Anesthesia, as a profession and medical specialty, has time and again undergone growth and redefinition. Since the first administration of ether in the 1840s, anesthesiology has grown exponentially. Concurrent with advancements in technology, the field has grown to provide perioperative care to an ever-expanding population, infiltrating virtually every area of modern medical care. Patients with diverse and far-ranging pathology are now routinely carried through invasive and complex surgical procedures. This type of state-of-the-art care has become the expected norm, and it has been possible only with the rigorous drive toward standardized excellence that has marked our profession’s growth over the years.

Coexistent with this growth has been change, and, in an admirable way, the practice of anesthesia has evolved to fill each surgical niche virtually as soon as it has appeared. This is especially seen with the advent of cardiac anesthesia in the 1970s and with anesthesia for minimally invasive surgery in the 1990s.

Now a new surgical niche is emerging, and most assuredly our field is evolving to fill it. There are a myriad of ways to state it, but simply put, office-based anesthesia is hot. It is not hard to see why. Office-based anesthesia marries convenience with financial incentive. It is attractive to both surgeon and patient; the former benefiting from greater control over schedule, operating costs, and revenue generation, and the latter gaining in comfort and convenience. One needs look no further than recent national statistics for evidence of the popularity of this emerging subspecialty. In 2005, more than 10 million surgical procedures were performed in doctors’ offices. This number has doubled since 1995. Currently, approximately one in ten surgeries are office based (1). This growth has been explosive, and it is sobering when one realizes that in the United States only 22 states currently have legislation regarding office-based surgery. This has led many to characterize office-based anesthesia as the “Wild West” of health care.

This manual is intended to be a survival guide to the office setting. We will provide the current recommendations to a field that is wide open for change. Historically, anesthesiologists have used the closed claims study to improve our practice, using data garnered from past adverse events as a gauge to create a safer anesthetic. There is an inherent problem with this model. It takes 3 to 5 years for the adverse events to come to light, causing an unacceptable delay in the implementation of changes in safer practices. Because the field of office-based anesthesia has grown so rapidly in such a short time, because there exists a lack of regulatory oversight, and because patient safety depends on it, we created this manual to present the latest recommendations to those who need it most.

In the year 2002, the American Society of Anesthesiologists (ASA) published an informational manual titled “Office-Based Anesthesia: Considerations for Anesthesiologists in Setting Up and Maintaining a Safe Office Anesthesia Environment (2)”. This manual thoroughly delineates the concerns facing anesthesiologists who are planning on beginning or joining an office-based practice and it gives some very useful guidelines. The advice that is offered is extremely valuable, for it helps the anesthesiologist meet the supreme challenge of office-based anesthesia: to make the care delivered in the office surgical suite tantamount to that delivered in a full-fledged hospital. The specific recommendations from the ASA publication will be
presented and elaborated upon later in this text; however, in this chapter we would like to frame the discussion.

Anesthesia in the nonhospital setting is a unique subspecialty with its very own particular challenges and concerns. This book is intended to familiarize the reader with all of these issues and to impart a solid knowledge base to anyone delving into the new field of office-based anesthesia. It is necessary to take a view of this field from the ground up. Focus should first be on the principles underlying office-based anesthesia, which may be summarized by four overarching dictums (see Box 1.1).