Office Anesthesia Safety Brings Comments

JC Lydon, MD

Letters to the Editor:Motives for Office Surgery, Increased Safety Risk Cited from FL

To the Editor: Regarding the article in the Spring, 2000, Florida Society of Anesthesiologists Today by Dr. Charles Laurito, can we at least approach the debate about office-based anesthesia in a completely open and honest fashion? THE RAISON D’ ETRE FOR SURGERY AND ANESTHESIA IN AN OFFICE IS TO INCREASE THE SALARY OF THE SURGEONS PERFORMING THE SURGERY. Period, end of story. One can talk around that basic precept and fabricate various notions as to why the increase is acceptable, but the motivation remains purely an economic one.

Is anyone prepared to equate the safety profile of office-based anesthesia with that performed in an accredited ambulatory or hospital facility? A recent issue of the Anesthesia Patient Safety Foundation Newsletter speaks of an eighty times greater risk of dying in the office setting than in the hospital. In the May, 2000, ASA Newsletter, Drs. Twersky and Springman report data from the January 2000 issue of the Journal of the American Society of Plastic and Reconstructive Surgeons. This journal reports approximately one death per 5000 liposuction cases performed by board certified plastic surgeons, which “raises serious concerns about the types of procedures being conducted in offices.”

Why does this statistic not raise an outcry by the ASA to immediately cease performing this procedure until a thorough investigation into the cause of these problems is performed? Do any of us truly believe that surgeons are willing to equip their offices with state-of-the-art technology in order to insure that an anesthetic which is provided in his/her office will be as safe as one provided in an accredited outpatient facility? They want a cheaper alternative, period. Drs. Twersky and Springman also state that “anesthesiologists must personally conduct investigations of areas that would be taken for granted in the hospital or ambulatory surgical facility, such as responsibility for facility construction, medications, supplies, and equipment. Anesthesiologists providing care in the office should also ensure that established policies and procedures are in place regarding fire safety, drugs, emergencies, staffing, training and unanticipated patient transfers.” Realistically, how many among us are qualified to handle such a multitude of daunting tasks?

Dr. Laurito states that “managed care is a major factor for the shift of procedures from hospitals to office.” Where are the data to support this statement? Clearly, as he mentions in his article, the major impetus behind the growth of office procedures is the area of elective plastic surgery. “Third parties don’t pay for operations that are purely aesthetic,” as Dr. Laurito states. It appears as though this is the economic motivation for plastic surgeons to offer the cheapest price possible for the various cosmetic procedures they perform.

Would any of us choose this location for ourselves or our loved ones for a general anesthetic? I would not. Are we, as a profession, not contributing to the “sense of consumerism” regarding unsafe medical practices to which Dr. Laurito refers, when we endorse office-based anesthesia and even form a society for its practicing members.

As for “receiving care in less intensive medical settings,” a reason professed by Dr. Laurito as to why patients want to have their operations in an office setting, nothing could be more convenient and safe for the patient than to have surgery performed in an efficient ambulatory center. As a bonus for having surgery in one of these settings, backup for an anesthetic emergency is not “CALL 911,” as it is in the office-based setting.

I have provided anesthesia care in developing countries on many occasions, with inferior equipment and other substandard conditions, out of necessity, to bring care where it would otherwise not be available. Such is not the case in our country. We as a professional society should not be fostering practices which lower the safety standards for anesthesiology, which so many great clinicians before us have achieved through their magnificent efforts.”Patient demand” will only increase as long as we anesthesiologists do nothing to inform them of the inherent increased risk of office-based surgery.

JC Lydon, MD
Melbourne, FL