Apfelbaum Ambulatory Anesthesia, An Issue of Anesthesiology Clinics

1. Auflage 2014
ISBN: 978-0-323-29934-3
Verlag: Elsevier HealthScience EN
Format: EPUB
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)

E-Book, Englisch, Band Volume 32-2, 329 Seiten

Reihe: The Clinics: Internal Medicine

Ambulatory anesthesia is used for surgical procedures where the patient does not need to stay overnight in the hospital. The same anesthetics that are used in the operating room setting are used in the ambulatory setting, including general, regional and local anesthetics. Sedation anesthetics are also given in the ambulatory setting. This issue will cover best practices and procedures for perioperative care, regional anesthesia, pediatric anesthesia, administering office anesthesia, and more.

Autoren/Hrsg.

Apfelbaum, Jeffrey

Inhaltsverzeichnis

1;Front Cover;1
2;Ambulatory
Anesthesiology;2
3;copyright
;3
4;Contributors;4
5;Contents;8
6;Anesthesiology Clinics
;14
7;Foreword
;16
8;Preface
;18
9;Perioperative Management of Co-Morbidities;24
9.1;Perioperative Evaluation and Management of Cardiac Disease in the Ambulatory Surgery Setting;26
9.1.1;Key points;26
9.1.2;Introduction;26
9.1.3;Hypertension;27
9.1.4;Functional capacity;27
9.1.5;Coronary artery disease;27
9.1.6;Heart failure;28
9.1.7;Coronary stents;29
9.1.8;Cardiovascular implantable electronic devices: pacemakers and implantable cardioverter defibrillators;29
9.1.9;Aortic stenosis;30
9.1.10;Prosthetic heart valves;31
9.1.11;Preoperative testing;32
9.1.12;Perioperative medical management;32
9.1.13;Prophylaxis for infective endocarditis;32
9.1.14;Putting it all together: a stepwise practical approach for ambulatory surgery;33
9.1.15;Preoperative cardiac evaluation on the horizon;35
9.1.16;References;35
9.2;Perioperative Consideration of Obstructive Sleep Apnea in Ambulatory Surgery;38
9.2.1;Key points;38
9.2.2;Introduction;38
9.2.3;Risk factors and pathophysiology;39
9.2.4;Diagnostic criteria of OSA;39
9.2.5;Methods for perioperative screening for OSA;39
9.2.6;Preoperative evaluation of the patient with suspected or diagnosed OSA for ambulatory surgery;39
9.2.7;Outcome of patients with OSA undergoing ambulatory surgery;41
9.2.8;Perioperative care of patients with OSA for ambulatory surgery;41
9.2.9;Postoperative disposition and unplanned admission after ambulatory surgery;42
9.2.10;Summary;43
9.2.11;References;43
9.3;Management of Diabetes Medications for Patients Undergoing Ambulatory Surgery;46
9.3.1;Key points;46
9.3.2;Preoperative inquiries;46
9.3.2.1;Medications for Type 2 Diabetes Mellitus;46
9.3.2.2;Insulin;47
9.3.2.3;Insulin Pumps;47
9.3.3;Hypoglycemia;47
9.3.4;Significance of diabetes in surgical outpatients;49
9.3.4.1;Glycemic Disturbances;49
9.3.4.2;Evidence for Glucose Control in Critical Care and Surgical Patients;49
9.3.5;Perioperative management of diabetes medications;49
9.3.5.1;Insulin Dosing;49
9.3.5.1.1;Day prior to surgery;49
9.3.5.1.2;Day of surgery;51
9.3.5.1.3;Correction doses of insulin;52
9.3.5.1.4;Insulin pumps;52
9.3.5.2;Oral Medications;52
9.3.6;Anesthesia care;53
9.3.6.1;Scheduling;53
9.3.6.2;Glucose Measurement;54
9.3.6.3;Abnormal Blood Glucose Values;54
9.3.6.4;Postoperative Care;54
9.3.7;References;54
10;Regional Anesthesia;58
10.1;Peripheral Nerve Blocks for Ambulatory Surgery;60
10.1.1;Key points;60
10.1.2;Introduction;60
10.1.3;Upper extremity PNBs;63
10.1.3.1;Interscalene Block;63
10.1.3.2;Supraclavicular Block;65
10.1.3.3;Infraclavicular Block;65
10.1.3.4;Axillary Block;67
10.1.4;Lower extremity PNBs;67
10.1.4.1;Femoral Nerve Block;68
10.1.4.2;Sciatic Nerve Block;68
10.1.5;Summary;69
10.1.6;References;69
10.2;Neuraxial Anesthesia for Outpatients;76
10.2.1;Key points;76
10.2.2;Introduction;76
10.2.3;Selection of agents;76
10.2.4;Epidural anesthesia;79
10.2.5;Selection of agents;83
10.2.6;Side effects;84
10.2.7;Summary;87
10.2.8;References;87
11;Anesthesia for Procedures;90
11.1;Anesthesia for Ambulatory Diagnostic and Therapeutic Radiology Procedures;92
11.1.1;Key points;92
11.1.2;Introduction;92
11.1.3;Contrast;93
11.1.4;Other contrast media;93
11.1.5;MRI;93
11.1.5.1;Magnet Safety;93
11.1.5.2;Anesthetic Considerations for MRI;93
11.1.5.2.1;Monitoring/patient access;95
11.1.5.2.2;Ear safety;96
11.1.6;Interventional radiology;96
11.1.6.1;Radiation Safety;96
11.1.7;Anesthetic considerations for interventional radiology;97
11.1.7.1;Anesthetic;97
11.1.7.2;Monitoring/Equipment;98
11.1.8;Procedures;98
11.1.9;Postprocedure care;100
11.1.10;Summary;100
11.1.11;References;100
11.2;Ambulatory Anesthesia for the Cardiac Catheterization and Electrophysiology Laboratories;102
11.2.1;Key points;102
11.2.2;Introduction;102
11.2.3;Consultation: a multidisciplinary approach;102
11.2.4;General strategies for the ambulatory anesthesiologist;103
11.2.5;Higher risk procedures in the ambulatory surgery setting;103
11.2.5.1;Complex Catheter Ablation;103
11.2.5.2;Lead Extractions for Cardiovascular Implantable Electronic Devices;104
11.2.6;Transcatheter aortic valve replacement;105
11.2.7;Radiation safety;105
11.2.8;Summary;106
11.2.9;References;106
11.3;Nonoperating Room Anesthesia for the Gastrointestinal Endoscopy Suite;108
11.3.1;Key points;108
11.3.2;The patients;109
11.3.3;The procedures;109
11.3.4;Anesthesia techniques for GI endoscopy;110
11.3.5;Preanesthesia preparation for the GI endoscopy suite;111
11.3.6;Anesthetic technique;111
11.3.7;Postanesthesia care;113
11.3.8;An increasing role for anesthesia in the GI endoscopy suite of the future;113
11.3.9;References;114
11.4;Chronic Pain;116
11.4.1;Key points;116
11.4.2;Introduction;116
11.4.3;History of interventional pain management;116
11.4.4;Anesthesia techniques in off-site locations;117
11.4.5;Interventional pain-relieving procedures;117
11.4.6;Complications related to anesthetic techniques in interventional pain procedures;123
11.4.6.1;Airway Compromise;123
11.4.6.2;Disinhibition and Agitation;123
11.4.6.3;Predisposition to Neural Injury;124
11.4.7;Summary;128
11.4.8;References;128
11.5;Pediatric Ambulatory Anesthesia;132
11.5.1;Key points;132
11.5.2;Introduction;132
11.5.3;Patient selection;133
11.5.3.1;Upper Respiratory Infection;133
11.5.3.2;Apnea Risk in Infants;134
11.5.3.3;Sleep Apnea and Tonsillectomy;135
11.5.3.4;Cardiac Risk;135
11.5.3.5;Undiagnosed Weakness or Hypotonia;136
11.5.3.5.1;MH;136
11.5.3.5.2;Hyperkalemic cardiac arrest;136
11.5.3.5.3;PRIS;137
11.5.3.6;Preoperative Pregnancy Testing;137
11.5.4;Preoperative management;137
11.5.4.1;Nonpharmacological Anxiolysis;137
11.5.4.1.1;Clowns and magicians;137
11.5.4.1.2;Audiovisual material and games;139
11.5.4.1.3;Humor and verbal methods;139
11.5.5;Intraoperative management;139
11.5.5.1;Intubation Without Neuromuscular Blockade: Remifentanil;139
11.5.5.2;Pain Management for Circumcision;141
11.5.5.3;Acetaminophen: Rectal Dosing;141
11.5.6;Summary;143
11.5.7;References;143
11.6;Initial Results from the National Anesthesia Clinical Outcomes Registry and Overview of Office-Based Anesthesia;152
11.6.1;Key points;152
11.6.2;Introduction;152
11.6.3;Administrative and safety issues;153
11.6.3.1;Literature Review;153
11.6.3.2;Accreditation and Other Administrative Issues;155
11.6.3.3;Facility, Patient, and Procedure Selection;156
11.6.4;Data analysis from the Anesthesia Quality Institute;158
11.6.5;Future direction of OBA;163
11.6.6;References;163
11.7;Airway Management;166
11.7.1;Key points;166
11.7.2;Introduction;166
11.7.3;Lessons learned from recent studies;167
11.7.3.1;The Fourth National Audit Project of the United Kingdom;167
11.7.3.2;2013 Update: ASA Difficult Airway Algorithm;169
11.7.3.3;The SGA: When Might It Fail?;170
11.7.3.4;Videolaryngoscopes: Glottic View Versus Successful Intubation;170
11.7.4;Airway assessment;174
11.7.4.1;Developing an Airway Strategy;175
11.7.4.2;SGA Tips for Success;176
11.7.4.3;VL: Tips for Success;177
11.7.5;Anesthetic emergence and extubation;177
11.7.5.1;The Bailey Maneuver;177
11.7.6;Emergency equipment;179
11.7.7;Summary;181
11.7.8;References;181
11.8;New Medications and Techniques in Ambulatory Anesthesia;184
11.8.1;Key points;184
11.8.2;Introduction;184
11.8.3;Novel sedative-hypnotics drugs and delivery systems;185
11.8.3.1;Propofol Formulations;185
11.8.3.2;Alternate Propofol Emulsion Formulations;185
11.8.3.2.1;Ampofol;185
11.8.3.2.2;IDD-D Propofol 2%;185
11.8.3.2.3;AM149;186
11.8.3.2.4;Propofol-Lipuro 1% and 2%;186
11.8.3.2.5;Albumin emulsions;187
11.8.3.3;Nonemulsion Formulations;187
11.8.3.3.1;Propofol cyclodextrin formulation;187
11.8.3.3.2;Micelle formulations;188
11.8.3.4;Propofol Prodrugs (Fospropofol, HX0969w);188
11.8.3.4.1;SEDASYS System;189
11.8.3.5;Benzodiazepine Receptor Agonists;190
11.8.3.5.1;PF0713;190
11.8.3.5.2;Remimazolam (CNS 7056);190
11.8.3.5.3;AZD 3043 (previously named TD-4756);190
11.8.3.5.4;JM-1232 (-) (MR04A3);191
11.8.3.6;Etomidate Derivatives;191
11.8.3.6.1;Methoxycarbonyl etomidate;192
11.8.3.6.2;Cyclopropyl MOC etomidate;192
11.8.3.6.3;MOC-carboetomidate;193
11.8.3.7;Other Class;193
11.8.3.7.1;Melatonin;193
11.8.4;Novel neuromuscular blocking/reversal agents;193
11.8.4.1;Gantacurium (GW280430A);194
11.8.4.1.1;CW 002;194
11.8.4.1.2;Sugammadex;194
11.8.5;Novel analgesics and analgesic delivery systems;194
11.8.5.1;Kappa-Opioid Agonists;195
11.8.5.1.1;CR665 (JNJ-38488502);196
11.8.5.1.2;CR845;196
11.8.5.2;Local Anesthetics;197
11.8.5.2.1;EXPAREL (bupivacaine liposome injectable suspension 1.3%);197
11.8.5.2.2;SABER-Bupivacaine;199
11.8.5.2.3;Nonintravenous formulations of fentanyl;199
11.8.6;Summary;200
11.8.7;References;200
12;Postop Issues/Care/Discharge;208
12.1;Postoperative Issues;210
12.1.1;Key points;210
12.1.2;Postanesthetic recovery;210
12.1.3;Discharge scoring system;211
12.1.3.1;Fast-Tracking;211
12.1.3.2;Discharge from Ambulatory Surgical Unit;212
12.1.3.3;Discharge After Regional Anesthesia;212
12.1.3.4;Postdischarge Instructions;214
12.1.4;Summary;215
12.1.5;References;215
12.2;Acute Pain Management;218
12.2.1;Key points;218
12.2.2;Introduction;218
12.2.3;Identify: risk stratification, preprocedural planning;220
12.2.4;Implement: MMA, regional anesthesia;220
12.2.5;Implement: MMA, pharmacotherapy;222
12.2.6;Implement: nonpharmacologic techniques;223
12.2.7;Intervene: recovery room rescue;223
12.2.8;Summary;223
12.2.9;References;224
12.3;Long-Acting Serotonin Antagonist (Palonosetron) and the NK-1 Receptor Antagonists;228
12.3.1;Key points;228
12.3.2;Introduction;228
12.3.3;Risk factor identification;229
12.3.4;Pharmacologic intervention;229
12.3.4.1;Palonesetron;231
12.3.4.2;Aprepritant, Casopitant, Rolapitant;231
12.3.5;Clinical evidence of efficacies;232
12.3.5.1;Palonosetron;232
12.3.5.2;Neurokinin Receptor Antagonist;234
12.3.6;Summary;236
12.3.7;References;236
13;Administrative Issues;240
13.1;Scheduling of Procedures and Staff in an Ambulatory Surgery Center;242
13.1.1;Key points;242
13.1.2;Introduction;242
13.1.3;Basic definitions;243
13.1.4;Systems for procedure scheduling;243
13.1.5;Using utilization to assign or time;247
13.1.6;Prediction of procedure duration;247
13.1.7;Categories of OR delays;249
13.1.8;Summary;251
13.1.9;References;251
13.2;Practice Management/Role of the Medical Director;254
13.2.1;Key points;254
13.2.2;Introduction;254
13.2.3;History and development of the ambulatory surgery medical director;255
13.2.4;Management by outcomes and process improvement;256
13.2.5;Care pathway development: reducing error and improving quality by reducing variation;261
13.2.6;Summary;261
13.2.7;References;263
13.2.8;Appendix 1 Example of a multidisciplinary algorithm of care resulting from a safety event;263
13.2.8.1;Surgical Team;263
13.2.8.2;Anesthesia Team;264
13.2.8.3;Pre-operative/Recovery Nurse;265
13.3;Legal Aspects of Ambulatory Anesthesia;266
13.3.1;Key points;266
13.3.2;Practice-related legal issues;266
13.3.2.1;Professional Liability;266
13.3.2.1.1;Patient selection;267
13.3.2.1.2;Informed consent;267
13.3.2.1.3;Professional association standards;268
13.3.2.2;Regulatory Considerations;268
13.3.2.2.1;CMS conditions for coverage;268
13.3.2.2.2;State law requirements;269
13.3.2.2.3;Kickbacks;269
13.3.2.2.4;Stark and physician self-referrals;270
13.3.2.3;Contracts;271
13.3.3;Ownership-related legal issues;271
13.3.3.1;Federal Antikickback Statute Restrictions on Ownership;271
13.3.3.2;Stark Law Considerations;272
13.3.3.3;State Law Requirements;273
13.3.3.3.1;Requirements that referring physicians perform the services themselves;273
13.3.3.3.2;Disclosure or sunshine requirements;273
13.3.4;Summary;273
13.3.5;References;273
13.4;Accreditation of Ambulatory Facilities;276
13.4.1;Key points;276
13.4.2;Introduction;276
13.4.3;Accrediting organizations;277
13.4.4;Deemed status;278
13.4.5;Ambulatory facility regulation by states;279
13.4.6;Quality reporting and outcomes;280
13.4.7;References;281
13.5;Anesthesia Information Management Systems in the Ambulatory Setting;284
13.5.1;Key points;284
13.5.2;Benefits;285
13.5.2.1;Medical Record Review;285
13.5.2.2;Support Links (Information Buttons);286
13.5.2.3;Organization of Information;286
13.5.2.4;Automatic Transfer of Vital Signs;286
13.5.2.5;Legibility;287
13.5.2.6;AIMS is Integrated with the EHR;288
13.5.2.7;Decision Support;288
13.5.2.8;Menus;289
13.5.2.9;Compliance;290
13.5.2.10;Icons Communicate Patient Status;291
13.5.2.11;Registries;292
13.5.2.11.1;Summary of benefits;293
13.5.3;Challenges;294
13.5.3.1;Report Management;294
13.5.3.2;Forest-for-the-trees Dilemma;294
13.5.3.3;Garbage In, Garbage Out;294
13.5.3.4;Short Cases Require an Experienced AIMS User;294
13.5.3.5;Device Integration;294
13.5.3.6;Support and Downtimes;295
13.5.3.7;Alerts After the Fact;295
13.5.3.8;Workstation Reliability and Availability;296
13.5.3.9;Cost;296
13.5.3.10;Medicolegal Concerns;298
13.5.4;The future;299
13.5.4.1;Standardization;299
13.5.4.2;Access and Portability in a Health Information Exchange;299
13.5.4.3;Wireless Monitoring and Integration;299
13.5.4.4;Mobile Technology;299
13.5.5;Summary;300
13.5.6;References;300
13.6;Quality Management and Registries;302
13.6.1;Key points;302
13.6.2;Why quality management is important and how to do it;302
13.6.3;External resources and registries;305
13.6.4;What data to collect;307
13.6.5;How to use QM data;308
13.6.6;Summary;310
13.6.7;References;310
14;Index;312

Leseproben

Preface The Four Ps: Place, Procedure, Personnel, and Patient
Jeffrey L. Apfelbaum, [e-mail],     Department of Anesthesia and Critical Care, Pritzker School of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 4028, Chicago, IL 60637, USA Thomas W. Cutter, MD, [e-mail],     Department of Anesthesia and Critical Care, Pritzker School of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 4028, Chicago, IL 60637, USA
Jeffrey L. Apfelbaum, MD, Editor
Thomas W. Cutter, MD, MAEd, Editor Patient ingress
As with all anesthetics, perioperative management may be divided into preoperative, intraoperative, and postoperative management. Preoperatively, one of the things that makes the practice of ambulatory anesthesia unique is the appropriate selection of patients. Most ambulatory anesthesiologists have encountered the patient who is deemed an inappropriate candidate because of his or her comorbidities. A question often asked of experienced ambulatory practitioners is whether there is a checklist or the like that can be applied to determine appropriate patients for the outpatient setting. This checklist might include answers to questions such as, “what is the maximum body mass index; should I care for a patient with a difficult airway; is a spinal anesthetic appropriate; are patients with an implantable cardiac defibrillator (ICD) acceptable?” There is potential value in creating such a checklist for the anesthesia provider and the proceduralist, but there are potential problems as well. To uniformly refuse service to all individuals with a given condition likely unduly limits access and does not allow the facility to take full advantage of its potential. Rather than a checklist that limits itself to just one aspect, it is best to recognize that it is not just the patient selection process that is important, but one must also consider the providers, the procedure, and the facility (place), taking into account the comorbidities of the patient, the skillsets of and access to providers, the procedure itself, and the availability of equipment in, and the location of, the facility. Facilities (place) where ambulatory anesthesia is practiced include hospitals, where there can be a designated suite of operating rooms for these cases or where they can be interspersed throughout the larger operating room suite. Alternatively, there can be a separate dedicated building where ambulatory procedures are performed, referred to as an “on-campus” setting. Outpatient procedures can also be performed in a freestanding surgicenter located some distance away from a major hospital. The final location is that of the office, which is probably the ne plus ultra of ambulatory anesthesia. Obviously, each of these settings has its advantages and limitations in terms of its ability to care for the more complex patient because of the available personnel and equipment and the proximity to other facilities for support or even transfer. The number of providers and their level of training also impact the selection process. The skillset of the ancillary staff is important, especially when it comes to postanesthesia care. Having a receptionist with no medical training who also serves as the individual who monitors the patient after the procedure limits the complexity of both the procedure and the anesthetic technique. Having two trained and capable postanesthesia care unit nurses may mean that more complex procedures and anesthetics may be performed. Having an anesthesia technician may provide more equipment support so more sophisticated techniques (eg, fiberoptic bronchoscopy) may be available. Thus, the caliber and quantity of primary and support personnel influence the selection process. The procedure is clearly an important part of the equation. In the 1990s, criteria for an acceptable procedure included minimal blood loss/fluid shift, duration of less than 90 minutes with simple equipment, minimal postoperative care, and minimal pain able to be treated with oral medications.1 In the twenty-first century, the requirement is merely that the patient be able to go home the same day or, in some settings, within 23 hours. There really are no hard and fast rules that can be applied to distinguish an ambulatory procedure from an inpatient procedure other than the ability to safely go home the same day. When an anesthesiologist can provide an anesthetic from which the patient should be able to recover within a few hours, the limiting feature becomes the postoperative care associated with the procedure. The final factor in the equation is the patient. Some may believe that only American Society of Anesthesiologists physical status class 1 or 2 patients should be cared for in an ambulatory setting, but this fails to take into account the impact of the place, the procedure, and the personnel. For example, a patient with obstructive sleep apnea can safely receive a lower extremity regional anesthetic with intravenous sedation and analgesia in many ambulatory facilities. There is little if any evidence that an otherwise healthy patient with a body mass index above a certain level is at increased risk for an ambulatory procedure, but there is the caveat that the operative table must be able to support the weight. While some may be loathe to care for a patient with an ICD in an office-based practice or a surgicenter, performing a procedure for this patient in an on-campus or integrated facility may be entirely appropriate. Thus, one must look at a variety of factors and integrate them into a meaningful whole to determine the appropriateness of admission to an ambulatory setting. Figs. 1 and 2 illustrate this principle, where a patient with an ICD is acceptable in an on-campus setting but not in an office setting.
Fig. 1 Patient, providers, procedure, and place all overlap: proceed. CST, certified surgical technician; MD, medical doctor; OR operating room; PACU, postanesthesia care unit; RN, registered nurse.
Fig. 2 Patient, providers, procedure, and place do not all overlap: do not proceed. Patient egress
The defining aspect of an ambulatory anesthetic is the patient’s ability to safely and comfortably leave the facility the same day. There are at least four sequelae to consider that are dependent on the anesthesiologist’s preoperative, intraoperative, and postoperative management. While these will be dealt with in greater detail in other articles, they can be summarized to provide an overall recommendation for perioperative management. These “barriers” to discharge include pain, postoperative nausea and vomiting, excessive sedation, and significant pathophysiologic derangements. Pain is regarded as the most common and most important adverse postoperative outcome.2–4 Multimodal therapy using low-dose opioids, nonsteroidal anti-inflammatory drugs, and regional anesthesia serves to mitigate this. Postoperative nausea and vomiting can likely be regarded as the second most significant impediment and is also amenable to a multimodal approach, both to avoid the problem and to treat it. Excessive sedation also results in delayed discharge,5 so preoperative and intraoperative sedative-hypnotics and intraoperative and postoperative opioids should be used judiciously. Morbid events, such as cardiac ischemia, hyperglycemia, cerebral vascular accident, or persistent hypotension, may also delay discharge, but the preoperative selection process and overall perioperative management should minimize this. Managing to avoid the sequelae of these comorbidities and other “complications” is of paramount importance to ensure a safe and timely discharge to home. For this issue of Anesthesiology Clinics, our authors have detailed many of the clinical and logistical perioperative ambulatory anesthesia concerns that may lead to suboptimal outcomes and offer ways to manage them. We have also included articles on the administrative aspect of the practice of ambulatory anesthesia, since quite often it is the anesthesiologist who serves as the medical director and administrative go-to person in the facility. We finish with a glimpse of the future, including articles on the electronic medical record and the application of quality assurance registries in the ambulatory domain. We hope to provide a relatively broad overview of the practice of ambulatory anesthesia while also yielding a deeper understanding of some of the more common or pressing issues. Summary
The bottom line is that proper preoperative selection and preparation and the application of certain intraoperative techniques will best ensure that those who walk in to an ambulatory surgery facility will be able to walk out the same day. References
1. White, P. F., Song, D. New criteria for fast-tracking after outpatient anesthesia: a comparison with the modified Aldrete's scoring system. Anesth Analg. 1999; 88:1069–1072. 2. Macario, A., Weinger, M., Truong, P., et al. Which clinical anesthesia outcomes are both common and important to avoid? The...