Office-based anesthesia (OBA) has established itself as a new and growing practice in the United States. In order to gain an understanding of the issues and problems associated with OBA, I attended a workshop on the subject which had attracted 146 anesthesiologists and 11 nurse anesthetists. The workshop was held in New Orleans in November, 1999 and was developed by Dr. Rebecca Twersky, Chair of the ASA Committee on Ambulatory Anesthesia. Dr. Twersky is the primary author of the ASA OBA guidelines approved by the ASA House of Delegates in October of 1999. The speakers at the, workshop, included Dr. Randall C. Cork, Dr. Richard Finder, Dr. Louis M. Guzzi and Dr. Walter C. Maurer.
A number of registrants mentioned that they wished to learn about current anesthetic techniques—and special problems to consider in office-based as compared to hospital anesthesia practice. One anesthesiologist sought to compare his techniques to minimize post operative nausea and vomiting (suction gastric contents and administer prophylactic Zofran) with what the experts did. Others were interested in the pros and cons of total intravenous anesthesia (TIVA) techniques using combinations of midazolam, remifentanil, ketamine and propofol, compared with inhalational agents. Some were concerned about the impact of the new (ASA) guidelines on requirements for anesthetic and monitoring equipment.
As demands for office-based anesthesia services increase, the absence of back-up systems in private offices which are required in hospital practices were sources of concern and apprehension. Would professional liability insurance coverage be limited – or unavailable – if the practitioner failed to provide, at potentially great cost, the equipment, monitors, and drugs not usually found in the surgeon’s office? Would individual practitioners purchase and carry their own supply of Dantrolene or abandon the use of potential MH triggering agents? Would complying with the new ASA guidelines afford the anesthesia provider a sense of security comparable to that in hospital settings? And could the new guidelines – too restrictive according to some – disqualify otherwise safe existing OBA sites.
During the workshop, the speakers cited other important distinctions between the two settings: hospitals had backup electric generators, reliable limitless oxygen sources, infusion pumps, full monitors, and fully powered wall suction. ICU and Recovery Room nurses, as well as other anesthesiologists and nurse anesthetists are usually available to assist in cases of emergencies during anesthesia. As a practical issue in office settings, the absence of competent relief for a sole practitioner, for even a brief bathroom break during a multi-hour MAC for cosmetic surgery, presented the bleak prospect of being charged with patient abandonment. The almost unanimous opinion that a patient should never be left alone for even the very briefest period, and even during the lightest planes of sedation, provoked a lively discussion.
The issue of when a patient could be discharged from surveillance by the anesthesia provider also generated considerable discussion. When could the anesthesiologist or nurse anesthetist delegate the care of the patient to personnel trained neither in anesthesia nor recovery room nursing? What skill levels were necessary in the absence of such training? Both speakers and registrants raised questions about the responsibility for patient selection for OBA. Under what circumstances could – or should – the anesthesia provider refuse to administer an anesthetic? Some commented that in office settings, the operating surgeon or physician, possibly less isolated from litigation than in hospital settings, would usually follow the advice of the anesthesiologist.
While anesthetic gases are routinely scavenged in hospital operating rooms, one anesthesiologist suggested that failure to do so in OBA settings may result in future litigation. During coffee breaks on the second day of the workshop, most of the registrants appeared satisfied that questions about anesthetic techniques, essential equipment and backup, especially as this related to the new ASA guidelines, were adequately addressed. A discussion that would have been hard to imagine not many years ago dealt with whether there really is the need to have an anesthesia machine available. The speakers generally agreed that a machine, while desirable, was not an absolute essential – provided that an self-inflating resuscitation bag and the means for securing the airway were available. There was no disagreement that the requisite skills and equipment necessary for resuscitation were essential and included the availability of a defibrillator and an positive pressure oxygen source. Dr. Twersky and her panel stressed the importance of current ACLS certification for anesthesiologists and nurse anesthetists.
Total intravenous anesthesia (TIVA) was cited by all speakers as an acceptable technique for providing OBA. Dr. Lou Guzzi described the intravenous titration of remifentanil and propofol for producing deep sedation without airway intervention. Dr. Richard Finder, a dental anesthesiologist, described the combined use of ketamine (inexpensive) with much smaller doses of propofol in dental operatories, reminding the audience that most surgeons did not wish to share the costs of drugs or equipment.
Dr. Maurer’s presentation precipitated questions about patient selection and the types of procedures that could – or should – be performed in office settings. Hospital credentialing committees are charged with granting privileges only for those procedures that practitioners, including anesthesiologists, are qualified to perform. Hospitals share the liability when procedures performed by unqualified practitioners result in bad outcomes. No such oversight exists in the physician’s private offices, which suggests that the anesthesia provider may have little knowledge of the qualifications of the physician requesting anesthesia services.
Dr. Finder informed the participants that most states have specific requirements mandated by dental boards regarding anesthesia practiced in dental offices, however at this time only four states have regulations dealing in any way with OBA in physicians’ offices (see Page 5).
Answers to post-presentation questions to the speakers were revealing. Not expected were the questions about the design and construction of such a facility. The speakers were not surprised by the sophistication of the questions and the ensuing discussions. The speakers also heard complaints about overwhelming paperwork, confusing state regulations, and worries about the future.
The extensive subscription to this workshop came as no surprise. Recent catastrophes in physicians’ offices and more which continue to be reported by the media in almost every part of the country have made both patients and physicians more cautious about the care expected and provided. A rare complication occurred when an anesthesia machine, not used for some months, was the source of carbon monoxide not properly flushed prior to its use in a case.
In the opinion of this observer, the number of attendees lined up at the microphones and the range of questions directed at the speakers suggested that many issues surrounding OBA have no easy answers. There is little doubt, however, that the financial considerations mean that OBA is here to stay for the foreseeable future. Equally, there is no doubt that until individual state or even national safety regulations are legislated or issued, patients will continue to face potentially very unsafe practices when undergoing procedures requiring anesthesia in physicians’ offices.
Dr. Siker, retired Chairman of Anesthesia at Mercy Hospital in Pittsburgh, former Executive Director of the Anesthesia Patient Safety Foundation, past President of the ASA and the ABA, and long experienced in anesthesia safety analysis, is one of the senior sages in American anesthesiology.