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KEY POINTS

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KEY POINTS

  1. The location for an outpatient surgical procedure can be in either a hospital or a freestanding outpatient surgery center. The organizational structure for outpatient surgery centers is determined by their location in relation to a hospital and their governance.

  2. Evaluation of patients in preparation for outpatient surgery involves the usual standards plus the added issue that the patient is expecting to go home the same day. Thus, the patient must be undergoing a procedure appropriate for same-day discharge, and they must be physiologically able to go home.

  3. There is no standard “best anesthetic” for outpatient surgery. An anesthetic plan must consider the planned procedure and the patient’s physiology in addition to surgeon, anesthesiologist, and patient preferences. The drugs and modalities are chosen for effectiveness and speed of emergence in addition to safety.

  4. Altough major morbidity and mortality are rare and hospital admissions and readmissions are uncommon, minor morbidities, especially pain and postdischarge nausea and vomiting, continue to pose significant challenges.

  5. Combination pharmacologic prophylaxis and treatment of PONV is probably the most effective approach, combined with adequate hydration and the least emetogenic anesthetic possible for a given procedure.

  6. Multimodal opioid-sparing pain management is most effective and enhances patient satisfaction and well-being. Peripheral nerve blocks are safer and more effective with the widespread use of ultrasound.

  7. A pediatric patient population has special needs requiring family-centered education about the entire perioperative practice. A quiet area for recovery benefits not only the child but also the adult patients.

  8. Although obese patients and those with obstructive sleep apnea are challenging, with appropriate selection of patient and procedure as well as careful management, these patients–once deemed unsuitable for outpatient surgery–are now safely enjoying its benefits.

  9. Despite increased understanding and preparedness of malignant hyperthermia (MH) in the past several years, the mortality associated with a MH event has actually increased several-fold. This complication poses unique challenges to ambulatory surgery centers.

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INTRODUCTION

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A BRIEF HISTORY OF AMBULATORY ANESTHESIA

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Ambulatory anesthesia in 2016, with its extensive range of surgical interventions, anesthetic techniques, and patient characteristics, is unrecognizable from its historical antecedents, although the reasons for its continued growth are similar to the reasons for its birth: convenience, cost-effectiveness, efficiency, and patient and physician satisfaction.1 Beginning in the 1840s, with neither the thought nor the ability to mix nitrous oxide with oxygen, dentists began using 100% nitrous oxide for the painless and necessarily expeditious extraction of teeth. Although a practical delivery system for nitrous oxide–oxygen mixture was available by the 1880s, the practice of hypoxic anesthesia with nitrous oxide continued until the 1950s. In the early twentieth century, the entrepreneurial anesthesiologist Ralph Waters began an enterprise that is the prototype of ambulatory surgery centers and office-based anesthesia. In 1915, he took the occasional request for anesthesia services from a dentist with a difficult extraction, and turned it into The Downtown Anesthesia Clinic in Sioux City, Iowa, where ...

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