ELECTRONIC REVIEW The electronic version included in this edition of Anesthesiologist’s Manual of Surgical Procedures is presented using the Inkling platform and application for portable devices. Content is also available through Amazon’s Kindle and Barnes and Noble’s Nook platforms, but they were not reviewed for this evaluation. Inkling is available through typical Web browsers found on a Mac or PC as well as the app available on tablets and smartphones using iOS or Android. The Inkling app allows the content to be easily downloaded and read without Internet access. Unfortunately, unlike portable document formats and other electronic access formats, Inkling does not allow the user to print any portions of the material. Inkling is an interface that allows the user to interact with the content via private or publically shared notes as well as highlighting, bookmarking, and copy/pasting into email or other applications. When the user makes notes or highlights on a device, it uses Inkling’s cloud to sync these additions across all the user’s devices and back up the data. The notes feature, while effective on the iPad, was not available on the iPhone. Within Inkling, the user can stream YouTube videos and access links to other Web sites provided she/he is connected to the Internet. The media are brought up within the Inkling interface, and when finished viewing a video, one can easily transition back to the previous location within the text. At the time of our review, 2 videos were already unavailable, which is a potential problem when referencing material that is managed by the public and YouTube (parent company Google, Inc.). The YouTube videos are grouped together at the end of each section under the heading “suggested viewing” as opposed to the suggested readings that follow each individual procedure. In conclusion, Anesthesiologist’s Manual of Surgical Procedures, 5th ed., by Jaffe et al. continues the series legacy as an outstanding textbook for the novice learner in anesthesiology. The utilization of both surgeons and anesthesiologists as authors is important because it provides the information, perspective, and foundation necessary to formulate a plan of care for surgical patients. Of course, anesthetic plans are not meant to be “cookbook” in nature but tailored to the specifics of both the procedure and the patient. This reference textbook, with the added portability and user-friendly Inkling interface, serves as an invaluable reference for residents and trainees in anesthesiology. Although the 5th edition has been updated and offers improved multimedia content, the significant amount carried forward from the previous edition makes it difficult to suggest it as a must-have for those with the 4th edition. The exception would be for those that value the electronic platform provided by Inkling. For those people, the 5th edition is an excellent resource that will enrich their digital library. Robert McLennan, MD Jeremy S. Dority, MD Department of Anesthesiology University of Kentucky College of Medicine Lexington, Kentucky [email protected]

Transition to Office-based Obstetric and Gynecologic Procedures

Office-based surgery is increasingly desired by patients and providers due to ease of access, overall efficiency, reimbursement, and satisfaction. The adoption of office-based surgery requires careful consideration of safety, efficacy, cost, and feasibility within a providers practice. This article reviews the currently available data regarding patient and provider satisfaction as well as practical considerations of staffing, equipment, and supplies. To aid the practitioner, issues of office-based anesthesia and safety with references to currently available national guidelines and protocols are provided. Included is a brief review of billing, coding, and reimbursement. Technical procedural aspects with information and recommendations are summarized.

Office-Based Anesthesia

Office-Based Anesthesia

A heartfelt thank you to Dr Joel Weaver.

It is a great honor to assume the editorship of Anesthesia Progress. I am humbled to be taking over this position from my good friend, mentor, brother anesthesiologist, and fellow researcher, Dr Joel Weaver. The legacy of the legendary doctors practicing anesthesia for dentistry who have been past editors includes Drs Harcourt Stebbins, Bruce Douglas, Norman Trieger, Raymond Dionne, and John Yagiela. Dr Weaver, however, has devoted more years to this journal than any other editor and has overseen tremendous advances. Under Dr Weaver's watch, the quality of the articles has improved from its already high level; a continuing education section led by Dr Dan Becker was instituted and was very informative; an online submission system was initiated; and the journal became online accessible for current and most back issues as well. The latter 2 advances are remarkable particularly for those of you who know Joel and how he feels about his computer literacy skills! But, happily, even these have moved steadily forward over these 19 years. Importantly, Dr Weaver has been editor for so long that many of you probably do not remember that editorials were infrequent in the past, and many times, the editorial authors were invited experts. Joel, however, began publishing his own editorials for every edition of Anesthesia Progress. And what editorials they were. As honored as I am to take over this position, it is my hope that I can be half as insightful, cogent, and articulate as Dr Weaver has been. I always anticipated the arrival of Anesthesia Progress to see what Joel had to say and about what topic. Dr Weaver, everyone involved in sedation and general anesthesia for dentistry owes you a debt of gratitude for all you have done over the years in teaching, research, and service for this specialized area of dental practice. At the same time, I wish to thank the associate editors, Drs Ken Reed and Dan Becker, as well as the illustrious editorial board, for their work on making Anesthesia Progress the leading English language journal for anesthesia in dentistry. Dan will be retiring from his position but Dr Reed has agreed to stay on for a bit longer as associate editor. Dr James Tom, associate professor and dentist anesthesiologist at University of Southern California Ostrow School of Dentistry, will take over for Dr Becker. Finally, I wish to thank the staff at Allen Press, including Ms Lindsey Givens, Mr John Walker, Mr Chris Brower, and Mr Joe Barriger, for welcoming me to the journal and their hard work over the years. As I look ahead to the future of Anesthesia Progress, I hope to build on Dr Weaver's many contributions. Our online submission system has many advanced features, which I will be activating in the near future. This should help authors and the staff of Anesthesia Progress to improve communications and track the progress of submissions. In addition, other features will provide important data to help monitor and improve submissions to the journal. Building on Dr Becker's work, Dr Tom will expand the continuing education section with invited articles on sedation and general anesthesia management of patients presenting with various medical conditions, review articles on areas of interest to anesthesiology in dentistry, updates on medical conditions and new pharmacologic agents, and discussion of clinical cases. Additionally, I hope to expand the abstract section of Anesthesia Progress to include more abstracts from the Japanese Dental Society of Anesthesiology as well as other important anesthesia journals. Anesthesia Progress is the official journal not only of the American Dental Society of Anesthesiology, but also of the American Society of Dentist Anesthesiologists, the European Federation of for the Advancement of Anesthesia in Dentistry, and the International Federation of Dental Anesthesiology Societies, as well as dental anesthesia societies in Australia and Canada. The journal is truly a worldwide resource. Anesthesia Progress fulfills an important role for dental anesthesia researchers by providing an avenue for publication of important advances in the field. And, most importantly, it helps the clinician to advance his or her own knowledge in the fields of local anesthesia, sedation, and general anesthesia for our ultimate goal: improving the health and well-being of people everywhere. There are tremendous advances being made in anesthesia practice today. Not all will be applicable to office-based anesthesia, the predominate mode of practice for our readers. However, many will be. And I expect Anesthesia Progress to be the vehicle that delivers that information to the wider dental anesthesia community. I wish to thank the Board of the American Dental Society of Anesthesiology for allowing me this great opportunity to be of service to the society, to all the other societies who recognize Anesthesia Progress as their journal, and to the entire dental profession.

What factors are associated with a clinician's choice to use capnography in the office-based ambulatory anesthesia setting?

What factors are associated with a clinician's choice to use capnography in the office-based ambulatory anesthesia setting?

Office-based anesthesia: safety and outcomes.

The increasing volume of office-based medical and surgical procedures has fostered the emergence of office-based anesthesia (OBA), a subspecialty within ambulatory anesthesia. The growth of OBA has been facilitated by numerous trends, including innovations in medical and surgical procedures and anesthetic drugs, as well as improved provider reimbursement and greater convenience for patients. There is a lack of randomized controlled trials to determine how office-based procedures and anesthesia affect patient morbidity and mortality. As a result, studies on this topic are retrospective in nature. Some of the early literature broaches concerns about the safety of office-based procedures and anesthesia. However, more recent data have shown that care in ambulatory settings is comparable to hospitals and ambulatory surgery centers, especially when offices are accredited and their proceduralists are board-certified. Office-based suites can continue to enhance the quality of care that they deliver to patients by engaging in proper procedure and patient selection, provider credentialing, facility accreditation, and incorporating patient safety checklists and professional society guidelines into practice. These strategies aiming at patient morbidity and mortality in the office setting will be increasingly important as more states, and possibly the federal government, exercise regulatory authority over the ambulatory setting. We explore these trends, their implications for patient safety, strategies for minimizing patient complications and mortality in OBA, and future developments that could impact the field.

Beware of “Black Swans” and “Perfect Storms:” The Principle of Plenitude and Office-Based Anesthesia

A paradigm shift in the training, practice, and study of office-based anesthesia is necessary for our specialty. Practice improvement plans are required to prevent low-probability-high-consequence anesthesia mishaps in our offices. A scarcity of statistical data exists regarding the true risk of office-based anesthesia in oral and maxillofacial surgery. Effective proactive risk management mandates accurate data to correctly outline the problem before solutions can be implemented. Only by learning from our mistakes, will we be able to reduce errors and improve patient safety: "The only real mistake is the one from which we learn nothing"--John Powell.

Anesthésie des enfants en dehors du bloc opératoire : les expériences allemande et québécoise

The authors describe the way pediatric anesthesia is organized outside the operating theatre in their country. In Germany, children can be anesthetized outside the operating theater in the hospital but also outside the hospital according to the concept of office-based anesthesia. National recommendations have been published and their revision is currently underway. In Quebec, pediatric anesthesia outside the operating theatre are well organized in order to ensure quality of care, patient's safety and efficiency of the system.

Office-based Anesthesia

Office-based Anesthesia

Patient safety and office-based anesthesia

Office-based anesthesia is a new and growing subspecialty within ambulatory anesthesia. We examine major developments in office-based anesthesia and how patient safety can be maintained. The emergence of office-based anesthesia as a subspecialty of ambulatory anesthesia is a result of economic and social factors, and is also due to the development of better surgical techniques and anesthestic drugs. There is still a dearth of primary literature that addresses patient safety in the office-based setting. Some existing literature points to increased risk in the office, although others suggest that proper provider credentialing, qualifications, and appropriate facility accreditation can improve patient outcomes compared to surgicenters and inpatient facilities. There is a lack of state and federal oversight of office-based facilities. Increased regulation and standardization of care, such as the use of check lists and professional society guidelines, can help promote safer practices. There is no uniform standard of care for performing procedures in the office-based setting. Healthcare providers are facing the challenge of creating a safer, efficient, cost-effective and patient-centered environment. Available data show that the office-based practice can be as safe as any ambulatory surgicenter or hospital, as long as patients, regulators, and physicians become educated advocates of safer practices. In addition, procedures can be performed safely with general anesthesia or conscious sedation, provided that there are properly trained personnel and adequate equipment and facilities. Moreover, physicians should be credentialed to perform the same procedure in a hospital that they perform in an office.

Office-Based Total Intravenous General Anesthesia With Laryngeal Mask Airway: Pump vs. Bump Technique

Office-Based Total Intravenous General Anesthesia With Laryngeal Mask Airway: Pump vs. Bump Technique

Clinical Ambulatory Anesthesia

Northwestern University Feinberg School of Medicine, Chicago, Illinois. r-boyer@northwestern.eduEdited by Johan Raeder, M.D., Ph.D. New York, Cambridge University Press, 2010. Pages: 194. Price: $ 55.00.There have been a myriad of textbooks and manuscripts written about the practice of ambulatory anesthesia, both as a subspecialty and as a subset of a general anesthesia practice. Unfortunately some authors writing on the subject have had little actual practice experience in the subspecialty. Because currently most surgeries globally are performed on an outpatient basis, for both clinical and financial reasons, it is refreshing to review a text by an author whose clinical and academic focus is the subject of the matter.Johan Raeder serves as Professor in Anaesthesiology at the University of Oslo, and in addition clinically practices ambulatory and office-based anesthesia and trauma care at Ullevaal University Hospital in Oslo. His stated purpose in writing Clinical Ambulatory Anesthesia is to help equip anesthesia providers with valuable tools and practical insight, based on his 30 yr of clinical practice focused on ambulatory and office-based anesthesia in Norway. His intended audience is the postgraduate anesthesiologist as well as, in the United States, certified registered nurse anesthetists. Dr. Raeder's focus is sensible and pragmatic and the short (194 pages) text is basically meant to assist those clinically involved with the daily perioperative care of the ambulatory surgical patient.This is a not an exhaustive review of current controversies and differing opinions, but a well-researched, realistic review of the background and history of ambulatory anesthesia, its basic organization, practical pharmacology, preoperative patient preparation, anesthetic techniques, and postoperative care as well as his anesthesia “recipes” and vision of the future of the subspecialty.The procedure, patient selection, and preoperative patient preparation chapter is exceptionally thorough and the author's methodology regarding presurgical/postsurgical patient information gathering/distribution is excellent. His well-researched, reasonable approach to preanesthesia evaluation could also be applied to most inpatient surgical venues.The well-annotated pharmacology section clearly reflects the author's additional academic and research interest in anesthetic pharmacology and anesthetic depth monitoring. It is complete with excellent tables and graphs, which assist the reader's understanding of this sometimes complex subject.Most chapters of the book, with the exception of that dealing with clinical pharmacology, are written in an almost informal, conversational tone and represent the author's reasonable approach to preoperative, intraoperative, and postoperative anesthesia care.Notwithstanding, there are several current periprocedural anesthesia management conundrums, where the author's beliefs may differ from current suggested practice guidelines in United States. A case in point is the recommended routine “safe” use of droperidol for postoperative nausea and vomiting. Another example of this is his approach to perioperative management of patients with obstructive sleep apnea. In 2006, the American Society of Anesthesiologists published suggested practice guidelines for the perioperative management of patients with obstructive sleep apnea that are fairly more robust than his suggested management paradigm.Nonetheless, this is a very readable reference for the practitioner not particularly desiring extensive data, charts, statistics, or tables, but who is more interested in a practical review of current preoperative, intraoperative, and postoperative ambulatory anesthesia issues and the author's experienced opinion and treatment strategies garnered from his 30 yr of clinical experience practicing anesthesia in Norway.

Is Goldilocks anesthesia the optimal paradigm for ambulatory outpatient & office-based anesthesia

Is Goldilocks anesthesia the optimal paradigm for ambulatory outpatient & office-based anesthesia

Safety of Deep Sedation in an Urban Oral and Maxillofacial Surgery Training Program

To study the safety of deep sedation in an urban-based oral maxillofacial surgery training program. Charts of patients undergoing an intravenous sedation from January 2005 through December 2009 were reviewed. Data recorded included age, gender, type of procedures performed, and intravenous medications. Patients were divided in 2 groups depending on whether they received a general anesthetic agent (propofol or ketamine) or not. Anesthesia complications and failures were recorded and categorized. In total, 1,167 intravenous sedations were recorded. Eight patients developed adverse reactions, 3 of which required further evaluation in the emergency department. In addition, 7 intravenous sedations needed to be aborted because of patient agitation and combativeness. No deaths or long-term morbidities were reported. The safety of deep sedation in an urban-based oral maxillofacial training program is similar to office-based anesthesia. Sedations failures may be attributed to paradoxical benzodiazepine reactions.

Teaching residents out-of-hospital anesthesia—what are we waiting for?

To the Editor, Out-of-hospital anesthesia is a rapidly growing field with up to 55% of all ambulatory procedures in the US currently being performed outside the hospital. In Canada, this practice includes anesthesia in non-hospital surgical facilities, out-of-hospital premises (OHPs), and various office settings (office-based anesthesia), some of which – depending on provincial regulations – may be regulated or accredited. An article reviewing this topic was recently published in the Journal. Teaching in large tertiary care hospitals may not prepare trainees adequately for out-of-hospital anesthesia that requires different knowledge and practice. The Association of Canadian University Departments of Anesthesia (ACUDA) is developing a national ambulatory curriculum; however, the program does not include specific consideration or mention of out-of-hospital anesthesia and its particular aspects of facility administration and patient care considerations in the preintraor postoperative phase (personal communication). In order to assess the need for an expanded curriculum, we sought to evaluate 1) the current training of Canadian anesthesia residents and 2) their knowledge of out-ofhospital anesthesia. Both portions of the study were approved by the primary author’s Hospital Research Ethics Board. During the first phase of our study, we asked the 16 directors of the Canadian training programs who were in attendance at the June 2009 ACUDA meeting to complete a previously published survey questionnaire that was designed to provide information regarding their programs’ educational activities and the exposure of their residents to out-ofhospital anesthesia. The response rate for the ACUDA survey was 14/16 (87%). Six (43%) of the 14 programs (95% confidence interval [CI], 34-52%) provided some services outside of hospitals, but only four (29%) of the 14 departments (95% CI, 21-37%) occasionally provided experience for their residents. Eleven (79%) of the 14 departments (95% CI, 71-87%) had no educational activities, and 12 (86%) departments (95% CI, 80-92%) had no formal rotation for out-of-hospital anesthesia. During the second phase of our study, we developed a ten-item test questionnaire that was validated by four experts in out-of-hospital ambulatory anesthesia using the Delphi method. The questionnaire was designed to assess knowledge about topics relevant to out-of-hospital anesthesia. It entailed written responses to questions on fire and electrical safety, management of malignant hyperthermia, control of infection, delegation of care, facility regulation, discharge criteria, and considerations for various pertinent clinical scenarios (e.g., obesity, obstructive sleep apnea, pediatrics, and thromboprophylaxis). The responses were scored by two independent raters who had not been M. M. Kurrek, MD (&) F. Chung, MD University of Toronto, Toronto, ON, Canada e-mail: m.kurrek@utoronto.ca

Office-Based General Anesthesia Using Total Intravenous Anesthesia and Laryngeal Mask Airway: A Simplified Technique

Statement of the Problem: Outpatient office-based general anesthesia is an integral part of the Oral and Maxillofacial Surgeon's daily practice. This service has been provided to OMS patients in a safe and effective manner demonstrated by few complications, and overall patient satisfaction with anesthesia provided by the OMS. While office-based anesthesia can be performed a multitude of different ways, the ability of the OMS to control the patient's airway remains paramount to patient safety. Some practitioners are currently using an endotracheal tube (ETT) or laryngeal mask airway (LMA) for a more controlled airway.

Poster Board Number: 01: Complications Associated With Office-Based General Anesthesia and Elevated Body Mass Index

Poster Board Number: 01: Complications Associated With Office-Based General Anesthesia and Elevated Body Mass Index

The Difficult Airway in Office-Based Anesthesia

The Difficult Airway in Office-Based Anesthesia

Office-based anesthesia

Ambulatory office-based anesthesia (OBA) is a relatively new but rapidly growing field. OBA requires a different approach than that used in the hospital, because there are unique considerations that must be recognized when administering anesthesia in a free-standing office facility. This review provides a summary of the important issues and aspects of safe patient care. The Medline, Embase, Biological Abstract, Science Citation Index, and Healthstar databases were searched under the key words "office-based anesthesia" for relevant English language articles from 1966 to December 2008. Relevant publications were queried from governing institutions, such as the American Society of Anesthesiologists (ASA), as well as from colleges in various provinces across Canada. Office-based anesthesia remains poorly regulated in many parts of Canada (and the US). Despite continuing concerns regarding patient safety, the rates of death and reported major complications for OBA appear to be very low, especially in accredited facilities. Multiple considerations for facility design, administration, and patient care need to be taken into account. Appropriately so, an increasing number of provinces (Canada) and states (US) are beginning to regulate office-based facilities and require accreditation.