FUTURE PERSPECTIVES

Advances in anesthetic and surgical practices have facilitated the rapid growth in ambulatory surgery throughout the world.^[591] With the availability of rapid, short-acting anesthetic, analgesic, sympatholytic, and muscle relaxant drugs, as well as improved cerebral monitoring techniques, it has been possible to minimize the adverse effects of anesthesia on the recovery process. Improvements in the perioperative care of outpatients has allowed surgeons to perform an increasing array of more invasive surgical procedures on an ambulatory (day-case) basis.

Major surgical procedures (e.g., extensive knee and shoulder reconstruction, laparoscopically assisted vaginal hysterectomy, gastric fundoplication, nephrectomy, splenectomy, and adrenalectomy) are routinely performed at many ambulatory centers around the world. Even patients undergoing carotid endarterectomy, pulmonary lobectomy, prostatectomy, and minor craniectomy procedures are being discharged on a same-day (or 23-hour admit) basis. Although it is commonly assumed that the primary reason for the continued expansion in ambulatory surgery is related to pressure from third-party payers and governmental agencies to reduce health care costs, there may be other less obvious benefits for patients and their families. More aggressive rehabilitation leads to faster recovery of organ function, fewer surgical and anesthetic complications, reduced mental and physical disability, and most importantly, earlier resumption of normal activities (e.g., return to work). For patients "at risk" for hospital-acquired infections (e.g., immunosuppressed patients), ambulatory surgery may also reduce postoperative infectious complications.

As perioperative physicians, anesthesiologists can play an important role in facilitating ambulatory (and short-stay) surgery by actively becoming involved in the preoperative, intraoperative, and postoperative care of this expanding patient population. To achieve the desired outcome, careful consideration must be given to each phase of the ambulatory surgical process.

First, it is important to ensure that all patients are in "optimal" medical condition before their elective operation. Recent changes in NPO policies ^[592] have allowed patients to continue taking chronic medications and avoid the uncomfortable symptoms of dehydration, hypoglycemia, and caffeine withdrawal. In addition, oral premedication with preventive analgesics (e.g., rofecoxib, 50 mg) can improve pain control during the postoperative period. The use of small doses of sedative-anxiolytic drugs for premedication has been found to improve the perioperative experience of patients without adversely affecting the recovery process.

Second, the use of anesthetic techniques that optimize intraoperative surgical conditions while providing for rapid early recovery ("fast-tracking") has assumed increased importance in the current health care environment.^[515] The introduction of more rapid and shorter-acting volatile anesthetics (e.g., desflurane and sevoflurane) and opioid analgesics (e.g., remifentanil) has allowed practitioners to more consistently achieve a recovery profile that facilitates "fast-tracking" after general anesthesia. The use of cerebral monitoring can improve titration of maintenance anesthetics and thereby facilitate the early recovery process. Although recovery after central neuraxis blockade is improved by decreasing the local anesthetic dosage and adding a potent opioid analgesic, discharge times are still prolonged in comparison to general anesthesia or local anesthesia with sedation. Increasingly, practitioners are turning to MAC as an alternative to both general and regional anesthesia. The availability of drugs such as propofol, alfentanil, remifentanil, and dexmedetomidine has clearly improved the intraoperative conditions for patients undergoing more extensive surgical procedures with local anesthesia.

Third, preventing postoperative pain and other untoward side effects is critical to successfully implementing a fast-track program in the ambulatory setting and facilitating earlier resumption of normal activity. The use of a multimodal approach to preventing postoperative pain will decrease the dependence on opioid analgesics. NSAIDs (e.g., ketorolac, diclofenac, COX-2 inhibitors) and other nonopioid analgesics (e.g., local anesthetics, acetaminophen, ketamine, clonidine) have assumed an increasingly important role in controlling pain after ambulatory surgery. Similarly, the use of prophylactic antiemetic drugs can be extremely helpful in facilitating the recovery process and improving patient satisfaction. Multimodal strategies for minimizing side effects after surgery have assumed even greater importance because of rapid expansion of the variety of surgical procedures performed in the ambulatory setting.^{[524] [593]}

Finally, providing patients and their families with information on how to avoid problems after discharge will also facilitate the rehabilitation process. The importance of discussing the implications of undergoing surgical procedures on an ambulatory basis with the patient and family before the operation will also increase acceptance and patient satisfaction with early ("fast-track") discharge. As perioperative physicians, anesthesiologists will be required to assume an increasingly important role in minimizing postoperative pathophysiologic changes and facilitating the rehabilitation process. To optimize patient outcome, a care team approach involving the patient, the patient's family, the nursing staff, and the surgeon and anesthesiologist is essential. As more extensive surgical procedures are performed on an ambulatory basis, more innovative "multimodal" approaches to providing post-discharge recovery care will be required.^[593] As the emphasis in health care shifts towards so-called value-based care, it is increasingly apparent that ambulatory surgery provides the best outcome at the most reasonable cost.