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Current Controversies in Adult Outpatient AnesthesiaJeffrey L. Apfelbaum, M.D. Chicago, Illinois

103Page 1

Introduction

When the freestanding ambulatory surgery movement was initiated in the United States in 1970, therewas a need to establish a strong safety profile and credibility with all involved consumers, i.e., patients, physicians,and third party payors. Consequently, only "healthy" patients were acceptable candidates for ambulatory surgery.Today, the subspecialty of ambulatory anesthesia has progressed to the total complex care of a broad spectrum of surgical patients undergoing thousands of different procedures under all types of anesthetics. Several experts have predicted that by the end of this year, nearly 80% of all surgery performed in the United States will be done on anambulatory basis. The 21st century brings a new era of cost-containment to the arena of ambulatory surgery whichforces the practitioner of modern ambulatory anesthesia to reevaluate our practice patterns.This Refresher Course will provide an update on current controversial issues in adult outpatient anesthesia,including online preoperative evaluation, patient preparation and selection, the elimination of intensive postoperative care using short acting, fast emergence anesthetics, and an update on potential alternatives for perioperative pain management.

The Hows And Whys Of Preoperative Evaluation

The continued growth of outpatient surgery has created new potential roles for the anesthesiologist which seemingly demand skills in addition to "giving a good anesthetic."Particularly in the freestanding and office environments, it is often the anesthesiologist who is most involved in thedirect medical care of the patient; we are the physicians who must insure that the patient is appropriately screened,evaluated, and informed prior to the day of surgery. Indeed, the anesthesiologist/patient relationship whichsometimes develops often takes on a primary care quality. Although sometimes difficult to arrange, the preoperativeinterview and evaluation by a consultant anesthesiologist (particularly in high risk patients) can be extraordinarily beneficial. In addition to lessening anxiety about the surgery and anesthesia, in most cases, the anesthesiologist will be able to identify potential medical problems in advance, determine their etiology, and if indicated, initiateappropriate corrective measures. In most facilities, the goal is to resolve preoperative problems well in advance of the day of surgery, thereby minimizing the numbers of both cancellations and complications.At the present time, there are several commonly used approaches to screening patients for ambulatorysurgery. These include: (1) facility visit prior to the day of surgery, (2) office visit prior to the day of surgery, (3)telephone interviews/no visit, (4) review of health survey/no visit, (5) preoperative screening and visit on themorning of surgery, (6) computer assisted information gathering, and (7) the use of telemedicine technology. Eachsystem has its own advantages and disadvantages. Many currently available options will be presented during thelecture.

Should Patient Age or ASA Physical Status Influence Case Selection?

Although the vast majority of individualsscheduled for outpatient surgery are relatively healthy (ASA Physical Status 1 and 2), practitioners are constantly being pressured by third party payors to consider "simple outpatient surgery" for patients with significant baselinedisease. A survey of members of the Society for Ambulatory Anesthesia (SAMBA) published in the Spring of 2002, revealed that half the respondents felt that their practice “pushes the envelope of patient safety by performingoutpatient surgery on patients with serious pre-existing conditions,” and that 40% of respondents felt that their practice “pushes the envelope of patient safety by performing complex or lengthy surgical procedures onoutpatients.” In the past, many individuals had arbitrarily stated that freestanding ambulatory surgical facilities wereseverely limited in the type of patients they could anesthetize, particularly with regard to age and physical status.Clinical experience, however, suggests otherwise. In a retrospective study of over 1,500 cases of patientsanesthetized for ambulatory surgery, Meridy

was unable to demonstrate an age-related effect on the duration of recovery or the incidence of postoperative complications. Additionally, a retrospective review of cases performed atthe Methodist Ambulatory Surgicare Center in Peoria, Illinois between 1981 and 1985 demonstrated anunanticipated admission rate of 1.1% for patients over the age of 60 compared to an overall unanticipated admissionrate of 0.8%. With regard to the issue of physical status, in a prospective study involving over 13,000 patients at afreestanding ambulatory surgical center, Natof

concluded that ASA 3 patients whose systemic diseases were wellcontrolled preoperatively were at no higher risk for postoperative complications than ASA 1 or 2 patients.Furthermore, in 1987, the Federated Ambulatory Surgery Association (FASA) published the results of a surveyinvolving over 87,000 patients and concluded that there appeared to be little or no cause and effect relationship between pre-existing disease and the incidence of perioperative complications.

Chung examined predictors of adverse events in ambulatory surgery in the elderly, as well as factors contributing to prolonged stay after ambulatory surgery in elderly patients. This data demonstrated that outpatient surgery is safe in this patient population, with elderly patients sustaining more minor cardiovascular events than their younger counterparts, and

103Page 2less postoperative nausea and vomiting, pain, and drowsiness.

4,5

In summary, outpatient surgery is no longer restricted to young, healthy patients. Geriatric and higher risk (physical status 3 and 4) patients may be consideredacceptable candidates for outpatient surgery if their systemic diseases are well controlled and the patient’s medicalcondition is optimized preoperatively.

The Inappropriate Patient - Who's OK And Who's Not

There are few data to reliably categorize theinappropriate adult surgical outpatient. As anesthesiologists have become more experienced with the anestheticmanagement of the problem surgical outpatient, the list of "inappropriate" patients has dwindled. We mustindividualize our decision with regard to each patient; with few exceptions, the appropriateness of a case for outpatient surgery is determined by a combination of factors including patient considerations, surgical procedure,anesthetic technique, and anesthesiologist's comfort level.At the University of Chicago Hospitals, we have distinguished several groups of patients who may not beappropriate candidates for ambulatory surgery. As one might expect, this list is frequently modified to adapt to theever-changing conditions of our social and medicolegal environment.• Unstable ASA Physical Status 3 and 4: At the present time we are reluctant to proceed with elective ambulatorysurgery in a medically unstable patient. Instead, we use our perioperative medicine clinic to screen these patients,refer them to appropriate medical consultants, and, together with the primary care surgeon or interventionalist,establish a plan to proceed with the surgery or intervention after medical stabilization. Contrary to the original"ground rules" of ambulatory surgery, studies involving tens of thousands of patients seem to suggest that neither increasing age nor the presence of stable pre-existing disease affect the incidence of postoperative complications inthe surgical outpatient.• Malignant Hyperpyrexia: In our facility, overnight hospitalization and observation is usually indicated for patientswith a history of malignant hyperpyrexia or with identified susceptibility to malignant hyperpyrexia. However, patients who are well educated, have a good understanding of their disease process, and have ready access tomedical care may be treated as outpatients by some centers.• Complex Morbid Obesity/Complex Sleep Apnea: Although patients who have a history of sleep apnea or who aremorbidly obese without systemic disease are acceptable candidates for ambulatory surgery, we prefer overnighthospitalization and postoperative observation for morbidly obese surgical patients with pre-existing cardiac, pulmonary, hepatic or renal compromise or those patients with a history of complex sleep apnea. Practice guidelinesfor the perioperative management of patients with obstructive sleep apnea have recently been developed by theAmerican Society of Anesthesiologists and offer recommendations for preoperative evaluation, preoperative preparation, intraoperative management, postoperative management, and “site” of surgery (inpatient vs. outpatient).

• Acute Substance Abuse: Because of the increased likelihood of acute untoward cardiovascular responses whenone administers an anesthetic to a patient who has recently abused illicit drugs, we preoperatively counsel these patients and inform them that any sign of recent drug abuse on the day of surgery will result in immediatecancellation of their anesthetic. We tell them that no elective surgical procedure "is worth dying for" and encouragetheir preoperative participation in a rehabilitation program.Anesthesiology directed perioperative medicine clinics are used to optimize the medical condition of a patient in preparation for surgery. These clinics have been shown to enhance patient safety

, improve patientsatisfaction

, minimize preoperative consultation

, and reduce day of surgery case cancellations and case postponements.

Eliminating Intensive Post-Operative Care in Same Day Surgery Patients Using Short Acting FastEmergence Anesthetics

Newer anesthetics have the pharmacokinetic and pharmacodynamic advantages of ashorter duration of action and a more rapid rate of recovery, which permit a faster emergence from anesthesia.However, their use in routine clinical practice is often challenged because of higher drug acquisition costs. Showingthe value of these agents is required to increase their acceptance and foster further development. Less than 30 yearsago, it was unthinkable that patients would be able to return home on the day of surgery. Today, advances in surgeryand anesthesiology make it possible to perform up to the vast majority of all surgical procedures, safely andeffectively, on an ambulatory basis. In today’s cost sensitive healthcare environment, the processes of ambulatorysurgical care must be continually re-evaluated to take advantage of advances in medicine and to optimize theefficiency of the surgical center without detriment to patient safety and satisfaction.Traditionally, ambulatory surgical patients go from the operating room to an intensive care setting (postanesthesiacare unit (PACU) or recovery unit) for their immediate postoperative recovery from anesthesia and then to a secondstage recovery unit (SSRU) for preparation for home readiness. The PACU is traditionally an expensive, labor-intensive environment that monitors post surgical patients intensively. After a set of recovery criteria

11, 12, 13

are met

103Page 3in the PACU, the patient is usually transferred to the SSRU. In the SSRU, the patient-to-nurse ratio is considerablyhigher (i.e., nursing care in the SSRU is less labor intensive) than in the PACU. Only basic monitoring andobservation are performed as the patient and his or her escort are prepared for home readiness. Because of the rapidrecovery of patients undergoing anesthesia with this new class of anesthetics, some have questioned if allambulatory surgical patients need to receive intensive postoperative care in the PACU setting or whether recoveryfrom anesthesia can be achieved in the operating room. The SAFE study evaluates the impact of selective patient bypass of the PACU on both the outcomes of ambulatory surgical patients and the use of resources in the surgicalarena.

This study was designed to evaluate the rapid recovery of patients undergoing ambulatory surgery usingshort-acting, fast emergence anesthetic agents and to determine if policies and procedures could be developed thatwould allow patients to safely bypass first stage post-anesthesia care units (PACU) and whether such changes in therecovery paradigm would result in financial savings for the surgical center. Five community based facilities(hospitals or surgery centers) participated in this prospective observational study. While in the operating room at theend of the surgical procedure, anesthesiologists were instructed to assess all ambulatory surgical patients for recovery using standardizing discharge criteria typically used at the end of a PACU stay (Table 1). If the patient metthe discharge criteria, they were transferred from the OR directly to the less labor intensive second stage recoveryunit (SSR). Financial data were provided from all five sites detailing all costs associated with the recovery process.Clinical data on every elective ASA 1, 2 and 3 ambulatory surgical patient were collected over a three month time period. During month one, data collected established a baseline of case mix, time stamps, adverse events, bypassrates, and financial data at each site. During month two, an educational intervention was provided on a multi-disciplinary basis to all units in the surgical center discussing the implications of the bypass paradigm. After implementation of the paradigm (month three) weekly feedback reports were provided to the site featuring the keyoutcomes of the study, and these reports were distributed to the health care providers. Nearly 5,000 patients wereentered into the study. The overall bypass rate increased from 15.9% in the baseline month to 58.9% in the monthfollowing the educational intervention (p < 0.0001). The change in process in this study went beyond reducing timespent in the PACU to eliminating the time spent in the PACU while not increasing the time spent in the operatingroom or SSRU. In fact, the average (SD) time spent in the SSRU was significantly shorter for patients who bypassedthe PACU than for those who did not bypass the PACU. There were no significant differences in other parametersof patient outcome. Annualized savings ranged from $50,000 to $160,000 per site.The results of this study suggest that important cost savings can be achieved without compromising patientsafety after implementing a bypass paradigm. A team approach to an educational intervention and paradigmimplementation, along with objective, data driven, ongoing feedback to clinicians and administrators on patient and process outcomes were key factors in achieving the financial success experienced at each site.

How Well Do We Manage Postoperative Pain?

The International Association for the Study of Pain has definedthe word “pain” as “…an unpleasant sensory and emotional experience associated with actual or potential tissuedamage or described in terms of such damage.”

Acute pain is a complex and subjective response and may be produced in a wide variety of situations, including surgical settings, renal colic, and acute medical conditions. Acute pain, including “surgical” pain following ambulatory surgery results in a wide variety of physiologic changes,including the general neuroendocrine stress response, as well as secondary effects on the respiratory, cardiovascular,gastrointestinal, genitourinary, and musculoskeletal systems. Inadequate pain relief is believed to lead to significantdeleterious outcomes; relief of post-surgical pain may, in and of itself, play a major role in mediating post-operativeresponses.As the subspecialty of ambulatory anesthesia has expanded to include the total complex care of a broadspectrum of surgical patients, practitioners have been challenged to improve their perioperative pain managementtechniques. Despite development of the Agency for Health Care Policy and Research (AHCPR) guidelines on acute pain management, a survey conducted one year after issuance indicated 77% of patients still experienced pain postoperatively.

We have recently completed a similar survey which demonstrated that 80% of patientsexperienced pain after discharge, with 82% of those patients reporting their pain was moderate, severe or extreme.

Patient preference for future care was also assessed; interestingly, the vast majority of patients preferred a non-opioid (67%) vs. an opioid (17%), with 16% expressing no preference.

COX-2 – The Next Generation of NSAIDs?

In the early 1970’s, Sir John Vane hypothesized that nonsteroidalanti-inflammatory drugs (NSAIDs) act by inhibiting the catalytic activity of the enzyme cyclooxygenase (COX). In1991, Needleman discovered that 2 isoforms of COX exist (COX-1 and COX-2) COX-1 is expressed constitutivelyand is always present in the GI tract (arachidonic acid metabolites preserve gastric mucosa and limit acid secretion),