Letters to the Editor:
Office-Based Anesthesia Issue Provokes Responses
SOBA Citation Missed in Office-Based Issue
To the Editor:
I read with disappointment your Spring 2000 Newsletter featuring Office-Based Anesthesia Safety as a Ôspecial issue.' Had the ASA not recognized SOBA, the Society for Office-Based Anesthesia (www.soba.org), in its official guide for educational meetings, the absence of its mention would have been understandable. The only hint of its existence comes in reference 4 (Laurito, CE, President of SOBA) in Dr. Robert Morell's front page article. I consider any reference to the Grazer/deJong Plastic & Reconstructive Surgery article on the danger of excessive blood lidocaine from tumescent liposuction (reference 8) nothing short of hysterical. The statistically biased sampling errors in this piece would not permit its publication in any anesthesia journal.
OBA is not new. Ralph Waters had the Downtown Clinic almost a century ago. OBA has resurfaced due to the economic pressures of our day. I have been engaged full time in OBA since March of 1992 and recently published an update of my seven-year, 1857 patient experience in the October 1999 & April 2000 SAMBA (Society for Ambulatory Anesthesia) Newsletters. My propofol -ketamine, opioid avoidance, room air, spontaneous ventilation (RASV) technique was specifically designed to maximize patient safety in the remote (office) setting. To date (> 8 years, > 2,100 patients), no hospital admissions have resulted for either PONV or pain, the two commonest causes of unexpected admission from day surgery. My outcomes are congruent with my belief system.
The most consistent error anesthesia practitioners continue to make in OBA is the routine use of opioid analgesics. Opioids not only contribute to the invariable persistence of PONV but also set the stage for unrecognized postoperative respiratory depression with the rare but totally avoidable patient demise. Please see my letter in the August 2000 issue of Anesthesiology, "Non-opioid analgesia improves outcomes."
No one has a greater interest in patient safety than those of us engaged in the full time practice of OBA. Having no significant input from or reference to SOBA diminishes the credibility of your otherwise laudable effort.
Barry L. Friedberg, MD
Clinical Instructor in Anesthesia
University of Southern California
Los Angeles
Office-Based Anesthesia, an American Tradition
To the Editor:
Concerning motives for the dramatic increase in office surgery, let us recall that ambulatory surgery centers were also originally developed for economic reasons and were opposed by hospitals on the same grounds now cited in opposition to office-based surgery. In my practice, the vast majority of office surgeries are minor cases on ASA class 1 and 2 . These patients are provided Level 2 anesthesia (MAC with regional blocks) with AANA and SOBA standards observed. The few Level 3 anesthesia cases (general or spinal) I've had, were in an office surgery suite better equipped than many rural hospitals in which I have worked. It had all policies and protocols in place with back up systems, etc.
If one is to practice office anesthesia, then you must verify all equipment, supplies, medications, policies, and protocols are in place at each office. If they are not, you must put them in place. This expertise is available from various professional organizations. Far from being criticized, Dr Laurito is to be commended for establishing a society to first create and then raise the level of standards for office-based anesthesia practice. Also the 3A's, 4A's and JCAHO have developed accrediting standards to insure patient safety. APSF has devoted an entire issue to office practice.
I believe most patients and surgeries are not candidates for office surgery or anesthesia. For the ones that are, the same procedure can be preformed in the office for about three thousand dollars less than in a hospital in this area. This benefits patients, insurance and yes, the surgeons and ourselves. If and when office surgery evolves through bureaucracy and over-regulation to the point it is no longer economic, then you will see surgery centers on Indian reservations and cruise ships. Offering a quality product or service at a reasonable price is an American tradition. When we forget that, we are forced to compete politically and then quality suffers while cost increases.
Ernest P. Ayo, DP, CRNA
Sturgis, Michigan
Is the U.S. Behind the U.K. (Again) on Office-Based Anesthesia?
To the Editor:
I was interested to read the letter from JC Lydon, MD, Melbourne, FL (APSF Newsletter, Summer 2000) emphasizing that the raison d'tre for surgery and anaesthesia in an office is to "increase the salary of the surgeons." In the UK, general anaesthesia as an outpatient in the dental surgery was a constant feature in the anaesthetic landscape for many years. Most of the original bickering concerned the low fees paid to the administrator of the anaesthetic. After 1959, concern focused more on safety. Committees were formed, commissions appointed and Working Parties convened. All made recommendations but sporadic, usually avoidable, deaths in the dental surgery continued to occur. I was involved in a number of discussions and it was plain that the solution of banning general anaesthetics in the dental surgery was unacceptable because of the effect on the income of the dentist (who often used to administer the anaesthetic), and the "anaesthetist" where this was an attending doctor, often a general practitioner.
It was not until 1999 that the UK government took the decision to ban general anaesthesia in the dental surgery. It seems ironic that it took UK 40 years to reach the point of accepting that general anaesthesia is safest when given in a fully equipped and fully staffed facility when there appears to be increasing interest in "office-based" surgery and anaesthesia in the USA. Boulton has given a fascinating account of the story of anaesthesia in the dental surgery.1
Dr. John S M Zorab,
FRCA
Consultant Anaesthetist (retired)
Bristol, UK
Reference
1. Boulton, TB, The Association of Anaesthetists of Great Britain and Ireland
1932-1992 and the Development of the Specialty of Anaesthesia. (Association
of Anaesthetists of Great Britain and Ireland) 1999.
Call GA What It Is, Not Just "A Little Sedation"
To the Editor:
I would like to respond to Dr. Balaklaw's letter about "a little sedation." I certainly agree that the term is misleading and is in fact often referring to a short IV general anesthetic. However, I find no problem with the procedure itself.
If patients are told that they will be "put to sleep" for a few minutes so that they don't feel the block there should be no problem with doing just that. Most people want to get the procedure over, feel no pain, and feel good afterward. These goals are easily reached with a short IV anesthetic.
There are risks with all anesthetics. If your patients are kept NPO, and supplemental oxygen is used, this format is no greater risk than any other GA for another procedure. Obviously discretion must be used for those at high risk for aspiration.
Semantics are important. We need to give the patient the desired result, do it safely, and not be afraid to call it what it really is.
Rod Xuereb, MD
Valley Anesthesia Associates
Renton, WA