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

3. 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.

6. 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

7. 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

9. 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).

10. 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

11. Without Safety, Anesthesia is Nothing!

12. 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

14. 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.

17. 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.

18. Discharge Criteria : modified Aldrete scoring system

20. Quality Assurance

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

26. 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

27. Morgan & Mikhail’s
Clinical Anesthesiology,
5th edition

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

30. We are small, but think BIG.