Anesthesia for Ambulatory Surgery: Vol. 32, No. 3 of International Anesthesiology Clinics, Paul F. White, ed. Boston: Little, Brown and Co., 1994, ISSN 0020-4907, 177 pp, $39.00 single issue or $99.00 subscription for four issues.
This volume of International Anesthesiology Clinics is devoted to current issues in ambulatory surgery. This multiauthored edition includes nine chapters encompassing clinical and administrative issues as they relate to outpatient anesthesia and surgery. This monograph seems to serve as an abridged update to Dr. White's previous well-acclaimed publications, highlighting issues of practical importance for those involved in ambulatory surgery.
The opening chapter provides an overview of the field and could serve as a publication by itself, but space constraints limit discussion in both Chapter 1 and subsequent chapters. Interestingly, Dr. White identifies appropriate procedures for outpatient surgery as those that can be performed in a reasonable period (<90 min); however, this time policy has been dismissed in most active ambulatory surgery units, and duration of surgery should no longer be a criterion for patient selection. In the same chapter, reference is made to transcutaneous fentanyl patch and transmucosal fentanyl citrate as drug delivery systems that are available for managing moderate-to-severe pain after ambulatory surgery. However, these are not approved indications, and caution should be exercised. A succinct overview of preoperative preparation briefly reviewing organ systems and laboratory testing is provided in Chapter 2. A good review of the literature regarding prophylactic antiemetic and acid-aspiration treatment is summarized in tabular form. The chapters on pediatric, general, and regional anesthesia techniques are appreciably well-written, including concise discussion and up-to-date references. A limited discussion about newly available and soon-to-bereleased drugs (e.g., rocuronium, ondansetron, sevoflurane, and remifentanil) in both children and adults leaves the reader in anticipation of further reading material. Specific detail is provided in the General Anesthetic Technique chapter regarding proper insertion of the laryngeal mask airway (LMA), but the authors seem a bit overoptimistic in stating that the "LMA has all but revolutionized airway management during general anesthesia for ambulatory surgery."
Because the use of monitored anesthesia care (MAC) for outpatients has increased in both traditional operating room and nonoperating room settings, the chapter on MAC is well received. The author emphasizes the skill needed when cosedating with the various sedative-hypnotics and analgesics and provides good recommendations; patient-controlled sedation techniques may be used more in the future. The controversial roles of nonsteroidal antiinflammatory drugs, alpha2 agonists, and benzodiazepine antagonists as possible components of MAC are raised, making this chapter particularly current. A chapter devoted solely to Postoperative Pain Management underscores how today's ambulatory practice is focused on attempting to plan the best strategy for postoperative analgesia. Controversy regarding the opioid sparing effects and relative advantages when using nonsteroidal antiinflammatory drugs (NSAIDs) perioperatively is presented; generous use of local anesthetic techniques is predictably supported. The author's recommendation to apply the concept of "balanced analgesia"--by administering a combination of drugs that affect the various nociceptive processes with fewer side effects--is appreciated. The chapter on Postanesthesia Care discusses the etiology and management of outpatient complications, albeit infrequent, of nausea and vomiting, cardiorespiratory, and neurologic events. The author correctly indicates that variance between the "home readiness" state and recovery of cognitive and psychomotor function favors the development of clinically applicable discharge criteria. This list of criteria has been even more modified. Finally, the chapter on Medicolegal Considerations highlights the legal hazards of anesthesia in the ambulatory setting. Some of the statements, however, seem a bit inaccurate and possibly outdated: the author ranks anesthesiology as the second leading source of medical malpractice. In another section, the author attributes the less frequent use of general anesthesia in ambulatory surgery as a reason for fewer bad outpatient outcomes than inpatient outcomes, contradicting what was discussed in an earlier chapter on general anesthetic techniques; an error in a case discussion illustrating the concept of causation repeatedly describes the patient as suffering from malignant hypothermia (viz. hyperthermia). Nevertheless, the chapter does emphasize that clinicians need to be vigilant, particularly in the areas of preoperative evaluation, informed consent, discharge process, and documentation of perioperative care. This discussion is frequently overlooked in anesthesia texts and therefore adds a very valuable component to the book.
Overall, this volume has attained its goals of reviewing the current issues in ambulatory anesthesia and surgery, and the authors are to be commended for their fine efforts.
Rebecca S. Twersky, MD
Department of Anesthesiology, SUNY Health Science Center at Brooklyn, Brooklyn, NY 11201