Office-based anesthesia is expanding. At the present time, there has not been a good review of what is needed for those who practice anesthesia in the office. Drs. Fred Shapiro, Nathan Punwani, Noah Rosenberg, Arnaldo Valedon, Rebecca Twersky and Richard Urman, from various institutions around the United States, are individuals who do both office and ambulatory surgery and are leaders in the field. Their review, titled “Office-Based Anesthesia: Safety and Outcomes,” is published in this month’s issue of Anesthesia & Analgesia.
As the authors note, offices might not have the same resources as a hospital or an ambulatory surgical center. One retrospective study analyzed adverse events that were reported to the Florida Board of Medicine from 2000 to 2002. This study provided data showing that the risk of complications from office-based surgery (OBS) and office-based anesthesia (OBA) was more than 10 times higher than for ambulatory surgery centers (ASCs). Others have not corroborated these same findings, and the total number of procedures (the denominator) may have been too low. Other studies have shown similar risk for procedures performed in a physician’s office facility, an ASC, or a hospital. Accreditation would make outcome more transparent to the public. Some states are mandating accreditation of office-based practices. If a board-certified anesthesiologist cares for these patients in a hospital, an ASC, or an office-based setting, would or should the outcome be any different?
The right type of patient should be selected for procedures performed in an office and each office should have appropriate standards that include an assessment of a patient’s medical history, family history, current medications, drug or latex allergy, deep vein thrombosis, pulmonary embolus risk, and social and psychological history. Patients with risk factors such as morbid obesity, obstructive sleep apnea, recent myocardial infarction, etc., should be deferred to ambulatory surgical facilities or hospitals. Screening questionnaires can help identify at-risk patients.
Appropriate procedures should be selected for the office based anesthesia. For example, procedures associated with significant blood loss or severe postoperative pain should not be performed in a physician’s office facility. Procedures with the possibility of extended recovery time should also not be performed. In addition, the intent should be for the patient to be discharged to home, not to a hospital. Liposuction procedures may be associated with higher risk, particularly if they are combined with another procedure such as abdominoplasty, or if the total operative time is long, e.g., longer than 5 hours. Also, the risk of thrombosis or pulmonary embolus is higher for certain cosmetic procedures, especially abdominoplasty.
Backup power and dedicated suction should be available. If inhaled anesthetics are used then gas scavenging should be available. No anesthetic drug has been shown safer than another. Long-acting antiemetics would be appropriate.
Quality improvement and outcome monitoring are just as important in the office as they are in other anesthetizing locations.
Office-based anesthesia can be delivered safely, provided that a trained anesthesia provider provides the care, and the anesthesia provider adheres to the ASA guidelines for safe anesthesia care, including personnel, patient evaluation, monitoring, equipment, and availability of equipment and support for resuscitation if necessary.
More study is needed to help define what characteristics of an office-based practice maximize safety.