ANESTHESIA UPDATE:

ANESTHESIA UPDATE:
Exploring Current Trends in ASCs

By Kris Ellis

A significant component of the effort to provide quality patient care for any ambulatory surgery center (ASC) involves excellent anesthesia services. From the initial decision as to whether or not a case will be accepted through patient discharge, anesthesia practices and considerations weigh heavily on outcomes. Consequently, ASCs must be acutely aware of the ways in which anesthesia-related issues can impact their practices. From the anesthesiologist’s perspective, inherent differences from the hospital environment create several concerns in terms of emergency preparedness. “Part of it is that you’re isolated from the rest of the clinical world in the sense that if you have to draw on extra resources quickly, it can be difficult,” notes D. John Doyle, MD, PhD, FRCPC, former president of the Society of Airway Management and a staff anesthesiologist in the Department of General Anesthesiology at Cleveland Clinic Foundation. “In a large center like the Cleveland Clinic for example, if we have a problem, we can get a deluge of clinical help simply by pushing the red button — people will come down in droves and help you out.”

In this case, additional personnel who can handle vital tasks such as starting an IV, helping with the patient’s airway, drawing up necessary medications, and retrieving equipment could make all the difference in managing a crisis. “In a surgery center type environment, that may be more problematic, because you may be the person who has to do everything,” Doyle continues. “If you need special equipment like a fiber optic bronchoscope, because there are so many ORs in a big center, that tends to be readily available, but if you’re in a small ASC, you may not have as many resources as the big institution, so for example, there may be only one fiber optic bronchoscope, or even none, and if you want one, that may be a problem. That’s a unique challenge.”

In terms of potential emergencies, ASCs should be prepared for the worst and expect the best, according to Neil Gordon, MD, medical director of the New England Surgical Center at The Retreat at Split Rock, as well as clinical instructor of surgery at Yale University School of Medicine. “You can’t wait for an issue to occur to worry about whether or not you’re prepared for it,” he says. “What you have to look at as an ASC is, what do I need to keep the patients safe and stable and to get them to a different facility if they need that? So you need to look at things like appropriate cardiac medications, defibrillators, and life support machines and/or medications that can take care of any life crises. Malignant hyperthermia is also a classic anesthesia complication that you need to be prepared for.”

Oftentimes, patient safety is dependent upon on the ability of ASCs to choose their patients wisely. “Patient safety is not an unknown and it’s not a variable issue,” Gordon says. “The most important thing is patient selection; taking pre-screened patients for elective surgery is of the utmost importance.”

Marc Koch, MD, MBA, president and chief executive officer of Somnia, Inc., emphasizes that determining the suitability of a candidate for surgery is a multi-dimensional process that involves asking the right questions, such as:

• What surgery is being performed?
• Where is the surgery being performed — is it an office setting or a state-licensed surgery center?
• What is the proposed anesthetic?
• What is the health status of the patient?
• Does the patient have a history of alcohol or substance abuse?

“If you take a look at the nexus of those four items, it will guide you in terms of whether or not that setting is appropriate for that patient,” Koch says. “You may have somebody who is very elderly undergoing a foot surgery in an office-based setting, and if it’s being done under straight local anesthetic, it may be viewed very differently than a knee arthroscopy done under general anesthesia in an ASC. You have to take a look at those four variables and how they interplay.”

“The first thing you have to look at is the medical necessity of the procedure,” Gordon says. “Are we doing an elective cosmetic procedure, or are we doing a non-elective procedure that can be done in an outpatient setting? If we’re differentiating from an ASC vs. a hospital, then you have to look at what would create a potential for a patient to need an overnight stay. If the procedure that you’re doing — the type, the anesthesia that’s required — would be very unlikely to produce an overnight stay, then it’s an appropriate patient to do in an ASC.”

For instance, Gordon explains that it is not uncommon for a facial cosmetic procedure to take up to six hours surgically. “But because the anesthesia requirements are fairly low, meaning they can use intravenous propofol, and the patients are pre-screened and appropriate for the procedure, and there are other inherent safeguards — being able to use warming blankets, being able to use compression stockings to prevent pulmonary embolisms — these patients actually do very well over an extended period of time and routinely leave the facility without the need for inpatient care.”

Looking exclusively at the duration of a procedure can be misleading, however. For example, a shorter duration surgery that is more invasive and may require a higher level of anesthesia or create more potential issues might not be an ideal case to do in an ASC. “That’s where you have to look at it from a procedure-specific, patient-specific perspective and define who’s appropriate and who’s not,” Gordon continues. “It’s fluid — it’s a continuum now; what’s appropriate in 2005 may not have been in 1995. With improvements in anesthesia medications, care, and technique, as well as surgical technique, there are things that are appropriate today that may not have been a decade ago.”

The anesthesiologist’s evaluation of a patient’s health status, involves several specific points that may factor in to his or her approach. “You want to go over past medical history, organ system by organ system, past surgical history along with any anesthesia problems that they’ve had, as well as the family history in terms of any adverse events to anesthesia,” Koch notes. “You also want to review what medications they’re currently on along with doses and routes of administration, and any allergies they may have.” Herbal remedies must be taken into consideration as well. “Oftentimes a patient may be taking echinacea or St. John’s Wort, and those things can have an impact. For instance, St. John’s Wort may affect clotting. If they’re taking high doses of certain vitamins, it can also impact clotting.”

Koch explains that the scope of pre-operative testing should be determined by factors that will affect outcomes. “I think it’s important for every doctor or CRNA (certified registered nurse anesthetist) to evaluate what tests are going to make a difference,” he says. “Is a chest X-ray on a 60-year-old person going to make a difference in the anesthesia intervention, is it going to change the outcome of the surgery? Is getting a full battery of blood chemistries going to impact the surgery or the anesthesia for, let’s say, a rhinoplasty?”

However, Koch notes that for a patient who has kidney disease the outcome may be impacted by getting blood chemistries. Similarly, a chest X-ray may be necessary for a patient with lung problems. “It’s taking a look at the patient as a whole, their health status; what tests you order should clearly be ordered with an eye on impacting outcomes.”

Regulation of ASCs is one issue that presents concerns from the anesthesiology perspective. Because of the broad spectrum of services available at different ASCs, generalizing can be problematic. “Regulation based on factors such as how long it takes to perform the surgery may not be taking the whole story into consideration, Gordon contends. “For instance, they look at American Society of Anesthesiologists (ASA) classes sometimes, and to say that you can’t do an ASA III or higher in an ASC — those things are not necessarily accurate because there are some stable conditions that can make you an ASA III that can make you a fine candidate, whereas there are many ASA IIIs that would not be good candidates,” he explains. “What you have to be able to do is look on a case-by-case basis; it’s very difficult to regulate, yet regulations are occurring and there’s not a lot of data to support what we’re regulating and how.”

For instance, Gordon explains that some states do not allow operations longer than four hours outside of a hospital. “If you have a six-hour operation, and you analyze the risks involved with the operation and you find the biggest risks are intubation and extubation,” he says. If two three-hour operations are done to stay within regulations, two instances of intubation and extubation are now required, instead of only one. “So you’ve actually increased your risk,” Gordon concludes. “That’s why our unique data to really understand what creates risk and what doesn’t is important — different surgeries have different risk profiles and some of the other things that we’ll tend to look at, for example a patient’s age or how long the operation takes, are not necessarily factors that influence problems or morbidity.”

Increasing rates of obesity in the United States will continue to pose a challenge in terms of patient selection and airway management, according to Doyle. “Difficult airways happen all of the time in the real world,” he says. “We face a problem in that a good deal of our patients are potentially difficult from an airway management point of view simply by virtue of their excess pounds.”

This is just one dilemma that ASCs face as far as deciding which patients are acceptable for surgery. “What about the patient who you suspect to be difficult to intubate but is otherwise healthy — should you simply refuse them?” Doyle asks. “Or should you say you need to be especially well prepared, and what does that constitute? What about people who are excessively obese, whatever that is? What about people who are simply frail by virtue of illness or age? What’s the maximum age you’d accept for people undergoing a simple procedure?”

Ultimately, ASCs must navigate these issues based on the resources available to them and on their comfort level in terms of dealing with potentially difficult situations. “It would be nice if there were specific guidance available in the way of standards, recommendations, and consensus statements, but for a variety of reasons, such resources are not readily available,” Doyle says. “Part of it is people say, ‘Well if we establish these standards, then we don’t allow for clinical judgment.’ Or if there’s a violation of the standards, then you’re set up for a lawsuit. It gets complicated. If you say we’re not going to anesthetize anyone over 300 pounds, for example, well what about the guy who’s 290? It introduces all sorts of complexities and gray areas, which of course we’re used to in medicine.”

Koch notes that excellent resources do exist to offer guidance for anesthesia issues, however. “The ASA and the Society for Ambulatory Anesthesia (SAMBA) have been and continue to be real assets to the people who practice ambulatory surgery and outpatient anesthesia,” he says. “They are frequently discussing these things and, as a conduit of information provide every single practitioner of anesthesia and outpatient surgery a great opportunity to learn about the latest and greatest findings.”

Doyle points out relevant issues such as airway management will be on the agenda for SAMBA’s mid-year meeting this month. “One of the talks deals with supraglottic airways, and the laryngeal mask airway is one class of supraglottic airways,” he says. “There are new supraglottic airways becoming available, and they may make airway management more straightforward, either because you go directly to a supraglottic airway like a laryngeal mask, or because if you run into trouble with intubation you can switch to a supraglottic airway.”

Other discussions at the meeting, scheduled for Friday, Oct. 21, 2005 in New Orleans, cover topics such as ASC patient selection, administrative aspects of ASCs, and malignant hyperthermia.

Please click here to go to part 2.