SPECIAL CONSIDERATIONS

Office-Based Anesthesia

Office-based anesthesia is simply a variant of ambulatory anesthesia that has attracted growing interest around the world.^[550] Ralph Waters opened the first office-based anesthetic practice (the Downtown Anesthesia Clinic) almost 100 years ago in Sioux City, Iowa. In response to an occasional call from a dentist for anesthesia, Dr. Waters set up "a modest office with a waiting room and a small operating room with an adjoining room containing a cot on which a patient could lie down after his anesthetic before going home."^[25] In a recent series involving over 30,000 office-based ENT procedures with 72% receiving "deep sedation" or general anesthesia, the complication rate was only 1.3% and only two patients required overnight hospitalization.^[551] In a recent chart review of over 4000 consecutive patients who had undergone office-based surgery with MAC, postoperative complication rates were less than 0.1% and only 2 patients required overnight hospitalization.^[552]

For many years, simple minimally invasive surgical procedures have been performed in physicians' offices. Certified registered nurse anesthetists, dental anesthesiologists, and increasingly, practicing anesthesiologists have been active in office-based surgery. It is currently estimated that only 5% to 10% of outpatient surgical procedures are performed in the office setting, and this number is anticipated to approach 20% by 2010. As pressure from third-party payers to reduce the overall cost of surgical procedures continues to increase, surgeons and anesthesiologists are moving cases to facilities where they have more direct control over costs. For example, a cost comparison of laparoscopic inguinal herniorrhaphy was performed by Shultz, who reported that the total cost for this procedure in the hospital was $5494 versus $1534 in an office facility.^[553] Similarly, the hospital-based fee for a conventional "open" inguinal herniorrhaphy was $2237 versus $895 in an office facility.

Office-based facilities have lower overhead than hospital or freestanding ambulatory surgical centers do and are comfortable and convenient for patients, which has contributed to the growing interest in office-based surgery centers. It is important to select patients appropriately

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The optimal anesthetic techniques for office-based surgical procedures are similar to those used for hospital-based and freestanding ambulatory surgery procedures. Most procedures involve the use of local anesthesia supplemented with intravenous sedation or "light" general anesthesia and an LMA or facemask for airway management.^{[318] [501] [502] [554]} Propofol is used for providing sedation, as well as for induction and maintenance of anesthesia, along with sevoflurane and desflurane. Nitrous oxide was shown to decrease the propofol requirement and allow patients to be discharged within 60 minutes after the procedure without increasing the incidence of PONV. Because most office suites do not have stretchers or recovery beds, patients have to be able to get up from the operating room table and transfer themselves (with assistance) to a reclining chair or ambulate to an area where they can rest until they are ready to get dressed and go home.

Although the modern practice of office-based anesthesia is relatively new in the United States, a similar practice of office-based dental anesthesia has been in place for several decades in the United Kingdom. After a review of several anesthetic deaths in dental offices in the United Kingdom, it was recommended that all anesthetics be administered by an accredited anesthesiologist whose training included specific experience in dental anesthesia.^[554] There were also recommendations regarding resuscitation equipment and the availability of drugs needed for emergency use. In the years after publication of the Poswillo report, the number of dental offices offering general anesthesia for office-based procedures significantly decreased.^[555] The high cost required to equip and maintain such locations was the main reason for this change of practice in the United Kingdom. Based on the U.K. experience, it is obvious that if office-based anesthesia is going to be successful in North America, issues other than cost must be considered.^[27]

Office-based surgery practice guidelines established by the ASA, the American Association of Nurse Anesthetists, and JCAHO include the following:

1. Employment of appropriately trained and credentialed anesthesia personnel
2. Availability of properly maintained anesthesia equipment appropriate to the anesthesia care being provided
3. As complete documentation of the care provided as that required at other surgical sites
4. Use of standard monitoring equipment according to the ASA policies and guidelines
5. Provision of a PACU or recovery area that is staffed by appropriately trained nursing personnel and provision of specific discharge instructions
6. Availability of emergency equipment (e.g., airway equipment, cardiac resuscitation)
7. Establishment of a written plan for emergency transport of patients to a site that provides more comprehensive care should an untoward event or complication occur that requires more extensive monitoring or overnight admission of the patient
8. Maintenance and documentation of a quality assurance program
9. Establishment of a continuing education program for physicians and other facility personnel
10. Safety standards that cannot be jeopardized for patient convenience or cost savings

Beyond their responsibility to provide safe care in the office, modern-day office-based anesthesiologists have an opportunity to expand their role as perioperative physicians. This practice has the potential to heighten public awareness of the vital role of anesthesiologists in the ambulatory setting and enhance the professional image of our specialty.^[556] Patients must be confident that the office setting adheres to the same standards of care required in a hospital-based or a freestanding ambulatory surgery facility.