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Providing value in ambulatory anesthesia

Fosnot, Caroline D.a; Fleisher, Lee A.a; Keogh, Johna,b

Current Opinion in Anesthesiology: December 2015 - Volume 28 - Issue 6 - p 617–622
doi: 10.1097/ACO.0000000000000255
AMBULATORY ANESTHESIA: Edited by Thomas Fuchs-Buder

Purpose of review The purpose of this review is to discuss current practices and changes in the field of ambulatory anesthesia, in both hospital and ambulatory surgery center settings. New trends in ambulatory settings are discussed and a review of the most current and comprehensive guidelines for the care of ambulatory patients with comorbid conditions such as postoperative nausea and vomiting (PONV), obstructive sleep apnea and diabetes mellitus are reviewed. Future direction and challenges to the field are highlighted.

Recent findings Ambulatory anesthesia continues to be in high demand for many reasons; patients and surgeons want their surgical procedures to be swift, involve minimal postoperative pain, have a transient recovery time, and avoid an admission to the hospital. Factors that have made this possible for patients are improved surgical equipment, volatile anesthetic improvement, ultrasound-guided regional techniques, non-narcotic adjuncts for pain control, and the minimization of PONV. The decrease in time spent in a hospital also decreases the risk of wound infection, minimizes missed days from work, and is a socioeconomically favorable model, when possible. Recently proposed strategies which will allow surgeons and anesthesiologists to continue to meet the growing demand for a majority of surgical cases being same-day include pharmacotherapies with less undesirable side-effects, integration of ultrasound-guided regional techniques, and preoperative evaluations in appropriate candidates via a telephone call the night prior to surgery. Multidisciplinary communication amongst caregivers continues to make ambulatory settings efficient, safe, and socioeconomically favorable.

It is also important to note the future impact that healthcare reform will have specifically on ambulatory anesthesia. The enactment of the Patient Protection and Affordable Care Act of 2010 will allow 32 million more people to gain access to preventive services that will require anesthesia such as screening colonoscopies. With this projected increase in the demand for anesthesia services nationwide comes the analysis of its financial feasibility. Some early data looking at endoscopist-administered sedation conclude that it offers higher patient satisfaction, there were less adverse effects than anesthesiologist-administered sedation, and is economically advantageous. This and future retrospective studies will help to guide healthcare policymakers and physicians to come to a conclusion about providing ambulatory services for these millions of patients.

Summary Ambulatory anesthesia's popularity continues to rise and anesthetic techniques will continue to morph and adapt to the needs of patients seeking ambulatory surgery. Alterations in already existing medications are promising as these modifications allow for quicker recovery from anesthesia or minimization of the already known undesirable side-effects. PONV, pain, obstructive sleep apnea, and chronic comorbidities (hypertension, cardiac disease, and diabetes mellitus) are perioperative concerns in ambulatory settings as more patients are safely being treated in ambulatory settings. Regional anesthesia stands out as a modality that has multiple advantages to general anesthesia, providing a minimal recovery period and a decrease in postanesthesia care unit stay. The implementation of the Affordable Healthcare Act specifically affects ambulatory settings as the demand and need for patients to have screening procedures with anesthesia. The question remains what the best strategy is to meet the needs of our future patients while preserving economically feasibility within an already strained healthcare system.

aDepartment of Anesthesiology and Critical Care

bPerelman Center for Advanced Medicine, Perelman School of Medicine University of Pennsylvania School of Medicine Philadelphia, Philadelphia, USA

Correspondence to Caroline D. Fosnot, DO, MS, Assistant Professor of Clinical Anesthesiology, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA 19104, USA. Tel: +1 215 439 4777; e-mail:

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