Office-based Anesthesia Research Articles

Office-Based Anesthesia: Requirements for Patient Safety

Thank you for honoring me with your Society's Heidbrink Award. It is a humbling truth, however, that as I look back on my 45 years of practicing anesthesia, I feel ill prepared to become clairvoyant regarding the newest and latest things that will advance our practices to the next level of patient care. Many changes have occurred in our practices over the past decades. These include technical, socioeconomic, and cultural changes. Also, for the most part, each subsequent change is a little more complex than its predecessor. However, the question remains: have changes been made for the betterment of patient care, or for the benefit of the health-care industry?

The Anesthesiologist’s Manual of Surgical Procedures, Third Edition.

Mayo Clinic, Rochester, Minnesota. danielson.david@mayo.eduThe Anesthesiologist’s Manual of Surgical Procedures, Third Edition. Edited by Richard A. Jaffe and Stanley I. Samuels. Philadelphia, Lippincott Williams & Wilkins, 2004. ISBN: 0-7817-4332-X. Price: $129.00.Question : Why publish a Third Edition of this book?Answer : The rapidity of change in surgical care.For those not familiar with the previous editions of this Manual , a few words are in order. Drs. Jaffe and Samuels have now edited three editions of a unique book. With the collaboration of their Anesthesiology and Surgery colleagues at Stanford, they have gathered into one volume a work that has several features. First is a diagram-rich, fact-filled summary of just about every surgical operation. Then comes an outline of a good anesthetic plan for each of those operations. Each section has a list of current references for further reading. There are additional teaching points and patient care tips sprinkled liberally throughout. It is organized into 15 chapters based on types of procedures. The style and quality are surprisingly even throughout the text; a tribute to the editors. However, I would not call it a “manual.” It will never fit in your lab coat pocket; it is a full-size, heavyweight reference book. But it is a reference book that provides quick and easy access to information and, dare I say, does not put me to sleep.House Officers, this book is for you. Most of you did not enter anesthesiology via surgical routes; here is the easy way to begin to understand what is happening on the other side of the drapes. In addition, if you read the anesthesia plans and some of the references before each case, you will take better care of your patients and impress your faculty.Who else could benefit from this book? Faculty members should have it nearby for learning about new operations. Practitioners should reference it for the same reason. Anyone on call who needs quick information to set up for an unfamiliar type of case will want this book. I keep a copy in our Preop Evaluation Center for our colleagues from Internal Medicine who have not been in the operating room since medical school.The Third Edition is bigger than the previous edition by approximately 150 pages, lists more operations, contains more material in the appendices, and is subtly, though not markedly improved. The Second Edition was not flawed; it was merely 5 yr old. This is the heart of the matter, though, reflecting rapid changes in surgery and surgical care. The Third Edition merits a spot on your bookshelf because of new material, such as the section on laparoscopic bariatric surgery, the expanded chapter on esthetic surgery, the additional material on Out-of-Operating Room Procedures, and new chapters on Office-Based Anesthesia and Emergency Procedures for the Anesthesiologist.The appendices deserve mention because of their blend of old, revised, and new material. Appendix H still lists the acronyms and abbreviations used in the text, and I continue to find it helpful. Some of the revisions seem minor at first glance, but nevertheless, improve readability and quality, like the overhaul of the first Table in Appendix A on Diagnosis-Based Preop Testing, and the longer list of Herbal Agents that can cause drug interactions in Appendix F. More importantly, the addition of a new section in Appendix A on perioperative beta blockade is timely and reinforces that patient safety issue.Question : Would I buy the 3rd Edition?Answer : It’s already on my shelf.Mayo Clinic, Rochester, Minnesota. danielson.david@mayo.edu

Anesthesia-compatible Magnetic Resonance Imaging

The University of California, San Francisco, San Francisco, California. llitt@post.harvard.eduObservations and conversations have convinced me that anesthesiologists are involved in many more “near miss” magnetic resonance imaging (MRI) safety incidents than are reported, with some having the potential to be as lethal as the highly publicized pediatric death that occurred from head injury after an anesthesiologist inadvertently carried a ferromagnetic oxygen tank into an MRI suite.1The letter by Miyasaka et al. is highly relevant to such incidents because of the very important points it makes regarding setting up MRI suites and their procedures to prevent unintended safety violations during clinical anesthesia in the magnet room. Miyasaka et al. note that in many instances, input from anesthesiologists is sought only after an MRI suite has been constructed and procedures have been streamlined for use by patients who are neither sedated nor anesthetized. Strong support is appropriate for Miyasaka et al.' s call for early involvement by anesthesiologists, both in establishing hospital procedures for anesthesia care in MRI suites and for orienting (reorienting?) industry thinking such that there is harmony and balance in the form of asking manufacturers to be anesthesia-compatible at the same time that anesthesiologists are asked to be MRI-compatible. Particularly worthy of attention is Miyasaka et al.'s point that hospital managers, contractors, and equipment managers have no professional guidelines or standards regarding the design and construction of anesthesia facilities inside the magnet room of an MRI suite. The America Society of Anesthesiologists has produced The Operating Room Design Manual and a booklet on setting up safe office-based anesthesia, but these do not address key MRI safety issues.*Advances in magnet technologies and medical imaging are likely to require that anesthesiologists function in environments having stronger magnetic field gradients (which exert mechanical force) and more intense radiofrequency power (an energy source with the potential for burns) than one currently encounters. Anesthesiologists undergo training and make considerable efforts to learn about MRI-related dangers, and they and the patients deserve anesthesia-friendly, patient-safe systems in MRI suites. But there is truth in the title of Chester L. Karrass' widely known book “You Don't Get What You Deserve, You Get What You Negotiate.” In pointing out the need for MRI suite anesthesia standards Miyasaka et al. are really calling for help in negotiating what is deserved. What should be the form? One solution would be a comprehensive statement sanctioned by the appropriate American Society of Anesthesiologists committees, possibly involving other relevant professional groups. If there are manufacturers who do not find anesthesia safety issues to be “compelling,” then anesthesiologists need to provide better, more persuasive arguments, as there can be no compromise on safety. I am impressed by the altruism I have seen in the technical people I have met who are associated with medical manufacturers. Many, in choosing their profession, have shown that they are as highly motivated by seeing patients helped by optimum imaging technologies as surgeons and anesthesiologists are about seeing patients helped by the best invasive procedures. Altruism, however, was not something that the late Senator Everett Dirksen relied on almost half a century ago in a saying he was fond of: “When I feel the heat, I see the light.” It seems appropriate that there be follow-up to the letter by Miyasaka et al. in the form of anesthesiologists getting together to provide some heat and light for themselves, hospital colleagues, and equipment manufacturers.The University of California, San Francisco, San Francisco, California. llitt@post.harvard.edu

Sevoflurane for office-based pediatric general anesthesia

Statement of the Problem: The options for office-based anesthesia of pediatric patients undergoing short oral surgical procedures include IV, IM, or inhalation techniques. Historically none possesses ideal properties. Materials and Methods: Retrospective data analysis of pediatric patients receiving inhalation anesthesia, from July 2003 to January 2004, within a private oral and maxillofacial surgery practice. Method of Data Analysis: Fifty-five patients were seen for minor dentoalveolar procedures, such as dental extractions and soft tissue procedures. Descriptive statistics were applied. Results: Patients treated were 53% male and had a mean age of 8 years (2–15 years), mean weight of 35 kg (67–12 kg), average sevoflurane MAC of 7 (6–8 MAC), and average N2O concentration of 50% (50–60%). No patients experienced oxygen saturation less than 98% and all other vital signs remained stable (HR, NIBP). No emergence delirium was observed in any patients. All patients were discharged to parental care within 1 half-hour of anesthesia termination. Conclusion: Sevoflurane and N2O general anesthesia with mask induction and maintenance, without airway manipulation or establishment of IV access, within a private office-based oral surgery practice is safe, time effective, and is not associated with emergence delirium as reported in the anesthesia literature. References Lee M, Bennett HE, Gordon N: Sevoflurane general anesthesia: An alternative technique in the pediatric oral and maxillofacial surgery patient. J Oral Maxillofac Surg 61:1249, 2003 Lerman J, Davis PJ, Welborn LG, et al: Induction, recovery, and safety characteristics of sevoflurane in children undergoing ambulatory surgery: A comparison with halothane. Anesthesiology 84:1332, 1996

Office-based anaesthesia for vitreoretinal surgery

The objectives of this study were to consider the effectiveness of local anaesthesia (LA) for office-based vitreoretinal (VR) surgery, the requirement to supplement the anaesthetic blockade, the demographic pattern of the sample and the acceptance of LA by patients. This prospective observational audit involved 111 patients that had undergone 128 VR procedures. Assessment data included: patient’s information, details of type of anaesthetic, and pain during surgery. A clinical audit was also carried out with telephone survey to establish the postoperative use of analgesics, the frequency of nausea, emesis, and insomnia. Results suggest that VR surgery can be carried out effectively and safely with LA, in an office-based surgery, provided that experienced surgeons exist. We noted a high degree of patient acceptance, a reasonable level of postoperative pain and a low frequency of nausea and vomits.

Advances in office-based anesthesia

The practice of office-based anesthesia is quickly emerging as an important field for the anesthesia provider. The number of procedures being done in offices around the country has steadily increased, as has the invasiveness of these procedures. This creates new anesthetic considerations. To date most training programs have not addressed this area of practice. As practitioners enter the field, however, they should have information as to how to provide quality care in a location where very often they are completely alone. Many of the safety mechanisms we as anesthesia providers take for granted in a hospital setting are often not present in a surgical office, and it becomes our responsibility to help in establishing standards. Some questions exist as to the 'safety' of many surgical offices in which anesthesia care is provided. Many medical professional societies have begun issuing recommendations as to the standards of care that should exist. Different anesthetic techniques are also emerging that are appropriate to the office setting. As office-based anesthesia continues to mature as a specialty, we the anesthesia providers must be proactive in establishing guidelines and recommendations to make the practice safe. We should be informed of the rules and regulations that exist in our states, and we should provide a voice for the patients who put their faith in us.

Pharmacologic and technologic updates in office-based anesthesia practice

Several anesthetic agents including propofol and sevoflurane are relatively new arrivals to the office-based practice. The pharmacokinetics of propofol compare favorably to methohexital. If the latter returns to the marketplace, it can be mixed with propofol to incorporate the “best qualities” of both. The induction doses for both are similar whether for deep sedation or general anesthesia. If anything, higher doses of propofol are needed to accomplish the same clinical endpoint. Programmable pumps are available and an efficient method of delivering either propofol or a mixture of propofol/methohexital.

The art and science of office-based anesthesia in dentistry: a 150-year history.

Office-based anesthesia in dentistry dates back over 150 years to the discovery of general anesthesia itself, and the fields of dentistry and anesthesiology have maintained close ties ever since. Many of the world's firstanesthetics were administered in dental offices, and for years, more anesthetics have been administered for dentistry than for any other procedure. Today, dentist anesthesiologists continue to practice state-of-the-art anesthesia, upholding the proud tradition of dentists in the delivery of quality office-based services. Over the years, numerous improvements in the art and science of office anesthesia have helped the specialty of oral and maxillofacial surgery to achieve the distinguished status that it now enjoys as a respected member of the health care community. Historically, the willingness of a general dentist to refer patients to an oral surgeon for dental extractions had more to do with the surgeon's skills in providing general anesthesia than his or her ability to remove teeth. With major contributions coming from the dental profession, anesthesia delivery in the hospital environment has evolved into a scientific practice based on sound principles. Ironically, at present there is increasing pressure on physicians to move out of the hospital or surgery center operating room and, like their dental colleagues, perform more diagnostic and surgical procedures in the office setting. Dentists have demonstrated an enviable safety record in the practice of outpatient anesthesia, leading the way in developing techniques that permit rapid induction and recovery in the office for procedures that encroach on the airway. While the modern practice of office-based anesthesia for oral surgery has certainly benefited from the wonderful scientific progress seen in medicine, it remains an art with a proud legacy in the field of dentistry.

Propofol ketamine anesthesia for cosmetic surgery in the office suite.

Before 1968, the operating room did not exist outside the four walls of the hospital for most anesthesiologists. The first free-standing ambulatory surgicenter (ASC) was created in Phoenix, Arizona, in 1968. This initiated an era in which operating rooms were no longer confined to the hospital setting. In the mid-1980s, the Society for Ambulatory Anesthesia (SAMBA) was formed as a result of the ASC movement. In the past two decades, this society has grown, and it is estimated that more than 60% of all surgery in the United States is currently done on an outpatient basis. However, not all outpatient facilities are of equal caliber. Although office practitioners such as Ralph M. Waters, MD, operated the Downtown Clinic in Sioux City, Iowa, in 1919, the modern era of office-based anesthesia for cosmetic surgery is considered to have begun in the mid-1970s. One of the pioneers of this enterprise was Charles A. Vinnik, MD, a Las Vegas plastic surgeon. Unable to secure dedicated professional anesthesia services, Vinnik developed the “diazepam/ketamine” technique, which eliminated the hallucinatory side effects of ketamine by preceding the dissociative dose of ketamine with hypnotic doses of incremental diazepam. Diazepam/ketamine is a nontriggering technique that eliminated the need for either an anesthesia machine or dantrolene to treat the rare syndrome of malignant hyperthermia. A recent American Society of Anesthesiologists’ (ASA) publication validated the nontriggering approach for office anesthesia as safe without an anesthesia machine. While manufacturers continue to shrink the size of anesthesia machines, interoffice transport and scavenging requirements impose added burdens to the office anesthesiologist. Aside from these issues, it is difficult for me to justify any risk of malignant hyperthermia in a patient population having surgery without medical indication (i.e., elective cosmetic surgery). Vinnik’s breakthrough discovery was published in the plastic surgery literature, where it lay unnoticed and unappreciated by the anesthesia community for over a decade. In December 1991, I attended a lecture by

New Concepts and Techniques in Pediatric Anesthesia: Vol. 20, No. 1 (March 2002) of Anesthesiology Clinics of North America

New Concepts and Techniques in Pediatric Anesthesia: Vol. 20, No. 1 (March 2002) of Anesthesiology Clinics of North America Linda J. Mason and Michelle S. Kim, editors Darien, Illinois: WB Saunders Company, 2002. ISBN 0889-8537; 246 pp, $154.00 per year. This book is an engaging volume that discusses practical concepts needed to take care of a child who is being anesthetized. The guest editors, along with 22 contributors, have done a wonderful job putting together a significant number of practice issues related to pediatric anesthesia in a comprehensive and clinically oriented pattern. This monograph consists of 12 chapters, including one on cardiac arrest and another addressing ethical dilemmas in pediatric surgical patients. The contributors have done a nice job of writing their chapter with minimal duplications. The chapters are easy to read and easily understood. The material is presented lucidly with appropriate references and data. The chapter on cardiac arrest reflects current practice and provides a quick algorithm for treatment of cardiac arrest in children. The chapter on psychological preparation of children prior to surgery imparts a good overview on the control of preoperative anxiety and the common clinical options available for anxiolysis prior to surgery in children. The chapter on the perioperative control of pain reviews current information regarding the use of cyclooxygenase-2 inhibitors, alpha 2 agonists, and opioids; the authors recommend using an integrated approach to achieve adequate analgesia. The chapter on pediatric regional anesthesia is well written and provides descriptions of the procedures and avoidable errors. There is even a chapter describing sedation and analgesia for pediatric patients outside the operating room or in the office. This is a good source for guidelines and policies issued by the ASA and JCAHO. This chapter also emphasizes the need for office-based anesthesia with its advantages and disadvantages. These reviewers especially enjoyed the last chapter on ethical dilemmas for pediatric surgical patients because all will occasionally face such situations, especially when they present as surgical emergencies. The contributors emphasize a detailed, stepwise approach to decision-making, including concern for legal and ethical issues surrounding minors with illustrative case examples. One should realize that this is not a textbook of pediatric anesthesia, but an update on important current practices. Thus, this issue of the Anesthesiology Clinics of North America is recommended because it provides a quick and easy reference and a valuable tool for newer concepts and techniques in pediatric anesthesia (the title of this issue).

Anesthesia's new frontier: ensuring patient safety in the office setting.

Advancements in technology and pharmacology, as well as improved techniques and instrumentation have allowed for much greater flexibility in how and where surgical and anesthesia care can be provided safely. Many procedures now take but a fraction of the time they used to take to complete and can be performed with minimal risk of blood loss and far less postoperative pain. Office-based surgery has emerged as a safe and viable alternative to traditional in-hospital surgery. This article provides an overview of the comprehensive "Standards for Office-Based Anesthesia Practice" developed by the American Association of Nurse Anesthetists (AANA).

Perspectives on Office-Based Anesthesia

Perspectives on Office-Based Anesthesia

What's new in practical patient monitoring and support equipment

The author discusses state-of-the-art technology for patient monitoring in office-based anesthesia. New technology includes bispectral index monitoring to evaluate the depth of anesthesia, signal extraction for more accurate oxygen saturation monitoring, and online S-T segment analysis for monitoring multiple electrocardiographic leads.

Anesthesia for remote sites: General considerations

Summary The administration of anesthesia in remote sites has important implications for the patient and the anesthesiologist. Remote site procedures are now commonly undertaken, especially in this period of office-based anesthesia. The role of the anesthesiologist will be to ensure safe and appropriate anesthesia and to treat acute complications that may result from the procedure. Numerous difficulties will continue to exist in these areas unless the use of anesthesia becomes a routine event. The anesthesiologist has to know the patient's clinical problems intimately and be familiar with the environment, the type of procedure, and the special anesthetic requirements. The challenges of working in the remote site can be easily met with careful planning and adherence to all the principles of safe anesthesia.

Intravenous Anesthesia for Oral and Maxillofacial Office Practice

Summary Intravenous anesthesia has evolved over the past decade. Primary in that evolution has been the introduction of midazolam and propofol. Factors such as the pharmacokinetics and pharmacodynamics of each drug as well as the pharmacoeconomics have further influenced the use of each of the drugs in oral and maxillofacial surgery. This article discusses different anesthetic drugs and techniques that have applicability to oral and maxillofacial surgery. It appears that intravenous anesthesia will remain the foundation of office-based anesthesia. This article attempted to review some of the basic concepts and introduce the reader to some of the new concepts that may influence the intravenous anesthetic techniques of the future.

Propofol regimen preferred for office-based anaesthesia

Propofol regimen preferred for office-based anaesthesia

Propofol regimen preferred for office-based anaesthesia

Propofol regimen preferred for office-based anaesthesia

Recovery Profile, Costs, and Patient Satisfaction with Propofol and Sevoflurane for Fast-track Office-based Anesthesia

Office-based surgery is becoming increasingly popular because of its cost-saving potential Both propofol and sevoflurane are commonly used in the ambulatory setting because of their favorable recovery profiles. This clinical investigation was designed to compare the clinical effects, recovery characteristics, and cost-effectiveness of propofol and sevoflurane when used alone or in combination for office-based anesthesia. One hundred four outpatients undergoing superficial surgical procedures at an office-based surgical center were randomly assigned to one of three general anesthetic groups. In groups I and II, propofol 2 mg/kg was administered for induction followed by propofol 75-150 microg x kg(-1) x min(-1) (group I) or sevoflurane 1-2% (group II) with N2O 67% in oxygen for maintenance of anesthesia In group m, anesthesia was induced and maintained with sevoflurane in combination with N2O 67% in oxygen. Local anesthetics were injected at the incision site before skin incision and during the surgical procedure. The recovery profiles, costs of drugs, and resources used, as well as patient satisfaction, were compared among the three treatment groups. Although early recovery variables (e.g., eye opening, response to commands, and sitting up) were similar in all three groups, the times to standing up and to be "home ready" were significantly prolonged when sevoflurane-N2O was used for both induction and maintenance of anesthesia. The time to tolerating fluids, recovery room stay, and discharge times were significantly decreased when propofol was used for both induction and maintenance of anesthesia. Similarly, the incidence of postoperative nausea and vomiting and the need for rescue antiemetics were also significantly reduced after propofol anesthesia. Finally, the total costs and patient satisfaction were more favorable when propofol was used for induction and maintenance of office-based anesthesia Compared with sevoflurane-N2O, use of propofol-N2O for office-based anesthesia was associated with an improved recovery profile, greater patient satisfaction, and lower costs. There were significantly more patients who were dissatisfied with the sevoflurane anesthetic technique.

ANESTHESIA FOR OFFICE-BASED ORAL AND MAXILLOFACIAL SURGERY

This article is divided into two sections, each encompassing the various aspects of anesthesia used for dental procedures ranging from single tooth extraction to more complex reconstruction and tumor eradication. The various types of anesthesia used for each of these kinds of dental surgery are explored, and the effectiveness and cost efficiency of office-based anesthesia procedures are discussed.

Use of propofol for office-based anesthesia: effect of nitrous oxide on recovery profile

Study Objective: To evaluate the effect of nitrous oxide (N2O) on the recovery profile and the incidence of postoperative nausea and vomiting (PONV) after office-based surgery performed under propofol anesthesia.Design: Prospective, randomized, single-blind study.Setting: Office-based surgical center.Patients: 69 ASA physical status I, II, and III healthy, consenting outpatients undergoing superficial surgical procedures lasting 15 to 45 minutes.Interventions: After a standard propofol induction (1.5 mg · kg−1 IV), anesthesia was initially maintained with propofol, 100 μg · kg−1 · min−1 IV, in combination with either air or N2O 65% in oxygen. The propofol infusion rate was subsequently varied to maintain an adequate depth of anesthesia. All patients received local anesthetic infiltration prior to the surgical incision, as well as during the operation. No prophylactic antiemetics were administered.Measurements and Main Results: Recovery times and the incidences of PONV were recorded during the first 24 hours after surgery. Early and late recovery variables were similar in the two treatment groups; however, 65% N2O produced a 19% decrease in the propofol maintenance dosage requirement. One patient (3%) experienced nausea prior to discharge in the propofol-N2O group, and two patients (6%) experienced nausea at home in the propofol alone group. None of the patients vomited or received antiemetic medication during the 24 hours postdischarge period. Ninety-seven percent of patients receiving propofol alone and all of the patients in the propofol-N2O group were “very satisfied” with their anesthetic experience.Conclusions: In outpatients undergoing office-based surgical procedures with propofol anesthesia, administration of 65% N2O decreased the anesthetic requirement without increasing PONV. Therefore, use of a propofol-N2O combination may be a cost-effective alternative to propofol alone for office-based anesthesia.