CHAPTER
31
Office-Based Anesthesia
An office-based anesthetic is defined as an anesthetic that is performed in an outpatient venue (office, procedure room) that is not accredited as either an ambulatory surgery center (ASC) or as a hospital (Hausman LM, Rosenblatt MA. Office-based anesthesia. In: Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Ortega R, Stock MC, eds. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins; 2013:860–875). Along with providing safe anesthesia to patients (healthy to medically challenged) undergoing increasingly complex procedures, anesthesia professionals must understand office safety and policy, legal and financial issues such as antitrust laws, and billing and collection issues. A challenge to office-based practitioners is that presently there is little or no training in office-based anesthesia (OBA) within the standard anesthesia residency program.
I. BRIEF HISTORICAL PERSPECTIVE OF OFFICE-BASED ANESTHESIA
A. Over the past several decades, as a result of both surgical and anesthetic advances the surgical experience has changed (laparoscopic techniques, fast onset and offset anesthetics), lending increasing numbers of procedures to be suitable for performance in outpatient venues.
B. During the 1970s, <10% of all surgical and diagnostic procedures were performed on an ambulatory basis, and virtually all were performed in hospitals. By 1987, approximately 40% of all procedures were performed as ambulatory. The vast majority of plastic surgical procedures are performed on an ambulatory basis, and many are performed in private offices.
II. ADVANTAGES AND DISADVANTAGES (Table 31-1)
III. OFFICE SAFETY. Injuries and deaths occurring in offices are often multifactorial in their causation (including overdosages of local anesthetics, prolonged surgery with occult blood loss, accumulation of multiple anesthetics, hypovolemia, arterial hypoxemia, and the use of reversal drugs with short half-lives).
A. Both the Anesthesia Patient Safety Foundation and the American Society of Anesthesiologists (ASA) have emerged as leaders in the field of OBA safety and have advocated that the quality of care in an office-based practice be no less than that of a hospital or ASC.
B. Reports of morbidity and mortality within office-based practices vary dramatically.
1. The challenge of acquiring accurate morbidity and mortality data for OBA is complicated by the fact that many offices are not required to report adverse events.
2. There are reported cases of injuries to patients in offices resulting from obsolete and malfunctioning anesthesia machines, as well as resulting from alarms that have not been serviced or are not functioning properly (Table 31-2). The ASA has created guidelines for defining obsolete anesthesia machines.
TABLE 31-1 ADVANTAGES AND DISADVANTAGES OF OFFICE-BASED ANESTHESIA
Advantages
Cost containment (facility fee)
Ease of scheduling
Patient and surgeon convenience
Decreased patient exposure to nosocomial infections
Improved patient privacy
Continuity of care
Disadvantages
Issues of patient safety and peer review
May be an absence of regulations regarding certification of the surgeon or anesthesiologist
May be an absence of documentation, policies, and procedures and reporting of adverse outcomes
TABLE 31-2 CAUSES OF INJURY IN THE OFFICE
Inadequate resuscitation equipment
Inadequate monitoring (most commonly, no pulse oximetry)
Inadequate preoperative or postoperative evaluation
Human error
• Slow recognition of an event
• Slow response to an event
• Lack of experience
• Drug overdosage
IV. PATIENT SELECTION
A. Before presenting for an office-based procedure, the patient must be medically optimized. The patient should have a preoperative history and physical examination recorded within 30 days, all pertinent laboratory tests performed, and any medically indicated specialist consultation(s) done.
1. Patient selection for OBA is a controversial topic. The ideal patient for an office-based procedure has an ASA physical status of 1 or 2. The ASA also has developed recommendations regarding patient selection.
2. When determining whether a patient is suitable for OBA, it is important to realize that the location is often remote and the anesthesiologist may be unable to get assistance if it is required. Therefore, anticipated anesthetic problems must be avoided (Table 31-3).
B. Obesity and Obstructive Sleep Apnea. It is estimated that 60% to 90% of all patients with obstructive sleep apnea (OSA) are obese. The majority of the patients with OSA have not been formally diagnosed. There may be failure to intubate the trachea or ventilate the lungs, they may have respiratory distress soon after tracheal extubation, or they may experience respiratory arrest with preoperative sedation or postoperative analgesia. These patients tend to be exquisitely sensitive to the respiratory depressant effects of even small dosages of sedation or analgesics.
C. Pulmonary embolism from deep vein thrombosis is a significant cause of perioperative morbidity and mortality from office-based surgical procedures.
TABLE 31-3 CHARACTERISTICS OF PATIENTS WHO MAY NOT BE GOOD CANDIDATES FOR OFFICE-BASED PROCEDURES
Poorly controlled diabetes mellitus
Expected significant blood loss or postoperative pain
History of substance abuse
Seizure disorder
Susceptibility to malignant hyperthermia
Potential difficult airway
Morbid obesity
Obstructive sleep apnea syndrome
NPO <8 hours
No escort
Previous adverse outcome from anesthesia
Significant drug allergies
Pulmonary aspiration risk
NPO = nil per os.
V. SURGEON SELECTION
A. The relationship between the surgeon and anesthesiologist must be one of mutual trust and understanding. There have been cases reported of surgeons performing procedures for which they have little or no training.
B. A system should be in place for monitoring continuing medical education as well as peer review and performance improvement for both surgeons and anesthesiologists (Table 31-4).
VI. OFFICE SELECTION AND REQUIREMENTS
A. The office needs to be appropriately equipped and stocked to perform general anesthesia (Table 31-5). All equipment described in the ASA algorithm for management of the difficult airway should be present. Perioperative monitoring must adhere to the ASA standards for basic anesthetic monitoring.
1. The office-based anesthesiologist should be prepared to begin the initial treatment of malignant hyperthermia, which requires having at least 12 bottles of dantrolene (www.mahus.org).
2. Drug accounting must be performed in accordance with state and federal regulations.
3. A medical director who is responsible for overall operations should be identified for every office. There should always be at least one member of the health care team with Advanced Cardiovascular Life Support or Pediatric Advanced Life Support certification present in the office.
B. Emergencies can occur in an office-based setting (Table 31-6). Destinations for a patient in need of hospital admission must be identified with a formal written arrangement with a nearby hospital. Contingency plans must be in place in the event of a power supply interruption or electrical failure.
C. Accreditation (Tables 31-7 and 31-8). The actual improvement in safety conferred by performing surgery in an accredited office has yet to be determined, and as long as there is no mandatory reporting system in place, it will be impossible to determine true morbidity rates associated with an office-based practice.
TABLE 31-4 SENTINEL EVENTS THAT SHOULD TRIGGER A CHART REVIEW AND BE PRESENTED AT A PERFORMANCE IMPROVEMENT QUALITY ASSURANCE MEETING
Dental injury
Corneal abrasion
Perioperative myocardial infarction or stroke
Pulmonary aspiration
Reintubation of the trachea
Return to the operating room
Peripheral nerve injury
Adverse drug reaction
Uncontrolled pain, nausea, or vomiting
Unexpected hospital admission
Cardiac arrest
Death
Incomplete charts
Controlled substance discrepancy
Patient complaints
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