Anesthesia for Office-Based Pediatric Anesthesia

Anesthesia for Office-Based Pediatric Anesthesia Richard Berkowitz and David Barinholtz

Chapter

35

CONTENTS Why Office-Based Surgery and Anesthesia?  1080 Safety and Outcome  1080 Legislation and Regulations  1084 Clinical Aspects  1086 l Patient and Procedure Selection  1086 l Preoperative Preparation  1087 l Intraoperative Care  1088 l Anesthetic Technique  1088

Depth of Anesthesia Monitoring  1089 Postanesthesia Care  1090 Establishing an Office-Based Practice  1092 l Equipment and Supplies  1093 l Staffing  1094 l Reimbursement  1094 Summary  1095 l l

“A pediatrician’s dream of the ideal world would be to have individuals knowledgeable about the special needs of infants and children assembled wherever children are to be treated” (Avery, 1975). Little did Dr. Avery know back in 1975, as she wrote these words in the journal Anesthesiology as a guest editor introducing a symposium on pediatric anesthesia, to what extent and in what places children were to be anesthetized and by whom. The prophetic nature of her question, “Where will pediatric surgery be done in the future?” and her statement, “Surely the anesthetist should contribute to the definition of what can be done in what setting,” is astounding when considering how rapidly the surgical and anesthetic care of children has progressed from the hospital to the ambulatory surgery center to the office-based setting since Dr. Avery’s remarks (1975). The concept of office-based anesthesia and surgery is not a novel one, because dentists, oral surgeons, and plastic surgeons have been using office-based procedures for decades. In fact, dentists and oral surgeons have been at the forefront of office anesthesia and surgery dating back to one of the first officebased anesthetics, involving Colton and Wells in 1844, for an extraction of a wisdom tooth (Jacobsohn, 1995; Yagiela, 1999). Surgical practice has now come full circle, because before the early 1900s many surgical procedures were performed in offices. Subsequently, because surgical procedures became more complex, the hospital became the major site for surgery (Yagiela, 1999). Despite this shift, the development of ambulatory anesthesia continued throughout the twentieth century with the development of the first free-standing surgical center in 1916, by Waters, and ultimately with the first ambulatory surgery center established by Reed and Ford in the late 1960s (White, 1997).

Over the past several years, the concept of office-based anesthesia and surgery has become well publicized. In addition to the increasing number of clinical reports, professional society publications, review articles and texts looking at the efficacy or regarding the subject of office-based anesthesia, there are unfortunately numerous reports of significant morbidity and mortality, as well as near misses both in the medical and dental literature and in the lay press (LaMendola, 1998; Laurito, 1998; Schulte and Bergal, 1998; de Jong, 1999; Neergaard, 1999; Rao et al., 1999; Tang et al., 1999; Arens, 2000; Morrell, 2000; Stoelting, 2000; Vogt, 2000; Hilton, 2001; Joshi, 2003; Gooden, 2006; Kaushal et al., 2006; Hussain, 2006; Hausman and Frost, 2007; Shapiro, 2007; ASA, 2008a, 2008b, 2008c; Coldiron et al., 2008; Heard et al., 2009; Sherry, 2009). The initial reports of mortality in the office-based setting have been highlighted by the unexpected death of the mother of music celebrity Kanye West and consequent legislation in California (Carter, 2007; McGreevy, 2009). Resident training in office-based anesthesia has also recently been advocated by some within the field of anesthesia. This information, along with the fact that there is an ongoing closed-claim analysis of office-based anesthesia and surgery within the American Society of Anesthesiologists (ASA) (lending itself to the knowledge that this entity does exist and that improvements to existing procedures have been started), must be compelling evidence for the anesthesiologist to realize that office-based surgery and anesthesia are here to stay (Domino, 2001; Hausman et al., 2006; Hausman, 2008; Posner, personal communication, January 2009). Interest in office-based anesthesia is also manifesting in the increasing number of societies—specifically, the Society for Ambulatory Anesthesia (SAMBA), and the Anesthesia Patient Safety Foundation (APSF)—that promulgate educational and 1077

1078   P a r t  III    Clinical Management of Specialized Surgical Problems

TABLE 35-1. Specialty-Specific Guidelines for Sedation and Analgesia and Office-Based Anesthesia and Surgery* Organization

Document

Adopted

Revised

American Society of Anesthesiologists (ASA)

Guidelines for Ambulatory Anesthesia and Surgery

1973

2008

Statement on Nonoperating Room Anesthetizing Locations

1994

2008

Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists (DVD)

1995

2009

Guidelines for Office-Based Anesthesia

1999

2009

Continuum of Depth of Sedation

1999

2009

Qualifications of Anesthesia Providers in an Office-Based Setting

1999

2009

American College of Surgeons (ACS)

Guidelines for Optimal Ambulatory Surgical Care and Office-Based Surgery

1994

2005

American Academy of Pediatrics (AAP)

Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures‡

1985

2006

Guidelines for the Pediatric Perioperative Environment

1999

NA

American Academy of Pediatric Dentistry (AAPD)

Guideline on the Use of Anesthesia-Trained Personnel in the Provision of Gen Anesthesia/Deep Sedation to the Peds Dental Patient

2001

2009

American Dental Association (ADA)

ADA Policy Statement: The Use of Sedation and General Anesthesia by Dentists

2007

NA

Guidelines for the Use of Sedation and General Anesthesia by Dentists

2007

NA

American Society of Dentist Anesthesiologists (ASDA)

Ascribe to ADA guidelines

2007

American Society of Plastic Surgery (ASPS)

Patient Safety in Office-Based Surgery Facilities. I. Procedures in the Office-Based Setting

2001

NA

Patient Safety in Office-Based Surgery Facilities. II. Patient Selection§ Practice Advisory on Liposuction¶

2003

NA

Standards for Office-Based Anesthesia Practice

1987

2009

American Association of Nurse Anesthetists (AANA)

†

From American College of Surgeons: Guidelines for optimal ambulatory surgical care and office-based surgery, ed 3, Chicago, 2005, American College of Surgeons; American Dental Association: ADA policy statement: the use of sedation and general anesthesia by dentists, 2007. Available at http://www.ada.org/prof/resources/positions/statements/ statements_anesthesia.pdf; accessed October 26, 2009; American Dental Association: Guidelines for the use of sedation and general anesthesia by dentists, 2007. Available at http://www.ada.org/prof/resources/positions/statements/anesthesia_guidelines.pdf; accessed October 26, 2009; American Society of Anesthesiologists: Practice guidelines for sedation and analgesia by nonanesthesiologists, 2009. Available at http://www.asahq.org/publicationsAndServices/sedation1017.pdf; American Society of Anesthesiologists Office of Governmental and Legal Affairs: Office-based surgery and anesthesia, statutes, regulations, and guidelines, rev. ed., Washington, D.C., 2009, American Society of Anesthesiologists; American Society of Plastic Surgery (ASPS) Committee on Patient Safety: Practice advisory on liposuction: executive summary, Arlington Heights, Ill, 2003, ASPS; American Association of Nurse Anesthetists : Standards for office-based anesthesia practice, 2009. Available at http://www.aana.com/WorkArea/showcontent .aspx?id=23028; accessed October 26, 2009. *Not a complete list, as other professional societies may also have related guidelines. † These guidelines specify surgery by facility class (A, B, C) depending on the invasiveness of the surgery and type of anesthesia used. ‡ Joint statement with the American Academy of Pediatric Dentistry. § Practice advisory only. ¶ In this practice advisory, the ASPS recommends that in the event that sedation or analgesia is used, the surgeon follow the ASA Guidelines for Sedation and Analgesia by Non-Anesthesiologists.

safety-related literature in this relatively new arena for anesthesiologists. Also, the ASA, as well as other groups including, but not limited to, The American College of Surgeons and various surgical subspecialty societies, the American Dental Association, the American Academy of Pediatric Dentistry, and the American Association of Nurse Anesthetists, have published guidelines specifically addressing office-based anesthesia or surgery or both (Table 35-1). Furthermore, the ASA Committee on Ambulatory Surgical Care and SAMBA have published a “how-to” manual for setting up a safe office environment (ASA, 2008d). In an effort to establish consistency in the safe administration of sedation and anesthesia to children, some societies have established joint guidelines or updated guidelines outlining the use of anesthesia personnel to its membership (American Academy of Pediatrics, 2006; American Academy of Pediatric Dentistry, 2009). All of these societies have developed their guidelines or policies in response to the overwhelming ­interest

and growing participation by their memberships in this area, as well as an overall common concern for patient safety. Also significant, and perhaps legitimizing the presence of office-based anesthesia and surgery in present-day medicine, is the ever-increasing number of states developing legislation that specifically address this area. Consequent to this dynamic period of law making and law revision is that the ASA Office of Legal Affairs continues to compile information pertinent to the states that have developed and those that are developing legislation regulating office-based anesthesia and surgery. Simply stated, office-based anesthesia is the practice of anesthesia in the free-standing physician’s office and is defined as the provision of anesthesia service in an operating area or a procedure room that is not licensed as an ambulatory surgery center. The most important distinctions are that it occurs within the four walls of a physician’s office where surgery is offered as a secondary service, and only physicians who are members of the

C h a p t e r 35    Anesthesia for Office-Based Pediatric Anesthesia   1079

practice perform procedures in this space. It is the most “liberated” form of anesthesia practice and is at the most extreme end of the spectrum of “out-of-the-operating-room” or “off-site” anesthesia. In a sense, it is anesthesia for the most remote location (except, perhaps, for those individuals delivering anesthesia care in isolated areas of Third World countries). Traditionally, office-based anesthesia has been the realm of various specialists, including but not limited to dentists, oral surgeons, plastic surgeons, podiatrists, certified registered nurse anesthetists (CRNAs), and in some instances, gastroenterologists. Until recently, few anesthesiologists dared to venture out of their conventional roles as hospital-based or ambulatory surgery–based physicians. To what extent is the office-based surgical volume increasing that it requires or necessitates the continued evolution of this new “subspecialty” of ambulatory anesthesia? Estimates of the actual number of surgical cases completed, pediatric or otherwise, in an office setting, are difficult to ascertain. It is estimated that there were 10 million office-based surgical procedures performed in 2005, consistent with one marketing study from several years ago, that estimated that by 2006 the total number of outpatient procedures performed would be approximately 40 million, with 11 million of these being office-based procedures (Fig. 35-1) (SMG MarketingVerispan, L.L.C., 2002; Twersky, 2008). In 2009, these numbers are holding steady; however, the dynamic nature of the reimbursement environment and the development of minimally invasive surgical technologies may make the number of officebased procedures skyrocket over the next several years. According to a 2009 report from the National Center for Health Statistics, in 2006 there were approximately 35 million

ambulatory surgery visits in the United States, with most of these being in hospital-based facilities vs. free-standing facilities (Cullen et al., 2009). Just over 7% of these reported ambulatory surgery visits were by children younger than 15 years of age. Although the total number of ambulatory surgery visits for this age group went up in 2006, the percentage decreased from the 8.5% reported for 1996 (Hall and Lawrence, 1998). As  is suggested, without mandatory reporting of all ambulatory surgery procedures requiring anesthesia to a central agency, officebased anesthesia data will remain obscure (Perrott, 2008). Although many different types of surgical procedures, including otolaryngologic, urologic, cosmetic, ophthalmologic, and radiologic (including single-photon emission computed tomography [SPECT]) scanning are performed on children in the office-based setting, the majority of procedures requiring anesthesia or sedation in the office setting for children are dental procedures (Cartwright et al., 1996; Goldblum et al., 1996; Grevelink et al., 1997; Yagiela, 1999; Siegel et al., 2000; Smith and Smith, 2000; Garin et al., 2001; Friedman et al., 2002; Ross and Eck, 2002; Barinholtz, 2009; Gravningsbraten et al., 2009). The most common reason for children to require dental procedures is related to early childhood caries (ECC), with an incidence in primary teeth of 41% in children between ages 2 and 11 years (Beltrán-Aguilar et al., 2005). Furthermore, a majority of ECC in the United States occurs in children from lowincome households. (Vargas et al., 1998; Nunn et al., 2009). Yagiela (1999) reports that a survey by the American Academy of Pediatric Dentistry estimated in 1995 that the number of children who received anesthesia for dental procedures was close to 200,000. Presently, the actual number of dental procedures performed with patients under general anesthesia is

60,000

50,000

Volume (000)

40,000

30,000

20,000

10,000

0 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001* 2003* 2005* 2007* Years Inpatient surgeries

FOSC surgeries

Total outpatient surgeries

Outpatient surgeries

POBS surgeries

Total surgical volume

Total hospital-based surgeries

n  FIGURE 35-1. This graph represents past and future trends in surgical volumes in specific patient-care sites. Notice the increasing surgical volumes in the free-standing outpatient surgery center (FOSC) and physician office-based surgery (POBS) center. (Courtesy SMG Marketing-Verispan, LLC., 2002, Chicago, Ill.)

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difficult to determine because of underreporting, and because estimates are generated from Medicaid-provided information of hospital-based care (Casamassimo et al., 2009). The actual ­number of children requiring anesthesia for these procedures may be significantly greater than this, with the discrepancy being because of a paucity of access to the appropriate care secondary to a lack of primary-care access and as important, a lack of insurance coverage. Significantly, this access to care can be positively impacted by state legislation. White and others (2008) report that non–Medicaid and Medicaid dental visits increased by approximately 60% and 30% (p < .05), respectively after the State of North Carolina introduced ­general-anesthesia legislation for preschool-aged children. In a 2006 survey of Illinois dentists licensed to give some form of sedation or anesthesia, close to 116,000 cases were performed with some form of sedation and general anesthesia (Flick et al., 2007). Most of these sedation and anesthesia cases (90%) were performed by oral and maxillofacial surgeons (63%  of ­survey respondents); however, general dentist and pediatric dentist respondents (29%) accounted for most of the remaining sedation and anesthesia. The number of pediatric patients cared for, however, was not specified.

WHY OFFICE-BASED SURGERY AND ANESTHESIA? As one can see from the information presented in Figure 35-1, there is a compelling need to be able to provide quality surgical and anesthesia services in the office-based setting. The actual reasons as to why this boom has occurred and continues to evolve and why anesthesiologists are more aggressively entering this arena are severalfold. Ostensibly, the most persuasive argument for a paradigm shift to the office-based setting is financial. Potential and realized limitations and reductions in reimbursement because of health care reform and economic constraints are causing physicians to become more creative in facilitating cost-effective approaches to surgery. Costs can be reduced by reducing or eliminating facility fees that ordinarily accompany the cost-sharing charges at hospital-based and ambulatory surgery-based centers. Much of office-based surgery, especially cosmetic surgery, is performed on a cash-payment, fee-for-service basis, and therefore cost containment by limiting facility-fee overhead becomes crucial to patient affordability. This affordability is critical in the case of pediatric dental procedures, where in many instances, neither dental nor medical insurance covers out-of-office dental procedures and anesthesia costs (Ross and Eck, 2002). Although the lack of a facility fee is ideal and helps provide the surgeon with a cheaper alternative for the patient, the reality of the situation is that surgeons often include a facility fee in their global fee to the patient to offset the overhead required to run an office-based practice (e.g., personnel and supplies). In some instances, insurance companies may reimburse physicians a facility fee, but the cost to the third-party payers may still be less than if the procedure is performed in a hospitalor surgery center-based setting. Consequently, the procedure becomes financially advantageous for the surgeon, the anesthesiologist, the insurance company, and the patient. One surgical study from the United States as early as 1994 compares the cost of performing an inguinal herniorrhaphy in the hospital with that of the cost in an office setting. This study finds the latter a more cost-effective alternative with a r­ eduction

in cost of a laparoscopic approach or an open approach of approximately 70% and 60%, respectively when compared with the hospital outpatient setting (Schultz, 1994). In one pediatric study, Lalwani and others (2007) show a per-patient savings of close to $5000 when patients with special health care needs who require anesthesia or sedation undergo dental rehabilitation procedures in an office-based setting when compared with those receiving care in a hospital operating room. Operating in the office affords the surgeon not only financial but also logistic advantages. Office-based surgical practice virtually eliminates the lost time caused by turnover delays, bumping cases secondary to emergencies, overscheduled cases, and travel times between facilities. In the office-based setting, whatever turnover delays do occur can be quickly remedied by the surgeon, because he or she has total control over the personnel and the facility. The ability of the surgeon to schedule on-site clinic visits between surgical cases allows for the efficient use of time. This eliminates the usual routine of having to rush back to the office between procedures or having office hours at the conclusion of a long and busy day at the hospital or surgery center. Another advantage of office-based procedures is the more private, less stressful, and more familiar environment. For the anesthesiologist, office-based anesthesia may allow for an enhanced income, a better work environment (working with a limited number of surgeons or, in some instances, the same surgeon), and in most practices, the lack of a nighttime call schedule. Furthermore, this type of practice provides the anesthesiologist with the opportunity to have complete control over all aspects of practice for which he or she is ultimately responsible. Whether these potential advantages of establishing or taking part in an office-based practice prevail over the relative disadvantages of working in an extremely remote environment, routinely providing anesthesia care for cases of decreased complexity (compared with those cases in a hospital setting, but this may be changing), providing anesthesia services under itinerant conditions, and perpetually competing with other anesthesiologists and anesthesia providers for business, become individual decisions.

SAFETY AND OUTCOME With the government, medical community, third-party payers, and the consumers (patients) pushing for more expeditious and cost-effective (and hence potentially more profitable) ways in which to provide surgical and anesthesia services, the anesthesia services provided are moving further away from the hospital safety net. Dr. Ervin Moss (1998), the impetus behind tighter regulation of office-based anesthesia and surgery in the state of New Jersey and perhaps beyond, stated, “Some say the major difference between the office-based and hospital-based anesthesiologist is that the former must be more courageous or foolhardy.” Whether or not Dr. Moss’s characterization of the officebased anesthesiologist holds true, the fact remains that anesthesia care must be provided safely, if not more vigilantly, than hospital-based or surgery center-based anesthesia. Although some have questioned whether the convenience of office-based surgery and anesthesia is worth the risk, consensus opinion, as this specialty area continues to develop, is that it must be done correctly and consistently (Arens, 2000; Bridenbaugh, 2005). Although anesthesia-related mortality risk continues to be difficult to assess, perhaps because of methodologic issues, it has nevertheless decreased over the past several decades (Lagasse,

C h a p t e r 35    Anesthesia for Office-Based Pediatric Anesthesia   1081

2009). Anesthesia-related mortality risk in the United States has recently been quoted to range from 0.1: 10,000 to approximately 0.8:10,000 procedures performed (Biboulet et al., 2001; Lagasse, 2002, 2009; Newland et al., 2002; Li et al., 2009). These numbers appear slightly lower than the rate published outside the United States, at 1.12:10,000 cases (Braz et al., 2006). In children, the incidence of cardiac arrest from anesthesia is reported to range from 1.4:10,000 to 4.6:10,000 with the incidence of anesthesia-related mortality being reported by some as between 1.2:10,000 and 7.7:10,000 cases in ASA Physical Status (PS) I-II and ASA PS III-IV, respectively (Morray et al., 2000). This disparity seen between patients of lower and higher ASA PS is consistent with morbidity statistics presented by Murat and others (2004) in a report of over 24,000 anesthesia cases over 2½ years and by Kakavouli and others (2009) in a study comparing adverse events for patients receiving anesthesia in the operating room (2.5%) with those outside the operating room (3.5%). Respiratory events were the leading cause in both studies, 1.7% and 1.9%, respectively (Zuercher and Ummenhofer, 2008; Bharti et al., 2009). Interestingly, the number of pediatric arrests related to medications decreased almost 20% from 1994 to 1997 (37%) and from 1998 to 2004 (18%) as reported in an update on the pediatric perioperative cardiac arrest (POCA) registry (Bhananker et al., 2007). The authors suggest that this may be because of the decreased use of halothane in pediatric anesthesia. This is important in that the relatively newer, faster onset and offset (desirable characteristics in the office-based setting) volatile agents, sevoflurane and to a lesser extent desflurane, may confer a larger therapeutic index in the office-based setting. Furthermore, these authors report that airway causes for pediatric arrest still occur with a high incidence (27%), reemphasizing the importance of having superior airway management skills in pediatric anesthesia regardless of location. Despite this information, an accurate assessment of the safety profile of office-based anesthesia and surgery relative to the pediatric population is difficult secondary to the paucity of site-­specific information. Until across-the-board mandatory reporting for morbidity and mortality related to office procedures exists, in order to make an assessment of the relative safety of office-based anesthesia and surgery, it is imperative to continue to analyze data reviewing the safety of pediatric ambulatory and in-patient surgery, pediatric dental office surgery, and pediatric sedation and analgesia, as well as the adult literature that reviews this topic. Many of the cases brought to the attention of the medical, dental, and lay community involve children undergoing dental procedures (Morell, 2000; Hussain, 2006; Sherry, 2009). This information is not only tied intimately to the present topic but also is the point of origin for much of the controversy over the safety and efficacy of office-based anesthesia for children. In two reports from the United States, Coté and others (2000a, 2000b) retrospectively analyzed information obtained from the Food and Drug Administration, the United States Pharmacopoeia, and a survey of pediatric specialists to report on contributing factors to critical incidents and medications used in sedation as they relate to adverse sedation events in children undergoing diagnostic and therapeutic procedures. In the first report, Coté and others (2000a) reported on 95 incidents. Over half of these incidents resulted in death (n = 51) or permanent neurologic injury (n = 9). The remaining patients either had prolonged hospitalization without injury (n = 21) or sustained no harm as a result of the adverse event (n = 14). Of note

was that those children who were cared for in non–­hospital-based facilities (older and healthier) had a much higher rate of death and permanent neurologic injury (93%) than did those cared for in hospital-based facilities (37%). The authors also reported that inadequate resuscitation was a major factor in the non–hospitalbased facilities (57%) compared with the hospital-based setting (2.5%) and that patients cared for in the nonhospital setting were more likely to sustain a cardiac arrest as the second or third event compared with those in the hospital setting (p < .001). In the second report, Coté and others (2000b) used the same 95 incidents to determine whether there was a relationship between medications and adverse events. Although the authors noted no relationship between the class of drug used, the route of administration, and the incidence of death and permanent neurologic injury, they did note that adverse outcomes were associated with the administration of drug overdoses and administration of three or more sedating medications. Furthermore, 11 of 12 patients (all younger than 6 years of age) sustained adverse outcomes either at home or in a car. Two of the 12 patients, who had received sedative medication at home before their procedure, sustained an adverse event at home before the scheduled procedure. Of note was that over one third of the reported events occurred during sedation for dental procedures (n = 32). Twenty-nine of these resulted in death or permanent neurologic injury. Most of the involved practitioners were either oral surgeons or dentists, three were pedodontists, and one was a nurse anesthetist under the supervision of a dentist. None of the practitioners was an anesthesiologist (Coté et al., 2000b). The dental practices were the only sites in these reports to have used nitrous oxide. In addition to the greater tendency toward the use of nitrous oxide, there was a greater tendency for these practitioners to use multiple drugs (more than three) compared with other practitioners: 39% and 13%, respectively. The authors conclude that many of these adverse events may have been prevented by consistency between monitoring guidelines (as now exists with sedation guidelines promulgated by the American Academy of Pediatrics and the American Academy of Pediatric Dentistry) and by practice and training requirements among health care professionals of differing specialties who administer sedation and anesthesia. Although these conclusions may seem intuitive to those who regularly care for children, they are reinforced by recent reports suggesting that severe adverse outcomes in pediatric sedation or analgesia outside the operating room may be improved by consistency in guidelines, training, and adverse-event reporting across institutions and specialties that are implemented through well-designed sedation services (Cravero et al., 2006, 2009; Bhatt et al., 2009). In the latter study, Cravero and others (2009) show that whereas the incidence of pulmonary events (e.g., stridor, laryngospasm, excessive secretions, and central and obstructive sleep apnea) is high, they report a low incidence for cardiopulmonary resuscitation (0.4:10,000) and no mortalities in approximately 50,000 sedation procedures performed by various nonanesthesiologist pediatric specialists. Lightdale and others (2006) advocate the use of microstream capnography to enhance the safety of pediatric patients undergoing procedures under sedation or analgesia via early detection of hypoxemia caused by alveolar hypoventilation. Although there are anecdotal reports and studies of adverse outcomes, complications, and side effects related to sedation and anesthesia in the dental literature, others have reported

1082   P a r t  III    Clinical Management of Specialized Surgical Problems

on a safety record that is as good as, if not better than, that of the anesthesia community (Denman et al., 1968; Yee et al., 1985; Blayney et al., 1999; Girdler and Smith, 1999; Laskin, 1999; Saxen et al., 1999; Whitmire, 1999; Johnson et al., 2001; Manoharan et al., 2001; Yagiela, 2001; Perrott et al., 2003). The incidence of mortality rates in dental anesthesia is reported to be anywhere from 1:250,000 in the United Kingdom to 1:300,000 to less than 1:1 million in the United States (Cartwright, 1999; Brandom and Herlich, 1999; D’Eramo, 1999; Laskin, 1999). As if there is not enough controversy within the anesthesia community, within the dental community there is also debate over who can best serve the patient requiring anesthesia for a dental procedure. Yagiela (2001) points out that members of the American Society of Dental Anesthesiologists, those who provide “approximately 25,000 pediatric general anesthetics per year,” subscribe closely to the American Academy of Pediatrics and American Society of Anesthesiologists guidelines for sedation and anesthesia. He also states that “since the organization’s inception 2 decades ago, there have been no known incidents of mortality or significant morbidity in children managed in the dental office by a dentist anesthesiologist” and intimates that safety may be improved in dental offices with a greater adherence to these guidelines by the dental community as a whole (Yagiela, 2001). In contrast to the paucity of information about the safety and outcomes related to office-based anesthesia, the efficacy of anesthesia in pediatric ambulatory surgery in general is well known. As reported by Willetts and others (1997), outpatient surgery may date back to James H. Nicoll, a Glasgow surgeon who in the early 1900s successfully performed several thousand ambulatory procedures on young children at the West Graham Street Dispensary for Children. Contemporary literature continues to confirm over the past 50 years that for a growing variety of surgical procedures, the ambulatory setting for surgery and anesthesia is safe, cost effective, and therefore preferable to inpatient surgery (Postuma et al., 1987; Patel and Hannallah, 1988; Hannallah, 1991; Ghosh and Sallam, 1994; Blacoe et al., 2008; Shah et al., 2008; Mattila et al., 2009). In one prospective study examining the efficacy of pediatric day surgery at the Children’s Hospital of Eastern Ontario, the overall complication rate was very low. The investigators, over 5 years, prospectively studied children undergoing various outpatient procedures, including myringotomy, tonsillectomy and adenoidectomy, dental procedures, and inguinal hernia repairs. Most of the children were between 2 and 7 years old, and the total number of cases approached 25,000. The reported complication rate was 1.6% per year. The most common complication was postoperative bleeding, primarily secondary to tonsillectomy and adenoidectomy. None of the complications resulted in permanent disability (Letts et al., 2001). In a retrospective study from Children’s National Medical Center focusing on pediatric otolaryngology procedures, Shah and others (2008) report that in close to 5000 cases (55% of total surgical cases) over 7 years, the rate of unanticipated outcomes was 0.2%. Similar to the previous study, the majority of adverse outcomes were related to posttonsillectomy and adenoidectomy bleeding. Most of the information relative to the outcomes for officebased anesthesia and surgery is related to adult patients. In a retrospective report specifically looking at outcomes for plastic surgical procedures, Hoefflin and others (2001) reported no significant morbidity and no mortality over 18 years in more than 23,000 procedures in which general anesthesia was used. The anesthesia was provided by a board-certified anesthesi-

ologist, and the single facility was accredited by the American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF) (Hoefflin et al., 2001). In this report, most of the patients underwent cosmetic surgery, with some patients having multiple procedures. The only incidents reported as significant by the authors were the rare occurrence of electrocardiograph and oxygen-monitor failure. None of these events resulted in any patient complications, although three patients were hospitalized for custodial care. Minor anesthetic complications included nausea and vomiting (fewer than 5%), postextubation sore throat (fewer than 5%), shivering, one case of dental damage, one case of delayed (10 days) deep vein thrombosis, and one case of carpal tunnel syndrome after intravenous catheter infiltration. In a retrospective study comparing outcomes in physician offices and ambulatory surgery centers in Florida, Vila and ­others (2003) found that despite new regulations imposed by the Florida Board of Medicine in the year 2000, between 2000 and 2002 there was a significantly increased risk of adverse incidents and deaths in offices (65.8:100,000 and 5.3:100,000, respectively) compared with ambulatory surgery centers (9.2:100,000 and 0.8:100,000, respectively). Furthermore, the authors estimated that a significant number of injuries and at least six deaths per year could have been prevented had all surgical cases been performed in an ambulatory surgery center. In another report and as a follow-up study to previous reports, Coldiron and others (2008) reviewed critical surgical incidents that occurred in physicians’ offices in the state of Florida from 2000 to 2007 subsequent to mandatory reporting that began in February 2000 (Coldiron 2001, 2002). This mandatory reporting initially resulted from several newspaper accounts of poor patient outcomes and questions of whether office anesthesia and surgery were safe. Those incidents requiring reporting are listed in Box 35-1. In the data obtained from Florida’s Agency for Health Care Administration, there were 31 deaths and 143 procedure-related complications and hospital transfers. Most of the bad outcomes occurred during “nonmedically-indicated” cosmetic surgery such as liposuction or liposuction with abdominoplasty. Plastic surgeons were responsible for 48% of all deaths and 52% of hospital transfers. Interestingly, most of the deaths (78%) occurred in ASA PS I patients. These authors note that the reported deaths and complications were unrelated to whether the physician was board certified or whether the physician had similar surgical

Box 35-1 Incidents in Surgical Offices Requiring Reporting by the State of Florida l l l l l l l l l

Death Brain damage Wrong patient surgery Wrong site surgery Wrong procedure Surgery to remove an unplanned foreign object from a ­surgical procedure Transfer of a patient to a hospital Spinal damage Surgical repair of injuries or damage resulting from a planned surgical procedure

From Coldiron B: Office surgical incidents: 19 months of Florida data, Dermatol Surg 28:710, 2002.

C h a p t e r 35    Anesthesia for Office-Based Pediatric Anesthesia   1083

privileges in a hospital (the latter being a mandatory requirement in some states). However, only 40% of facilities reporting adverse events were accredited by an independent agency. Despite the latter data, there are those who suggest that rigid state regulations and licensing laws along with accreditation of office-based surgical and anesthesia practices will help ensure patient safety (Kaushal et al., 2006). Bitar and others (2003) retrospectively reviewed close to 5000 office-based plastic surgery procedures that were ­performed under monitored anesthesia care with sedation. The procedures in this study were performed by board-certified plastic surgeons, and anesthesia was provided by a CRNA. Nearly all patients were reported to be ASA PS I or II (99.9%), and the majority of patients were adult females (92%). The most common complications reported in this study were dyspnea (0.05%, n = 2), protracted nausea and vomiting (0.2%, n = 6), and unplanned hospital admission (0.05%, n = 2). One patient required intubation without prolonged sequelae. The author reported no cardiac arrests, deaths, or any incidence of deep vein thrombosis or pulmonary embolus. The author concluded that office anesthesia and surgery were safe when using appropriate protocols and patient selection. One Pittsburgh-based office dental anesthesiologist practice, delivering approximately 30,000 anesthetics from between 2004 and 2009, reports no mortality or major morbidity, including central nervous system injury. Furthermore, this practice reports no instances of aspiration, pulmonary embolism, local anesthetic toxicity, or malignant hyperthermia. There was one unplanned hospital admission, not related to anesthesia, involving massive bleeding from a mandibular arteriovenous malformation from which the patient made a full recovery after transfer to an acute care hospital (Finder, personal communication, January 2010). In another office-based dental anesthesia practice in Seattle, 4321 pediatric (younger than 12 years old) dental procedures have been completed since the year 2000 (Isackson, personal communication, 2010). Dr. Isackson reports no serious adverse events. There were no unplanned hospital admissions, although one patient was referred to a primary care physician for cardiac evaluation. Minor respiratory events and immediate and delayed postoperative nausea and vomiting (PONV) each occurred in 0.07% of cases, with one patient in the group who experienced nausea and vomiting requiring office assessment by a primary care physician. Koch and others (2003) reported on several office-based anesthesia practices from various regions of the United States that were performed between 1981 and 2002. In this report, the authors noted no intraoperative deaths in over 64,000 anesthesia cases. Furthermore, in a subset of pediatric patients that comprised this report, one Chicago-based office anesthesia practice reported no intraoperative deaths, significant perioperative morbidity, or emergent hospital transfers in over 600 pediatric anesthesia cases. This number is now approximately 1200 cases and includes only one pediatric emergent hospital transfer (a possible malignant hyperthermia case). All complications continue to be minor, with a reported incidence of immediate and delayed PONV of less than 0.07% and 1%, respectively. Children in this subset ranged in age from 18 months to 17 years. Most of the children were younger than 6 years old and were classified as ASA PS I or II patients (Barinholtz, personal communication, 2009). These safety results are consistent with those reported by others caring for special-needs dental patients in the office-based setting (Caputo, 2009).

TABLE 35-2. Patient Characteristics in Analysis of Claims Made in Office-Based Anesthesia Incidents Ambulatory (n = 753)

Office Based (n = 14)

Age (mean yr)

41

  45

Female (%)

58

  64

ASA PS class I/II (%)

82

  89

Elective surgery (%)

97

100

General (%)

66

  71

MAC (%)

10

  14

Dental (%)

 3

  21

Plastic surgery (%)

32*

  64*

Other (%)

64

  14†

Anesthesia type

Surgical procedure

†

From Domino KB: Office-based anesthesia: lessons learned from the Closed Claims Project, ASA Newsletter, 2001, American Society of Anesthesiologists. *p < 0.05, Ambulatory vs. office based. † p < 0.01, Ambulatory vs. office based. MAC, Monitored anesthesia care.

In a review of the ASA’s Closed Claims Project database, Domino (2001) compared claims (all age populations) made against anesthesiologists in the office setting (n = 14) with those made in other ambulatory surgery settings (n = 753). Claims for dental damage and for nonoperative pain management were excluded from this analysis. Although patient demographics were similar in both groups (Table 35-2), most of the claims in the office-based setting were related to plastic surgery or dental procedures, whereas in the ambulatory setting, most claims were related to procedures other than plastic or dental. The severity of injury appeared greater in the office-based setting compared with other ambulatory sites. In this initial report, most of the claims made in other ambulatory sites (62%) were for “temporary or nondisabling injury,” whereas most of the claims from the office-based setting were for death (64%). The author pointed out, however, that without a denominator, a true risk assessment for each site cannot be ascertained. Subsequent data from the ASA Closed Claims Analysis, with more claims in both the ambulatory (total, n = 877) and office-based settings (total, n = 29), continue to show a preponderance of death and brain damage in the office-based setting, although at a reduced (40%) incidence (Posner, personal communication, 2009). Likewise, Jimenez and others (2007), in a closed claims analysis of 532 pediatric cases from 1973 to 2000 (not exclusively ambulatory or office-based, but from 1990 to 2000 the highest percentage of the claims involved dental, otolaryngologic, and maxillofacial surgeries), found that death and brain damage were also the dominant injuries in malpractice claims, although the proportion of these claims decreased in the 10  years before 2001. In both office-based settings and ambulatory settings, Domino (2001) noted that respiratory events were most common. A summary of airway-related complications and drugrelated complications in office-based claims is shown in Table 35-3. Although the timing for injury was similar for both

1084   P a r t  III    Clinical Management of Specialized Surgical Problems

TABLE 35-3. Damaging Events in Office-Based Anesthesia Claims Ambulatory Anesthesia (n = 666)

Office Based (n = 12)

Type of Event

Number

%

Number

%

Respiratory

150

22

6

50

Cardiovascular

  67

10

1

 8

Equipment

  74

11

1

 8

Drug related

  58

 9

3

25

Block-needle trauma

  41

 6

1

 8

From Domino KB: Office-based anesthesia: lessons learned from the Closed Claims Project, ASA Newsletter, 2001, American Society of Anesthesiologists.

sites, there tended to be fewer claims for events occurring after discharge in the other ambulatory claims (7%) than for the office-based claims (21%). The Closed Claims Project analysis also discloses that a greater number of office-based claims continue to be potentially preventable with better monitoring (Posner, personal communication, 2009). In the earlier report, a greater percentage of office-based claims involved substandard care compared with other ambulatory settings (not statistically significant), and payment was made in a higher percentage of claims (92% vs. 59%) and for a higher median payment ($200,000 vs. $85,000) for office-based claims than for other ambulatory settings (Domino, 2001).

LEGISLATION AND REGULATIONS There are many entities presently imparting their influences on the practice of office-based anesthesia and surgery. These include, but are not limited to, state regulatory bodies; federal regulatory agencies such as the Centers for Medicare and Medicaid Services (CMS) and the Office of the Inspector General (OIG); national medical professional societies; national medical and safety organizations such as the Federation of State Medical Boards (FSMB, 2002), the National Committee for Quality Assurance (NCQA), and the National Patient Safety Foundation (NPSF); accrediting organizations such as the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), the Accreditation Association for Ambulatory Health Care (AAAHC), and The Joint Commission; and the insurance industry. Also, in 2003, the AMA published the Core Principles for Office-Based Surgery that are currently endorsed by government agencies, the accrediting bodies, and specialty societies. The main problem with regulation and legislation concerning office-based surgery and anesthesia is the wide regulatory variability that exists among states. Some states are highly regulated, whereas other states have no regulations (Fig. 35-2). In the states that do have regulations, these regulations are often ambiguous. State regulations regarding facility structure, personnel, equipment, and credentialing of individual practitioners differ widely. A more complete compendium of state regulations is available through the ASA Office of Governmental and Legal Affairs (ASA, 2009). In addition to state agencies and legislation,­

professional societies can regulate practice by establishing practice guidelines, practice standards, and advisories. The disadvantage of professional societies is that they run the risk of being self-interest groups. Consistent regulatory control could also be achieved by recognizing established accrediting bodies as oversight organizations. The organizations most commonly involved in the accreditation of ambulatory surgery centers are AAAASF, AAAHC, and The Joint Commission. Historically, AAAASF, known until the early 1990s as the American Association for Accreditation of Ambulatory Plastic Surgery Facilities (AAAAPSF), was created to accredit only outpatient plastic surgery facilities. However, as other medical specialties moved procedures to free-standing outpatient settings, this organization became active in accrediting these facilities as well (AAAASF, 2003). In contrast to AAAHC and The Joint Commission, AAAASF accredits facilities over a much narrower spectrum of medical specialties. The surgical specialties include colon and rectal surgery, obstetrics and gynecology, ophthalmology, orthopedic surgery, otolaryngology, plastic surgery, general surgery, and urology. AAAASF is particularly restrictive in its practitioner credentialing. This organization requires all surgeons to be certified by the American Board of Medical Specialties (ABMS) and requires all of its surgeons practicing at an ambulatory or office-based facility to have hospital privileges for the same procedures being performed in the office facility (AAAASF, 2003). AAAASF will only accredit a practice where the surgeons practice in their area of board certification. Furthermore, the AAAASF will not accredit an organization if propofol is not administered by an anesthesiologist or a properly supervised CRNA or anesthesia assistant. The Joint Commission and AAAHC, in addition to the facilities mentioned for AAAASF, approve facilities where oral and maxillofacial, dental, dermatologic, podiatric, cosmetic, vascular, and pain procedures are performed. Although these two organizations are not as restrictive on the practitionerprivilege issue as the AAAASF, their credentialing policies are complete. In addition to defining requirements for surgical personnel, all three organizations offer accreditation processes that outline expectations for the facilities as they relate to meeting standards for the facility physical plant (e.g., by ensuring that state, local, Occupational Safety and Health Administration [OSHA], and National Fire Protection Association regulations are followed), anesthesia administration, monitoring, equipment and personnel, ancillary staff, patient transfer policies, patient safety and emergency resuscitation issues, quality improvement, and patient satisfaction issues. A summary of some of the similarities and differences between the three most visible accrediting organizations is given in Table 35-4. Whether accreditation affects outcomes in office-based surgery and anesthesia is uncertain. In a survey study, the AAAASF sent a questionnaire to its accredited facilities that addressed patient safety in plastic surgery office facilities. Two hundred forty-one of 418 facilities responded to the questionnaire. Over 5 years 400,000 surgical procedures were studied, and the authors reported the risk of significant complications to be 1:213 and the risk of death to be 1:57,000 cases. They concluded that overall risk in an accredited office is comparable with that of other ambulatory surgery sites (free-standing or hospital based) (Morello et al., 1997). In a retrospective review of an accredited office-based plastic surgery facility, Byrd and others

C h a p t e r 35    Anesthesia for Office-Based Pediatric Anesthesia   1085 2009 OFFICE−BASED SURGERY AND ANESTHESIA REQUIREMENTS This table was current as of the time of the publication, however state health statutes, regulations, health department, and medical licensure regulations are different for each state and should be reviewed and updated accordingly. A summary of state regulations is provided by the ASA Washington Office that can be found at www.asahq.org/Washington/rulesregs.htm. This site is maintained by the ASA and contains a state by state summary of Office-Based Anesthesia legislative activity. AL AZ4 CA CO CT FL Accreditation of Facility

X1

X

Physician Supervision of CRNAs

X2

X* X*

X X

CME for Surgeons Supervising CRNAs

IL

KS LA MA MS NJ NC NY OK OH OR PA

X11

X X

IN

X

X15 X18

X12

X

X

X7 X10

Hospital Privileges to Perform Procedures

X6

Reporting Requirements

X3

Transfer Agreement

X

X5 X

X

X8

X

X

X

X

X*

X32 X35 X X

X21 X24 X13

X9 X

X27 X30

X16 X19

X25 X28

X

X

X

X

X

X23 X

X

X36 X39 X43 * X

X

X

X33

X40

X34

X37 X41 X44

X14 X17 X20 X22 X26 X29 X31 X

RI SC TN TX47 VA 48

X

X*

X38 X42 X45 X49 X51 X

X

X

X

X46 X50 X

*Physician supervision or direction requirements derived from other sources of state law, not from OBA requirements. 1AL: Encouraged for Levels 4 (deep sedation) and 5 (general). 2AL: Direction of the general and regional anesthesia should be provided by a physician who is immediately and physically present. 3AL: Report within 3 business days surgical related deaths and events resulting in emergency transfer to hospital, anesthetic surgical events requiring CPR, unscheduled hospitalization related to surgery, and surgical site deep wound infection.

17LA: Report within 15 days after occurrence resulting in transfer to ER, office readmission with 72 hours of discharge, unscheduled hospital admission within 72 hours of discharge, death within 30 days of surgery. 18MA: Level II, III: Pre-accrediting suvey prior to surgical procedures; definitive accreditation survey 6 months after procedures begin. 19MA: Level II, III: Surgeon must have staff privileges at hospital or accredited

4AZ: A physician who uses general anesthesia when performing office-based

outpatient facility or document satisfactory completion of training such as Board certification/Board eligibility or comparable background, formal training, or experience as determined by MA BRM.

surgery using sedation must obtain a health care institution license as required by the Department of Health Services.

20MA: Reporting requirements are not specific; guidelines recommend

5CA: Report within 15 days after occurrence death or transfer to hospital for period exceeding 24 hours.

21MS: Level I: Surgeon’s CME should include proper dosages and

6CO: Surgeon should have staff privileges or document satisfactory completion of training such as Board certification or certify comparable background, training and experience. 7FL: Level I: Surgeon’s CME should include proper dosages; management of toxicity or hypersensitivity to regional anesthetic drugs.

following all BRM adverse incident rules. management of toxicity or hypersensitivity to regional anesthetic drugs. 22MS: Report within 15 days after occurrence any surgical event in the immediate peri-operative period that is life-threatening, or requires special treatment or hospitalization that is related to anesthesia or surgery. 23MS: Level II, III: required of surgeon who does not have privileges at hospital

8FL: Level II, IIA: Surgeon must have staff privileges or be able to document satisfactory completion of training such as Board certification or comparable background, training and experience. Level III: Physician must have staff privileges. 9FL: Send incident report by certified mail within 15 calendar days after

within reasonable proximity.

occurrence of the adverse incident. 10IL: An operating physician must either maintain clinical privileges to

25NJ: Physician who performs surgery should have hospital privileges or seek

administer anesthesia in a hospital or ASC or have CMEs in anesthesia to administer anesthesia or enter into a practice agreement with a CRNA to provide anesthesia. Training and experience may be met by completing CME hours: 8 hours for conscious sedation, 34 hours for deep sedation, regional anesthesia and/or general anesthesia. No training and experience requirements when an anesthesiologist administers or supervises the administration of anesthesia. (upheld by Illinois Appellate Court)

26NJ: Report within 7 days death, transfer to hospital exceeding 24 hours.,

11IN: Effective January 1, 2010 12IN: CRNAs must administer anesthesia under the direction of and in the immediate presence of a physician. 13IN: Privileges at either an accredited hospital or ASC. Alternatively, the governing body of the office is responsible for a peer review process for privileging practitioners based on nationally recognized credentialing standards. 14KS: Report withing 15 calendar days of discovery of event: transfer to ER: unscheduled hospital admission withing 72 hours of discharge: death within 72 hours of surgery; unplanned extension of surgery (more than 4 hours); foreign object remaining in patient; wrong surgical procedure, site, or patient. 15LA: Accreditation not required, but offices accredited by JCAHO, AAAASF, or AAAHC and those that are part of but physically separated from a licensed hospital are exempt from the regulations. 16LA: Physician performing surgery must have current staff privileges or board certification in specialty encompassing office procedure and possess current hospital admitting privileges.

24NJ: A physician who administers or supervises the administration of general anesthesia must complete at least 60 Category I hours of CME in anesthesia; regional and conscious sedation-8 hours. (upheld by NJ Supreme Court) Board-approved privileges. untoward event occurring within 48 hrs. of surgery. 27NC: Level II or III should show substantial compliance with guidelines or obtain accreditation. 28NC: MD should be credentialed by hospital, ASC or comply with Board criteria to perform surgical or special procedures that require administration of anesthesia. 29NC: Should report complications. 30NY: Effective July 14, 2009. 31NY: Effective January 14, 2008, licensees (physicians, physician assistants, and special assistants) must report adverse events to the Department of Health’s Patient Safetley Center within one business day of the occurrence. 32OH: Required if using moderate sedation/analgesia or anesthesia services (deep sedation/analgesia, regional or general anesthesia) 33OH: Moderate sedation/analgesia: Hold privileges to provide moderate sedation/analgesia from hospital or ASF or complete at least 5 hours of Category I CME; Deep sedation/analgesia, regional or general anesthesia; Hold privileges to provide anesthesia services from hospital or ASF; Completed a residency training program in anesthesia; or complted at least 20 hours of category I CME. Qualifications apply whether a CRNA or anesthesiologist administers anesthesia.

35OR: Accreditation by a Board-recognized national or state orgainization. Facilities where office surgeries are already being performed, accreditation by August 1, 2009; new offices must be accredited within 1 year of the start date of the procedures being performed. 36RI: Office shall apply within 9 months of initial licensure; attain within 24 months. 37RI: Surgical procedures shall only be performed by physicians or podiatrists who have current surgical privileges for the same or similar class of procedures at a nearby hospital. 38RI: Within 72 hrs. of receipt of information, notify of death within 30 days, transfer to ER, hospital admission within 72 hrs. of discharge, extension of surgical procedure beyond 4 hrs., unplanned readmission to office operatory within 72 hrs., subjecting patient to procedure not offered or intended by pysician, incidents reported to malpractice insurer. 39SC: Level II, III 40SC: Level I: Surgeon is encouraged to pursue CME in proper dosages, management of toxicity or hypersensitivity to local anestthetic and other drugs. 41SC: Surgeon must have staff privileges or document satisfactory completion of training such as Board certified or Board eligibilty, or comparable background, formal training, experience. 42SC: Report within 3 business days anesthetic or surgical mishaps requiring resuscitation, emergency transfer, or death. 43TN: Level III by AAAHS, AAAASF, or JCAHO. 44TN: Level III; Physician performing office procedure must have staff privileges to perform same procedure at hospital within reasonable proximity. 45TN: Applies to Level II surgeries; report within 15 calendar days following physician’s discovery of event. 46TN: Level II: required if physician performing procedure does not have staff privileges at hospital withing reasonable proximity. 47TX: Physicians shall follow ASA standards and guidelines. 48TX Offices accredited by AAAHC, JCAHO, and AAAASF and those that are part of a licensed hospital or ASC are exempt from the guidelines. 49TX: Notify BME within 15 days if procedure resulted in unanticipated and unplanned transport to hospital for period exceeding 24 hrs., death intraoperatively or within 72 hrs. of procedure. 50TX: If physician does not have hospital privileges must have written transfer agreement. 51VA: Report within 30 days incidents resulting in death within 72 hr. post-operative period or transport to hospital exceeding 24 hrs.

34OH: Holding current privileges at hospital or ASF, among other qulifications, demonstrages sufficient certification, training, experience.

n  FIGURE 35-2. 2009 Office-based surgery and anesthesia requirements. (From ASA Office-based anesthesia: considerations for anesthesiologists in setting up and maintaining a safe office anesthesia environment. American Society of Anesthesiologists, 2008d.)

1086   P a r t  III    Clinical Management of Specialized Surgical Problems

TABLE 35-4. Similarities and Differences Between Various Accreditation Organizations Accreditation Body

AAAASF

AAAHC

TJC

Medicare deemed status

Yes

Yes

Yes

Requires board certification of surgeon

Yes

No

No

Requires physician supervision of anesthesia*

Yes

Yes

Yes

Additional educational requirements for nonanesthesiologists supervising

Yes

No

No

Accreditation cycle

3 Years

6 Months, 1 year, or 3 years

3 Years

Approximate base cost†

$4265

$3000-$5000

$6950

Corporate website

www. aaaasf. org/

www. aaahc. org/

www. jointcommission. org

From Accreditation Association for Ambulatory Health Care (AAAHC): Summary of state activities on office-based surgery, August 2003 update, accessed, September 29, 2003. *This requirement may not apply in the event a state’s governor has opted out of the physician supervision of nonanesthesiologist anesthesia providers requirement. † Cost for an accreditation survey may be influenced by the number of offices to be accredited, the number of surgeons and surgical specialties, and whether a facility is asking for Medicare “deemed” status. AAAASF, American Association for Accreditation of Ambulatory Surgical Facilities; AAAHC, American Association for Ambulatory Health Care; TJC, The Joint Commission.

(2003) reported no deaths in over 5000 cases. However, these authors noted that several patients required hospital admission for various medical problems. Another dynamic that is and will continue to influence the push toward accreditation is the recognition by payers of the significant cost savings that can be realized in the office-based setting. Although the payers want to leverage these savings, they have to be reassured and be able to reassure their subscribers that they will only sanction care in a safe environment. Because the industry standards have been established by the accrediting bodies, it wouldn’t be surprising if this fueled the push toward uniform requirement for accreditation more quickly than the state legislatures or the federal government.

CLINICAL ASPECTS Particular attention must be paid to patient and case selection, preoperative preparation, special problems related to anesthetic administration, and postoperative care. Absence of a plan specifically related to these issues by the anesthesiologist caring for a child in the office can lead to a practice that is fraught with safety dilemmas and logistic and scheduling problems that negatively impact the success of an office-based anesthesia practice. Time constraints are the rule rather than the exception in office-based practice.

Patient and Procedure Selection The decision process that occurs when determining which patients are appropriate to care for in the office-based setting does not differ greatly from that of caring for patients in the “free-standing” ambulatory surgery center. The factors that most commonly determine whether a child is an appropriate candidate for office-based anesthesia and surgery are patient age, associated medical illnesses and ASA physical status, type of surgery, potential for blood loss, potential for significant postoperative complications, and duration of surgery. Because most office-based procedures for pediatric patients involve dental procedures, a majority of the children undergoing these procedures are older than 1 year of age. However, as the realm of office surgery for children expands (including tonsillectomies), and because there are no prospective studies as yet in the office-based anesthesia literature looking at outcomes and patient age for children undergoing office-based surgery, it seems that the present guidelines for other ambulatory surgery venues should be used (Gravningsbraten et al., 2009). When taking this latter point into consideration, the minimum age requirement (other parameters such as type of procedure not withstanding) for children undergoing office-based procedures can be determined by whether a child requires prolonged postoperative monitoring based on postconceptual age or the administration of opiate analgesics and other respiratory depressant agents (Welborn and Greenspun, 1994; Galinkin and Kurth, 1998). Although postanesthesia care unit (PACU) complications resulting from respiratory complications may be more common in neonates and infants, any other minimum age requirements are often arbitrary and may reflect the comfort level of the surgeon, office staff, and anesthesia personnel caring for the child (Westman, 1999; Ross and Eck, 2002; Murat et al., 2004). Adherence to policies and guidelines set forth for minimum age requirements for outpatient anesthesia in ambulatory surgery centers and hospital-based ambulatory surgery departments is critical. Most children cared for in the office-based setting are ASA PS I and II patients. In some situations, it may be acceptable to provide anesthesia care for those children with stable comorbidities who are ASA PS III patients despite the fact that these patients in general may be more susceptible to adverse outcomes from anesthesia (Morray, 2002; Murat et al., 2004; Jimenez et al., 2007). Not surprisingly, getting consensus from pediatric anesthesiologists as to which comorbidities are appropriate for hospital-based or free-standing ambulatory surgery is difficult, but some of the pediatric comorbidities considered high risk for the office-based surgical suite are listed in Box 35-2 ­(Abu-Shahwan, 2007). In an early prospective study looking at prolonged recovery stay and unplanned hospital admission after ambulatory surgery in pediatric patients, the authors reported annual rates of approximately 4% and 2%, respectively. PONV and respiratory complications were the most common factors leading to prolonged recovery stay, whereas respiratory complications (32%) and surgical reasons (30%) were the factors most commonly responsible for unplanned hospital admission. These authors also found that higher ASA physical status had a direct relationship to unplanned hospital admission and adverse respiratory events (D’Errico et al., 1998). Subsequently, Dornhoffer and Manning (2000), in a retrospective chart review, evaluated unplanned hospital admission

C h a p t e r 35    Anesthesia for Office-Based Pediatric Anesthesia   1087

Box 35-2 Pediatric Comorbidities Considered High Risk for the OfficeBased Surgical Suite l l l l l l l l

Obstructive sleep apnea Labile asthma and other significant pulmonary disease Complex congenital heart disease Labile diabetes mellitus Significant neurologic and neuromuscular disorders Sickle cell disease Upper respiratory tract infection Increased body mass index

after four types of otologic procedures (not including myrin­ gotomy tube placement) in adult and pediatric outpatients. The unplanned hospital admission rates for children and adults were 5.7% and 2.3%, respectively. The most common reason for unplanned hospital admission was PONV. These findings are relatively consistent over time, and in a more recent study, Blacoe and others (2008) in Scotland found an overall unplanned admission rate of 1.8% in over 13,000 day-surgery cases. The  combined percentage of admissions for two surgical complications (postoperative bleeding, 13.9%, and more extensive surgery than planned, 11.8%) exceeded that for the most common anesthesia-related cause for admission, PONV (23.5%). Dornhoffer and Manning (2000) also noted that tympanomastoidectomy with ossicular reconstruction, procedures lasting longer than 2 hours, and asthma were risk factors predicting the need for postoperative admission. In contrast to this study, Mingus and others (1997) reported that surgical cases lasting as little as 1 hour may be associated with a higher rate of unplanned hospital admission. In a study by Fortier and others (1998) involving over 15,000 patients, unplanned hospital admission after ambulatory surgery was related to longer duration of anesthesia and surgery, higher ASA PS (classes II and III), postoperative bleeding, excessive pain, and nausea and vomiting. Of note, and similar to the more recent study of Blacoe and others (2008), is that surgical reasons are identified to be more commonly responsible for hospital admission than are anesthesia-related issues (38% and 25%, respectively). The fact that the office-based setting is best suited for those children who are healthy without significant comorbidity and are undergoing minimally invasive procedures may inherently result in few postoperative complications.

Preoperative Preparation Preanesthetic Interview As is the case with ambulatory surgery in general, rarely is the preanesthetic interview for office-based surgery for pediatric patients conducted in person. For the anesthesiologist who works in a limited number of offices, preanesthetic interviews may be possible during the patient’s presurgical office visit if the anesthesiologist should be attending that particular office on the same day. This is the exception rather than the rule when anesthesiologists provide itinerant care for a multitude of offices. Although some authors have advocated ­presurgical

evaluation in certain instances on the same day of surgery (Overdyk et al., 1999; Mangia et al., 2009), citing economic and logistic advantages for practitioners and patients, most preanesthetic interviews will be initiated by telephone before the day of surgery. The preanesthetic interview for office-based procedures does not differ much from that described for other ambulatory settings (Ferrari, 2004; Polaner, 2006). However, there are caveats relative to the preanesthetic interview for an office-based procedure. First, the anesthesiologist should make some initial contact with a child’s parents or guardian before the day of surgery. Unlike the ambulatory surgery center or hospital-based ambulatory surgery department, the parents often cannot associate their child’s scheduled procedure with the community-acquired reputation of a particular private or academic institution. An anesthesiologist’s reputation in the office-based environment is based on the advocacy of the child’s private physician, surgeon, or dentist and unfortunately is only as good as the anesthesiologist’s last case (or self-advocacy literature). The initial telephone interview must be used as a way to instill confidence in his or her abilities and to alleviate parental anxiety by relating one’s level of experience or training background or by discussing a cogent and acceptable anesthetic plan. These few “public relations” minutes are invaluable. Second, the interview process must elicit enough of a history to determine whether a child is a candidate for the scheduled office-based procedure or whether the procedure needs to be delayed. The dreaded same-day cancellation leaves an undesirable block of open time for the anesthesiologist and the surgeon. Finally, in many instances, the preanesthetic telephone interview is used not only as the mechanism by which parents receive final preoperative instructions (e.g., NPO guidelines, medication instructions) but also to make final financial arrangements.

Preoperative Laboratory Testing Because most children receiving office-based anesthesia services are healthy and are undergoing minimally invasive procedures, the necessity for preoperative laboratory testing is rare. As is advocated by other authors, any laboratory testing should be determined on an individual patient basis by clinical need after the preanesthetic interview (Meneghini et al., 1998; Friedberg, 2003; Maxwell, 2004; Polaner, 2006). Despite agreement on the lack of clinical utility and increased cost of routine preoperative laboratory screening among anesthesia professionals, an anesthesiologist providing office-based anesthesia services must be aware of any state and local government mandates for such testing. Additionally, each practitioner must establish a policy for determining the cost-to-benefit yield (especially in the office setting where cost savings are a key advantage) on more controversial laboratory testing such as pregnancy testing, especially in adolescents and teenagers (Wheeler and Coté, 1999; Hennrikus et al., 2001; Kahn et al., 2008; Bodin et al., 2010).

Preoperative Sedation Despite the ostensibly less intimidating environment of the office, the anxiety that pediatric patients (and their parents) undergoing office-based procedures experience is probably no less than that in other surgical environments. The need

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for ­preoperative sedation or some other useful mechanism by which the anesthesiologist can reduce preoperative anxiety is critical for a couple of reasons. First, parents are becoming more educated about the perioperative process via the Internet and the lay press, and second, the space-limited environment of many office practices and the close proximity to office waiting rooms and other patients may make preoperative sedation of children most at risk for preoperative anxiety even more important (Baldauf, 2009). The group of children most likely to undergo a mask induction of anesthesia is also the age group of children most likely to experience preoperative anxiety (Kain et al., 1996, 2002; McCann et al., 2001; Watson and Visram, 2003). Most children receiving preoperative sedation receive midazolam (McCann et al., 2001; Rosenbaum et al., 2009). Although various routes of administration are advocated, including intranasal and rectal, oral administration of midazolam is the most common (Levine et al., 1993; Davis et al., 1995; Griffith et al., 1998; McGraw and Kendrick, 1998; Marhofer et al., 1999). Ease of administration as determined by acceptance by the child, in most instances, dictates the route of administration. Most often in practice, a dose of 0.5 to 1 mg/kg (maximum dose, 20 mg) orally is effective. Although some have found that certain routes of administration of midazolam have no impact on discharge times (Davis et al., 1995; Kain et al., 2000), others find that there are significant delays in recovery or discharge times with the use of orally administered midazolam in combination with various anesthetic techniques (Viitanen et al., 1999). Despite a report on the decreased efficacy in the levels of preoperative sedation using oral melatonin compared with oral midazolam, Kain and others (2009) did show a significant (p < 0.05) dose-related lower incidence of emergence agitation (another office undesirable) in those patients receiving melatonin. Furthermore, the use of combination preoperative sedation, such as intramuscular ketamine and midazolam, in uncooperative children may be inappropriate for the officebased setting because of prolonged discharge times (Verghese et al., 2003). For children tolerating preoperative intravenous catheter placement (with or without application of local anesthetic cream), the use of midazolam may not be necessary. Small repeated doses (0.25 to 0.5 mg/kg) of intravenous propofol under constant monitoring provide excellent preoperative anxiolysis without respiratory depression and in most instances will provide excellent amnesia to the immediate preoperative period. This technique is especially advantageous in short surgical procedures. However, propofol is associated with pain on injection, and lidocaine may have to be added to the bolus syringe or infusion. The benefit of parental presence in reducing preoperative anxiety remains questionable (to the child and parent), especially compared with other nonpharmacologic and pharmacologic approaches to preoperative anxiety reduction (McCann et al., 2001; Kain et al., 2003; Chundamala et al., 2009; Yip et al. 2009). Whatever a practitioner’s personal preference, the officebased environment may provide an excellent opportunity for parental presence during induction of anesthesia, especially in cases where sterility concerns are minimal, such as for dental restoration or radiologic procedures. When choosing parental presence as the sole method of anxiety reduction, it is important to consider the information available that may enhance the success of this approach. Some

authors report that specific patient behavior profiles, specific parent-child anxiety level combinations (e.g., calm parent and anxious child), and the presence of a child’s mother as opposed to the father may have the most impact on reducing the anxiety level of the child (Messeri et al., 2004; Kain et al., 2006a; Chorney and Kain, 2009). If the administration of a preoperative sedative is indicated, the anesthesiologist must take into consideration whether the benefit of sedation (to the patient, parents, waiting patients, and office staff) outweighs the chance that the sedative will delay discharge after anesthesia. This is particularly true in instances where a physician must be present until the patient is discharged to home.

Intraoperative Care The intraoperative care of the pediatric patient in the officebased setting relative to induction and maintenance of anesthesia does not differ much from that in other ambulatory settings. Despite the minimal standards set forth by most states relative to office-based anesthesia, from the anesthesiologist’s perspective, monitoring and equipment standards and guidelines must not be different for the office than for other surgical and anesthesia sites. The anesthesiologist should adhere to the Standards for Basic Anesthetic Monitoring and Guidelines for Office-Based Anesthesia (ASA, 2005, 2009b) (see Chapters 10 and 11, Equipment and Monitoring). With this in mind, anesthetic technique is limited only by the equipment, supplies, and resources of the physical plant that are available. Most office-based surgical procedures using anesthesia require intravenous access and hydration. The child’s fluid deficit is based on the fasting period and is replaced with lactated Ringer’s solution. Despite liberalizing the fasting period (clear liquids 2 to 3 hours before anesthesia), administration of intravenous fluids both during and after the surgical procedure is important. There is evidence in both adult and pediatric populations that aggressive intraoperative fluid management may in fact decrease the incidence of PONV (Holte et al., 2007; Goodarzi et al., 2009).

Anesthetic Technique The concepts of “rapid onset, rapid recovery, and minimal side effects,” used often to describe the important characteristics of an appropriate anesthetic technique in an ambulatory setting, is equally important for the office setting. Although all types of anesthesia, including regional anesthesia, can be used in the office setting, general anesthesia and varying levels of sedation are most often used in children (Hausman, 2008). Even though anesthesiologists debate the clinical (safety and outcome) and cost efficacy of relatively newer anesthetic agents (e.g., sevoflurane, desflurane, remifentanil, and propofol) compared with some of the older agents (e.g., halothane and isoflurane), these newer agents offer a distinct advantage as it relates to their predictability and perhaps their safety (Tang et al., 1999; Moore et al., 2002; Fishkin and Litman, 2003; Bhananker et al., 2007). All levels of the continuum of anesthesia (minimal sedation to general anesthesia) are used in the office setting. The type of anesthesia is determined by the age and cooperation level of the child, the type of procedure, the ease with which

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local anesthetic can be administered, its efficacy in a particular surgical procedure, the specific routine of the anesthesiologist, and as stated previously, the available equipment. General anesthesia can be accomplished by using a pure volatile technique, a total intravenous technique, or a combination of the two (volatile induction with intravenous maintenance) techniques. The first and latter obviously depend on the availability of an anesthesia machine and on whether a specific office can comply with OSHA requirements relative to appropriate gas scavenging. Some surgical offices, depending on surgical volume and cost efficacy, may provide the anesthesiologist with a standard anesthesia machine; in other instances, the anesthesiologist may transport a single-vaporizer-equipped portable anesthesia machine to each office (Barinholtz, personal communication, 2009). All of the newer volatile agents are efficacious in pediatric ambulatory surgery (Moore et al., 2002; Polaner 2006). However, if the anesthesiologist is transporting a machine with single-vaporizer capability, then sevoflurane may be the agent of choice because of its efficacy in both induction and maintenance of anesthesia, as well as its rapid onset and offset characteristics. Although some advocate the use of desflurane for maintenance of anesthesia for ambulatory surgery because of its predictability relative to emergence, it is impractical as a complete office-based anesthetic agent in children because of its lack of efficacy for inhalation induction (Zwass et al., 1992; Olssen, 1995; Smiley, 1996; Fishkin and Litman, 2003). Similarly, the intravenous agents propofol and remifentanil have been shown to be useful in the ambulatory setting (Hannallah et al., 1994; Davis et al., 1997, 2000; Pinsker and Caroll, 1999; Cohen et al., 2001). Although remifentanil can be used successfully in an ambulatory setting when the airway is secured with an endotracheal tube, evidence suggests this narcotic should be used cautiously when the airway is not secured. Litman (1999) evaluated the use of remifentanil for moderate sedation in 17 patients (20 procedures) aged 2 to 12 years who were undergoing short, painful procedures. All patients received intravenous midazolam, 50  mcg/kg, in combination with remifentanil 1 mcg/kg followed by an initial infusion of remifentanil of 0.1 mcg/kg per minute. The remifentanil infusion was then titrated every 5  minutes to provide adequate sedation and analgesia. The average appropriate dose of remifentanil used was 0.4 mcg/kg per minute. Although the author reported successful use of this technique in 17 of 20 procedures, 1 child became unresponsive and required assisted ventilation, and hypoxemia was avoided in 10 of 13 ­children by continuous stimulation during the procedure. In adults, the combination of a propofol infusion, titrated to bispectral analysis (BIS) number, and intermittent ketamine boluses has been reported (Friedberg and Sigl, 2000; Friedberg, 2003). In children undergoing dental restoration procedures, Barinholtz (2009) noted that combining propofol (100 to 200 mcg/kg per minute, titrated by BIS) with ketamine (0.5- to 1.0-mg/kg boluses) completely avoided the need for opiate analgesics. In contrast to these latter two reports, successful implementation of sevoflurane for maintenance of anesthesia for dental restorations has been reported by multiple authors (Abu-Shahwan and Chowdary, 2007; König et al., 2009). Although it appears that any agent can be safely implemented in the office-based setting, it is imperative that the office-based anesthesiologist develop an anesthetic routine that allows for

an expeditious induction with appropriate maintenance levels of anesthesia while at the same time affording a rapid emergence. It is also essential that this anesthetic routine minimize the incidence of postoperative side effects such as nausea and vomiting. Another critical aspect of intraoperative anesthesia care in the office-based setting is airway management. Although multiple factors determine the type of airway, any type of airway from a mask to laryngeal mask airway to an endotracheal tube may be appropriate. For some procedures, especially when using only sedation, airway intervention is usually minimal; on the other hand, deciding on the appropriate airway intervention may be difficult in other cases. This is particularly true when providing anesthesia for dental or other intraoral procedures. Many dental cases are performed with oral sedation and nitrous oxide; however, longer dental restoration procedures may necessitate the use of an endotracheal tube (Saxen et al., 1999; Ross and Eck, 2002; Barinholtz, personal communication, October 2009). This is most prevalent in offices where the anesthesiologist may have limited access to the patient’s airway because of positioning or cramped quarters. Subsequently, ventilation is controlled by hand or mechanical means or the patient is allowed to breathe spontaneously. The anesthesiologist must be judicious in the use of muscle relaxants to facilitate intubation. Prolonged effects of these agents may lead to delayed emergence and consequently delayed discharge and turnover for subsequent cases. Another concern for the anesthesiologist practicing in an office-based setting is emergence agitation. The incidence of emergence agitation is reported to be approximately 12% to 18%, but Faulk and others (2010) report an incidence of approximately 30% in 400 patients undergoing dental procedures under general anesthesia with sevoflurane. The etiology of emergence agitation appears to be multifactorial and is associated with inadequate postoperative analgesia, high preoperative anxiety levels, rapid emergence, and the newer volatile agents, and it is reported to occur with both intravenous and volatile anesthetic techniques (Kain et  al., 2006b; Vlajkovic and Sindjelic, 2007; Kuratani and Oi, 2008; König et al., 2009). There may be some benefits, although inconsistent, to preoperative sedation with various agents such as midazolam, clonidine, and melatonin in reducing the incidence of emergence agitation (Cox et al., 2006; Almenrader et al., 2007; Kain et al., 2009). The incidence of emergence agitation is also shown to be reduced by the intraoperative use of regional anesthesia, opiates, 5-HT3 receptor antagonists and dexmedetomidine, as well as the administration of ketamine or propofol at emergence from sevoflurane anesthesia (Cohen et al., 2002; Ibacache et al., 2004; Weldon et al., 2004; Lankinen et al., 2006; Abu-Shahwan and Chowdary, 2007; Abu-Shahwan, 2008; Kim et al., 2009).

Depth of Anesthesia Monitoring The central theme of office-based anesthesia is to accomplish excellent, safe, time-efficient, and cost-effective anesthesia. Hence, the anesthesiologist can look favorably on any technology that can possibly aid in achieving these goals simultaneously. The BIS monitor (Aspect Medical; Newton, Massachusetts) was originally described as able to determine the level of sedation, predict the loss of consciousness, and thereby diminish

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intraoperative awareness when used with various anesthetic agents (Glass et al., 1997). Although in some early reports BIS was shown to minimize awareness, decrease anesthetic use, or hasten recovery in adult patients, a more recent report of a prospective study of 2000 adult patients by Avidan and others (2008) describes no advantage to using accepted target values for BIS (40 to 60) over target values of end-tidal anesthetic concentrations in preventing anesthesia awareness or in reducing the administration of volatile agent (Glass et al., 1997; Song et al., 1997). Consequently, these authors did not recommend routine use of BIS monitoring during anesthesia. The use of the BIS monitor is also controversial in pediatric anesthesia. A standard BIS number or range of numbers that precludes anesthesia awareness and simultaneously minimizes the amount of anesthesia delivered is difficult to establish, because subgroups of pediatric patients may have different baseline BIS numbers as is reported by Valkenburg and others (2009). In this report, intellectually challenged patients are found to have significantly lower BIS numbers while awake and while under anesthesia compared with patients in a controls group. This inconsistency is relevant, because care for intellectually challenged and special-needs children is commonplace in one of the higher volume areas using pediatric office-based anesthesia, the dental office. (Lalwani et al., 2007). In a report on an electronic mail survey of members of the British and French pediatric anesthesia societies, over 60% of respondents feel that intraoperative awareness is an important issue in pediatric patients, whereas 10% of respondents report using BIS routinely (Engelhardt et al., 2007). Thus, the vast majority of respondents still continue to use clinical monitoring and end-tidal agent concentrations to assess depth of anesthesia. There are also pediatric-anesthesia studies reporting advantages to BIS monitoring in patients receiving various types of anesthesia for a range of diagnostic and surgical procedures (Denman et al., 2000; Bannister et al., 2001; McCann et al., 2002; Religa et al., 2002; Messieha et al., 2005; Powers et al., 2005). Denman and others (2000) found that in children ages 0 to 12 years who were anesthetized with sevoflurane, the BIS value correlated to the depth of anesthesia. Furthermore, this study also found that for a particular level of anesthesia (BIS = 50), children younger than 2 years had a significantly higher endtidal concentration of sevoflurane than did children ages 2 to 12 years (1.55% vs. 1.25%, respectively). Bannister and others (2001) studied the effect of BIS on anesthetic use and recovery in 240 children. They noted that in patients aged 0 to 6 months the BIS had no effect on anesthetic emergence. However, in older children, BIS was associated with less anesthetic administration and an earlier emergence time. Religa and others (2002) evaluated the association between BIS and level of consciousness in pediatric patients (aged to 6 years) undergoing dental procedures using a sedation protocol. These authors find that there is a significant association between behavioral responses and levels of sedation. However, the authors note that BIS offered no advantage over routine clinical monitoring and behavioral assessment in this setting. Messieha and others (2005) report earlier times to extubation (5 ± 2 minutes sooner, p = .04) and PACU discharge (47 ± 17 vs. 63 ± 17 minutes, p = .02) in BIS-monitored patients receiving standardized doses of preoperative sedation with oral midazolam and sevoflurane for induction, with maintenance of anesthesia for dental procedures. Whereas these few “saved” minutes may

seem germane to the office-based setting, the cost effectiveness and clinical utility of level-of-consciousness monitoring across pediatric subpopulations still need to be elucidated.

Postanesthesia Care As in any ambulatory setting, the patient undergoing officebased surgery must meet established criteria before discharge to home, with the goal being to discharge the patient as quickly and as safely as possible (Patel et al., 2001). Actual discharge criteria include an adequate level of consciousness, good pain control, good hydration, minimal to no nausea, and a defined period of time since the last emesis (Ross and Eck, 2002; Fishkin and Litman, 2003). Furthermore, the appropriate personnel (at the minimum that which is outlined by the ASA Guidelines for Office-Based Anesthesia, 2009b) must remain with the child until discharge-ready status is reached. The causes for delayed discharge can be related to either anesthesia or surgery, but in the ambulatory setting two of the most common non–life-threatening causes are inadequate pain control and PONV. Unlike the typical ambulatory setting, where there exists the capability to care for patients with a prolonged recovery period, the office-based setting has little margin for error relative to these two problems.

Postoperative Pain Control The undertreatment of pain in pediatric patients in traditional surgical and hospital settings continues to be an issue (Stamer et al., 2005; Segerdahl et al., 2008; Fortier et al., 2009). In fact, one study that compared oral ibuprofen (10 mg/kg) with oral acetaminophen with codeine (1 mg/kg per dose of the codeine component) for the emergency room treatment of acute arm fractures found that ibuprofen was more preferable to (because of its side-effect profile) and at least as effective (analgesia) as acetaminophen with codeine; however, the high incidence of treatment failure in both groups, 20.3% and 31.0%, respectively, although not statistically significant between the groups, is clinically relevant to the previous point of potential undertreatment of pain in pediatric patients (Drendal et al., 2009). With this latter point in mind, the goals for postoperative pain control in the office setting are not dissimilar from the overall goals for office-based anesthesia and surgery. In situations where the use of local anesthesia is not possible or feasible, the anesthesiologist must attempt to use analgesic agents that are efficacious, have minimal side effects, and do not delay patient discharge. Although various opiate analgesics are routinely used in pediatrics and can be administered via conventional (e.g., intravenously, intramuscularly while asleep, or orally) and less conventional (e.g., intranasally) routes in traditional ambulatory surgery settings, their use in the office setting is often minimized or eliminated to help avoid postoperative sedation and PONV that are specific to drugs, dose, and perhaps patients (Weinstein et al., 1994; Anderson et al., 2000; Galinkin et al., 2000; Finkel et al., 2001; Duedahl et al., 2007; Howard et al., 2008a, 2008b; Voronov et al., 2008). Furthermore, because a preponderance of complications leading to unplanned hospital admission after ambulatory surgery in infants is related to the respiratory system, opiate use, which can cause respiratory depression in this age group, could potentially increase these numbers (Westman, 1999).

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Because most office-based procedures in children are minimally invasive (at least for now), standard use of nonopioid analgesics such as the nonsteroidal antiinflammatory drugs (NSAIDs) and acetaminophen, when not contraindicated, is advocated. Ketorolac is found to be useful with an excellent safety profile for postoperative analgesia in a variety of pediatric surgical procedures, and it can be administered intravenously in a dose of 0.5 to 0.8 mg/kg (maximum dose, 30 mg) (Lynn et al., 2007). Relative to pediatric dental procedures, Needleman and others (2008) report that 95% of 90 children undergoing dental rehabilitation under a standardized general anesthesia regimen without local anesthetic infiltration experience postoperative pain. Increased postoperative pain was reported to be more likely in children who had dental extractions, those at least 4 years of age, and those who had experienced a greater number of procedures. It seems intuitive, then, that local anesthetic infiltration should be an excellent analgesic supplement for children undergoing dental rehabilitation. However, Townsend and others (2009) report that in children, 3 to 5½ years old, undergoing oral rehabilitation while under general anesthesia and receiving local anesthetic infiltration in addition to intravenous ketorolac did no better relative to postprocedural pain than those children receiving intravenous ketorolac alone. In fact, these authors report a greater (but not statistically significant) incidence of lip and cheek biting in those children receiving local anesthetic infiltration. In some pediatric dental rehabilitation cases done under general anesthesia, patients receive 0.5 mg/kg of intravenous ketorolac with supplemental fentanyl (1 to 2 mcg/kg only when extractions are performed) after induction of anesthesia. More than 95% of patients qualify to bypass phase I recovery and rarely require supplemental analgesics before discharge. Those receiving intraoperative fentanyl receive prophylactic ondansetron, 0.15 mg/kg. This experience with ketorolac is similar to those of Purday and others (1996) who found ketorolac, 0.75 mg/kg, 1.0 mg/kg, and 1.5 mg/kg to be as efficacious with statistically less PONV as 0.1 mg/kg of morphine sulfate in treating postoperative pain in patients aged 2 to 12 years undergoing dental restoration procedures. Similarly, Maunuksela and others (1992) noted ketorolac to be as efficacious as morphine after pediatric eye surgery. In contrast, Kim and others (2003) report that topical ketorolac is ineffective in treating the pain associated with strabismus surgery. Ibuprofen can also be used to treat postoperative pain, but reports on its effectiveness for some surgical procedures are mixed. Kokki and others (1994) showed that preoperative administration of rectal ibuprofen, 40 mg/kg, divided into four equal doses, was effective in the treatment of postoperative pain in children aged 1 to 4 years in that it reduced the need for supplemental morphine postoperatively. In contrast, Bennie and others (1997), in a ­double-blind, placebo-controlled study of children older than 6 months who were undergoing bilateral myringotomy and tube placement, found no benefit to the preoperative oral administration of ibuprofen (10 mg/kg) or acetaminophen (15 mg/kg) in the treatment of postoperative pain compared with a placebo group. Joshi and others (2003) reported success with preoperatively administered oral rofecoxib, a cyclooxygenase-2 NSAID, given in a dose of 1 mg/kg, in treating postoperative pain and reducing PONV in children (3 to 11 years old) undergoing tonsillectomy.

Acetaminophen administration is also effective for postoperative analgesia, especially in procedures resulting in mild or moderate pain (Tobias, 2000). Although high-dose acetaminophen (40 mg/kg) administered rectally has been shown to be effective and has opiate-sparing effects, the restrictive quarters of some offices may make this route of administration somewhat prohibitive (Korpela et al., 1999). Similarly, preoperative high-dose acetaminophen (40 mg/kg), administered orally in a one-time dose is shown to be effective in the treatment of postoperative pain after myringotomy and tube placement in children ages 17 months to 6 years, without reaching toxic plasma levels (Bolton et al., 2002). This is contrary to the aforementioned studies, where oral acetaminophen in standard doses (15 mg/kg) was shown to be ineffective (Bennie et al., 1997). Although NSAIDs alone, or in combination with acetaminophen are opiate-sparing in certain types of surgical procedures, opiate analgesics are not totally precluded from office-based surgery and may in fact at times be necessary (Purday et al. 1996; Hiller et al., 2006; Riad and Moussa, 2007). When either NSAIDs or acetaminophen is inadequate in the treatment of postoperative pain, then traditional combination drugs such as acetaminophen with codeine (0.5 to 1.0 mg/kg of the codeine component) may be appropriate. Whether interesting alternatives or adjuncts to traditional analgesia regimen, such as innovative nerve blocks and acupuncture, for specific surgical procedures can be time efficient and efficacious in the office setting warrants further study (Voronov et al., 2008; Lin et al., 2009).

Postoperative Nausea and Vomiting The etiology of PONV is multifactorial, with perhaps a genetic component in some individuals, and remains a major cause of prolonged discharge time and unanticipated hospital admission after ambulatory surgery in children (Awad et al., 2004; Blacoe et al., 2008; Rueffert et al., 2009). Adequate treatment of this side effect may play a significant role in improving patient satisfaction with the perioperative experience (Eberhart et al., 2002). Furthermore, the incidence of postdischarge nausea and vomiting (PDNV) is also significant after ambulatory surgery and has risk factors that do not totally mirror those of PONV. In fact, PDNV occurs in a significant number of individuals who do not experience immediate postoperative vomiting before discharge (Wu et al., 2002; Kolodzie and Apfel, 2009). The optimal treatments of both PONV and PDNV, whether prophylactic or rescue, are essential because of the negative influence these entities can have on an office-based practice (Tang et al., 1999; Kolodzie and Apfel, 2009). Prophylactic and rescue treatment of PONV and PDNV may not be completely effective, but Engelman and others (2008) show significant risk reduction in postoperative vomiting in a meta-analysis of 11 reports of the use of single- and multipledrug pharmacologic prophylaxis regimens in children. With this in mind and in addition to the information previously provided on the low incidences of PONV and PDNV anecdotally reported in children and adults by those practitioners intimately involved in the practice of office-based anesthesia, several studies examining the incidence and treatment of PONV and PDNV in this setting are available. Tang and others (2001) compared the use of propofol-N2O anesthesia with the use of desflurane-N2O anesthesia plus antiemetic prophylaxis on the incidence of PONV in patients

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­ ndergoing brief, superficial surgical procedures in an office u setting. Patients in the propofol group received no PONV prophylaxis, whereas those in the desflurane group received ondansetron (4mg), droperidol (0.625mg), and metoclo­ pramide (10mg) intravenously at the end of surgery. Neither group received opiate analgesics or muscle relaxants, and all patients received local anesthetic at the surgical site and ketorolac for postoperative pain management. The overall incidence of nausea and vomiting was very low in both groups (less than 10%) and did not differ statistically. Patient satisfaction in both groups was excellent. In another office-based study, Tang and others (2003) compared the addition of 5-HT3 receptor antagonists to a control regimen in patients receiving desflurane-N2O maintenance anesthesia after propofol induction. All patients received droperidol (0.625 mg) and dexamethasone (4 mg) as baseline antiemetic prophylaxis. Subsequently, patients were randomly assigned to receive placebo, dolasetron (12.5 mg), or ondansetron (4 mg) intravenously before emergence from anesthesia. The results of this study show that the incidence of nausea and vomiting was the same in all groups. It is obviously advantageous to the office-based practitioner to be able to predict which children are more likely to experience PONV and PDNV. A scoring system, included in management guidelines published by the Society for Ambulatory Anesthesia, predicting the risk of postoperative vomiting in children was presented several years ago and prospectively validated in another report (Eberhardt et al., 2004; Gan et al., 2007; Kranke et al., 2007). In this scoring system, the presence of one or more specific risk factors (surgery lasting longer than 30 minutes, strabismus surgery, age older than 3 years, and an immediate family with history of postoperative vomiting or PONV) increases the likelihood of postoperative vomiting. Although the best regimen for the prophylaxis and rescue treatment of PONV/PDNV in children is not known, the approach to management is multimodal (Kovac, 2007). Treatment includes reducing baseline risk factors (e.g., regional vs. general anesthesia and avoiding opiates, nitrous oxide, volatile agents, and neostigmine) when possible (Gan et al., 2007). Other authors show that appropriate hydration and superhydration decrease the incidence of postoperative vomiting in certain surgeries (Scuderi et al., 2000; Goodarzi et al., 2009). On the other hand, interventions such as routine use of an intraoperative nasogastric tube and its inherent difficulties and routine postoperative fasting may not be effective (Kerger et al., 2009; Radke et al., 2009). Pharmacologically, a multidrug approach to PONV prophylaxis in children is advocated, and medications from several drug classes are effective in prophylaxis and rescue treatment (Gan et  al., 2007; Kovac, 2007). Dexamethasone is shown to be an excellent choice for various procedures in the pediatric and adult populations either by itself or in combination with 5-HT3 receptor antagonists (Splinter, 2001; Subramaniam, 2001; Negri and Ivani, 2002; Sukhani et al., 2002; Liechti et al., 2007). Although the optimal dose for dexamethasone is unknown and reported to be from 0.1 mg/kg when used with ondansetron to 1.5 mg/kg when used alone, Kim and others (2007) report that a dose of 0.0625 mg/kg is as effective as 1 mg/kg (maximum dose, 24 mg) in the treatment of PONV in children undergoing tonsillectomy and adenoidectomy (Splinter and Rhine, 1998; Henzi et  al., 2000). Although in a quantitative systematic review, Henzi and

others (2000) found the use of dexamethasone to be safe in otherwise healthy patients, a report by Czarnetzki and others (2008) shows that despite a dose-­dependent decrease in PONV, there is an increased risk of bleeding in children receiving dexamethasone who undergo tonsillectomy and adenoidectomy. Rescue treatment should focus on using agents from different classes of medications from those used for prophylaxis in a particular patient, and there is evidence that ondansetron in oral disintegrating tablets may be effective in preventing PONV and PDNV, specifically in those children who do not require rescue therapy before discharge (Wagner et al., 2007; Davis et al., 2008). Whether prophylactic treatment of PONV and PDNV, either through a single-drug or multiple-drug approach, in low-risk patients undergoing office-based surgery and anesthesia is clinically and economically efficacious, as opposed to only treating patients who are at moderate and high risk, needs to be determined.

ESTABLISHING AN OFFICE-BASED PRACTICE The individual or hospital-based surgery-center group must decide whether committing resources to this type of practice is a worthwhile endeavor. The initial investment for this type of practice in the United States can be prohibitive, because the cost may run as high as $100,000 to $200,000 (Barinholtz, personal communication, 2009). These costs include, but are not limited to, costs for equipment, supplies and drugs, professional accreditation as discussed earlier, legal services for incorporation of the group, malpractice coverage, professional staff (i.e., physician, nurses, biomedical technicians, and secretarial and billing staff), policy and procedure development, and marketing. Of course, an office to house all of these things is also a necessary expense. It is also important to consider the type of office-based practice that should be initiated. The group or individual can be committed to one surgeon’s office, depending on case volume, or to several surgeons, traveling to various office locations. From a logistic perspective, the former is easier because it allows for centralization of resources, the most important of which are equipment and medications. However, from a business perspective, if an individual or group is going to commit significant resources to establishing an office-based anesthesia practice, it makes sense to diversify among many different clients and across multiple specialties. A group practice considering an office-based venture must decide whether it can designate a specific number of full-time equivalent staff to this site and still be able to provide sufficient clinical coverage to fulfill its contractual obligation to its home facility. If not, the group must then decide whether the cost of hiring new staff (e.g., physicians, recovery nurses, and technical staff) will be offset by the potential revenue generated by the new practice. As customer service is essential in office-based anesthesiology, the single biggest mistake large practices make when delving into an office-based practice is failure to give the client the personal attention required. For the solo practitioner who may be caught up in the excitement of a new practice, overcommitment to too many surgeons may result in scheduling nightmares and a failure to meet obligations. The individual or group must also meet the challenge of being able to market against other physicians or physician groups, as

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well as alternative and perhaps less expensive anesthesia providers in this competitive arena. Can the group provide a unique service, such as pediatric anesthesia coverage, that will make it more attractive to a particular surgeon or dentist? Finally, and probably as important as any of the other issues related to establishing an office-based practice, the potential political fallout related to a new practice cannot be overemphasized. An anesthesia group with obligations to specific hospital or surgery center facilities must be ready to justify to administrators its practice of providing office-based anesthesia services to surgeons who typically operate in these administrators’ facilities. This diversion of income-generating surgical procedures may be construed as a violation of a group’s service agreement and consequently prompt administrators to solicit the services of a new group. For a busy hospital or surgery center, however, there are now many procedures where the profit margin for the hospital or surgery center is narrow, and the ability to divert these cases from the overcrowded operating rooms to physicians’ offices may be looked upon favorably by administrators. Furthermore, this could be an opportunity for a joint venture between the hospital (that owns the equipment) and physician group (that doesn’t want to outlay capital dollars).

Equipment and Supplies Essentially all of the standard anesthesia equipment that is required in hospital ambulatory facilities (operating room and off-site) and surgery centers is required for office-based practice. All monitoring standards must be met in the office-­surgical suite. Monitoring equipment must have battery back-up capability, because some offices may not have emergency generator capabilities in the event of power failure. Working in one facility where the equipment is capitalized by the surgeon or capitalized by the anesthesiologist and stored in the surgeon’s office is much easier to deal with than the more common alternative of the anesthesiologist bringing the anesthesia workroom from place to place. Box 35-3 outlines general categories of supplies, standard and emergency, that must be transported to surgical sites by the office-based anesthesiologist. The array of portable equipment that exists these days is more than adequate to meet standards.

A

Box 35-3 General Categories of Required Supplies Transported by the OfficeBased Anesthesiologist Anesthesia supply box Defibrillator (with appropriate-sized paddles) Recovery supply box Anesthesia drug box Pediatric supply box Recovery drug box Airway box Emergency airway equipment (e.g., LMAs, fiberoptic bronchoscope, and cricothyrotomy kits) Portable suction equipment Monitoring equipment with disposables Malignant hyperthermia tray Portable anesthesia machine with vaporizer Positive pressure ventilation system Oxygen “E” cylinders Miscellaneous (e.g., batteries, records, other helpful items) Courtesy D. Barinholtz, Mobile Anesthesiologists, LLC, 2003.

For those practitioners who provide total intravenous anesthesia, an anesthesia machine is not necessary, but the presence of equipment capable of delivering positive-pressure ventilation with oxygen is mandatory. For those anesthesiologists providing care to pediatric patients, a vaporizer-equipped anesthesia machine is invaluable. Most anesthesia machines are moveable, but there are a few machines that are truly portable and available for care of pediatric and adult patients in the office setting. One such machine is the OBA-1 (OBAMED, Cardinal Medical Specialties; Louisville, Kentucky), which weighs approximately 35 pounds, is vaporizer equipped, and is compatible with magnetic resonance imaging (MRI) devices (Fig. 35-3). The OBA-1 allows only spontaneous or manually controlled ventilation, because it is not equipped with an internal ventilator. The Magellan-2200, Model 1/M (Oceanic Medical Products; Atchison, Kansas) and the Narkomed-Mobile (Draeger Medical; Telford, Pennsylvania) are also marketed for office anesthesia, and both contain an internal ventilator. The latter machine, despite its ability to be rolled, is a much heavier

B

n  FIGURE 35-3. Two types of portable anesthesia machines. A, The OBA-1 portable, MRI-compatible anesthesia machine. B, The DRE Integra portable anesthesia machine. (Courtesy Charles A. Smith, Vice-President of Operations, Research and Development, Cardinal Medical Specialties, Louisville, Ky.)

1094   P a r t  III    Clinical Management of Specialized Surgical Problems

unit and may not be practical for the anesthesiologist who is changing office venues on a daily basis. Regardless of the type of machine one chooses to use, caution must be used during transport; maintaining the machine’s vaporizer in an upright position is essential to avoid spillage and the administration of an inappropriately high concentration of volatile agent. Often, draining the vaporizer before transport minimizes this risk. Furthermore, familiarity with state and federal safety guidelines relative to the transportation of medical gases is critical. Whenever a volatile agent or succinylcholine is to be used, one must be prepared to treat malignant hyperthermia. A stock supply of dantrolene must be available, and it is the responsibility of the anesthesiologist or a representative of the practice to proactively educate the surgeon and the surgeon’s office personnel on appropriate protocol in the event of a malignant hyperthermia episode (see Chapter 37, Malignant Hyperthermia). Finally, the office-based anesthesiologist must become aware of and be in compliance with the rules and regulations (federal and state-specific) relative to the delivery, transport, clerical requirements (e.g., related to dispensing and wastage), and storage of opiates and other controlled substances that are used in the office setting.

Staffing In the United States, the providers of office-based anesthesia services presently fall into one of three major categories (exclusive of the operator-anesthetist scenario): physician anesthesiologists, dentist anesthesiologists (two years of anesthesia training after completion of dental school), and CRNAs. The  conditions under which each of these three groups can practice are determined by state regulations regarding the administration of anesthesia in dental and surgical offices. Consequently, the composition of office-based anesthesia groups may vary by geographic location and can be comprised of and owned by all physicians, all dentist anesthesiologists, CRNA groups with and without collaborating physician medical directors, or various combinations of these individuals. Beyond the anesthesia providers, however, are the ancillary personnel who are necessary to make a busy office-based practice successful. The individuals who are often required include nursing staff, biomedical and technical staff, credentialing personnel, and billing and clerical staff. The number of anesthesia sites a practice covers simultaneously and the volume of cases usually determine the staffing for a particular organization. In some practices, an anesthesiologist or a CRNA may travel alone to a site. In this instance, the anesthesia provider is responsible for preoperative, intraoperative, and postanesthesia care of the child and requires the assistance of the surgical nursing staff. When multiple cases are performed at a single site, then a surgical office nurse is responsible for monitoring a patient during recovery. In anesthesiologist-only practices, the preferred scenario is to have a staff nurse, employed by the group, available to assist with induction of anesthesia and to be responsible for monitoring the postanesthesia care of the child. Nurses with critical care or PACU experience, who are certified in advanced cardiac life support and pediatric advance life support (ACLS-PALS), are best suited for this type of position. Anesthesia practices are

sometimes able to procure reimbursement for the professional services rendered by these nurses for the care of patients in the PACU. Having such personnel relieves the surgical ancillary staff from any anesthesia-related patient care responsibility and facilitates timely turnover when multiple cases are being performed in a single office. Experienced nurses may also be used to initiate telephone screening to provide patients with their preoperative anesthesia and surgical instructions, coordinate anesthesia scheduling, assist in purchasing supplies and equipment, and educate surgical staff on the specifics of the anesthesia process.

Reimbursement Mentioned earlier is the potential for cost savings by moving surgical cases from hospital outpatient or ambulatory surgical facilities to the office. Unfortunately, in some arenas, ­anesthesia-requiring office procedures are the rule because of the lack of insurance coverage for these procedures. This is especially true in pediatric dentistry. With few exceptions in the United States, dental and medical insurance policies traditionally fail to cover the cost of anesthesia or hospitalization for children requiring dental procedures (Saxen et al., 1999; Yagiela, 1999; White et al., 2008). This has forced dentists to minimize costs for these children and their families by performing procedures in the office with or without the aid of an anesthesia provider. However, the American Dental Association reports that there are at least 31 states that have passed laws since 1995 (Medically Necessary Care or Special Needs Legislation) requiring that medical insurance plans pay for hospital and connected medical expenses (e.g., general anesthesia services) when the dental treatment occurs in the hospital, ambulatory surgery center, or dental office (Box 35-4) (O’Connor, personal communication, January 2010). Some of the elements of these state laws are similar and often determine which children are eligible to receive coverage based on minimum and maximum age and medical or behavioral conditions. Many of these laws, despite mandating coverage, also outline that any provisions of the existing policy, such as meeting prior authorization requirements by showing medical necessity or payable deductibles, still hold true. Some states also determine the acceptable facilities where the procedure can be performed by mandating insurance coverage only for procedures performed in the hospital or surgery center. Some laws also exempt dental-only insurance plans from their provisions. The number of states requiring coverage for the anesthesia portion of dental care may continue to increase, resulting in increased access to care for those children having the greatest need, regardless of qualified surgical site. Reimbursement and collections for anesthesia and surgery in offices are somewhat complex and often work differently for the surgical provider and the anesthesia provider (Koch et al., 2003). Fee-for-service reimbursement can be lucrative for the anesthesiologist in a high-volume cosmetic surgeon’s office. However, because patients undergoing cosmetic surgery are often charged a set global fee for a specific procedure, some surgeons may look toward a lower-cost anesthesia provider, so the surgeon may recover a greater amount of the preset fee. This may intensify competition among anesthesia providers for these types of procedures.

C h a p t e r 35    Anesthesia for Office-Based Pediatric Anesthesia   1095

Box 35-4 States (Some) Adopting Associated Medical Cost Laws Requiring Medical Plans to Pay for Hospitalization/General Anesthesia When Dental Treatment Must Be Performed in the Hospital or Medical Expenses Incurred When Treatment Is in the Dental Office Arkansas (2005)

Louisiana (1997)

North Carolina (1999)

California (1998)

Maine (2001)

North Dakota (1999)

Colorado (1998)

Maryland (1998)

Oklahoma (1998)

Connecticut (1999)

Michigan (2001)

South Dakota (1999)

Florida (1998)

Minnesota (1995)

Tennessee (1997)

Georgia (1999)

Mississippi (1999)

Texas (1997)

Illinois (2002)

Missouri (1998)

Virginia (2000)

Indiana (1999)

Nebraska (2000)

Washington (2001)

Iowa (2000)

New Hampshire (1998, 2003)

West Virginia (2009)

Kansas (1999)

New Jersey (1999)

Wisconsin (1997)

Kentucky (2002) Courtesy the American Dental Association, Department of State Government Affairs, January 20, 2010.

Reimbursement from third-party payers is at negotiated rates that usually vary by geographic location and payer. Despite the fact that some payers reimburse anesthesia practices for professional fees and supplies or equipment, there are those that invoke the CMS policy that a facility be licensed by the state in order to bill for the latter. Consequently, this may mean a greater cost burden to the patient (Barinholtz, personal communication, 2003). Koch and others (2003) point out that office-based anesthesia practices may become even more ubiquitous and successful by duplicating cost-recovery strategies of

surgeons—namely, better collection of facility fees and site-ofservice differentials that provide for greater reimbursement for procedures performed in offices. The reimbursement landscape for office-based surgery and anesthesia is improving significantly over the past several years. Payers are recognizing the significant cost savings that can be realized in the office compared with hospitals and surgery centers. Anthem in Virginia recently launched a program that pays facility fees in offices for over 2000 outpatient procedures. Blue Cross of Illinois is going to launch a similar program in 2010. The caveat to collecting these facility fees is that the facility must be accredited by the AAAHC, AAAASF, or The Joint Commission.

SUMMARY Anesthesiologists are heavily involved in the practice of officebased anesthesia and surgery. Consequently, anesthesiologists must be proactive in ensuring that patient safety is the principal concern for all professionals providing anesthesia services in the office setting. Although there is some progress in this arena, it seems unlikely that the various professional societies, whose memberships are actively involved in office anesthesia and surgery, will agree on a specific set of anesthesia-delivery guidelines. Consistency between states in the regulation of this practice, perhaps in the form of accreditation of both office-based facilities and anesthesia practices, is imperative and may be the only viable alternative in helping to ensure that “the standard of care is the standard of care.” This standard should be applicable regardless of surgical setting or patient age. Only further study will assist in determining whether the safety and cost profiles for office-based anesthesia are comparable with those of other ambulatory settings and ultimately whether office-based anesthesia will continue to be a worthwhile venture.

R eferences Complete references used in this text can be found online at www.expertconsult.com.