Anesth Analg 2003;96:903-906
© 2003 International Anesthesia Research Society
MEETING REPORT
The Society for Ambulatory Anesthesia: 17th Annual Meeting Report
Girish P. Joshi, MB BS, MD, FFARCSI
Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
Address correspondence to Girish P. Joshi, MB, BS, MD, FFARCSI, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75235-9068. Address e-mail to girish.joshi{at}utsouthwestern.edu
The Society for Ambulatory Anesthesia 17th annual meeting was in Orlando, FL, May 2–5, 2002. The Annual Meeting Chair, Walter Maurer, MD, Cleveland Clinic, OH, and Vice-Chair, Andrew Herlich, MD, Philadelphia, PA, organized presentations on state-of-the-art topics that were targeted to practitioners involved in the care of outpatients undergoing ambulatory surgery in hospital-based, freestanding, and office-based surgery facilities.
The meeting also provided the opportunity to participate in a comprehensive preconvention workshop on advanced cardiac life support, which was held on May 1–2. This workshop was designed to provide the knowledge and skills needed to evaluate and manage core advanced cardiac life support cases, including a respiratory emergency, four types of cardiac arrest (simple ventricular fibrillation (VF)/ventricular tachycardia (VT), complex VF/VT, prearrest emergencies (PEAs), and asystole), four types of PEAs (bradycardia, stable tachycardia, unstable tachycardia, and acute coronary syndromes), and stroke.
Meeting participants were also able to register for any of four workshops. Drs. Shelley (New Haven, CT), Bogetz (San Francisco, CA), Lichtor (Iowa City, IA), and Engel (Sacramento, CA) conducted a workshop on "Practical Uses of Technological Toys," with emphasis on the use of personal digital assistants (PDAs). PDAs are increasingly used for consulting reference manuals, keeping patient records, and writing prescriptions. Discussion also included pros and cons of the available devices, interfacing PDAs with other devices, such as personal computers, use of Web links, and downloading information from Web sites.
Drs. Schaefer III (Pittsburgh, PA), Gonzalez (Sellersville, PA), and Herlich (Philadelphia, PA) conducted the anesthesia-simulators workshop, which introduced the concept of crisis management and a team approach to patient management. In addition, it provided participants with hands-on experience with difficult airway algorithms and techniques.
Participants at the regional and pain management workshop rotated through five distinct stations featuring live models, which followed a brief didactic lecture by Kenneth Zahl, MD, Morristown, NJ. Dr. Zahl also demonstrated orbital and facial blocks. Lucinda Everrett, MD, Seattle, WA, addressed pediatric blocks, and Michael Mulroy, MD, Seattle, WA, spoke on upper-extremity blocks. Admir Hadzic, MD, PhD, New York, NY, demonstrated lower-extremity blocks, and F. Kayser Enneking, MD, Gainesville, FL, taught continuous block techniques.
Dr. Lee Fleisher of the Johns Hopkins Medical Center moderated the problem-based learning discussion workshop on perioperative management and led a discussion on the "Patient with Coronary Artery Disease Undergoing Knee Arthroscopy." Kathryn McGoldrick, MD, Valahlia, NY, spoke on the "Patient with Sleep Apnea Undergoing Airway Surgery," and Grover Mims, MD, Winston Salem, NC, covered the "Obese Patient for Shoulder Arthroscopy." All the case scenarios for problem-based learning discussion were challenging, and there was significant interaction among the participants.
Each morning during the meeting, attendees participated in research poster discussion sessions on current basic and clinical research relevant to the art and science of ambulatory anesthesia. Girish Joshi, MD, Dallas, TX, Melinda Mingus, MD, New York, NY, Yung-Fong Sung, MD, Atlanta, GA, and Brian Parker, MD, Cleveland, OH, served as facilitators for the discussion sessions. These sessions were lively, with numerous attendees participating in the discussion between the presenters and moderators. The small-group format facilitated discussion of the significance of research related to the practical aspects of ambulatory anesthesia.
The primary track of the annual meeting continued to be the general session panels, with two panel sessions presented each of the three mornings for a total of six such sessions. The first panel program was a session on "New Practice Guidelines," moderated by Burton Epstein, MD, Washington, DC. The first speaker, Frances Chung, MD, Toronto, Canada, addressed "American Society of Anesthesiologists (ASA) Postanesthetic Care Guidelines." She discussed the changes in the guidelines for discharge after outpatient surgery. The guidelines for postoperative monitoring were discussed. Furthermore, it was emphasized that the new guidelines do not mandate that patients tolerate oral fluids or void before discharge. The appropriate implementation of the new guidelines should reduce unnecessary delay in discharge after ambulatory surgery.
L. Reuven Pasternak, MD, from the Johns Hopkins Medical Center, spoke on the "ASA Preoperative Practice Advisory." Dr. Pasternak noted that anesthesiologists often manage patients with complex medical problems who are undergoing outpatient surgery with little prior information. However, preanesthesia evaluation is a crucial first step that may affect the postoperative outcome. Dr. Pasternak provided an algorithm to address the issue of timing of the preoperative evaluation. He suggested that low-risk patients undergoing low-risk procedures might have a preanesthesia assessment on the day of surgery on the basis of available preoperative data. However, low-risk patients undergoing medium- to high-risk surgical procedures or high-risk patients undergoing low- to medium-risk surgical procedures may require preanesthesia consultation on the basis of the nature of the patient’s medical condition and planned procedure. Finally, high-risk patients undergoing high-risk procedures should have a preanesthesia consultation with anesthesia staff before the day of surgery. He emphasized that all preoperative testing should be individually determined on the basis of the patient’s medical status, the severity of the surgical procedure, and the proposed anesthetic technique. Dr. Pasternak also presented an illustrative guideline for laboratory testing.
Rounding out the "New Practice Guidelines" panel was Ronald Gabel, MD, Rochester, NY, who presented the segment on "Participating in Sedation Guidelines for Non-anesthesiologists: Where Can We Get Help?" He noted that anesthesiologists are being increasingly involved in the development of institutional policies and procedures for sedation and analgesia. The definitions of the various levels of sedation and the concept of the ability to rescue from a deeper level of sedation were discussed. In addition, the methods for credentialing and training individuals intending to provide sedation were outlined. Finally, numerous resources, including Web sites for the implementation of the new practice guidelines, were provided.
The second panel on Friday morning was titled "Outpatient Anesthesia in the Geriatric Patient" and was presented in association with the Society for the Advancement of Geriatric Anesthesia. Terri Monk, MD, Gainesville, FL, moderated this discussion-stimulating program. Dr. Lee Fleisher discussed the topic "Applying the New American Heart Association Cardiac Preoperative Evaluation Guidelines to the Elderly Outpatient." These guidelines represent an update of those published in 1996 dealing with perioperative cardiovascular evaluation for noncardiac surgery.
Dr. Fleisher clearly outlined the preoperative cardiovascular evaluation, which integrates clinical risk factors, surgery-specific risk, and exercise tolerance. The first step in the clinical evaluation of a patient is identification of major risk factors. The major predictors include unstable coronary syndromes, such as recent myocardial infarction (MI) (<30 days) and unstable or severe angina, decompensated congestive heart failure (CHF), significant arrhythmias (high-grade atrioventricular block, symptomatic arrhythmias in the presence of underlying heart disease, and supraventricular arrhythmias with uncontrolled ventricular rate), and severe valvular disease (mostly aortic stenosis). It was emphasized that patients with acute coronary syndromes, such as unstable angina or decompensated CHF of ischemic origin, should not undergo elective outpatient noncardiac surgery because of the high risk of developing further decompensation, MI, and even death during the perioperative period.
Dr. Fleisher suggested that the severity of the surgical procedure dictates the need for preoperative information and significantly influences the perioperative outcome. For surgical procedures associated with low stress and low incidences of perioperative myocardial ischemia or morbidity, there is no benefit of further diagnostic testing. He then went on to discuss advantages and disadvantages of preoperative cardiac interventions (e.g., percutaneous transluminal coronary angioplasty (PTCA)/stenting/coronary artery bypass grafting (CABG)) on perioperative outcome. Although selected patients undergoing high-risk surgery may benefit from surgical intervention (i.e., PTCA or CABG), there is no benefit in patients undergoing lower-risk surgery. Finally, it was emphasized that ß-blockers (e.g., atenolol and bisoprolol) have been found to significantly reduce the incidence of perioperative cardiac complications. Despite these advantages, ß-blockers are underused in high-risk patients.
Dr. Stanley Muravchick, Philadelphia, PA, spoke on "The Aging Process: Anesthetic Implications in the Elderly Outpatient." He emphasized that it is necessary to differentiate between the process of aging and age-related disease. Age-related altered physiology occurs at the mitochondrial level, and changes in nervous system function have the most direct and important implications for the anesthetic management of an elderly outpatient. It is important that preoperative assessment of the elderly include the determination of cardiopulmonary reserve and overall metabolic and nutritional status and that it take into consideration the physiological disruption that may be produced by the intended surgical procedure. It was emphasized that routine preoperative testing contributes little to the quality of perioperative patient care, because abnormal values are not predictive of adverse outcome. Furthermore, ASA physical status and appropriate surgical risk stratification have been shown to predict adverse outcomes in elderly patients. However, anesthesia-related mortality is higher in the elderly than in the young adult. Risk factors associated with adverse cardiopulmonary outcome include chronic obstructive pulmonary disease, preexisting arrhythmias, heart failure, and arterial hypertension, particularly if these are associated with prior MI or cerebral infarction. Recently, there is increasing evidence to suggest that in the elderly, the return of postoperative cognitive function to preoperative levels may require several days. Postoperative delirium is more common in the elderly and is equally common whether regional or general anesthesia is used. Furthermore, regional anesthesia may increase the risk of neurological complications (e.g., nerve palsies) in the elderly.
The third speaker, F. Kayser Enneking, MD, Gainesville, FL, discussed the use of peripheral nerve blocks in geriatric patients undergoing ambulatory surgery. The physiologic changes in the elderly with respect to regional anesthetics were reviewed. The high patient acceptance of regional anesthesia in this population may be correlated with the clinical perception that peripheral nerve blocks last longer in the elderly patient, with less pain after block resolution. Dr. Enneking stated that the sensitivity to local anesthetics is increased in the elderly. Although local anesthetic doses do not need to be decreased with aging, inadvertent high blood levels may not be well tolerated. With respect to the detection of intravascular injection by use of an epinephrine test dose in sedated elderly patients, it was suggested that increased systolic blood pressure and decreased T-wave amplitude appear to be more reliable than a change in heart rate.
The panels presented on Saturday morning covered the subjects of postoperative pain management and real-world cases. Dr. T. J. Gan from the Duke Medical Center moderated a panel titled "What’s New in Postoperative Pain?" Dr. Gan addressed "Acute Pain Management: Patients’ Experience and Meeting the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Guidelines." He emphasized that patients still experience moderate-to-severe pain after their outpatient surgery despite the development of newer analgesics and techniques. In addition, the recent introduction of JCAHO pain management guidelines has not changed practice patterns. Dr. Gan discussed the new JCAHO pain guidelines and provided an approach to meet these requirements.
Dr. Gan’s presentation was followed by a presentation by Peter Glass, MD, Stony Brook, NY, who spoke on "Pain Management in the Ambulatory Environment—An Ever Growing Cook Book of New Recipes." Dr. Glass reviewed the pathophysiology of pain and its implications in developing new analgesic techniques. It was emphasized that a multimodal approach to pain management should be the mainstay of any analgesic technique. Preoperative (or preemptive) analgesia in the form of nonsteroidal antiinflammatory drugs and regional anesthetic techniques, including local anesthetic infiltration, should be used. He suggested the use of a cyclooxygenase-2-specific inhibitor administered an hour before surgery. In addition, a peripheral nerve block should be offered, if acceptable, or, at least, local anesthetic infiltration should be performed before the incision. Importantly, the use of opioids should be within the therapeutic range, and the administration of larger doses may not necessarily provide superior pain relief because of the possibility of acute tolerance. Dr. Glass also suggested the use of dextromethorphan and ketamine in patients with severe and prolonged pain. The benefits of opioid antagonists (e.g., naloxone and nalmefene) in reducing opioid tolerance were presented. Finally, the use of nonpharmacological techniques (e.g., acupuncture) to improve pain relief was also recommended.
Dr. Lucinda Everett, Seattle, WA, completed the program, leading a discussion on "Issues in Pain Management for Pediatric Ambulatory Anesthesia." She emphasized that inadequate pain relief may be associated with altered behavior changes that could last for several weeks after surgery. Various analgesic strategies for pediatric patients, including the use of regional anesthetic techniques, were discussed. The appropriate use of acetaminophen and nonsteroidal antiinflammatory drugs in the pediatric population reduces opioid requirements and thus may reduce opioid-related side effects. Dr. Everett also discussed the advantages and disadvantages of dexamethasone, ketamine, and clonidine as adjuncts to commonly used analgesics.
After the morning break, Dr. Barbara Gold, Minneapolis, Minnesota, moderated one of the most popular presentations at the Society for Ambulatory Anesthesia annual meeting: "In the Real World Cases." Panelists included Drs. Springman (Madison, WI), Conlay (Philadelphia, PA), Enneking (Gainesville, FL), and Litman (Philadelphia, PA). Thought-provoking cases stimulated lively discussions between panelists and the audience. The first case was an elderly patient with a recent cerebrovascular accident, who was taking coumadin and presented for open reduction and fixation of a distal radial fracture. The next case was a 5-yr-old boy with Down’s syndrome who was scheduled for outpatient adenoidectomy and complete oral rehabilitation. The final case discussed was an apparently healthy gentleman who gave a history of bicycling more than 100 miles per week and who presented for inguinal herniorrhaphy. He also had two episodes of syncope that were evaluated by imaging studies and electrocardiogram. The surgery was performed under regional anesthesia with sedation. The perioperative course was uneventful; however, the patient had a cardiac arrest in the parking lot and was successfully resuscitated. The various causes of cardiac arrest, including the Bezold-Jarisch reflex, were discussed extensively.
The Sunday morning panels covered "Critical Ambulatory Issues," moderated by Dr. Mims. The first speaker of this session, Philip Scuderi, MD, Winston-Salem, NC, addressed new issues in postoperative nausea and vomiting. He discussed the recent "black box" warning for droperidol and the lack of Food and Drug Administration investigation before issuing this warning. Dr. Scuderi suggested that it is necessary to identify patients at high risk of postoperative nausea and vomiting. He emphasized that in the high-risk population, two- or three-drug regimens (multimodal technique) are more likely to be successful than single-drug therapy. In addition, the use of supplemental oxygen and stimulation of the P6 acupoint with electrical stimulation may also be used to improve the success rate.
Dr. Beverly Philip, Boston, MA, discussed the latest regulatory issues from JCAHO, the Accreditation Association for Ambulatory Health Care, and the American Association for Accreditation of Ambulatory Surgery Facilities. Similar to Dr. Gabel, she also suggested that the ability to rescue patients from a deeper level of sedation and analgesia was a key regulatory issue. Furthermore, the need for identification of responsible practitioners and their qualifications was also emphasized. Minimal equipment and monitoring standards, as well as protocols for postoperative care, were discussed. Dr. Philip also provided references for contacting the various regulatory organizations, including ASA Web links.
Finally, Dr. Lydia Conlay, Philadelphia, PA, presented concerns regarding compliance with the Health Insurance Portability and Accountability Act and issues from the Office of the Inspector General. Much of Dr. Conlay’s discussion centered on the complexities of the Health Insurance Portability and Accountability Act and its overwhelming costs of implementation. She also noted that the law is complex. Subsequently, Dr. Conlay addressed the recent Office of the Inspector General report, which is critical of the oversight of ambulatory surgical facilities by state agencies and other accrediting organizations, as well as of the current state of accountability for this oversight to the Center for Medicare and Medicaid Services.
Rebecca Twersky, MD, New York, NY, moderated the sixth and final general session on office-based anesthesia. Dr. Karen Domino, Seattle, WA, presented the ASA closed claims data comparing office-based anesthesia malpractice awards with ambulatory surgery center data for the same period. The severity of injury and amount of payments for office-based claims were significantly greater than those for ambulatory surgery center claims. Furthermore, the amount of payments was also greater for office-based injury. A greater proportion of injuries in offices were judged to be preventable by monitoring in the postoperative period. She concluded that safety efforts involving office-based anesthesia should focus on improving care in the postoperative period. Dr. Twersky then presented a summary of state regulations concerning office-based anesthesia. She emphasized that the standard of care in an office surgical suite should be no less than that rendered in general acute-care hospitals or freestanding ambulatory surgery facilities. She also presented some of the regulations that organizations such as JCAHO, the Accreditation Association for Ambulatory Health Care, and the American Association for Accreditation of Ambulatory Surgery Facilities have implemented to ensure patient safety. She noted that anesthesia requirements for accreditation have been substantially revised to reflect the ASA standards and guidelines. Dr. Twersky’s presentation included an extensive bibliography and contact information for office-based regulations in various states.
The last speaker of the meeting was Dr. Thomas Andrews, Maitlan, FL. He presented the necessary requirements for setting up an office-based anesthesia practice. Dr. Andrews emphasized that a significant amount of planning, including the concept of backup personnel in the event of acute disability of the anesthesiologist during the administration of an office-based anesthetic, is important.
Accepted for publication November 5, 2002.
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