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Anaesthesiology
Office-Based Anesthesia
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
16 sections · 190 slides
Overview
- Scope of this presentation
Defining Office-Based Anesthesia
- Definition of office-based anesthesia
- Non-operating room anesthesia and ambulatory anesthesia
- Relationship between anesthesia venues
- Expanded role of the office-based anesthesiologist
- Training gap in office-based anesthesia
- Office treatment room
Historical Perspective
- Nineteenth-century office and home anesthesia
- Shift of surgery into the hospital
- Advances that returned surgery to the office
- Growth of ambulatory surgery
Advantages and Disadvantages
- Components of the cost of a procedure
- Cost comparisons for office versus hospital
- Cost savings in pediatric dental anesthesia
- Non-financial advantages of the office
- Procedure duration in office versus hospital
- Comparative safety of office and ambulatory surgery centres
- Disadvantages of office-based procedures
- Consequences of absent state oversight
- States which have regulations regarding office-based surgery and anesthesia
- States which have regulations regarding office-based surgery and anesthesia (continued)
Office Safety
- Origins of concern about office safety
- Causes of office injury and death
- Position of professional bodies on office safety
- Anesthesia mortality rates over time
- Morello survey of accredited plastic surgery offices
- Complication rates in the Bitar series
- Complication rates across the three venues
- Specific complication rates by venue
- Limitations of the office safety evidence
- Florida closed malpractice claims
- Reasons the venue itself affects safety
- Injuries from obsolete anesthesia machines
- Value of closed claims data
- Severity of injury in offices versus surgery centres
- Timing of office injuries in the perioperative period
- Causes of injury in the office-based practice
- Monitored anesthesia care claims compared with general anesthesia
- Preventability of adverse events by venue
- Financial outcomes of office and surgery centre claims
- Florida moratorium on office-based procedures
Patient Selection
- Preoperative requirements before an office procedure
- Scheduling by ASA physical status
- Plastic surgery recommendations on patient selection
- Unsuitable candidates for an office-based procedure
- Obesity and obstructive sleep apnea in the office
- Components of the STOP-BANG questionnaire
- Airway management in sleep apnea patients
- Respiratory sensitivity in sleep apnea patients
- Postoperative monitoring in sleep apnea patients
- Equipment and drugs to have available for sleep apnea patients
- Anesthetic planning for sleep apnea patients
- Pulmonary embolism after office-based surgery
- Burden of venous thromboembolism in plastic surgery
- Risk factors for the development of deep vein thrombosis
- Recommended treatment for prevention of deep vein thrombosis, stratified by risk
- Trend toward older and sicker office patients
Surgeon Selection and Quality Improvement
- Relationship between surgeon and anesthesiologist
- Credentials required of the operating surgeon
- Peer review in the office setting
- Design of a quality improvement program
- Anesthetic-related sentinel events that should trigger a case review
Office Selection and Requirements
- The anesthesiologist as patient advocate
- Waste anesthetic gas scavenging
- Total intravenous anesthesia in offices without scavenging
- Ventilation and oxygen supply requirements
- Difficult airway equipment in the office
- Laryngeal mask airway
- Video laryngoscopy in office practice
- Outcomes with video laryngoscopy
- Standards for basic anesthetic monitoring
- Pulse oximetry in the office
- Capnography across all depths of sedation
- Emergency drug requirements in the office
- Defibrillator and suction requirements
- Malignant hyperthermia preparedness
- Controlled substance handling and storage
- Equipment required for the safe delivery of office-based anesthesia
- Equipment required for the safe delivery of office-based anesthesia (continued)
- Legal structure and governance of the office
- Staff certification requirements
- Emergencies which require contingency plans
- Hospital transfer arrangements
- Patient transport plan
- The fire triad
- Fire prevention measures
- Management of an operating room fire
Accreditation
- Purpose and benefits of accreditation
- Facility fee reimbursement limits
- The three major accrediting bodies
- Scope of the accreditation review
- Factors considered in accrediting an office for surgical procedures
- Classification of surgical procedures by anesthetic depth
Procedure Selection
- Expansion of the range of office procedures
- Procedure duration and unplanned admission
- Recommended limits on procedure length
- Operative duration and complication rates
- Additional factors in judging procedure suitability
Specific Procedures
- Liposuction technique
- Lidocaine pharmacokinetics in tumescent liposuction
- Mortality and causes of death after liposuction
- Risk factors identified in liposuction deaths
- Postoperative management after liposuction
- Recommendations for office-based liposuction
- Propofol emulsion vial
- Facial aesthetic procedures and fire risk
- Breast procedures in the office
- Upper gastrointestinal endoscopy
- Cardiovascular effects of colonoscopy
- Who may administer propofol
- History of office dental anesthesia
- Oral and maxillofacial surgery outcomes
- Regional anesthesia in orthopedic and podiatric offices
- Gynecologic and genitourinary office procedures
- Ophthalmologic and otolaryngologic office procedures
- Patient selection for pediatric office anesthesia
- Guidelines for the pediatric perioperative anesthesia environment
- Guidelines for the pediatric perioperative anesthesia environment (continued)
Anesthetic Techniques
- Who may provide office anesthesia
- Requirements of the supervising physician
- Anesthesia as a continuum
- Continuum of depth of sedation
- Interpreting the sedation continuum
- Choosing drugs for an office anesthetic
- Mortality with monitored anesthesia care
- Growth of sedation claims over three decades
- Patient injuries during sedation and monitored anesthesia care
Anesthetic Agents
- Selecting an agent for office anesthesia
- Pharmacology of propofol
- Fentanyl and remifentanil
- Ketamine in office practice
- Remimazolam pharmacology
- Clonidine in office anesthesia
- Dexmedetomidine in office anesthesia
- Clinical effects of dexmedetomidine
- Total intravenous anesthesia in office practice
- Postoperative nausea reduction with total intravenous anesthesia
- Depth of anesthesia monitoring
- Rescue capability as the governing principle
Recovery and Discharge
- Expected recovery after an office procedure
- Monitoring standards in the recovery area
- Priorities in the office recovery area
- Discharge criteria and escort requirements
- Multimodal postoperative pain management
- Liposomal bupivacaine
- Non-opioid analgesics after office surgery
- Impact of postoperative nausea and vomiting
- Antiemetic strategy for office anesthesia
- Dexamethasone and aprepitant for nausea prophylaxis
Regulations, Business and Legal Aspects
- Accreditation compared with state regulation
- California regulations on office-based anesthesia
- Penalties for non-compliance in California
- New Jersey regulations on patient selection
- Practice in states without regulations
- Building a business model for office anesthesia
Conclusions and References
- Challenges of office-based practice
- Principles governing office anesthesia practice
- Key points to carry away
- Further key points
- Elements of a safe anesthetizing location
- References
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- References (continued)
- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition