Secondary Logo

Journal Logo

CASE REPORTS

Ambulatory Anesthesia Advances into the New Millennium

White, Paul F., PhD, MD, FANZCA

Author Information
doi: 10.1097/00000539-200005000-00047
  • Free

Recent advances in anesthetic and surgical practices have facilitated the rapid growth in ambulatory surgery throughout the world. With the availability of rapid, short-acting anesthetic, analgesic, sympatholytic, and muscle relaxant drugs, as well as improved monitoring devices, it has been possible to minimize the adverse effects of anesthesia on the recovery process. Improvements in the perioperative care of outpatients has allowed surgeons to perform an increasing array of more invasive surgical procedures on an ambulatory (day-case) basis.

Major ambulatory surgery procedures (e.g., extensive knee and shoulder reconstructions, laparoscopic-assisted vaginal hysterectomies, gastric fundoplications, splenectomies, and adrenalectomies) are being performed at many centers around the world. Even patients undergoing carotid endarterectomy, pulmonary lobectomy, prostatectomy, and minor craniectomy procedures are being discharged on a same-day (or 23-hour admit) basis. Although it is commonly assumed that the primary reason for the continued expansion in ambulatory surgery is related to pressure from third-party payors and governmental agencies to reduce health care costs, there may be other, less obvious, benefits for patients and their families (1). More aggressive rehabilitation leads to faster recovery of organ function, fewer surgical and anesthetic complications, reduced mental and physical disability, and, most importantly, earlier resumption of normal activities. For patients “at risk” of hospital-acquired infections (e.g., immunosuppressed patients), ambulatory surgery may also reduce postoperative infectious complications.

As perioperative physicians, anesthesiologists can play an important role in facilitating ambulatory (and short-stay) surgery by becoming actively involved in the pre-, intra-, and postoperative care of this expanding patient population. To achieve the desired outcome, careful consideration must be given to each phase of the surgical process.

First, it is important to ensure that all patients are in “optimal” medical condition before their elective operation. Recent changes in fasting policies (2) have allowed patients to continue taking chronic medications and avoid the uncomfortable symptoms of dehydration, hypoglycemia, and caffeine withdrawal. The use of small doses of sedative-anxiolytic drugs for premedication (3) improves the perioperative experience for the patient without adversely effecting the recovery process.

Second, anesthetic techniques that optimize the intraoperative surgical conditions while providing for a rapid, early recovery have assumed increased importance. The introduction of more rapid and shorter-acting volatile anesthetics (e.g., desflurane and sevoflurane), opioid analgesics (e.g., remifentanil), and muscle relaxants (e.g., rapacuronium) has allowed practitioners to more consistently achieve a recovery profile that facilitates “fast-tracking” after the administration of general anesthesia (4,5). The use of electroencephalographic bispectral index monitoring can improve titration of maintenance anesthetics and thereby facilitate the early recovery process (6,7). Although recovery after central neuroaxis blockade is improved by decreasing the local anesthetic dosage and adding a potent opioid analgesic (e.g., fentanyl, sufentanil) (8), discharge times are still prolonged compared with general anesthesia or local anesthesia with sedation (9,10). Increasingly, practitioners are turning to monitored anesthesia care as an alternative to both general and regional anesthesia (11). The availability of drugs, such as propofol, alfentanil (12), and remifentanil (13), has clearly improved intraoperative conditions for patients undergoing more extensive surgical procedures with local anesthesia.

Third, preventing postoperative pain and other untoward side effects (e.g., postoperative nausea and vomiting) is critical to successful implementation of a fast-tracking program in the ambulatory setting (14). The use of a multi-modal approach to preventing postoperative pain (15) will decrease the dependence on opioid analgesics. Nonsteroidal antiinflammatory drugs (16) and other nonopioid analgesics (e.g., local anesthetics, acetaminophen, proparacetamol) have become increasingly important in controlling pain after ambulatory surgery. Similarly, the use of prophylactic antiemetic drugs can be extremely useful in facilitating the recovery process and improving patient satisfaction (17). Minimizing side effects after ambulatory surgery has assumed even greater importance because of the rapid growth in office-based surgery (18).

Finally, providing patients and their families with information on how to avoid problems after discharge will facilitate the rehabilitation process. The importance of discussing the implications of undergoing surgical procedures on an ambulatory basis with the patient and his/her family before the operation will also increase acceptance and patient satisfaction with early discharge (19). As perioperative physicians, anesthesiologists will be required to assume an increasingly important role in minimizing the postoperative pathophysiologic changes and facilitating the rehabilitation process (20). To optimize patient outcome, a care team approach (involving the patient, the family, the nursing staff, as well as the surgeon and anesthesiologist) is essential. As more extensive surgical procedures are performed on an ambulatory basis, innovative approaches to providing recovery care will be required (21).

In conclusion, novel surgical and anesthetic techniques developed in the 1990s have allowed an increasing number of outpatients around the world to benefit from ambulatory surgery (22). As the emphasis shifts toward so-called value-based care, it is increasingly apparent that ambulatory surgery provides the best patient care possible at the most reasonable cost.

References

1. White PF. Ambulatory anesthesia in the 21st century. Curr Opin Anesthesiol 1998; 11:593–4.
2. American Society of Anesthesiologists Task Force on Preoperative Fasting. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures. Anesthesiology 1999; 90:896–905.
3. Van Vlymen JM, Sá Rêgo MM, White PF. Benzodiazepine premedication: can it improve outcome in patients undergoing breast biopsy? Anesthesiology 1999;90:740–7.
4. Song D, Joshi GP, White PF. Fast-track eligibility after ambulatory anesthesia: a comparison of desflurane, sevoflurane, and propofol. Anesth Analg 1998; 86:267–73.
5. Song D, White PF. Remifentanil as an adjuvant during desflurane anesthesia facilitates early recovery after ambulatory surgery. J Clin Anesth 1999; 11:364–7.
6. Song D, Joshi GP, White PF. Titration of volatile anesthetics using bispectral index facilitates recovery after ambulatory anesthesia. Anesthesiology 1997; 87:842–8.
7. Gan TJ, Glass PS, Windsor A, et al. Bispectral index monitoring allows faster emergence and improved recovery from propofol, alfentanil, and nitrous oxide anesthesia: BIS utility study group. Anesthesiology 1997; 87:808–15.
8. Vaghadia H, McLeod DH, Mitchell GW, et al. Small-dose hypobaric lidocaine-fentanyl spinal anesthesia for short duration outpatient laparoscopy. I. A randomized comparison with conventional dose hyperbaric lidocaine. Anesth Analg 1997; 84:59–64.
9. Song D, Greilich N, Tongier K, et al. Recovery profiles of outpatients undergoing unilateral inguinal herniorrhaphy: a comparison of three anesthetic techniques [abstract]. Anesth Analg 1999; 88:S30.
10. Li S, Coloma M, White PF, et al. A comparison of the costs and recovery profiles of three anesthetic techniques for ambulatory anorectal surgery. Anesthesiology. In press.
11. Sá R êgo MM, Watcha MF, White PF. The changing role of monitored anesthesia care in the ambulatory setting. Anesth Analg 1997; 85:1020–36.
12. Avramov MN, White PF. Use of alfentanil and propofol for outpatient monitored anesthesia care: determining the optimal dosing regimen. Anesth Analg 1997; 85:566–72.
13. Sá Rêgo MM, Inagaki Y, White PF. Remifentanil administration during monitored anesthesia care: are intermittent boluses an effective alternative to a continuous infusion? Anesth Analg 1999;85:518–22.
14. White PF, Song D. New criteria for fast-tracking after outpatient anesthesia: a comparison with the Aldrete’s scoring system. Anesth Analg 1999; 88:1069–72.
15. Kehlet H, Dahl JB. The value of multimodal or “balanced” analgesia in postoperative pain treatment. Anesth Analg 1993; 77:1048–56.
16. Souter A, Fredman B, White PF. Controversies in the perioperative use of nonsteroidal antiinflammatory drugs. Anesth Analg 1994; 79:1178–90.
17. White PF, Watcha MF. Postoperative nausea and vomiting: prophylaxis versus treatment. Anesth Analg 1999; 89:1337–9.
18. Tang J, Chen L, White PF, et al. Recovery profile, costs, and patient satisfaction with propofol and sevoflurane for fast-track office-based anesthesia. Anesthesiology 1999; 91:253–61.
19. Lehmann F, Fleisher LA, Lam J, et al. Patient preferences for early discharge after laparoscopic cholecystectomy. Anesth Analg 1999; 88:1280–5.
20. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78:606–17.
21. Oliveira IS. Recovery care facilities. Curr Opin Anaesth 1998; 11:623–7.
22. White PF. Ambulatory anesthesia and surgery: past, present and future. In: White PF, ed. Ambulatory anesthesia & surgery. London: WB Saunders, 1997.
© 2000 International Anesthesia Research Society