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Address correspondence and reprint requests to Girish P. Joshi, MB, BS, MD, FFARCSI, Professor of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, Texas 75235-9068. Address e-mail to girish.joshi{at}utsouthwestern.edu.
The Society for Ambulatory Anesthesia (SAMBA) 20th Annual Meeting was held May 12–15, 2005, at the J.W. Marriott Camelback Inn and resort in Scottsdale, Arizona. This year’s program provided a unique educational experience, bringing together internationally known experts from across the field of ambulatory and office-based anesthesia. Lucinda L. Everett, MD (Boston, MA) was program chair for the meeting. A highlight of the meeting included the presentation of the SAMBA Distinguished Service Award to Rebecca S. Twersky, MD (Brooklyn, NY) in recognition of her lifetime of outstanding contributions and distinguished service to the specialty of ambulatory anesthesia.
The program began on Thursday, May 12 with a day-long Preconvention Workshop on Preoperative Evaluation and Perioperative Medicine that provided participants information on both medical and logistical aspects of preoperative evaluation and about considerations for specific disease entities and patient population. The preconvention workshop was moderated by Catherine L. Cooper, MD (Richmond, Virginia) and Raymond G. Borkowski, MD (Cleveland, Ohio). Topics covered during this comprehensive program included "Preoperative Evaluation and Laboratory Testing" discussed by Dr. Cooper, "Preoperative Evaluation Systems" by Dr. Borkowski, "Evaluating the Geriatric Patient/Avoiding Cognitive Dysfunction" led by Terri G. Monk, MD (Gainesville, Florida), "The Patient with Congestive Heart Failure" presented by D. Eric Steidley, MD (Scottsdale, Arizona), "Pediatric Preoperative Evaluation" led by Raafat S. Hannallah, MD (Washington, DC), "Malignant Hyperthermia, Myopathies and Mitochondrial Diseases" addressed by John L. Bastien, MD (Portsmouth, Virginia), "Recognition and Management of Coagulopathies in the Pre- and Perioperative Periods" commented on by John K. Camoriano, MD (Scottsdale, Arizona), and "The Patient with Liver Disease" reviewed by Brian M. Parker, MD (Cleveland, Ohio).
Other optional programming presented on Thursday included a highly informative workshop on "Advanced Administrative" moderated by Douglas G. Merrill, MD (Federal Way, Washington), William O. Fitzpatrick, III, MD (Birmingham, Alabama), and Brian M. Parker, MD (Cleveland, Ohio). The program reviewed the principles and strategies surrounding the issues of accreditation, personnel credentialing and management, and outcome measurement use in an ambulatory surgery center. Specific examples of these issues were discussed, including pitfalls of facility accreditation, management of "difficult" surgeons, and clinical outcome measurement as a tool to improve quality and potentially increase market share. The workshop featured both a panel and a set of small roundtable discussions of participants’ own "real-world experiences."
An in-depth, two-session "Ultrasound in Anesthesia" workshop was also presented. This program was moderated by Dara S. Breslin, MD (Durham, North Carolina), Andrew T. Gray, MD, PhD (San Francisco, California) and Anahi Perlas, MD (Toronto, Canada). The workshop allowed participants to familiarize themselves with a handheld ultrasound device to facilitate regional anesthetic techniques and central venous cannulation using live models and illustrations. Workshop attendees learned the benefits of using ultrasound for block placement.
An American Society of Anesthesiologists Open Forum on Sleep Apnea hosted by Jeffrey B. Gross, MD (Farmington, Connecticut) gave SAMBA members the opportunity to voice their viewpoints on this important subject.
The general program began on Friday, May 13, with an Opening Ceremony moderated by Lucinda L. Everett, MD. The ceremony included a presentation on "History of Ambulatory Anesthesia" by Johnathan L. Pregler, MD (Los Angeles, California). Dr. Pregler concluded that procedures that were once performed on an inpatient basis are now routinely performed on an outpatient basis. Developments in surgical techniques should lead to further expansion of ambulatory surgery. Furthermore, there does not appear to be any sign of reversal of this trend or slowing of the growth of ambulatory surgery and anesthesia. Kathryn E. McGoldrick, MD (Valhalla, New York) presented the SAMBA Presidents Address, updating the Society’s members on the achievements made by the organization during the most recent year. Tong J. Gan, MD (Durham, North Carolina) delivered the International Anesthesia Research Society Address, providing a summary of the most relevant findings from recent articles in ambulatory anesthesia literature. These included studies evaluating the analgesic efficacy of cyclooxygenase (COX)-2 specific inhibitors, gabapentin, and intranasal hydromorphone. The current controversy regarding the cardiovascular effects of COX-2 specific inhibitors was also discussed. Other studies presented related to role of electro-acupoint stimulation, substance P (neurokinin-1) antagonist, and pharmacogenetics in management of postoperative nausea and vomiting. In addition, studies comparing regional anesthesia and general anesthesia, influence of spinal anesthesia-related transient neurologic symptoms, and regional anesthesia in obese patients, as well as recovery after ambulatory anesthesia, were presented.
The first general session of the meeting addressed "Risk and Outcome in Ambulatory Anesthesia" and was moderated by Walter G. Maurer, MD (Cleveland, Ohio). Frances Chung, MD (Toronto, Canada) spoke on "Outcomes in Ambulatory Anesthesia." Jeffrey P. Morray, MD (Paradise Valley, Arizona) focused on "Anesthetic-Related Pediatric Cardiac Arrest," and Lee A. Fleisher, MD (Philadelphia, Pennsylvania) looked at "Surgical Risk Reduction." Dr. Chung presented the overall incidence of outcomes after ambulatory anesthesia. She emphasized that the problem of escorting patients home is a major cause of unanticipated hospital admissions. The studies using driving simulation, electroencephalogram-verified sleepiness, and attention deficit report deficits at 2-h but return to normal values at 24-h after anesthesia. There appears to be a misconception that ambulatory anesthesia is minor; however, she cautioned that "there may be minor surgery, but there is no minor anesthetic." She presented the results of a study reporting that unanticipated hospital admission and mortality after ambulatory surgery in elderly patients are related to patient and procedure selection as well as location of care (e.g., outpatient facility versus physician office). Finally, functional status of patients after ambulatory anesthesia and patient satisfaction were discussed. In the next talk, Dr. Morray suggested that there has been reduction in anesthetic-related pediatric cardiac arrests over the past 50 yr, which may be a result of use of sevoflurane (instead of halothane) as well as of the avoidance of local anesthetic toxicity, hypovolemia, hyperkalemia (from massive blood transfusion), and central line complications (by using ultrasound devices). In addition, creation of a specialized environment for children and defining the scope of pediatric anesthesia practice (i.e., use pediatric anesthesiologist for high-risk children) should also reduce the risk of cardiac arrest. In the final talk of the session, Dr. Fleisher noted that despite the availability of level I evidence that specific interventions are associated with decreased perioperative morbidity and mortality, they are not uniformly adapted in clinical practice. This has lead to the introduction of the pay-for-performance program. The Surgical Care Improvement Project is initially targeting four areas with an incidence of expensive complications including surgical site infection, adverse cardiac events, deep vein thrombosis, and postoperative pneumonia. The strategies to reduce these complications include antibiotic administration before surgical incision and administration of ß-blockers in patients chronically receiving these drugs as well as those with known coronary artery disease. It was emphasized that several studies have questioned the utility of ß-blockers in non-high cardiac risk patients.
Friday afternoon featured optional workshops and an ASA Open Forum, providing an opportunity for members to participate in further educational programs or to enjoy the many amenities of the Camelback Inn. Those who opted to participate in the workshops had the option of participating in a program addressing "Regional Anesthesia: Single Injection and Catheter Techniques for Upper Extremity, Lower Extremity, and Paravertebral Blocks." Susan M. Steele, MD (Durham, North Carolina) moderated the program. Panelists included Dara S. Breslin, MD (Durham, North Carolina), Roy A. Greengrass, MD (Jacksonville, Florida), James B. Mayfield, MD (Augusta, Georgia), and Karen C. Nielsen, MD (Durham, North Carolina). Single injection and catheter techniques were demonstrated in a prerecorded videocast followed by discussions in small breakout sessions using live models and illustrations.
Jeffrey M. Feldman, MD (Philadelphia, Pennsylvania) and Michael Mitton, CRNA, MS (Madison, Wisconsin) teamed to present a workshop on "Understanding the New Anesthesia Machines." The workshop presented participants with an understanding of the physiology of mechanical ventilation in the operating room and the limitations of traditional anesthesia ventilators. Participants also learned the features of newer anesthesia ventilators that improve their performance, the indications for, and limitations of, different modes of ventilation including volume-controlled ventilation, pressure-controlled ventilation, pressure support ventilation, and how to use bedside respiratory monitoring effectively to optimize the ventilation strategy.
Michael T. Walsh, MD (Rochester, Minnesota) moderated a clinical forum on "Office-Based Anesthesia." Roy G. Soto, MD (Stony Brook, New York) and Kelly A. McQueen, MD, MPH (Phoenix, Arizona) served as panelists. Through discussion of clinical scenarios, participants examined the differences between the office environment and the more familiar ambulatory surgery care or hospital setting. Equipment, patient selection, and anesthetic techniques were discussed, and participants also learned about the regulatory and administrative considerations unique to office-based anesthesia, such as peer review, contracting, management of controlled substances, and legal responsibility for the patient during recovery and after discharge.
On the evening of Friday May 13th Mark A. Warner, MD (Rochester, Minnesota) hosted an open forum of the ASA Task Force on Perioperative Blindness.
Saturday, May 14 started with a General Session Panel on "Obesity and Sleep Apnea" moderated by Frances Chung, MD (Toronto, Canada). Panelists addressed the topics of "Anesthesia for the Morbidly Obese" by Peter E. Frasco, MD (Scottsdale, Arizona), "Sleep Apnea" by Kenneth L. Bachenberg, MD (Bellingham, Washington), and "Pediatric Sleep Apnea" by Karen A. Brown, MD (Montreal, Canada). Dr. Frasco presented the considerations of perioperative management of the morbidly obese with emphasis on ambulatory surgery. One of the concerns with the morbidly obese is the potential for difficult airway. However, recent studies have reported that body mass index is not a predictor of difficult tracheal intubation. However, obese patients with Mallampati III or IV and/or neck circumference of more than 60 cm might have difficult tracheal intubation. Another concern in the obese is the potential for pulmonary aspiration of gastric contents, although recent studies have not been able show any differences in the amount of gastric volume or gastric pH between the morbidly obese and lean patients. There is a belief that similar to tracheal intubation placement of the laryngeal mask airway (LMA) may be difficult in the obese, but a recent study reported successful placement of LMA in all obese patients.
The possibility of sleep apnea in the obese was also discussed. Dr. Bachenberg presented the recent information on management of adults with obstructive sleep apnea (OSA) and emphasized the potential for postoperative respiratory complications in these patients. Although ambulatory surgery in patients with OSA remains controversial, circumstances in which OSA patients may undergo outpatient procedures were discussed. In addition, discharge criteria after surgery in these patients were presented. Dr. Brown discussed the anesthetic management of OSA in children. It was pointed out that the incidence of preadolescent OSA might be as frequent as 10%–12%. Dr. Brown emphasized that obesity and medical conditions associated with OSA significantly increase the risks of perioperative complications. A diagnosis of OSA can increase the risk of postoperative respiratory morbidity more than 20-fold. The controversy regarding performance of adenotonsillectomy on an outpatient basis because of concerns of OSA in this patient population was discussed. Significant oxygen desaturation resulting from OSA has been reported after adenotonsillectomy. Post-tonsillectomy respiratory complications can be treated with administration of heliox, continuous positive airway pressure, insertion of a nasopharyngeal airway, and, if necessary, reintubation. Dr. Brown advised that it is important to ask parents if their child snores or stops breathing during sleep. The OSA-18 score that was developed in non-obese children may be used to screen children if polysomnography is not available.
The Saturday morning session continued with the highly popular "Cases from the Real World" moderated by Barbara S. Gold, MD (Minneapolis, Minnesota), who presented panelists with thought-provoking cases and stimulated audience discussion. Kenneth L. Bachenberg, MD (Bellingham, Washington), Catherine L. Cooper, MD (Richmond, Virginia), John B. Leslie, MD (Scottsdale, Arizona), and Raafat S. Hannallah, MD (Washington, DC) were this year’s panelists. This panel presented challenging clinical situations that are encountered by an anesthesiologist practicing in an outpatient or office setting. Time was permitted to allow for input from the audience.
The SAMBA Luncheon featured ASA President Eugene P. Sinclair, MD, who presented the annual update of ASA activities, including concerns confronting both the society and anesthesiologists.
The third general session of the meeting provided attendees an insight on "Regional Anesthesia" moderated by Brian A. Williams, MD (Pittsburgh, Pennsylvania). Karen C. Nielsen, MD (Durham, North Carolina) discussed the "Outcomes after Regional Anesthesia." She emphasized that use of regional techniques improves postoperative outcome by reducing the incidence of pain, nausea, and vomiting as well as reduces the length of hospital stay and the incidence of unanticipated hospital admission. In addition, regional analgesia improves postoperative sleep, reduces fatigue, and allows early return to normal activities and work. "Long-Term Follow-Up and Management of Regional Anesthesia Complications" was discussed by James B. Mayfield, MD (Augusta, Georgia). One of the major concerns with regard to peripheral nerve block is the possibility of nerve injury. However, the mechanisms of nerve injury after nerve blockade remain unknown, and therefore it is difficult to develop evidence-based methods to prevent these complications. Early recognition by patient education is necessary to reduce the severity of complications. Roy A. Greengrass, MD (Jacksonville, Florida) spoke on "Management of Peripheral Nerve Block Catheters at Home." Dr. Greengrass emphasized the use of multimodal analgesia along with continuous nerve block to prevent breakthrough pain. Patients and their caregivers should be provided with written instructions regarding the location of the catheter, infusion system, the infusion rates, protection of the insensate limb, and instructions regarding how and when to discontinue infusion. Furthermore, a 24-h contact number should be provided for any questions or potential complications. Importantly, safe use of ambulatory continuous nerve blocks includes the understanding of their limitations.
The SAMBA strives to encourage research by new investigators and prepare residents for life after residency training. These efforts have resulted in a large number of residents regularly attending the Society’s Annual Meeting. A highlight of the meeting is the much looked forward to Resident Session. This year’s session focused on the "Economics and Politics in Anesthesia" and was moderated by Thomas W. Cutter, MD (Chicago, Illinois). The residents were provided an insight of "Academic Practice" by Lee A. Fleisher, MD (Philadelphia, Pennsylvania), and Dean F. Smith, MD (Phoenix, Arizona) provided a glimpse at "Private Practice." During the program, residents discussed the implications of the various practice models and current political and regulatory issues affecting the anesthesiologist.
Saturday afternoon’s program concluded with two parallel track sessions. The first session, the "Nuts and Bolts of Regional Anesthesia" was moderated by John A. Dilger, MD (Rochester, Minnesota). Brian A. Williams, MD (Pittsburgh, Pennsylvania) spoke on the "Logistics for Regional Anesthesia," Susan M. Steele, MD (Durham, North Carolina) detailed "Teaching Regional Anesthesia," and Douglas G. Merrill, MD (Federal Way, Washington) provided comments on "Billing for Regional Anesthesia." Participants learned how regional anesthesia practice may enhance efficiency in the ambulatory setting and heard recommendations for active practitioners on how to teach residents and staff regional techniques. Information on billing for regional anesthesia was also presented.
The second parallel track session was devoted to "Administrative Issues," moderated by Louis A. Freeman, MD (Fresno, California). The topic "Patient Selection" was presented by William O. Fitzpatrick, III, MD (Birmingham, Alabama). Raymond G. Borkowski, MD (Cleveland, Ohio) talked about "Complying with Sedation Policies" and Karen A. Brown, MD (Montreal, Canada) spoke on "Pediatric Considerations." The panel addressed issues in patient selection for both adult and pediatric patients and reviewed sedation policies and the role of a medical director of the Ambulatory Surgery Center in complying with regulations in this area. It was emphasized that, although the development of policies, procedures, and guidelines may reduce complications, appropriate patient and procedure selection, physician skills (both anesthesiologist and surgeon), and length of procedure contribute to patient safety.
Sunday morning, May 15, activities began with panels focusing on "Patient Safety" and "The Cutting Edge (of Ambulatory Anesthesia)." Girish P. Joshi, MB BS, MD, FFARCSI (Dallas, Texas) moderated the "Patient Safety" session which featured a presentation titled "Heat, Fire, and Smoke: Shining Light on the Issue of CO2 Absorbents?" by Evan D. Kharasch, MD, PhD (Seattle, Washington). Terrance L Trentman, MD (Phoenix, Arizona) led a discussion on "Complications of the LMA," and Randolph H. Steadman, MD (Los Angeles, California) talked about "Critical Incidents." Dr. Kharasch discussed the issue of carbon dioxide (CO2) absorbents as related to "Compound A" production, carbon monoxide formation, and absorber canister exothermic reaction or fire. He emphasized that the cause of these complications is related to desiccated CO2 absorbers containing strong base. However, it is difficult to know when the absorbent has become desiccated. Therefore, the use of new CO2 absorbents that do not contain strong base should improve patient safety. Dr. Trentman emphasized that significant complications with the LMA are rare. Appropriate patient selection and LMA size selection as well as use of standard insertion technique and recommended inflation volumes should minimize LMA-related morbidity. Finally, Dr. Steadman discussed the approaches to management of critical incidents in the operating room. He concluded that advances in technology, monitoring, and drugs may improve perioperative outcomes. However, simulator training that can enhance the technical and behavioral skills needed for management of critical incidents should significantly reduce complications.
The final panel of the meeting, "The Cutting Edge," was moderated by Peter S. Glass, MD (Stony Brook, New York) and included presentations by John B. Leslie, MD (Scottsdale, AZ) on "Does Dexmedetomidine Have a Place in Outpatient Anesthesia?", Roy G. Soto, MD (Stony Brook, New York) on "Do I Need a Depth of Anesthesia Monitor?", and Terri G. Monk, MD (Durham, North Carolina) on "Can We Change Outcomes by Modulating the Inflammatory Response?" Dr. Leslie discussed the pharmacology and clinical use of the 
-2 agonist dexmedetomidine in ambulatory anesthesia. He concluded that the short duration of action and the lack of respiratory depression make dexmedetomidine an excellent adjunct analgesic, sedative, and hypnotic. However, he emphasized that dexmedetomidine may not provide adequate amnesia in the recommended doses and that it is not Food and Drug Administration approved for anesthesia. In addition, the drug is very expensive and is thus an unnecessary adjunct for routine use. Adverse effects of dexmedetomidine include bradycardia, hypotension, and potentiation of analgesics, sedatives, and anesthetics.
Dr. Soto discussed the current controversy regarding the use "Depth of Anesthesia" monitors. Although these monitors are advertised as appropriate for all patients undergoing any procedure with any anesthetic, current evidence does not conclusively show that these monitors prevent the incidence of intraoperative recall. He concluded that further research is needed before routine use of these monitors can be recommended.
In the final talk of the session, Dr. Monk emphasized that current evidence suggests that anesthesia management may affect long-term outcomes after major surgery. The factors that might affect perioperative outcome include excessive anesthesia, which might predispose patients to silent regurgitation and postoperative pulmonary complications, anesthetic effect on brain, and altered inflammatory response. She concluded that modulation of perioperative inflammatory response using ß-blockers and lipid-decreasing drugs (e.g., statins) might improve perioperative outcome.
The 21st SAMBA Annual Meeting will be held at the J.W. Marriott Hotel in Washington, DC, May 4–7, 2006. The SAMBA meeting is recognized for its stellar educational programs, providing both a tremendous learning opportunity for those involved in ambulatory and office-based anesthesia as well as an outstanding networking forum that promotes the sharing of ideals and experiences among peers.
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