Role of Anesthesiologists/CRNA in an Office Interventional Suite Krishna Jain MD, John Munn MD, Mark Rummel MD, Dan Johnston M.D, Syed Alam, MD OEIS 2016

Disclosure National Office Endovascular Labs LLC : President and CEO

Future of Vascular Surgery is in the Office* “No anesthesiologist’s expense and minimal preprocedural expenses were incurred” *Jain et al J Vasc Srg:2010;51:509-14

Evolution Dialysis cases Duration of Procedure Aortogram Iliac angioplasty SFA intervention Tibial intervention Radial approach Tibial approach Increasing

Contraindications Patients>400 lbs High cardiac risk Poor pulmonary function Low pain tolerance

Definition of Anesthesia Levels* Minimal sedation Anxiolysis Moderate/Sedation analgesia “Conscious sedation” Deep Sedation/Analgesia General anesthesia Responsiveness Normal response to verbal stimulation Purposeful response to verbal or tactile stimulation Purposeful response following repeated or painful stimulation Unarousable even with painful stimulus Airway Unaffected No intervention required Intervention may be required Intervention often required Spontaneous Ventilation Adequate May be adequate Frequently inadequate Cardiovascular Function Usually maintained May be impaired *Approved by ASA house of delegates and amended 2009

New York Law Office-based Surgery is any Surgical or other invasive procedures performed by a physician, PA or Specialist assistant, outside of a hospital, diagnostic and treatment center, ambulatory surgery center or other Public Health Law article 28 facility in which moderate or deep sedation or general anesthesia is used. Any sedation beyond minimal sedation requires accreditation.

State Regulations Surgery/Anesthesia guidelines in Louisiana, North Carolina, Texas Office anesthesia or surgery regulations in Alabama, Illinois, Mississippi, New Jersey, New York, Tennessee, Virginia

American Society of Anesthesiologist Reliable Oxygen source Adequate suction capability Adequate anesthesia drugs Adequate monitoring equipment Sufficient electric outlets Adequate lighting Adequate space Emergency cart Staff trained to help anesthesiologist Building and safety codes Appropriate post anesthesia management

Reasons to use anesthesia service Procedures are getting longer Sicker patients can be done in the office Patients with low pain tolerance Increased safety Quick recovery with the use of Propofol

Advantages to OBL Increased safety profile May be able to decrease one full time registered nurse May be able to increase volume

Disadvantages Anesthesiologist may require more blood tests pre procedure Every patient needs an intravenous line Potential of cancellation Patient gets one more bill

Satisfaction Our patients are more satisfied We think we made the right decision