Office-Based Anesthesia - UpToDate

Office-based anesthesia - UpToDate 17/01/23, 6:18
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Office-based anesthesia
Authors: Fred E Shapiro, DO, FASA, Brian M Osman, MD
Section Editor: Girish P Joshi, MB, BS, MD, FFARCSI
Deputy Editor: Nancy A Nussmeier, MD, FAHA
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Dec 2022. | This topic last updated: Apr 09, 2021.
INTRODUCTION
The number of elective surgical procedures performed in an office-based setting has

expanded rapidly. In part, this shift is due to newer surgical and anesthetic techniques that
have allowed more invasive procedures to be safely performed in non-hospital settings. Also,
more medically complex patients are now receiving office-based anesthesia. In the United
States, the proportion of all outpatient surgical procedures performed outside a hospital
setting has increased from <10 percent in 1979 to approximately 60 percent, with 15 to 20
percent performed in office-based settings [1].
This topic will review potential advantages and concerns, patient and procedure selection,
and anesthetic and postoperative management of patients undergoing procedures in office-
based settings.
OFFICE-BASED PROCEDURES DURING THE COVID-19 PANDEMIC
While only urgent and emergency surgical and other interventional procedures were
performed initially during the novel coronavirus disease 2019 (COVID-19) pandemic, elective
procedures, including office-based procedures, have been resumed in many institutions.
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Strategies to minimize infection risks during anesthesia and surgery vary according to local
resources and institutional protocols. Details regarding preoperative planning and
intraoperative management during the COVID-19 pandemic are available in a separate topic
[2-4]. (See "COVID-19: Perioperative risk assessment and anesthetic considerations, including
airway management and infection control".)
POTENTIAL ADVANTAGES AND BENEFITS
● Advantages – Potential advantages of performing procedures in an office-based

setting include [1,5,6]:
• Patient-specific advantages – Patient convenience with perception of greater

personal attention and privacy.
• Surgeon-specific advantages – Surgeon convenience with perception of greater ease

of scheduling, consistency in nursing personnel, and efficiency.
• Institutional advantages – Cost containment compared with hospital settings.

However, patient selection is important to avoid losing this advantage (eg, patients
who are more likely to require urgent or emergency care in the postoperative period
or hospital readmission). (See 'Patient selection' below.)
● Benefits – Potential benefits when procedures are performed in an office-based setting

include [5,7,8]:
• Possibly lower nosocomial infection rates
• Decreased thromboembolic complications
• Quicker postoperative mobilization, which may reduce complications
• Earlier physical therapy and rehabilitation
• Greater patient satisfaction
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SAFETY CONCERNS
Safety concerns have centered around the adequacy of individual facility resources and
governmental regulations for office-based facilities.
Adequacy of facility resources — Appropriate resources (eg, personnel, equipment,

medications, space) for performance of specific surgical procedures are necessary in an
office-based facility, particularly as more invasive and time-consuming interventions are
being offered in such settings [1,9].
Access to adequate resources may be critically important when procedural or anesthetic

complications occur [10]. Office-based facilities should have personnel, equipment, and
drugs to initiate treatment of any crisis situation including unanticipated difficult airway,
anaphylaxis, local anesthetic systemic toxicity, malignant hyperthermia [MH]), or major
cardiovascular events including cardiac arrest. The facility should stock difficult airway tools
(videolaryngoscopes), defibrillators, emergency drugs for advanced cardiac life support
(ACLS), and 20% lipid emulsion to treat systemic toxicity of local anesthetics. Furthermore,
drugs for MH crisis should be immediately available (eg, either dantrolene or its newer
preparation Ryanodex, which is easily reconstituted with 5 mL sterile water and administered
in less than one minute by a single healthcare practitioner) if any triggering agent such as
succinylcholine (SCh) or volatile inhalation anesthetics are stocked at the facility ( table 1).
Cognitive aids for management of these crises should also be immediately available [11], as
discussed in detail in a separate topic. (See "Cognitive aids for perioperative emergencies".)
Responsibilities for anesthesiologists planning to practice in office-based settings include

preanesthetic inspection of all anesthesia and emergency equipment ( table 1) (see
'Professional society guidelines' below and 'Anesthetic management' below). Also,
examination of the entire anesthesia work area is performed to ensure that space
requirements are met. Discussions with the perioperative team are important to ensure that
established policies and procedures regarding fire, safety, drugs, emergencies, staffing,
training, and unanticipated patient transfers are in place and up to date, and that compliance
with all applicable federal and state laws, codes, and regulations has been achieved
( table 2) [1]. (See 'Government regulations' below.)
Government regulations — Office-based facilities are typically subject to a lesser level of

state and federal regulations compared with hospitals and other ambulatory surgery
facilities [1,10,12]. Accreditation of office-based facilities allows a third party to monitor
activities and provide external benchmarking, validation, and acknowledgment of a
nationally recommended standard of care. However, state laws vary, and many lack
regulations specific for office-based settings [1,9,10].
Since the types of procedures and patient populations eligible for an office-based setting are
increasing in number and complexity, additional regulations have been implemented by
accreditation and state regulatory agencies, although uniformity and evidence-based
standards of care are lacking [10]. For example, the New York Department of Health has
mandated that office-based surgery practices must provide continuous monitoring of end-
tidal carbon dioxide using capnography during moderate or deep sedation, as well as during
general anesthesia, consistent with the 2018 American Society of Anesthesiologists (ASA)
practice guidelines for moderate procedural sedation and analgesia [13,14]. However, not all
states have this mandate.
Other differences in state regulations exist. For example, although patients may develop MH
after exposure to a triggering anesthetic agent (see "Malignant hyperthermia: Diagnosis and
management of acute crisis"), guidelines presented in 2017 by the Society for Ambulatory
Anesthesia (SAMBA) recognize that this is unlikely in office-based facilities that perform
procedures exclusively with oral or intravenous sedatives/analgesics ("class B" facility) [15].
Such facilities typically do not stock dantrolene, the antidote for MH, because no known
triggers (eg, volatile inhalation anesthetic agents) are used in the facility. Since SCh is
considered a trigger for MH, many such facilities do not stock SCh. However, SAMBA's
position statement notes that the risk of losing a patient's airway and needing appropriate
drugs such as SCh to manage this emergency exceeds the risk of an MH event [15]. Thus,
some accreditation and state regulatory agencies now allow facilities to stock SCh to manage
emergency airway rescue without requiring they also stock dantrolene to manage MH.
Professional society guidelines — We use guidelines for office-based anesthesia adopted

by the ASA, which emphasize that standards for anesthetic care in an office should be the
same as those in hospitals or ambulatory surgery centers (ASCs) [16]. These guidelines
address patient selection, monitoring, perioperative care, and facility management
( Guidelines for Office-Based Anesthesia), as well as qualifications of anesthesia providers,

training, and credentialing in this setting ( Statement on Qualifications of Anesthesia
Providers in the Office Based Setting), and distinguishing monitored anesthesia care (MAC)
from moderate sedation/analgesia (ie, conscious sedation) [14,17]. Guidelines also address
the need for qualified personnel being present for the entirety of the procedure until the
patient has been discharged from anesthesia care, documentation of the discharge decision
by a responsible clinician, and immediate availability of personnel with training in ACLS
and/or pediatric advanced life support (PALS) [1,16]. Ongoing training of office-based
personnel is emphasized so that rare emergencies will not overwhelm staff capabilities.
Similar professional society guidelines emphasizing core patient safety principles for office-
based surgical procedures have been endorsed by the American College of Surgeons (ACS)
[18], the World Federation of Societies of Anaesthesiologists (WFSA) [19], and some state
medical societies [20].
Use of checklists
Routine checklists and briefings — Use of checklists with an incorporated briefing such as

the World Health Organization (WHO) surgical safety checklist helps ensure that safety
measures are followed ( table 3). Other organizations have developed other checklists (eg,
the Association of periOperative Registered Nurses [AORN], the American
Gastroenterological Association [AGA], the American College of Gastroenterology, and the
American College of Surgeons) [21]. The Institute for Safety in Office-Based Surgery (ISOBS)
has developed a checklist that is based on the WHO surgical safety checklist but is specifically
adapted to the needs of an office-based setting ( form 1) [22,23]. Checklists that actively
involve the patient may increase satisfaction, decrease medical liability claims, and improve
thoroughness of medical care by empowering the patient to participate in his or her own
health care [4,24]. (See "Safety in the operating room", section on 'Briefings' and "Safety in
the operating room", section on 'Checklists'.)
A single-center study in a plastic surgery office-based setting demonstrated a reduced

complication rate from 15.1 to 2.72 per 100 patients after implementation of a safety
checklist [25]. However, in one survey, only 50 percent of office-based surgical practices
reported using a safety checklist [26]. Those not using checklists cited several obstacles to
their implementation (eg, no incentive to use a checklist, no mandate from a local or federal
regulatory agency, too time-consuming, lack of training).
Crisis checklists — Crisis checklists (also termed cognitive aids or emergency manuals)

have been developed to manage relatively rare crisis situations that may occur during any
surgical and other interventional procedures. These could be lifesaving during an emergency
in an office-based setting by ensuring that best practices are followed and no critical steps
are missed [4]. A set of such aids should be immediately available. An example is the 2018
ISOBS emergency manual customized to be specific for office-based settings (available at the
Emergency Manuals Implementation Collaborative website), which is designed to deal
with the most commonly encountered emergencies [11,27]. (See "Cognitive aids for
perioperative emergencies".)
Details regarding management of specific crisis situations can be found in separate topics:
● (See "Management of the difficult airway for general anesthesia in adults".)

● (See "Perioperative anaphylaxis: Clinical manifestations, etiology, and management".)
● (See "Local anesthetic systemic toxicity".)
● (See "Malignant hyperthermia: Diagnosis and management of acute crisis".)
● (See "Advanced cardiac life support (ACLS) in adults".)
● (See "Fire safety in the operating room", section on 'Management of a fire'.)
PATIENT SELECTION
Selection of appropriate patients for office-based anesthesia is an important decision that is

made jointly by surgeons and anesthesiologists [1]. A gradual transition to performing office-
based procedures in more medically complex patients has occurred, which may increase
patient and provider liability risks [1,28,29]. Although the ideal patient for an office-based
procedure has an American Society of Anesthesiologists (ASA) physical status (PS) of I or II
( table 4), nearly one-third of patients served in this setting in 2014 were ASA PS III [28].
Use of a detailed screening questionnaire completed by the patient may help to ensure a
thorough risk assessment [30]. Subsequently, review of the patient's medical records
includes evaluation for medical conditions that may confer unacceptable risk in an office-
based setting [10,31]. Since nearly all office-based procedures are elective, the
anesthesiologist has time to consider whether medical management of certain conditions is
optimal (eg, asthma, anemia) before surgery. All appropriate testing should be completed
and available before or on the day of the scheduled procedure. (See "Preoperative evaluation
for anesthesia for noncardiac surgery" and "Preoperative medical evaluation of the healthy
adult patient".)
The demand for office-based procedures for patients with challenging comorbidities may
exceed the qualifications of some office-based surgical teams, particularly if there would be
limited availability of additional personnel for management of an emergency. Thus, higher-
risk patients or procedures should ideally be performed in facilities that are formally
accredited (eg, by the American Association for Accreditation of Ambulatory Surgical Facilities
or the Accreditation Association For Ambulatory Health Care), and should be performed by
board-certified surgeons who are credentialed for the same procedures at a local hospital
[1,32-36]. (See 'Government regulations' above.)
Identification of poor-risk patients — Identifying patients at higher risk for complications

during anesthesia and surgery is important. In some cases, ensuring optimal medical
treatment may reduce risk [10]. In other cases, the patient should be referred to a facility
able to handle complications that may occur [16].
In a retrospective study of more than 1.4 million ambulatory surgery patients in

Massachusetts and New York states, comorbidities that predicted a higher likelihood of
unplanned hospital admission included malignancy, drug abuse, moderate or severe renal
failure, deficiency anemia, depression, congestive heart failure, liver disease, peripheral
vascular disease, diabetes, and chronic pulmonary disease [37]. Other examples of high-risk
abnormalities or conditions include a potentially difficult airway, obstructive sleep apnea,
morbid obesity, recent myocardial infarction within the past six months or recent stroke
within the past three months, sickle-cell disease, abnormal bleeding or clotting tendency,
inability to cooperate due to severe anxiety or poorly controlled psychiatric problems, history
of anaphylaxis, or family history of malignant hyperthermia (MH) [1,3,10,38,39]. General
perioperative considerations for these and other comorbidities are summarized in our topic
addressing preanesthetic evaluation for noncardiac surgery (see "Preoperative evaluation for
anesthesia for noncardiac surgery", section on 'Conditions that increase perioperative risk'),
and detailed discussions for each abnormality or disease can be found in various UpToDate
topics.
Other reasons for rescheduling procedures — Other factors that may prompt rescheduling
of an otherwise suitable patient on the day of surgery include active infection, acute
exacerbation of a comorbid condition, failure to abstain from ingestion of food or clear
liquids for an appropriate amount of time ( table 5) (see "Preoperative fasting in adults"),
suspicion of acute substance intoxication, or absence of a planned escort for transport after
discharge.
PROCEDURE SELECTION
The planned procedure is a factor in determining whether a patient can safely undergo
surgery in an office-based setting [1,10,11,40]. Examples of procedures that are often
performed in this setting include selected liposuction procedures; aesthetic facial and breast
surgery; ophthalmologic procedures; oral, maxillofacial, otolaryngology, and complex dental
procedures; gastrointestinal endoscopy; gynecologic procedures; orthopedic and podiatry
procedures; and endovascular or other vascular procedures [1,11]. (See 'Anesthetic
considerations and outcomes for selected procedures' below.)
The surgeon/proceduralist and the anesthesiologist are jointly responsible for determining
whether the following conditions are met [1]:
● The procedure is within the surgeon's scope of practice and the facility's capabilities.
● The duration and degree of complexity of the procedure allow for recovery and
discharge from the facility on the same day [16]. For example, the American Society of
Plastic Surgery has recommended that office-based procedures be limited to six hours,
and be completed by 3:00 PM, as long as the office remains fully staffed until a later
hour to meet patient recovery needs [41]. As newer surgical and anesthetic techniques
have been developed, longer and more complicated procedures have been performed
in office-based settings. However, duration has been correlated with a higher incidence
of unplanned hospital admission as well as increased incidence of postoperative nausea
and vomiting (PONV), pain, and bleeding [42,43]. In a retrospective study of more than
1.4 million ambulatory surgery patients in Massachusetts and New York states,
procedural categories with a higher likelihood of unplanned hospital admission
included vascular, mediastinal, pulmonary, urinary, nervous system, gastrointestinal,
endocrine, lymphatic, and musculoskeletal surgery [37].
Surgical procedures that are not appropriate for the office setting include those associated
with major fluid shifts or blood loss that may require transfusion, and those expected to
result in moderate to severe postoperative pain, particularly if postoperative opioid
administration may be necessary. (See 'Recovery and discharge' below and 'Local or regional
anesthetic techniques' below.)
ANESTHETIC MANAGEMENT
As with any ambulatory setting, the anesthetic goals for a patient having office-based
surgery are safety and rapid recovery from the effects of anesthetic agents, minimal side
effects, and rapid discharge from the office facility [10].
Standard monitors — In all office-based procedures, standard American Society of

Anesthesiologists (ASA) monitoring is necessary (ie, pulse oximetry, electrocardiogram, blood
pressure, capnography, temperature) ( table 6). (See "Basic patient monitoring during
anesthesia", section on 'Standards for monitoring during anesthesia'.)
Choice of anesthetic techniques — Anesthetic techniques suitable for office-based surgical

procedures include sedation at minimal, moderate, or deep levels, general anesthesia, and
regional anesthetic techniques. The choice of technique depends on the procedure and the
preferences of the surgeon, patient, and anesthesiologist. Whether any particular anesthetic
technique (eg, deep sedation or general anesthesia) is less safe in the office-based setting
has been debated [32,33,44]. Most studies support the safety of general anesthesia as well
as other techniques [1,5,6,8,11,34,36,45-47].
Although minimal, moderate, or deep sedation (with or without local anesthesia) are
common techniques, general anesthesia occurs along a continuum ( table 7) [10]. Thus,
the anesthesiologist must be able to "rescue" the patient from an anesthetic level that
becomes deeper than originally intended to avoid hypoxia or aspiration [48,49]. (See
"Monitored anesthesia care in adults".)
Although not specific for office-based anesthesia, a closed claims analysis of monitored
anesthesia care (MAC) claims is relevant for many office-based procedures [50]. Compared
with claims for general anesthetic cases, MAC claims involved older and sicker patients in
that analysis. Severe respiratory depression was identified as the most common cause of
injury [50]. Similar to general anesthesia, 40 percent of the claims were related to permanent
brain damage or death and were deemed preventable in 46 percent (eg, by improved
vigilance of the practitioner, better monitoring, and/or more reliable anesthesia alarms).
Selection of anesthetic agents — Ideal anesthetic agents for use in an office-based setting

will have a short duration of action, absence of postoperative nausea and vomiting (PONV),
and are cost-effective.
Short duration — To facilitate rapid discharge after the procedure (ideally, one hour or
less), only short-acting agents are used to produce either sedation (eg, propofol, ketamine,
midazolam, dexmedetomidine) or general anesthesia (eg, propofol, ketamine,
dexmedetomidine, and/or inhalation agents such as nitrous oxide, sevoflurane or
desflurane) [10]. Short-acting opioids may be used to provide analgesia (eg, fentanyl or
remifentanil).
Many anesthesiologists use nitrous oxide in combination with intravenous agents or with a
volatile anesthetic agent. Nitrous oxide reduces the doses of other agents and may reduce
costs and expedite emergence from anesthesia because of its rapid offset [51,52]. (See
"Maintenance of general anesthesia: Overview", section on 'Nitrous oxide gas' and
"Inhalation anesthetic agents: Clinical effects and uses", section on 'Nitrous oxide'.)
Avoidance of postoperative nausea and vomiting — Minimizing PONV is a major

consideration in any ambulatory surgery setting [53-55]. Since the incidence of PONV after
outpatient surgery may be as high as 50 percent, we use a multimodal approach to both
prophylaxis and treatment. In patients at risk for PONV, we employ a variety of antiemetic
agents targeting different receptors, as well as anesthetic and analgesic techniques that do
not cause PONV. Depending on patient-specific risks for PONV, prophylactic drugs may
include scopolamine (an anticholinergic worn as a patch), and/or intravenous agents such as
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dexamethasone (a steroid with a central antiemetic mechanism), and/or ondansetron (a 5-

hydroxytryptamine [5-HT] inhibitor). (See "Postoperative nausea and vomiting", section on
'Our strategy' and "Postoperative nausea and vomiting", section on 'Prevention'.)
Anesthetic techniques to minimize PONV include use of total intravenous anesthesia, usually
with propofol alone or in combination with an opioid [53]. Also, dexmedetomidine may be
used as an adjunct anesthetic agent because this alpha-2 agonist provides some analgesia
and sedation. Other techniques include use of neuraxial anesthesia (spinal or epidural) or
peripheral nerve blocks with or without catheters. Furthermore, opioid-sparing analgesics
are used when feasible (eg, acetaminophen and/or nonsteroidal antiinflammatory drugs
[NSAIDs]). (See "Postoperative nausea and vomiting", section on 'Anesthetic factors' and
"Postoperative nausea and vomiting", section on 'Reduction of baseline risk'.)
Ensuring adequate hydration may be useful in prevention of PONV by avoiding orthostatic

hypotension and consequent decreased blood flow to the midbrain emetic centers [38]. For
most healthy adult patients undergoing minimally-invasive relatively short outpatient
surgical procedures that are not associated with significant fluid shifts or blood loss, 1 to 2 L
of a balanced electrolyte crystalloid solution is administered during surgery. Such empiric
fluid administration addresses the mild dehydration caused by preoperative fasting, and is
associated with less PONV as well as less postoperative pain [53]. (See "Intraoperative fluid
management", section on 'Crystalloid solutions' and "Intraoperative fluid management",
section on 'Minimally/moderately invasive surgery'.)
In the postoperative period, rescue treatment for patients who develop PONV should include
a drug from a different class than any that have already been administered, unless the effect
of the first drug has worn off or a potentially inadequate dose has been administered.
Serotonin receptor antagonists such as ondansetron are particularly useful as rescue agents,
especially for same-day surgery patients, because they are nonsedating. In rare cases, it may
be necessary to admit a patient with persistent severe PONV to an inpatient facility. (See
"Postoperative nausea and vomiting", section on 'Rescue therapy'.)
Cost-effectiveness — Cost is a valid but lesser concern in selection of anesthetics. Cost is

balanced against potential side effects such as PONV and delayed recovery that might
negate cost advantages for certain agents and techniques [56,57].
Local or regional anesthetic techniques — Peripheral nerve blocks have been employed

for many procedures to decrease the need for deep sedation, general anesthesia, and opioid
use. (See "Overview of peripheral nerve blocks".)
Maximum allowable doses of local anesthetic agents that appear in various publications are
rough guidelines that are not evidence-based, and don't take into account the site or
technique of administration, or patient factors that increase toxicity risk ( table 8) [6,58].
Furthermore, calculated doses should be based on lean, rather than actual body weight
(calculator 1 and calculator 2). Addition of epinephrine to local anesthetic solutions can slow
the rate of absorption and reduce peak plasma levels, but do not prevent systemic toxicity in
all patients.
It is critically important that the anesthesiologists, surgeons, and nurses managing

perioperative care are well-versed in the signs and symptoms of systemic local anesthetic
toxicity in this setting ( table 9) [58]. Office-based facilities should have appropriate
equipment for monitoring the patient and managing adverse events in any location where
nerve blocks are placed. Emergency drugs and equipment must be immediately available to
manage allergic reactions, systemic toxicity of local anesthetics (seizures and/or
cardiovascular collapse), or rapid cephalad progression of anesthetic level due to unintended
intrathecal injection or epidural spread ( table 1). Less severe adverse effects of regional
anesthesia include postdural puncture headache or nerve damage that may result in a
hospital admission. Details regarding recognition and treatment of regional anesthesia
complications are discussed in separate topics:
● (See "Local anesthetic systemic toxicity".)

● (See "Overview of peripheral nerve blocks", section on 'Complications'.)
● (See "Overview of neuraxial anesthesia", section on 'Adverse effects and complications'.)
POSTOPERATIVE PAIN CONTROL
Optimal pain management often involves a multimodal approach that includes combinations
of drugs and techniques [59]. Although opioid medications have been a mainstay in
perioperative pain management and are effective in the acute setting, unwanted side effects
that are particularly undesirable in the outpatient setting include nausea and vomiting,
itching, constipation, respiratory depression, and altered mental status, as well as possible
dependence and tolerance issues. Thus, we use parenteral and/or enteral nonopioid
analgesics to reduce opioid requirements. These include acetaminophen and nonsteroidal
antiinflammatory drugs (NSAIDs) such as ketorolac, ibuprofen, or celecoxib ( table 10).
When appropriate, we also use regional techniques and long-acting local anesthetics (eg,
bupivacaine or ropivacaine with peripheral nerve blocks or liposomal bupivacaine for wound
infiltration). Other techniques include high-volume local infiltration analgesia [60] and
delivery of local anesthetics through wound catheters [61]. (See "Management of acute
perioperative pain in adults", section on 'Strategy for perioperative pain control' and
"Management of acute perioperative pain in adults", section on 'Therapeutic options'.)
RECOVERY AND DISCHARGE
Safe recovery and discharge depend on the office-based staff's ability to deliver appropriate
intensity and duration of postoperative monitoring. Complications such as respiratory events
(the most common mechanism of injury), delayed emergence from anesthesia, pain,
nausea/vomiting, urinary retention, and hypothermia must be recognized and treated. (See
"Overview of post-anesthetic care for adult patients".)
Discharge criteria are designed to determine a patient's readiness to safely leave the office
recovery area after surgery ( table 11). Fully trained nurses should be available to care for
all postoperative patients until discharge. Ideally, an anesthesiologist should assess each
patient prior to release to home. (See "Overview of post-anesthetic care for adult patients",
section on 'Discharge from the post-anesthesia care unit'.)
In a closed claims analysis of office-based settings compared with other ambulatory

anesthesia settings, a greater proportion of injuries were judged to be preventable by better
monitoring, particularly in the postoperative period [62].
ANESTHETIC CONSIDERATIONS AND OUTCOMES FOR SELECTED

PROCEDURES
Most literature reviews of adverse outcomes and mortality after various types of office-based
surgical procedures have concluded that surgery in this setting is safe and cost-effective
[1,8,10,21,28,40,59,63]. Improvements in patient outcomes are likely due to implementation
of more stringent credentialing and accreditation regulations, as well as use of routine safety
checklists and emergency manuals, as discussed above [1,4]. (See 'Safety concerns' above.)
Considerations and outcomes for specific procedures are noted below.
Cosmetic surgical procedures
Liposuction — Liposuction is accomplished by inserting hollow rods into small skin

incisions, in order to suction subcutaneous fat into an aspiration canister. Either general
anesthesia, moderate-to-deep sedation, or minimal oral sedation techniques have been used
( table 7) [41,44]. This tumescent technique uses large volumes (eg, 1 to 4 mL for each 1
mL of fat to be removed) of an infiltrate solution such as 0.9% saline or Ringer's lactate with
epinephrine 1:1,000,000 and lidocaine 0.025 to 0.12%.
Since the large injectate volumes that are employed may result in hypervolemia, close
attention to fluid and electrolyte balance is particularly important in the intraoperative and
postoperative periods [10,38]. Patients are also at risk for hypothermia because the injectate
fluids are not typically warmed. Active warming devices (eg, forced air warmers) are used in
many plastic surgery offices to avoid and treat hypothermia [10]. We agree with the
guidelines of the American Society of Plastic Surgeons stating that the total volume of
aspirant, including supernatant fat and fluid, should be limited to 5000 mL if the liposuction
procedure is performed in isolation, or 2000 mL if performed with a concurrent aesthetic
surgical procedure [10,40,41]. Body mass index is taken into account; the volume of aspirate
removed should be proportional to the patient's overall size [64]. Generally, aspirate volumes
>5000 mL are performed in an acute-care hospital or licensed/accredited facility due to
increased risk of complications [64].
The dose of epinephrine in the infiltrate solution used for the tumescent technique should
not exceed 0.07 mg/kg (eg, <5 mg in a 70 kg patient) in order to minimize risk for
cardiovascular effects [10]. Although epinephrine is rapidly metabolized with a half-life of
approximately two minutes, sustained peak levels have been demonstrated during and after
tumescent liposuction, possibly due to local vasoconstriction that results in delayed or

reduced systemic absorption. One small study in five patients undergoing tumescent
liposuction noted epinephrine peak blood concentrations ranging from 5.8 to 9.7 mg (0.08 to
0.12 mg/kg) one to four hours after injection, with return to baseline levels after
approximately 20 hours [65]. The total amount of absorbed epinephrine that was estimated
for each patient ranged from 1.8 to 2.2 mg (equivalent to 25 to 32 percent of the infiltrated
dose). Although none of the participants in this study exhibited any signs of toxicity after
exposure to these high epinephrine doses, timing for presentation of catecholamine toxicity
is unpredictable since drug absorption is variable. Severe reactions have been reported
during or after subcutaneous epinephrine doses as low as 3 mg [66].
Also, the dose of lidocaine in the infiltrate solution used for the tumescent technique is
typically 35 to 55 mg/kg, which is considerably higher than the 4.5 mg/kg maximum
recommended dose for regional anesthetic techniques [67-69]. These high doses are usually
well-tolerated because the tumescent technique results in single compartment clearance,
similar to that of a sustained-release medication [67,70]. However, absorption of local
anesthetic from the subcutaneous tissue is variable; thus, timing for onset of symptoms of
lidocaine toxicity is unpredictable [69,71]. Although blood lidocaine levels typically peak 12 to
16 hours after initial injection of infiltrate solution, peaks may occur within two hours of
injection, particularly if tumescent lidocaine without epinephrine is used (eg, for endovenous
laser therapy). Thus, close postoperative monitoring in the office-based recovery area is
necessary, and lipid emulsion should be immediately available for prompt treatment
( table 9) [69,70]. (See "Local anesthetic systemic toxicity", section on 'Lipid rescue'.)
The patient may not show signs of systemic local anesthetic toxicity (eg, dizziness, peripheral
numbness, metallic taste, tinnitus, confusion/anxiety, seizures) until after discharge home.
This is clinically relevant because signs of local anesthetic toxicity must be rapidly recognized,
and appropriate emergency procedures initiated [72,73]. All patients and their caregivers
should receive instructions regarding the need to seek emergency department care
immediately if signs or symptoms of local anesthetic toxicity become apparent after
discharge. (See "Local anesthetic systemic toxicity", section on 'Clinical presentation of
toxicity'.)
Liposuction has been considered to be a high-risk office-based procedure with reported
perioperative deaths attributed to anesthetic complications, abdominal viscus perforation,

fat embolism, hemorrhage, and unknown causes [74,75]. Liposuction is particularly risky
when combined with other procedures such as abdominoplasty [76,77]. However, a 2019
meta-analysis that included 20 observational studies and >700,000 liposuction procedures
noted that there were no reported deaths and only four serious adverse events (cardiac
arrhythmia requiring treatment) when liposuction was performed in nearly 24,000
procedures (four studies) with tumescent local anesthesia that included no or only minimal
systemic anesthesia (ie, moderate-to-deep sedation or general anesthesia) [44]. In this meta-
analysis, office-based liposuction procedures had lower rates of adverse events than those
performed in a hospital setting. (See "Obesity in adults: Overview of management".)
Other cosmetic surgery — Other plastic surgical procedures that may be performed in an

office-based setting with monitored anesthesia care (MAC) or deep sedation, or occasionally
with general anesthesia, include facial cosmetic surgery (eg, blepharoplasty, rhinoplasty,
facelift), breast procedures, and abdominoplasty.
In a prospective cohort review evaluating the safety of cosmetic surgery performed between
2008 and 2013 on the body, breast, face, or combination of regions in more than 129,000
patients (having a total of nearly 184,000 procedures), 15.9 percent were performed in an
accredited office-based setting by board-certified plastic surgeons, rather than in an
ambulatory surgery center (ASC) setting (57.4 percent) or hospital (26.7 percent) [8].
Complication rates, including hematomas, infections, and postoperative pulmonary
dysfunction, were lowest in the office-based setting (1.3 percent), compared with the ASC
setting (1.9 percent), or the hospital setting (2.4 percent). In a 2018 retrospective review of
174 patients undergoing primary facelift under local anesthesia with oral sedation in an
office-based setting, no mortality was reported, and complications were minor (primarily
hematoma formation [13 percent], with only two patients requiring operative evacuation)
[78]. Older retrospective studies of cosmetic surgery performed in an office-based setting
have noted similar low risks of significant complications [34,36,46,47,79-81]. Taken together,
these studies suggest that accredited office-based surgery suites are generally a safe
alternative to ASCs or hospitals for cosmetic surgical procedures. However, careful patient
selection is necessary, as noted above. (See 'Patient selection' above.)
In analyses of adverse incidents occurring during office-based surgery in Florida between
2000 and 2003, there were 13 procedure-related deaths, with seven involving elective
cosmetic procedures, five of which were performed under general anesthesia [32,33]. A
subsequent study noted mandatory reports of 31 deaths in Florida during office-based
plastic surgery over the seven-year period from 2000 to 2007 [74].
In particular, fire and facial burns are a particular risk for any facial procedure that requires
use of a laser, or even routine electrocautery, due to the presence of supplemental oxygen
(or nitrous oxide) in combination with combustible substances such as paper drapes and
alcohol prep [38]. Thus, nitrous oxide should not be used, and, when possible, avoidance of
supplemental oxygen is ideal (see "Fire safety in the operating room"). In a study MAC
conducted by the American Society of Anesthesiologists (ASA) using a closed claims
database, many of the patients were undergoing facial surgery [50]. Severe respiratory
depression was identified as the most common cause of injury in all MAC cases (21 percent),
followed by facial burn injuries in the presence of supplemental oxygen during facial surgery
(17 percent) [50]. Thus, these cases are among the highest-risk procedures performed in the
office setting [10].
Also, patients undergoing abdominoplasty may be at greater risk for later postoperative
complications such as venous thromboembolism and emergency department or hospital
admission, particularly if the procedure is performed concurrently with other cosmetic
surgery (eg, liposuction, breast procedures) [77,82].
Ophthalmology procedures — Cataract surgery is one of the most common procedures

requiring office-based anesthetic care; glaucoma and vitreoretinal surgical procedures are
often performed in this setting as well [11]. Details regarding anesthetic management and
potential complications of these procedures are available in a separate topic. (See
"Anesthesia for elective eye surgery".)
Oral and maxillofacial procedures — Oral, maxillofacial, and other head and neck surgical
procedures that are not complex (eg, tonsillectomy, nasal or intranasal procedures) may be
performed in an office-based setting [6].
In one large prospective cohort study of more than 34,000 patients undergoing oral or
maxillofacial surgery in this setting, 72 percent received deep sedation or general anesthesia,
15.5 percent received conscious sedation, and 12.5 percent received local anesthesia [45].
There were no deaths in this large study, and only two patients in this study had
complications requiring hospitalization, while 94 percent reported satisfaction with the
anesthetic.
Additional details regarding anesthetic management and potential complications of head

and neck procedures are available in separate topics. (See "Anesthesia for head and neck
surgery".)
Otolaryngology procedures — Selected otolaryngology procedures can be performed in an

office-based setting [6]. Local anesthesia can be used to anesthetize the immediate
surrounding tissues of the surgical bed or as an injection for regional cutaneous nerve
blockade for many otolaryngology surgical procedures. One small study of middle ear
surgery (ossiculoplasty) performed under local anesthesia in selected adult patients in this
setting noted no postoperative nausea, vomiting, dizziness, or other complications [83]. As
with other facial surgery, close attention must be paid to maximum allowable doses of local
anesthetic agents ( table 8) [6,58], and to risks of fire. (See 'Local or regional anesthetic
techniques' above and "Fire safety in the operating room".)
Dental procedures — Dental procedures are commonly performed in an office-based

setting [11]. In a retrospective review that included 1323 selected patients receiving sedation
or general anesthesia, there were only three events resulting in unplanned hospital transfers
(annual incidence 0.07 percent) [84]. These included one acute hypertensive crisis with
pulmonary edema, one potentially missing dental swab requiring radiographic confirmation
of its absence, and one failure of a caregiver to return for patient transport after discharge.
(See "Complications, diagnosis, and treatment of odontogenic infections".)
Gastrointestinal endoscopic procedures — Gastrointestinal endoscopy procedures are

commonly performed in an office-based setting. Details regarding anesthetic management
and potential complications for patients undergoing gastrointestinal endoscopy are
discussed in a separate topic. (See "Anesthesia for gastrointestinal endoscopy in adults".)
Gynecologic procedures — Termination of pregnancy (ie, abortion) is commonly performed

in an office-based setting. In a 2018 retrospective study that included more than 50,000 such
procedures, no differences in abortion-related adverse events were noted in this setting

compared with ASC settings [85]. Details regarding these procedures and potential
complications are available in a separate topic. (See "Overview of pregnancy termination".)
Other gynecologic procedures such as cervical or endometrial biopsy, curettage, and

hysteroscopy, insertion of intra-uterine devices (IUDs), and egg retrievals for fertility
treatments have also safely been performed in the office-based setting.
Orthopedic and podiatry procedures — Selected orthopedic procedures have been

performed in an office-based setting. Examples include diagnostic arthroscopy for knee and
shoulder intraarticular injuries [86]. One study of office-based kyphoplasty for treatment of
vertebral compression fractures reported use of local anesthesia and oral sedation in 99
consecutive patients with zero intraoperative complications [87]. Other outpatient orthopedic
surgical procedures that are being evaluated in ASCs include shoulder arthroscopy with
subacromial decompression and distal clavicle resection, knee arthroscopy with anterior
cruciate ligament repair, open reduction and internal fixation of bimalleolar ankle fracture,
open reduction and internal fixation of distal radius fracture, knee arthroscopy with medial
and lateral meniscectomy, total knee arthroplasty, and one level lumbar laminectomy [88].
Although many podiatry procedures are performed in office-based settings, published

research regarding sedation or anesthesia for such cases is scant.
Endovascular and other vascular procedures — Selected endovascular procedures such as

infrapopliteal interventions, as well as diagnostic arteriograms, arterial or venous
interventions, dialysis access, and venous catheter management can be safely performed in
an office-based setting [89,90]. (See "Overview of vascular intervention and surgery for
vascular anomalies".)
SUMMARY AND RECOMMENDATIONS
● The number of elective surgical procedures performed in the office-based setting has
expanded rapidly. Compared with hospital settings, the major advantages of office-
based anesthesia for surgical procedures are patient and surgeon convenience, cost
containment, and possibly lower nosocomial infection rates. (See 'Potential advantages
and benefits' above.)
● Safety concerns have centered around the adequacy of individual facility resources and
governmental regulations for office-based facilities. We use guidelines for office-based
anesthesia adopted by the American Society of Anesthesiologists (ASA), including
standard monitoring ( table 6). We also use routine and crisis checklists to further
ensure patient safety. (See 'Safety concerns' above and 'Standard monitors' above.)
● Patients at higher risk for complications during anesthesia and surgery are identified
preoperatively. Examples include potentially difficult airway, obstructive sleep apnea,
morbid obesity, severe or exacerbated chronic obstructive pulmonary disease, recent
myocardial infarction within the past six months or recent stroke within the past three
months, end-stage kidney or liver disease, severe anemia, sickle-cell disease, abnormal
bleeding or clotting tendency, extremes of age, acute or chronic substance abuse,
inability to cooperate due to severe anxiety or poorly controlled psychiatric problems,
history of anaphylaxis, or family history of malignant hyperthermia (MH). In some
cases, ensuring optimal medical treatment may reduce risk, but in other cases, the
patient should be referred to a facility that can handle complications that may occur.
(See 'Patient selection' above.)
● The surgeon/proceduralist and the anesthesiologist are jointly responsible for

determining whether the following conditions are met (see 'Procedure selection'
above):
• The procedure is within the surgeon's scope of practice and the facility's capabilities
• The duration and degree of complexity of the procedure will allow recovery and
discharge for the facility on the same day
Procedures generally inappropriate for office-based surgery include those associated

with a prolonged duration (more than six hours), significant blood loss or fluid shifts, or
moderate-to-severe postoperative pain.
● Minimal, moderate, or deep sedation, general anesthesia, or local/regional anesthetic

techniques are each suitable for appropriately selected office-based surgical
procedures. (See 'Choice of anesthetic techniques' above.)
● To facilitate a rapid discharge after the procedure, only short-acting agents are used to
produce either sedation or general anesthesia. Similarly, short-acting opioid agents are
used to control pain. (See 'Selection of anesthetic agents' above.)
● We use a multimodal approach to avoid and/or treat postoperative nausea and

vomiting (PONV), including multiple drugs targeting different receptors, alternate
anesthetic techniques (eg, total intravenous anesthesia with propofol, regional
anesthesia), adequate hydration, and nonopioid analgesics, particularly in patients at
high risk for PONV. (See 'Avoidance of postoperative nausea and vomiting' above.)
● We use a multimodal approach to postoperative pain management, including

combinations of drugs (eg, nonopioid analgesics) and techniques (eg, long-acting local
anesthetics). (See 'Postoperative pain control' above.)
● Safe recovery and discharge depend on the office-based staff's ability to deliver
appropriate intensity and duration of postoperative monitoring. Complications such as
respiratory events, delayed emergence from anesthesia, pain, PONV, urinary retention,
and hypothermia must be recognized and treated. Standard discharge criteria are used
to supplement the assessment of the responsible anesthesiologist for release home.
(See 'Recovery and discharge' above.)
● Anesthetic considerations and outcomes for selected procedures are discussed above
and in separate topics (see 'Anesthetic considerations and outcomes for selected
procedures' above):
• (See 'Liposuction' above.)

• (See 'Other cosmetic surgery' above.)
• (See "Anesthesia for elective eye surgery".)
• (See 'Oral and maxillofacial procedures' above.)
• (See 'Otolaryngology procedures' above.)
• (See 'Dental procedures' above.)
• (See "Anesthesia for gastrointestinal endoscopy in adults".)
• (See 'Gynecologic procedures' above.)
• (See 'Orthopedic and podiatry procedures' above.)
• (See 'Endovascular and other vascular procedures' above.)
Use of UpToDate is subject to the Terms of Use.
Topic 91909 Version 31.0
GRAPHICS
Equipment for office-based anesthesia
Monitors
Noninvasive blood pressure with an assortment of cuff sizes
Heart rate/ECG
Pulse oximeter
Temperature
Capnography
Airway supplies
Nasal cannulae
Oral airways
Facemasks
Self-inflating bag-mask ventilation device
Laryngoscopes with blades in multiple sizes and styles (eg, Macintosh and Miller)
Endotracheal tubes in multiple sizes
Stylettes
Supraglottic airway devices (eg, LMA) in multiple sizes
Emergency airway equipment (supraglottic airway devices [eg, LMAs] in multiple

sizes, videolaryngoscope [eg, Glidescope or CMAC], cricothyrotomy kit)
Suction catheters and suction equipment
Cardiac defibrillator
Emergency drugs
ACLS drugs (refer to UpToDate topics on ACLS)
Dantrolene and malignant hyperthermia supplies (refer to UpToDate topics on malignant

hyperthermia)
20% lipid emulsion for local anesthetic systemic toxicity
Anesthetic drugs
Vascular cannulation equipment
Safe delivery of office-based anesthesia requires the availability of the listed equipment.
ECG: electrocardiogram; LMA: laryngeal mask airway; ACLS: advanced cardiac life support.
Modified with permission from: Hausman LM, Rosenblatt MA. Office-Based Anesthesia. In: Clinical Anesthesia, 7th ed,
Barash PG, Cullen BF, Stoelting RK, et al (Eds), Lippincott Williams & Wilkins, Philadelphia 2013. Copyright © 2013
Lippincott Williams & Wilkins. www.lww.com.
Graphic 99792 Version 5.0
Factors considered in accrediting an office for surgical procedures
1. Physical layout of the office
2. Environmental safety/infection control
3. Patient and personnel records
4. Surgeon qualification
a. Training
b. Local hospital privileges (surgical and admission)
5. Office administration
6. Anesthesiologist requirements
7. Staffing intraoperatively and postoperatively
8. Monitoring capabilities both intraoperatively and postoperatively
9. Ancillary care
10. Equipment
11. Drugs (emergency, controlled substances, routine medications)
12. BLS, ACLS/PALS certification
13. Temperature
14. Neuromuscular functioning
15. Patient positioning
16. Pre- and postanesthesia care/documentation
17. Quality assurance/peer review
18. Liability insurance
19. PACU evaluation
20. Discharge evaluation
21. Emergency preparedness (fire/admission/transfer, etc)
BLS: basic life support; ACLS: advanced cardiac life support; PALS: pediatric advanced life support.
Reproduced with permission from: Hausman LM, Rosenblatt MA. Office-Based Anesthesia. In: Clinical Anesthesia, 7th ed,
World Health Organization surgical safety checklist
Sign in Time out Sign out
Before induction of Before skin incision Before patient leaves

anesthesia operating room
__ Confirm all team members
__ Patient has have introduced themselves Nurse verbally confirms
confirmed: by name and role with the team:
Identity __ Surgeon, anesthesia __ The name of the
Site professional, and nurse procedure recorded
Procedure verbally confirm
__ That instrument, sponge,
Consent Patient
and needle counts are
Site correct (or not
__ Site marked/not
applicable Procedure applicable)
__ Anesthesia safety Anticipated critical events __ How the specimen is

check completed labeled (including patient
__ Surgeon reviews: What are
name)
__ Pulse oximeter on the critical or unexpected
patient and steps, operative duration, __ Whether there are any
functioning anticipated blood loss? equipment problems to
be addressed
Does patient have a: __ Anesthesia team reviews:
Are there any patient- __ Surgeon, anesthesia
Known allergy? professional, and nurse
specific concerns?
__ No review the key concerns
__ Nursing team reviews: Has
for recovery and
__ Yes sterility (including indicator
management of this
results) been confirmed?
Difficult airway/aspiration patient
Are there equipment issues
risk?
or any concerns?
__ No
Has antibiotic prophylaxis been
__ Yes, and given within the last 60 minutes?
equipment/assistance
__ Yes
available
__ Not applicable
Risk of >500 mL blood loss
(7 mL/kg in children)? Is essential imaging displayed?
__ No __ Yes
__ Not applicable
__ Yes, and adequate

intravenous access
and fluids planned
This checklist is not intended to be comprehensive. Additions and modifications to fit local
practice are encouraged.
Reproduced with permission from: Weiser T, Haynes A, Dziekan G, et al. Effect of a 19-item surgical safety checklist
during urgent operations in a global patient population. Ann Surg 2010; 251:976. Copyright © 2010 Lippincott Williams
& Wilkins.
Safety checklist for office-based surgery
The Institute for Safety in Office-Based Surgery constructed a 28-step perioperative checklist to identify and co
different phases of an invasive office procedure. This checklist is not intended to be comprehensive. Additions
practice are encouraged.
DVT: deep vein thrombosis; NPO: nil per os (nothing by mouth); AED: automated external defibrillator; MH: ma
emergency medical services; N/A: not applicable; EBL: estimated blood loss.
Credit: Richard Urman, Fred Shapiro, Copyright the Institute for Safety in Office-Based Surgery.
American Society of Anesthesiologists Physical Status (ASA PS)

Classification System
ASA PS Examples, including, but not

Definition
classification limited to:
ASA I A normal healthy patient Healthy, nonsmoking, no or minimal

alcohol use.
ASA II A patient with mild systemic disease Mild diseases only without
substantive functional limitations.
Current smoker, social alcohol
drinker, pregnancy, obesity
(30<BMI<40), well-controlled
DM/HTN, mild lung disease.
ASA III A patient with severe systemic Substantive functional limitations;

disease one or more moderate to severe
diseases. Poorly controlled DM or
HTN, COPD, morbid obesity (BMI
≥40), active hepatitis, alcohol
dependence or abuse, implanted
pacemaker, moderate reduction of
ejection fraction, ESKD undergoing
regularly scheduled dialysis,
premature infant PCA <60 weeks,
history (>3 months) of MI, CVA, TIA,
or CAD/stents.
ASA IV A patient with severe systemic Recent (<3 months) MI, CVA, TIA, or
disease that is a constant threat to CAD/stents, ongoing cardiac ischemia
life or severe valve dysfunction, severe
reduction of ejection fraction, sepsis,
DIC, ARDS, or ESKD not undergoing
regularly scheduled dialysis.
ASA V A moribund patient who is not Ruptured abdominal/thoracic

expected to survive without the aneurysm, massive trauma,
operation intracranial bleed with mass effect,
ischemic bowel in the face of
significant cardiac pathology or
multiple organ/system dysfunction.
ASA VI A declared brain-dead patient whose

organs are being removed for donor
purposes
The addition of "E" to the numerical status (eg, IE, IIE, etc) denotes Emergency surgery (an
emergency is defined as existing when delay in treatment of the patient would lead to a
significant increase in the threat to life or body part).
BMI: body mass index; DM: diabetes mellitus; HTN: hypertension; COPD: chronic obstructive
pulmonary disease; ESKD: end-stage kidney disease; PCA: post conceptual age; MI: myocardial
infarction; CVA: cerebrovascular accident; TIA: transient ischemic attack; CAD: coronary artery
disease; DIC: disseminated intravascular coagulation; ARDS: acute respiratory distress syndrome.
ASA Physical Status Classification System (Copyright © 2014) is reprinted with permission of the American Society of
Anesthesiologists, 1061 American Lane, Schaumburg, Illinois 60173-4973.
Fasting guidelines of international anesthesia societies
Fasting requirements at
Country, year Comments
time of induction
American Society of 2 hours clear liquids, Healthy patients, not in

Anesthesiologists, 2017 [1] excluding alcohol labor, elective surgery
4 hours breast milk Light meal defined as toast
6 hours nonhuman milk, or cereal with clear liquid
formula, light meal
8 hours or more for fatty
meal, fried food, meat
European Society of Adults: Encourage oral fluid up to 2

Anesthesiology and Intensive 2 hours clear liquids hours
Care [2,3] 6 hours milk, solid food
Chewing gum and
sucking hard candy
allowed up until
induction
Children: Encourage oral fluid up

1 hour clear liquids until fasting time
3 hours breast milk
4 hours formula or
nonhuman milk, light
breakfast (weak
recommendations)
6 hours other solid food
Australian and New Zealand 1 hour clear fluid (≤3 Up to 400 mL of clear liquid
College of Anaesthetists [4] mL/kg/hour) for infants and up to 2 hours prior to
children induction for adults is likely
2 hours clear liquids adults safe
3 hours breast milk for
infants <6 months
4 hours formula for infants
<6 months
6 hours breast milk,

formula, limited solid food
for children >6 months and
adults
Association of Anaesthetists in 2 hours clear liquids Gum chewing treated as

Great Britain and Ireland [5] 4 hours breast milk clear
6 hours solid food, formula
and cow's milk
Canadian Anesthesiologists' 2 hours clear liquids

Society [6] 4 hours breast milk
6 hours light meal, infant
formula or nonhuman milk
8 hours meat, fried or fatty
food
Scandinavian Society of 2 hours clear liquids 2 hours for preoperative

Anaesthesiology and Intensive 4 hours breast milk and carbohydrate drinks
Care Medicine [7] infant formula intended for preoperative
6 hours solid food and nutrition
cows milk
2 hours chewing gum and
any tobacco product
Up to 1 hour prior to
induction, 150 mL of water
German Society of 2 hours clear liquids

Anesthesiology and Intensive 4 hours breast milk and
Care [8] infant formula
6 hours meal
Pediatric societies
Joint statement from 1 hour clear liquids for Encourage intake of clear
Association of Paediatric children up to 16 years of liquids
Anaesthetists of Great age
Britain and Ireland,
European Society for
Paediatric Anaesthesiology,
L'Association Des
Anesthésistes-
Réanimateurs Pédiatriques
d'Expression Française [9]
Canadian Pediatric 1 hour clear liquids for Encourage intake of clear

Anesthesia Society [10] children liquids
The Society for Paediatric 1 hour clear liquids for Encourage intake of clear
Anaesthesia of New children liquids
Zealand and Australia [11]
GERD: gastroesophageal reflux disease.
References:
1. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of
Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the
American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to
Reduce the Risk of Pulmonary Aspiration. Anesthesiology 2017; 126:376.
2. Smith I, Kranke P, Murat I, et al. Perioperative fasting in adults and children: guidelines from the European Society
of Anaesthesiology. Eur J Anaesthesiol 2011; 28:556.
3. Frykholm P, Disma N, Andersson H, et al. Pre-operative fasting in children: A guideline from the European Society
of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 2022; 39:4.
4. Australian and New Zealand College of Anaesthetists. Guideline on pre-anaesthesia consultation and patient
preparation. Available at: https://www.anzca.edu.au/getattachment/d2c8053c-7e76-410e-93ce-
3f9a56ffd881/PS07-Guideline-on-pre-anaesthesia-consultation-and-patient-preparation (Accessed on September
8, 2021).
5. Association of Anaesthetists of Great Britain and Ireland. Pre-operative Assessment and Patient Preparation - The
Role of the Anaesthetist. Available at: https://anaesthetists.org/Home/Resources-publications/Guidelines/Pre-
operative-assessment-and-patient-preparation-the-role-of-the-anaesthetist-2 (Accessed on October 8, 2021).
6. Dobson G, Chow L, Filteau L, et al. Guidelines to the Practice of Anesthesia - Revised Edition 2020. Can J Anaesth
2020; 67:64.
7. Søreide E, Eriksson LI, Hirlekar G, et al. Pre-operative fasting guidelines: an update. Acta Anaesthesiol Scand 2005;
49:1041.
8. Verbandsmitteilung DGAI. Praeoperatives Nuechternheitsgebot bei elektiven Eingriffen. Anaesthesiol Intensivmed
2004; 12:722.
9. Thomas M, Morrison C, Newton R, Schindler E. Consensus statement on clear fluids fasting for elective pediatric
general anesthesia. Paediatr Anaesth 2018; 28:411.
10. Rosen D, Gamble J, Matava C, Canadian Pediatric Anesthesia Society Fasting Guidelines Working Group. Canadian
Pediatric Anesthesia Society statement on clear fluid fasting for elective pediatric anesthesia. Can J Anaesth 2019;
66:991.
11. Society for Paediatric Anaesthesia in New Zealand and Australia. Available at:
https://www.anzca.edu.au/getattachment/d2c8053c-7e76-410e-93ce-3f9a56ffd881/PS07-Guideline-on-pre-
anaesthesia-consultation-and-patient-preparation (Accessed on October 22, 2021).
Basic monitoring during anesthesia
Primary physiologic
Monitoring Derived Additiona
process/parameter Principle
equipment information function
targeted
Oxygenation Inspired gas O 2 analyzer Paramagnetic Inspired/expired A low-level alarm

O 2 content (with a low- sensor, fuel O 2 concentration automatically
limit alarm in (galvanic) cell, when placed activated by tur
use) polarographic downstream from on the anesthes
(Clark) electrode, fresh flow control machine
mass valves
spectroscopy, or
Raman scattering
Blood Pulse The Beer-Lambert Hemoglobin Continuous

oxygenation oximeter law applied to saturation, pulse evaluation of
tissues and rate, relative pulse circulation, vari
pulsatile blood amplitude pitch pulse tone
flow. The relative displayed on and audible low
absorbency at plethysmography threshold alarm
wavelengths of waveform
660 and 940 nm is
used to estimate
saturation, which
is derived from
the ratio of
oxyhemoglobin to
the sum of
oxyhemoglobin
plus
deoxyhemoglobin.
Ventilation Exhaled Capnograph CO 2 molecules ETCO 2 , inspired Instantaneous

CO 2 absorb infrared CO 2 , diagnostic information abo
radiation at 4.26 waveforms, Perfusion (h
micrometers, respiratory rate, effectively C
proportionate to apnea detection being
the CO 2 transported
concentration through the
present in the vascular sys

breath sample Metabolism
effectively C
being produ
by cellular
metabolism)
Confirmation
tracheal tub
placement a
intubation
Integrity of Disconnection Detects the Alarms if a Alarms if high

ventilation alarm cyclical changes in significant decrease pressures are
system airway pressure in in rate or pressure sensed
during the normal range occurs
mechanical
ventilation
Pulmonary Pulmonary Volume of gas Inspired and Pressure volum

mechanics flow and proportional to a expired volume, and flow volum
(volume, pressure drum movement, flow, and airway loops
flow, sensors changes in pressure
pressure) differential
pressure (near the
Y-connector) or in
electrical
resistance (hot
wire housed in a
monitor or
ventilator)
Circulation Cardiac ECG The ECG monitor Heart rate and ST segment
activity detects, amplifies, rhythm depression/elev
displays, and and trend over
records the ECG with an audible
signal. alarm warning
significant
arrhythmias or
asystole
Arterial BP Noninvasive Oscillometric Arterial BP Indicator of org

BP monitor devices perfusion
automatically
inflate and deflate
the cuff, and have
electronic
pressure sensors
that record the
pressure
oscillations of the
arteries. The
pressure at which
maximal
oscillations occur
as the cuff is
deflated
corresponds with
MAP. Proprietary
algorithms are
used to calculate
systolic and
diastolic BP.
Temperature Temperature Devices with a Core or peripheral A greater than 2

monitor semiconductor, temperature core-to-periphe
electrical temperature
resistance gradient is indic
decreases as of low cardiac
temperature output.
decreases
Temperature monitoring is conditional and can be waived according to the ASA document.
O 2 : oxygen; CO 2 : carbon dioxide; ETCO 2 : end-tidal carbon dioxide; ECG: electrocardiogram; BP:
blood pressure; MAP: mean arterial pressure.
American Society of Anesthesiologists (ASA) definitions of levels of

sedation/anesthesia
1. Minimal sedation (anxiolysis)
a. Drug-induced sedation
b. Patient responds normally to verbal commands
c. Cognitive and motor function may be impaired
d. Ventilatory and cardiovascular functions maintained normally
2. Moderate sedation/analgesia (conscious sedation)
b. Patient responds purposefully to verbal commands either alone or with light tactile
stimulation
c. Patient maintains a patent airway and spontaneous ventilation
d. Cardiovascular function maintained
3. Deep sedation/analgesia
b. Patient cannot be easily aroused but can respond purposefully to repeated or painful
stimulation
c. Ventilatory function may be impaired, requiring assistance in maintaining a patent airway,

and spontaneous ventilation may be inadequate
d. Cardiovascular function is usually maintained
4. General anesthesia
a. Drug-induced loss of consciousness
b. Patients are not aroused by painful stimulation
c. Ventilatory function is often impaired; patient may require assistance in maintaining a patent
airway
d. Spontaneous ventilation may be impaired, as well as neuromuscular functioning
e. Positive pressure ventilation is often required
f. Cardiovascular function may be impaired
Definitions of levels of sedation/anesthesia by the American Society of Anesthesiologists

(adopted October 13, 1999, by the House of Delegates).
Reproduced with permission from: Hausman LM, Rosenblatt MA. Office-Based Anesthesia. In: Clinical Anesthesia, 7th ed,
Local anesthetics commonly used for peripheral nerve block
Maximum
Duration of Duration of dose* ¶
Onset
Anesthetic anesthesia* analgesia* (mg/kg)
(minutes)
(hours) (hours) without/with
epi
2% lidocaine 10 to 20 2 to 5 3 to 8 4.5/7
1.5% 10 to 20 2 to 5 3 to 10 5/7
mepivacaine
0.2% ropivacaine 15 to 30 n/a 5 to 16 3/3.5
0.5% ropivacaine 15 to 30 4 to 12 5 to 24 3/3.5
0.25% 15 to 30 n/a 5 to 26 2.5/3

bupivacaine
0.5% bupivacaine 15 to 30 5 to 15 6 to 30 2.5/3

(+epi)
epi: epinephrine; n/a: not applicable.

* Duration varies widely by site of injection. These are generalized ranges of duration.
¶ Maximal doses represent general guidelines for tissue infiltration, nerve block, or epidural
injection. Systemic toxicity may occur with doses below the recommended range, particularly
with intravascular injection. Doses in excess of the recommended maximums have been
administered without toxicity. These recommendations do not account for the site of injection,
rate of administration, or the presence of risk factors for systemic toxicity (eg, renal or hepatic
dysfunction, cardiac failure, pregnancy, or extremes of age).
Adapted from: Gadsen J. Local Anesthetics: Clinical Pharmacology and Rational Selection. The New York School of
Regional Anesthesia website, October 2013.
Local anesthetic systemic toxicity: Rapid overview [1]
Etiology
Unintended intravascular injection of LA

Systemic absorption of LA
Risk factors
Extremes of age (ie, <4 months or >79 years)

Cardiac conduction disease
Ischemic heart disease
Renal dysfunction
Hepatic dysfunction
Pregnancy
Carnitine deficiency
Highly vascular block site
Signs and symptoms* LAST can occur >15 minutes after injection of LA
CNS: ¶
Tinnitus
Circumoral numbness
Metallic taste
Agitation
Dysarthria
Seizures
Loss of consciousness
Respiratory arrest
Cardiovascular: ¶
Hypotension
Bradycardia
Ventricular arrhythmias
Cardiovascular collapse
Treatment*
Stop injection or infusion

Call for help and lipid emulsion
While stabilizing the patient, arrange for cardiopulmonary bypass

Airway management: Ventilate with 100% oxygen, prevent hypoxemia, hypercarbia, and
acidosis
Suppress seizures: Benzodiazepines preferred (avoid large doses of propofol)
Manage arrhythmias and cardiac arrest per ACLS EXCEPT:
Reduce individual epinephrine boluses to ≤1 mcg/kg
Avoid vasopressin, calcium channel blockers, beta blockers, and LA
Administer amiodarone as the first line antiarrhythmic
Institute lipid emulsion therapy with 20% lipid emulsion
Adults >70 kg: Bolus 100 mL IV over 2 to 3 minutes, followed by infusion of 200 to 250 mL
over 15 to 20 minutes
Children or Adults <70 kg: Bolus 1.5 mL/kg IBW IV over 2 to 3 minutes, followed by
infusion at 0.25 mL/kg/minute
Repeat bolus once or twice and double infusion rate for persistent cardiovascular
instability
Continue infusion for at least 10 minutes after hemodynamic stability is achieved
Maximum dose lipid emulsion approximately 12 mL/kg IV
Note: Propofol is not a substitute for lipid emulsion
Institute cardiopulmonary bypass for LAST unresponsive to lipid emulsion and ACLS
For further information, refer to UpToDate content on local anesthetic systemic toxicity.
LA: local anesthetic; LAST: local anesthetic systemic toxicity; CNS: central nervous system; TPN:
total parenteral nutrition; ACLS: advanced cardiac life support; IBW: ideal body weight; IV:
intravenous.
* Not all signs and symptoms occur in every patient.
¶ Cardiovascular collapse may occur without CNS signs or symptoms, especially with rapid
intravascular injection.
Reference:
1. Neal JM, Barrington MJ, Fettiplace MR, et al. The Third American Society of Regional Anesthesia and Pain Medicine
Practice Advisory on Local Anesthetic Systemic Toxicity: Executive Summary 2017. Reg Anesth Pain Med 2018;
43:113.
Parenterally available nonopioid analgesic and nonsteroidal

antiinflammatory drugs (NSAIDs): Usual dosing for adults with acute pain
or inflammation
Usual
Maximum
analgesic Selected characteristics and role
Drug dose per
dose in therapy
day (mg)
(intravenous)
Para-aminophenol derivative
Acetaminophen Weight ≥50 kg: Weight ≥50 Short-term treatment of mild to

(paracetamol, 650 mg IV every kg: 4000 mg IV moderate acute pain and febrile
APAP) 4 hours or 1000 conditions when oral administration
Weight <50 kg:
mg IV every 6 is not available and as part of a
75 mg/kg per
hours multimodal analgesic regimen for
day up to 3750
treatment of moderate to severe
Weight <50 kg: mg IV
acute pain when a rapid onset is
12.5 mg/kg IV
needed (eg, postoperatively).
every 4 hours or
15 mg/kg IV Also an option for use prior to or
every 6 hours during surgery (ie, preemptive
analgesia strategy) when oral route
is not an option.
Onset 5 to 10 minutes.
Minimal alteration of platelet
functioning.
Less risk of GI bleeding, renal, and
cardiovascular toxicity than
nonselective NSAIDs.
Lacks antiinflammatory activity.
Patients should be well hydrated.
Recommended infusion regimen
requires 15 minutes and
administration in 100 mL volume
per 1000 mg dose.
Avoid or use a lower total daily dose
(maximum 2000 mg per day) in
older adults, patients at risk for
hepatotoxicity (eg, regular alcohol

use, malnourished) or with
significant renal or hepatic
impairment.
Nonselective NSAIDs*
Ketorolac Age <65 years Age <65 years A frequently used option for short-
and weight ≥50 and weight term treatment of acute pain when
kg: 15 to 30 mg ≥50 kg: 120 oral NSAID administration is not
IV every 6 hours mg IV per day available, and as part of a
for up to five multimodal analgesic regimen for
Age ≥65 years
days the treatment of moderate to severe
or weight <50
pain when rapid onset is required
kg: 15 mg IV Age ≥65 years
(eg, postoperatively).
every 6 hours or weight <50
kg: 60 mg per Onset ~30 minutes.
day IV for up Duration of platelet dysfunction ~24
to five days hours.
Administered as IV bolus over 15
seconds in minimal fluid volume.
Risk of gastropathy and renal failure
is related to dose and duration of
use.
Patients should be well hydrated
and without significant kidney
disease (CrCl >60 mL/minute).
Avoid use in patients with a history
of ischemic heart disease, stroke, or
heart failure.
According to the US label, NSAID use
is contraindicated for the treatment
of perioperative pain in the setting
of coronary artery bypass graft
(CABG) surgery.
Ibuprofen 400 to 800 mg 3200 mg IV Short-term treatment of mild to

IV every 6 hours moderate acute pain when oral
administration is not available and
as part of a multimodal analgesic
regimen for treatment of moderate
to severe postoperative pain.

Onset ~30 minutes.
Duration of platelet dysfunction ~8
hours.
Recommended infusion regimen
requires 30 minutes and
administration in 100 mL volume
per 400 mg dose or 200 mL per 800
mg dose.
Avoid use in patients with a history
of ischemic heart disease, stroke, or
heart failure.
According to the US label, NSAID use
is contraindicated for the treatment
of perioperative pain in the setting
of CABG surgery.
Selective COX-2 inhibitor
Parecoxib 20 to 40 mg IV Age <65 years: For short-term or single-dose

(not available in every 6 to 12 80 mg IV treatment of postoperative pain.
United States) hours Also a potential option for use prior
Age ≥65 years
and body to or during surgery (ie, preemptive
weight <50 kg: analgesia strategy).
40 mg IV Onset <15 minutes.
Minimal or no alteration of platelet
functioning.
Administered as rapid IV bolus in
minimal fluid volume.
Increased risks of adverse
cardiovascular thromboembolic
events and surgical wound
complications have been observed
in CABG postoperative safety

studies.
Parecoxib is a prodrug of valdecoxib;
chronic use of valdecoxib has been
associated with an increased risk of
serious cardiovascular thrombotic
events, myocardial infarction, and
stroke relative to some nonselective
NSAIDs.
Use is contraindicated in patients
who are at increased risk for
cardiovascular thrombotic events,
during the perioperative period of
coronary artery bypass graft (CABG)
surgery, and/or with a history of
sulfonamide hypersensitivity.
Dose reduction needed for older
adults and weight <50 kg.
Semi selective COX-2 inhibitor
Meloxicam 30 mg IV once Once daily parenteral NSAID

every 24 hours alternative.
Administer by IV bolus injection over
15 seconds.
Onset of analgesia in 6 to 8 minutes,
maximal effect in 2 to 3 hours.
Meloxicam preferentially inhibits
COX-2 at low doses, but loses COX-2
selectivity at doses recommended
for acute pain. When used clinically,
meloxicam has effects, drug
interactions, and toxicities similar to
other nonselective NSAIDs
described above.
Undergoes hepatic metabolism by
CYP2C9; with repeated dosing (eg,
>2 to 3) may accumulate when given
with CYP2C9 inhibitor drugs (eg
fluconazole, voriconazole) and/or in
patients with slow CYP2C9 function

(poor metabolizers; <5%
population).
Use of parenteral nonopioid analgesics as opioid-sparing agents in multimodal postoperative

pain management is discussed in the UpToDate topic review of perioperative pain management.
A calculator to determine creatinine clearance (CrCl) is available separately in UpToDate. For
additional information, refer to Lexicomp individual drug monographs included with UpToDate
and local product information.
NSAID: nonsteroidal antiinflammatory drug; IV: intravenous; CABG: coronary artery bypass graft;
COX-2: cyclooxygenase isoform 2; CrCl: creatinine clearance.
* Nonselective NSAIDs inhibit platelet functioning and are contraindicated as preemptive
analgesics before major surgery and intraoperatively prior to establishment of hemostasis. Use
of parenteral NSAIDs should not exceed five days. In some countries, a maximum duration of use
of ≤2 days or a single dose is recommended. Safety concerns are addressed in the UpToDate
topic review of nonselective NSAIDs overview of adverse effects.
A commonly used postanesthesia care unit (PACU) discharge criteria

score
Postanesthetic discharge scoring system
Vital signs
2 = BP + pulse within 20% preop baseline
1 = BP + pulse within 20-40% preop baseline
0 = BP + pulse >40% preop baseline
Activity
2 = Steady gait, no dizziness, or meets preop level
1 = Requires assistance
0 = Unable to ambulate
Nausea and vomiting
2 = Minimal/treated with PO medication
1 = Moderate/treated with parenteral medication
0 = Severe/continues despite treatment
Pain
Controlled with oral analgesics and acceptable to patient:
2 = Yes
1 = No
Surgical bleeding
2 = Minimal/no dressing changes
1 = Moderate/up to two dressing changes required
0 = Severe/more than three dressing changes required
Score ≥9 for discharge
BP: blood pressure; PO: oral.
Modified with permission from: Fowler MA, Spiess BD. Postanesthesia recovery. In: Clinical Anesthesia, 7th ed, Barash PG,
Cullen BF, Stoelting RK, et al (Eds), Lippincott Williams & Wilkins, Philadelphia 2013. Copyright © 2013 Lippincott
Williams & Wilkins. www.lww.com.

Office-Based Anesthesia - UpToDate

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Office-Based Anesthesia - UpToDate

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Office-based anesthesia - UpToDate 17/01/23, 6:18

Official reprint from UpToDate®

The number of elective surgical procedures performed in an office-based setting has

OFFICE-BASED PROCEDURES DURING THE COVID-19 PANDEMIC

POTENTIAL ADVANTAGES AND BENEFITS

● Advantages – Potential advantages of performing procedures in an office-based

• Patient-specific advantages – Patient convenience with perception of greater

• Surgeon-specific advantages – Surgeon convenience with perception of greater ease

• Institutional advantages – Cost containment compared with hospital settings.

● Benefits – Potential benefits when procedures are performed in an office-based setting

• Possibly lower nosocomial infection rates

• Decreased thromboembolic complications

• Quicker postoperative mobilization, which may reduce complications

• Earlier physical therapy and rehabilitation

• Greater patient satisfaction

Adequacy of facility resources — Appropriate resources (eg, personnel, equipment,

Access to adequate resources may be critically important when procedural or anesthetic

Responsibilities for anesthesiologists planning to practice in office-based settings include

Government regulations — Office-based facilities are typically subject to a lesser level of

Professional society guidelines — We use guidelines for office-based anesthesia adopted

( Guidelines for Office-Based Anesthesia), as well as qualifications of anesthesia providers,

Routine checklists and briefings — Use of checklists with an incorporated briefing such as

A single-center study in a plastic surgery office-based setting demonstrated a reduced

Crisis checklists — Crisis checklists (also termed cognitive aids or emergency manuals)

● (See "Management of the difficult airway for general anesthesia in adults".)

Selection of appropriate patients for office-based anesthesia is an important decision that is

Identification of poor-risk patients — Identifying patients at higher risk for complications

In a retrospective study of more than 1.4 million ambulatory surgery patients in

Standard monitors — In all office-based procedures, standard American Society of

Choice of anesthetic techniques — Anesthetic techniques suitable for office-based surgical

"Monitored anesthesia care in adults".)

Selection of anesthetic agents — Ideal anesthetic agents for use in an office-based setting

Avoidance of postoperative nausea and vomiting — Minimizing PONV is a major

dexamethasone (a steroid with a central antiemetic mechanism), and/or ondansetron (a 5-

Ensuring adequate hydration may be useful in prevention of PONV by avoiding orthostatic

Cost-effectiveness — Cost is a valid but lesser concern in selection of anesthetics. Cost is

Local or regional anesthetic techniques — Peripheral nerve blocks have been employed

It is critically important that the anesthesiologists, surgeons, and nurses managing

● (See "Local anesthetic systemic toxicity".)

POSTOPERATIVE PAIN CONTROL

RECOVERY AND DISCHARGE

In a closed claims analysis of office-based settings compared with other ambulatory

ANESTHETIC CONSIDERATIONS AND OUTCOMES FOR SELECTED

Considerations and outcomes for specific procedures are noted below.

Cosmetic surgical procedures

Liposuction — Liposuction is accomplished by inserting hollow rods into small skin

tumescent liposuction, possibly due to local vasoconstriction that results in delayed or

Liposuction has been considered to be a high-risk office-based procedure with reported

perioperative deaths attributed to anesthetic complications, abdominal viscus perforation,

Other cosmetic surgery — Other plastic surgical procedures that may be performed in an

In analyses of adverse incidents occurring during office-based surgery in Florida between

Ophthalmology procedures — Cataract surgery is one of the most common procedures

Additional details regarding anesthetic management and potential complications of head

Otolaryngology procedures — Selected otolaryngology procedures can be performed in an

Dental procedures — Dental procedures are commonly performed in an office-based

Gastrointestinal endoscopic procedures — Gastrointestinal endoscopy procedures are

Gynecologic procedures — Termination of pregnancy (ie, abortion) is commonly performed

procedures, no differences in abortion-related adverse events were noted in this setting

Other gynecologic procedures such as cervical or endometrial biopsy, curettage, and

Orthopedic and podiatry procedures — Selected orthopedic procedures have been

Although many podiatry procedures are performed in office-based settings, published

Endovascular and other vascular procedures — Selected endovascular procedures such as

SUMMARY AND RECOMMENDATIONS

Anesthesia safety Anticipated critical events How the specimen is