Safety in Office-Based Anesthesia Shih-Tai Hsin Specialist, Anesthesiology Chief, Department of Anesthesiology, Wei-Gong Memorial Hospital

Ambulatory/Office-Based Anesthesia Outpatient/ambulatory anesthesia: pre-op, intra-op, and post-op anesthetic care, patients undergo elective, same-day surgical procedures, rarely require admission, discharge after the procedure. Office-based anesthesia (OBA): deliver anesthesia in a practitioner’s office, with a procedural suite incorporated into its design; cosmetic surgery, dental procedures, et al.

Administration and Facility Quality of care: medical director, anesthesiologist, personnel, with valid license or certificate Facility and safety: local laws, fire prevention, building construction and occupancy, accommodations for the disabled, occupational safety and health, and disposal of medical waste and hazardous waste

Clinical Care Patient and procedure selection: ASA physical status class, undue risk for complications Peri-operative care: personnel with ACLS certificate Monitoring and equipment: oxygen, suction, resuscitation equipment and emergency drugs, all equipment should be maintained, tested Emergencies and transfers: train and regularly review emergency protocols, CPR emergencies, fire, malignant hyperthermia,… alternate care facility

Candidates for Office-Based Anesthesia ASA physical status, thorough history and physical exam Systemic illnesses and current management, airway management problems (sleep apnea, morbid obesity), previous adverse anesthesia outcomes (eg, malignant hyperthermia), allergies. Availability of difficult airway equipment (LMA or videolaryngoscope) additional experienced anesthesia providers, surgeons/ anesthesiologists capable of performing emergent airway (tracheostomy/cricothyroidotomy).

Intra-operative Considerations Aim: rapid emergence, good analgesia, and minimal PONV, create acceptable operating conditions Oxygen supply Inhalational anesthesia vs total intravenous anesthesia (TIVA) Regional anesthesia: speed discharge time, reduce the incidence of PONV Multimodal peri-operative analgesia

Without Safety, Anesthesia is Nothing!

Advances in Office-Based Anesthesia Short-acting anesthetic agents (propofol, rocuronium): make ambulatory surgery easier Inhalational agents (sevoflurane, desflurane): prompt emergence, contribute to post-operative nausea and vomiting (PONV) Propofol, total intravenous anesthesia (TIVA): have antiemetic effects, potentially reduce PONV; require more time for patients to meet discharge criteria

Regional techniques: decreases post-op opioid requirements, potentially reduces PONV Improved airway management using devices: laryngeal mask airway (LMA) and video laryngoscopy, better able to avoid airway catastrophes.

Post-Anesthesia Recovery and Discharge Emergence from anesthesia, pain, and PONV: critical to expediting discharge. Plan: handle and focus on minimizing complications as pain and PONV, preoperatively to standardize, optimize, and streamline management as much as possible. Multimodal approaches to both complications are advised.

Discharge Criteria : modified Aldrete scoring system

Quality Assurance

“ Big Little Problem. ” “ Final Therapeutic Challenge “ Big Little Problem!” “ Final Therapeutic Challenge!” “ Big Big Problem of ambulatory surgery!”

Consequences of PONV Dehydration and electrolyte Imbalance Tension on suture lines or wound dehiscence Hypertension Increased bleeding under skin flaps Increased risk of pulmonary aspiration Mallory-Weis tear, esophageal rupture Postoperative pain and discomfort Increased nursing care time and delayed discharge

Morgan & Mikhail’s Clinical Anesthesiology, 5th edition

We don’t follow the world standard. We set them.

We are small, but think BIG.