With the surge in ambulatory surgical cases, the ability to perform anesthesia safely and efficiently in an ambulatory setting is a valuable skill to possess. Ambulatory surgical centers (ASCs) continue to increase in numbers throughout the United States. The rate of patients visiting free-standing ASCs has increased about 300% from 1996 to 2006, and many experts believe the rates will continue to rise. In addition to some social and economic factors, improved surgical techniques and minimally invasive procedures have also driven the growth of ASCs. The growth of anesthesia provided at ASCs also led to changes in the anesthesia field itself. Improvements in monitoring devices, shorter-acting anesthetic agents, better perioperative care, multimodal pain control, including advances in regional anesthesia, and preventive treatment of postoperative nausea and vomiting (PONV) have greatly assisted in the growth of cases performed in an ambulatory setting.
Ambulatory surgery is defined as outpatient procedures at a facility that typically does not have inpatient services immediately available. ASCs must have appropriate surgical equipment, resuscitative equipment, including access to a malignant hyperthermia cart, and the ability to transport a patient for an unexpected admission. Surgical patients must be accompanied by another responsible adult if anesthesia medications are given before a patient can be safely discharged home.
PATIENT AND SURGICAL SELECTION
Numerous guidelines are available to help guide and aide anesthesiologists and surgeons in acceptable surgical procedures and in screening patients for ambulatory surgery. The American Society of Anesthesia (ASA), The Society of Ambulatory Anesthesia (SAMBA), The Ambulatory Surgery Center Association, and The Accreditation Association of Ambulatory Health Care are a few organizations that provide guidelines and standards for ambulatory anesthesia and surgery.
ASA physical status 1, 2, 3, or even some ASA 4 adults can be candidates, depending upon patient and surgical factors. Regarding ASA 4 patients, there are several acceptable patients and surgeries. Surgeries with local anesthesia only or minimal sedation would suffice. Several examples of acceptable surgical procedures for ASA 4 patients include cystoscopy, minor orthopedic procedures, lumpectomy, and minor plastic surgery. Home oxygen therapy should not exclude patients from ambulatory surgery in and of itself. Patients with implantable cardioverter defibrillators (ICDs) with anticipated electrocautery may pose significant risks at an ASC and should likely be done at a larger hospital. Surgical procedures with extensive blood loss or need for transfusion should also not be done at an ASC.
Many surgical centers have weight restrictions or body mass index (BMI) restrictions on patients, depending upon local factors and equipment at each center. Currently, there is insufficient evidence to provide strong recommendations regarding a “cutoff” weight or BMI for patients undergoing ambulatory surgery. BMI (or weight) alone should not be the only determinant of patient selection for ambulatory surgery. Nevertheless, it appears that the super obese (BMI > 50 kg/m2) may be at a ...