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Ambulatory surgery is commonplace for a multitude of procedures and a wide range of patients.
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The types of procedures performed in the ambulatory setting are becoming more work-intensive, and patients with comorbidities make for a challenging environment.
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For a safe environment for surgery in ambulatory facilities, the complex task of patient selection is necessary.
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Until an algorithm is created that includes provider, procedure, facility, and patient comorbidities, clinicians rely on general guidlines rather than precise recommendations.
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When determining if a patient is suitable for ambulatory surgery, multiple factors must be assessed.
Ambulatory surgical volume in the United States increased 300% between 1992 and 2006.
In 2006, an estimated 53.3 million procedures were performed in ambulatory centers, 19.9 million in hospitals, and 14.9 million in freestanding surgical centers.
The increase has occurred partly because of financial incentives, changes in clinical practice from advances in technology, and patient expectations. Whether a case is appropriate for the ambulatory setting depends on where the surgery will occur, the personnel involved, the surgical procedure, and the patient’s medical status. Consideration of these 4 criteria will help achieve optimal patient outcomes.
Ambulatory surgery can occur in a physician’s office, freestanding ambulatory surgical center, building on a medical campus, or hospital. In the hospital setting, ambulatory procedures can be consolidated in one location or interspersed with inpatient procedures. Transportation between the procedural facility and a hospital for additional postoperative care also must be considered, and a transfer process should be in place. A facility that is accredited by the American Association for Accreditation of Ambulatory Surgery Facilities, the Accreditation Association for Ambulatory Health Care, or the Joint Commission is essentially obliged to operate in a manner consistent with the American Society of Anesthesiologists (ASA) standards and guidelines. In addition to the physical plant, the available equipment and supplies will also influence what procedures may be performed. The ASA and others have set expectations for ambulatory anesthesia in the form of standards and guidelines that apply independent of location.
For example, the ASA and the Agency for Healthcare Research Quality recommend that equipment for standard monitoring include a noninvasive blood pressure monitor, a means to record heart rate and respiration, an electrocardiograph, and a pulse oximeter.
Evidence-based patient safety advisory: patient selection and procedures in ambulatory surgery. Agency for Healthcare Research and Quality Web site. Available at: http://guidelines.gov/content.aspx?id=15334. Accessed September 1, 2012.
Safety is a continuum from the preoperative to the postoperative phase of care; at the time of discharge, patients should received written postoperative instructions and be discharged to the care of a responsible adult. Ideally, when surgery is performed in a freestanding ambulatory surgery center or office, the surgeon performing the surgery should have credentials to perform that procedure in a hospital and should be operating within the scope of his specialty training.
Another consideration is the personnel staffing the center. Will anesthesia be required, and if so, how much and administered by whom? Will a registered nurse be sufficient if anesthesia is given as a local injection with moderate sedation, or will the services of an anesthesiologist or a certified registered nurse anesthetist (CRNA) be needed? One study showed that anesthesia provided by nonanesthesiologists was associated with significantly higher rates of unexpected hospital admissions compared with that provided by solo anesthesiologists or a care team of physician and CRNA.
Who will perform the procedure? Will it be a physician, physician’s assistant, or CRNA who may require physician supervision? Do the recovery room personnel have postanesthesia care experience commensurate with the type of anesthesia anticipated? Will they be able to handle possible complications from the procedure or the anesthetic? In summary, the staffing for all procedures should be adequate to meet the needs of the patient and the providers.
Initially, ambulatory procedures were restricted to those associated with minimal blood loss that could be performed in less than 90 minutes with simple equipment, requiring minimal postoperative care and producing only mild pain that could be controlled with oral medications.
Now the only criterion strictly applied is that the patient is able to go home the same day of the procedure, although for some patients a 23-hour hospital stay or other nursing care environment is necessary.
The most complex variable is the patient, whose comorbidities determine whether a procedure may be performed in an ambulatory facility. In 1940, a classification scheme was created to standardize and define the operative risk of patients based on the history and physical examination.
Over the past 70 years, this original classification has been modified, with the current ASA physical status (PS) classification divided into 6 categories (Box 1). Although the ASA classification was not created originally as a predictive index of perioperative risk, it has been used as a proxy for risk in several studies.
National Surgical Quality Improvement Program (NSQIP) risk factors can be used to validate American Society of Anesthesiologists Physical Status Classification (ASA PS) levels.
A patient with severe systemic disease that is a constant threat to life.
5.
A moribund patient who is not expected to survive without the operation.
6.
A patient who has been declared brain-dead and whose organs are being removed for donor purposes.
Overall surgical mortality for patients with ASA PS 1 through 3 is low (Table 1), but as PS class increases, so does the risk for morbidity. In a prospective analysis of 38,598 patients undergoing 45,090 ambulatory procedures, patients with ASA PS 3 constituted 24% of the morbidity.
A retrospective study of 28,921 patients undergoing ambulatory surgery found no significant difference in unplanned admissions between those with ASA PS 3 and those with ASA PS 1 and 2, although those with ASA PS 3 experienced more pain than patients with ASA PS 1 and 2.
and ASA PS alone should not determine eligibility for ambulatory surgery.
Table 1American Society of Anesthesiologists classification and 30-day surgical mortality
Data from Davenport DL, Bowe EA, Henderson WG, et al. National Surgical Quality Improvement Program (NSQIP) risk factors can be used to validate American Society of Anesthesiologists Physical Status Classification (ASA PS) Levels. Ann Surg 2006;243:636–44.
The prevalence of coronary heart disease (CHD) in the United States is now 6%, with the greatest incidence in people 65 years of age or older (19.8%), followed by people aged 45 to 64 years (4.6%).
In 2007, the American College of Cardiology (ACC) and the American Heart Association (AHA) published updated guidelines for cardiac evaluation and care for patients undergoing noncardiac surgery (Fig. 1).
ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).
For patients with unstable coronary syndromes, such as unstable or severe angina or recent myocardial infarction, decompensated heart failure, arrhythmias (high-grade or Mobitz II atrioventricular block, third-degree atrioventricular block, symptomatic ventricular arrhythmia, supraventricular arrhythmias with uncontrolled ventricular rate, symptomatic bradycardia, and newly recognized ventricular tachycardia), or severe valvular disease (severe aortic stenosis and symptomatic mitral stenosis), elective surgery should be delayed until further evaluation.
ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).
In a 1978 study of patients who had a myocardial infarction within 6 months before surgery, 27.3% experienced a perioperative infarction or cardiac death.
A 2012 study of the risk of perioperative myocardial infarction in 971,455 patients who had an infarction before surgery demonstrated that only 2% experienced a reinfarction.
For some patients, ambulatory surgery may not be a low-risk procedure.
Fig. 1Cardiac evaluation and care algorithm for noncardiac surgery. Stepwise approach to preoperative cardiac assessment. *Subsequent care may include cancellation or delay of surgery, coronary revascularization followed by noncardiac surgery, or intensified care.
(From Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 2002;39(3):542–53. http://dx.doi.org/10.1016/S0735-1097(01)01788-0; with permission.)
A patient’s functional status is the last criterion to be evaluated under the ACC/AHA algorithm. One metabolic equivalent (MET), the amount of oxygen consumed while sitting at rest, is equal to 3.5 mL of oxygen per kilogram of body weight per minute.
ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).
The threshold for good functional capacity is 4 METs (able to climb 1 flight of stairs or perform light housework). Patients who were not able to perform 4 METs during daily activities had increased perioperative and long-term risks, and an inverse relationship was seen between the number of blocks or flights a patient could walk and perioperative cardiovascular events.
If a patient does not have good functional capacity or is unable to perform 4 METs during daily activities, clinical predictors (eg, ischemic heart disease, heart failure, cerebrovascular disease, diabetes, renal insufficiency) and surgical risk will determine whether further perioperative testing is needed.
ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).
For patients with cardiac stents, the ACC, AHA, and the American College of Surgeons have developed joint advisory recommendations for dual antiplatelet therapy. Patients with a bare metal stent should be treated with clopidogrel, 75 mg, and aspirin, 325 mg, for a minimum of 1 month, a sirolimus drug-eluting stent (DES) for a minimum of 3 months, and a paclitaxel DES for a minimum of 6 to 12 months to prevent stent thrombosis.
Antiplatelet therapy in patients with coronary artery stents. A science advisory from the American Heart Association, the American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians.
In a large observational study in which antiplatelet therapy was discontinued prematurely for patients with a DES, 29% of patients developed stent thrombosis.
Surgery is not recommended for at least 90 days after implantation of a bare metal stent. The odds ratio (OR) for a major cardiac event after surgery within 30 days of stent placement was 3.6, and was 1.6 for surgeries performed between 31 and 90 days of placement. For patients with DES implants, the rate of serious cardiac events was 5.7% to 6.6% for surgeries performed in fewer than 365 days from stent placement and 3.3% in surgeries after 365 days. A cardiologist should be consulted before discontinuation of antiplatelet therapy in these individuals. Patients who are on β-blocker therapy should continue these agents through the perioperative period.
ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).
The ACC/AHA guidelines provide the tools to determine whether additional cardiac testing is required before surgery, and following the guidelines for antiplatelet and medical therapy further decreases patient risk. Individuals at high risk for perioperative cardiac events and those with recent myocardial infarctions or cardiac interventions may not be suitable for procedures in an ambulatory setting without access to interventional cardiology.
Pulmonary risk factors
Asthma affects 24.6 million people in the United States, or approximately 8.2% of the population.
Chronic obstructive pulmonary disease (COPD) is identified in at least 10 million adults, and the Centers for Disease Control and Prevention (CDC) believes it is underdiagnosed.
and in the case of ambulatory surgery, unplanned admissions. In one study of morbidity and mortality within 1 month of ambulatory surgery, respiratory failure constituted 16% of all morbidity.
In a respiratory risk index developed for respiratory failure after vascular or general surgery, respiratory failure was defined as postoperative mechanical ventilation for longer than 48 hours or unanticipated reintubation. Twenty-eight variables were independently associated with respiratory failure, including alcohol use (>2 drinks per day for 2 weeks before the procedure), greater than 10% weight loss in the previous 6 months, elevated blood urea nitrogen levels, low albumin levels, smoking, general anesthesia, and a surgical time from 2.5 to 4 hours.
The site and complexity of the operation are the most important factors for evaluating risk of respiratory failure. For procedures with relative value units (RVUs) from 10 to 17, such as orthopedic surgery, exploratory laparotomies, or hysterectomy, the OR for respiratory failure is 2.299 (confidence interval [CI], 1.937–2.728); for RVUs greater than 17 (eg, cardiac surgery, airway surgery, craniotomies), the OR is 4.445 (CI, 3.720–5.312). In other words, patients who undergo cardiac, thoracic, major vascular, or upper abdominal surgery, or head and neck procedures are at increased risk for postoperative respiratory failure.
such as atelectasis, pneumonia, respiratory failure, and exacerbation of underlying chronic lung disease. In an analysis of 15 studies, the OR was 1.79 (CI, 1.44–2.22) for pulmonary complications in patients with COPD.
and should be closely monitored. COPD in isolation is only a minor risk factor for postoperative respiratory failure.
Whether spirometry or chest radiographs help with pulmonary risk stratification or provide incrementally more information than the history and physical examination has not been determined,
and these tests should not be performed routinely for preoperative assessment. Guidelines from the American College of Physicians recommend that patients with stable COPD, irrespective of forced expiratory volume in the first second of expiration (FEV1), be treated with inhaled bronchodilators. Patients with symptomatic COPD and an FEV1 less than 60% of predicted percentage should be treated with either a long-acting inhaled anticholinergic or a long-acting inhaled β-agonist
Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society.
and treatment should continue through the perioperative period. As for intraoperative management, a meta-analysis showed that spinal and epidural anesthetics decrease postoperative mortality, deep vein thrombosis, pneumonia, and respiratory depression.
Patients with asthma have varying degrees of airway obstruction, inflammation, and hyperresponsiveness. During anesthesia, aspiration, infection, instrumentation of the airway, the administration of certain drugs, or an inadequate depth of anesthesia may induce bronchospasm,
As with patients with COPD, preoperative optimization is critical. Current guidelines indicate that inhaled corticosteroids are the most effective agents for long-term control of the disease.
Smoking cessation is a preoperative measure that can decrease the hyperreactivity of the airway, and not smoking for as few as 4 weeks preoperatively improves outcomes.
Pulmonary risk factors alone do not predict postoperative pulmonary complications; the type of procedure and the surgical location are the most important predictors.
COPD is not an absolute contraindication to any surgery, but elective surgery should be postponed to treat an exacerbation of COPD or asthma. Well-controlled asthma does not increase risk for perioperative complications.
Currently in the United States, 39.6 million Americans are older than 65 years, and by 2030, the Census Bureau estimates the number will exceed 72.1 million.
Elderly patients may benefit greatly from an ambulatory procedure because they will be discharged home the day of surgery and may experience less cognitive impairment.
In addition to neurologic deterioration, aging causes physiologic changes in the body, including “vascular stiffening,” which elevates blood pressure and increases pulse pressure. Unlike diastolic blood pressure (DBP), systolic blood pressure (SBP) increases an average of 6.2 mm Hg per decade,
In the lungs, elastic recoil diminishes, the chest wall stiffens, and motor power for respirations weakens in a smaller intervertebral space, all of which can promote atelectasis. Elderly people also have an impaired respiratory response to elevated carbon dioxide and hypoxia, making them more sensitive to the respiratory effects of narcotics and other anesthetic agents.
Elderly people are at greater risk for intraoperative events, such as hypertension, hypotension, and arrhythmia (OR, 1.42); intraoperative bleeding (OR, 1.31); and postoperative bruising (OR, 1.75),
Inpatient hospital admission and death after outpatient surgery in elderly patients. Importance of patient and system characteristics and location of care.
and elderly patients with a previous hospital admission within 6 months of the surgery have a 2-fold greater risk for unanticipated postoperative admission. Unanticipated hospital admissions rates after outpatient surgery remain at less than 3%.
Inpatient hospital admission and death after outpatient surgery in elderly patients. Importance of patient and system characteristics and location of care.
Despite the risks, the overall mortality for elderly patients undergoing ambulatory procedures remains low. Of 564,267 outpatient surgical procedures in patients older than 65 years, the overall death rate per 100,000 was 2.3 on the day of the procedure, 5.1 on days 1 to 7 afterward, and 6.6 on days 8 to 30.
Inpatient hospital admission and death after outpatient surgery in elderly patients. Importance of patient and system characteristics and location of care.
Despite physiologic changes in the elderly, ambulatory surgery has proven to be safe, which can be attributed to careful patient selection via a thorough preoperative assessment.
To evaluate an elderly patient for ambulatory surgery, consideration is given to the type of surgery, the surgical and anesthetic risk, and the functional capacity of the patient. The medical condition of the patient is optimized before surgery to minimize risk and reduce the likelihood of adverse events.
Ambulatory anaesthesia: there is room for further improvements of safety and quality of care—is the way forward further simply one of evidence-based risk scores?.
In the United States, 1 in 3 individuals has hypertension. Although men younger than 45 years have a higher prevalence, the percentages of men and women equalize thereafter.
The diagnosis of hypertension requires, “the average of two or more properly measured, seated blood pressure readings on each of two or more office visits.”
Stage 1 hypertension is a SBP of 140 to 159 mm Hg or a DBP of 90 to 99 mm Hg. Stage 2 is an SBP greater than or equal to 160 mm Hg or DBP greater than or equal to 100 mm Hg.
Although not described in the updated National Institutes of Health model of 2007, the literature describes stage 3 of hypertension as an SBP greater than or equal to 180 mm Hg or DBP greater than or equal to 110 mm Hg.
ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).
Hypertension in outpatient surgery has not been extensively studied, and most of the outcome data have come from the studies conducted on inpatients. Beyer and colleagues
evaluated 125,000 procedures over 5 years and found that patients with hypertension had a 40% increased risk of an intraoperative arrhythmia or hemodynamic abnormalities. Wax and colleagues
found that increased levels of preinduction SBP and DBP were an independent risk factor for postoperative myocardial injury, infarction, or death. In the outpatient setting, Chung and colleagues
found that hypertension was associated with increased intraoperative events, primarily cardiovascular, and included hypertension, arrhythmias, hypotension, tachycardia, and bradycardia. It was also associated with increased postoperative events, including hematoma. They recommend careful preoperative blood pressure control and perioperative management. This recommendation is consistent with the 2007 ACC/AHA guidelines that state if a patient presents for initial evaluation with stage 1 or 2 hypertension and has no end-organ disease or associated metabolic abnormalities, there is no reason to delay surgery. The meta-analysis by Howell and colleagues
further supports the ACC/AHA recommendation, which found insufficient evidence of an association between SBP less than 180 mm Hg and DBP less than 100 mm Hg and perioperative complications. However, the ACC/AHA guidelines recommend that elective surgery be postponed for patients with stage 3 hypertension to improve blood pressure control over several days or even weeks.
ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).
Although the literature does not have any consensus about delaying or canceling surgery for stage 3 hypertension, it does suggest that hypertension should not be looked at in isolation when determining whether to proceed, and that it need not be regarded as an absolute contraindication. For patients with end-organ damage induced by hypertension (eg, ischemic heart disease, heart failure, renal or cerebrovascular disease) whose perioperative risk would be substantially decreased by delaying the procedure, hypertension management should be considered. In addition, the urgency or necessity of the procedure should be taken into consideration.
Because of a concern for possible perioperative complications, a question exists about the appropriateness of allowing patients with OSA to undergo ambulatory surgery.
Individuals with OSA have physical alterations of the lateral pharyngeal walls and tongue. Their computed tomography and magnetic resonance imaging studies reveal fat deposits and submucosal edema, which narrow the pharyngeal airway.
Risk of postoperative hypoxemia in ambulatory orthopedic surgery patients with diagnosis of obstructive sleep apnea: a retrospective observational study.
Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery.
A meta-analysis by the Society of Ambulatory Anesthesia (SAMBA) found no increase in mortality and no correlation between adverse events and clinically significant adverse outcomes. Despite postoperative hypoxemia, no intubation or ventilator assistance was required.
Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery.
In a consensus statement on preoperative selection of patients with OSA scheduled for ambulatory surgery, SAMBA recommended screening patients with the STOP BANG questionnaire because it is simple to administer (Box 2) and accurately predicts the probability that a patient has moderate to severe OSA. A STOP BANG score of 5 had an OR of 4.5 for moderate/severe OSA and an OR of 10.4 for severe OSA. A score of 7 to 8 had an OR of 6.9 for moderate/severe OSA and an OR of 14.9 for severe OSA.
they are often cared for in an ambulatory surgery center. Many of the recommendations for glucose management in patients with diabetes undergoing ambulatory surgery have been extrapolated from studies of inpatient surgeries.
These catabolic hormones combine with the inhibited insulin secretion that results from the stress response to raise blood glucose levels in the perioperative period.
Pharmacologic treatment of patients with diabetes includes oral hypoglycemic medications, long- or short-acting insulin, or a combination of the aforementioned agents. Patients taking oral hypoglycemic medications should be instructed to take their medications as they normally would on the day before surgery, but these agents should be discontinued on the day of surgery. Patients taking long-acting or intermediate-acting insulin take their prescribed doses while eating a normal diet.
On the day of surgery, patients who take intermediate-acting agents (eg, neutral protamine Hagedorn insulin [NPH], Lente) may need to decrease or discontinue the dose, because they may experience hypoglycemia if a meal is omitted.
Patients taking long-acting insulin agents reduce the dose on the day of surgery.
On the day of surgery, blood glucose should minimally be measured on the patient’s arrival at the surgical facility and postoperatively. If the surgical procedure is prolonged, blood glucose levels should be checked intraoperatively.
Consensus has not been reached on an optimal intraoperative blood glucose level, but the NICE-SUGAR study found that patients with a blood glucose level less than 180 mg/dL had a lower mortality rate than those whose glucose level was tightly controlled between 81 and 108 mg/dL.
Diabetes in and of itself is not a contraindication to ambulatory surgery, but patients with diabetes often have other comorbidities, such as hypertension, dyslipidemia, obesity, and chronic kidney disease. The evaluation of a patient’s medical status determines whether an ambulatory setting is appropriate for the procedure. If a surgical facility is going to care for patients with diabetes, it must have the necessary equipment to test and monitor blood glucose levels.
Obesity
Obesity is defined as a body mass index (BMI) greater than 30 kg/m2; morbid obesity is a BMI greater than 40 kg/m2.
The CDC reports that by the year 2030, 42% of Americans will be obese. The CDC also predicts that in 2030 the severely obese will constitute 11% of the population.
Obese patients are likely to have hypertension, coronary artery disease, OSA, asthma, diabetes, and metabolic syndrome. Obesity alone is not a risk factor for unanticipated admissions after ambulatory surgery,
but obese patients have a statistically significant higher incidence of intraoperative bronchospasm than nonobese patients and require supplemental oxygen postoperatively.
The patient’s comorbidities, the anesthetic required, and the type of surgery determine whether a patient is a candidate for a procedure in an ambulatory setting.
Preoperative testing
Screening laboratory tests have not been shown to be useful and are likely a waste of resources. Preoperative tests for screening purposes tend to be nonspecific and do not change the anesthetic management of the patient in the ambulatory setting.
A study of 1061 patients randomized to undergo either directed preoperative testing or no preoperative testing showed no significant difference in rates of adverse events between ambulatory surgical groups. The authors concluded that testing may be safely eliminated in selected patients.
Ambulatory surgery is commonplace for a multitude of procedures and a wide range of patients. The types of procedures performed in the ambulatory setting are becoming more work-intensive, and patients with comorbidities make for a challenging environment. For a safe environment for surgery in ambulatory facilities, the complex task of patient selection is necessary. Until an algorithm is created that includes provider, procedure, facility, and patient comorbidites, clinicians must rely on general guidelines rather than precise recommendations. When determining whether a patient is suitable for ambulatory surgery, multiple factors must be assessed. The surgical procedure, who will be performing the surgical procedures, whether anesthesia is required, the type of anesthesia provider (eg, conscious sedation with a surgeon and nurse, an anesthesiologist, or a CRNA), and the surgical setting (eg, hospital-based ambulatory surgical center vs free-standing surgical center vs a physician’s office) all must be taken into account. In addition to these factors, patients and their comorbidities must be considered. Individual medical problems (eg, coronary artery disease, COPD, diabetes) taken in isolation often are not absolute contraindications to ambulatory surgery; patients must be evaluated as a whole to determine whether the procedure can be performed on an ambulatory basis.
References
MEDPAC Report to the Congress: Medicare Payment Policy. 2004.
Evidence-based patient safety advisory: patient selection and procedures in ambulatory surgery. Agency for Healthcare Research and Quality Web site. Available at: http://guidelines.gov/content.aspx?id=15334. Accessed September 1, 2012.
National Surgical Quality Improvement Program (NSQIP) risk factors can be used to validate American Society of Anesthesiologists Physical Status Classification (ASA PS) levels.
ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).
Antiplatelet therapy in patients with coronary artery stents. A science advisory from the American Heart Association, the American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians.
Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society.
Expert panel report 3: guidelines for the diagnosis and management of asthma.
US Department of Health and Human Services. National Institutes of Health, National Heart, Lung, and Blood Institute,
Bethesda (MD)2007 (Available at:)
Inpatient hospital admission and death after outpatient surgery in elderly patients. Importance of patient and system characteristics and location of care.
Ambulatory anaesthesia: there is room for further improvements of safety and quality of care—is the way forward further simply one of evidence-based risk scores?.
Risk of postoperative hypoxemia in ambulatory orthopedic surgery patients with diagnosis of obstructive sleep apnea: a retrospective observational study.
Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery.
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