4 Considerations for Ambulatory Anesthesia From SAMBA's Dr. Peter Glass

Ambulatory anesthesia can create a new set of challenges for anesthesiologists accustomed to working at inpatient settings. Anesthesia in ambulatory surgery centers must be approached from a different perspective.

Dr. Peter Glass, SAMBAPeter Glass is the immediate past president of the Society for Ambulatory Anesthesia. He is also an ex-officio member of the ambulatory anesthesia division of Anesthesia & Analgesia. Dr. Glass is the chair of the department of anesthesiology at Stony Brook Medicine in New York.

Here are Dr. Glass' four considerations for ambulatory anesthesia:

1. Patient experience matters. The patient experience is always a priority in ASCs. In a hospital, operating rooms are tucked far away from where patients are admitted and the layout is not designed to maximize efficiency.

However, freestanding ASCs are usually compact facilities, where patients are processed and walked a few yards away to a changing room and operating room, Dr. Glass says. "The whole experience for patients is more efficient and pleasant," he says.

Anesthesiologists are also working with generally healthy patients, rather than critically ill patients in a hospital. Since ASC patients tend to have fewer co-morbidities, the emphasis is more on a quick recovery and how to make the experience pleasant with the least impact to the patient.

2. Techniques are the same, but mentality is different. Techniques for administering anesthesia do not vary much from hospitals to surgery centers, Dr. Glass says, but considerations are different for each environment.

In ASCs, anesthesiologists can speak to their patients and reassure them about the minor nature of the procedure and anesthesia. "We like to walk our patients into the OR," he says. "That way, you don't feel like you're sick."

Anesthesia for outpatient procedures must also be quick to subside, so patients can wake up shortly after the procedure is finished. ASC anesthesiologists are also very aggressive with pain management and managing post-operative vomiting and nausea.

"We are geared toward getting the patient out in a positive way as soon as possible," he says. "This is not the same modus operandi in hospitals, which have different objectives."

ASC anesthesiologists, more than hospital-based providers, opt for propofol as an anesthetic because it is short lasting and an effective antiemetic.

3. Technology will bring new procedures. As surgical techniques and technology improve, procedures will continue to move from inpatient to outpatient settings, including to ambulatory surgery centers.

"What previously we were forced to do in the main hospital can, in many instances, now be done in the ASC environment," Dr. Glass says. "We will continue to see new technology moving patients toward an ambulatory environment."

It's difficult to predict which procedures are likely to receive approval for the outpatient setting, but Dr. Glass expects to see total joints being performed in ASCs in the near future. "The thing that is keeping them inpatient is the pain and the rehabilitation," he says. Once incision sizes can be reduced, the pain can be more easily managed and allow for ambulatory rehabilitation.

4. Not all patients are a good fit. Sleep apnea is becoming a more common condition for patients and requires a risk assessment prior to administering anesthesia.

Not all patients with the condition are good candidates for outpatient surgery. It depends on several factors, including the severity of the sleep apnea, the procedure being done and how long a center is willing to keep a patient in the recovery room.

"Each ASC needs to determine what level of risk they are willing to take from any given patient," Dr. Glass says.

Sleep apnea can be problematic during the procedure, but it also poses a risk to patients the day after surgery while they are recovering at home.

When performing anesthesia on a patient with sleep apnea, anesthesiologists could consider using regional anesthesia, rather than general, if the procedure permits. They could also opt for non-opioid narcotics for pain management and short-lasting sedatives.

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