Episode 308: Keywords Part 30: Ambulatory Anesthesia
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Hello, and welcome back to ACRAC. I'm Jed Wolpaw, and I'm thrilled to be doing another keyword episode with the one and only Dr. Tim Kais-Turra. We are going to tackle ambulatory anesthesia today. It's a topic that's big enough that we're just doing the one, and it is definitely something you're going to see asked about a lot on your boards. It's becoming a bigger and bigger topic, and so I think this is going to be really helpful for folks, and I'm excited that Tim is here to do it. Tim, welcome back to the show. Thank you. Pleasure to be here as always.

How should we start?

I think with a little bit of an overview. So like you said, we're doing anesthesia for ambulatory surgery and always worth looking at the actual content outlines to know what they exactly want you to know. Here it's under advanced topics, clinical subspecialties, and that's where anesthesia for ambulatory surgery falls. It's point number 10 and it's divided into four subcategories, patient selection and preoperative management, anesthetic management,

The third one is discharge criteria and postoperative follow-up, including continuous nerve blocks. And the fourth is office-based anesthesia, and they want you to know equipment, safety, organization, and patient management for those. And like you said, it's a big episode. We'll spend the whole episode, big topic, we'll spend the whole episode talking about it. And while it won't be quite even, I think we might as well break things up into those four subcategories.

And this topic presents a bit of a unique challenge to discuss since doing anesthesia in ambulatory settings still requires all of our other anesthesia knowledge and we could cover a textbook worth of material. The subcategories help a little bit, but if you think about preoperative management, that's still really broad.

So since these episodes are geared more towards board examination prep, we're going to let the types of questions asked on written examinations really guide the discussion here more than anything else. That means there's a decent amount of material we won't cover that you need to know how to actually do ambulatory anesthesia.

And hopefully we'll cover that in other episodes we already have. And we'll also leave out questions that just happen to take place in an ambulatory setting but aren't specific to that. So if you're asked about the toxic dose of lidocaine, it's the same whether you're in a level one trauma center or an office-based setting, and we won't bother going over that today.

With that introduction disclaimer, do you want to talk about patient selection and preoperative management? Yeah, let's do it. And I'll just say, as you said, that this is such a broad topic, there's no way we can cover it all. But I like that we're going to hit some of the key points, and then obviously folks can study additional depth on their own.

All right, so key concept one for us today will be that procedures performed in ambulatory settings should be elective cases associated with low rates of complications and short duration allowing for a quick recovery for the patient without a lot of provider management. And that's sort of one of the keys that you'll see

in these topics, there aren't a lot of super clear guidelines saying this patient cannot or this patient must be in an ambulatory setting. So look for cases and patients that will give you low rates of complications and be able to get out of recovery quickly. Key concept two, likewise, patient selection for ambulatory settings should consider factors that increase complication rates such as obesity, obstructive sleep apnea, poorly controlled medical conditions,

as well as the procedure being performed and the available anesthetic approaches. A patient does not need to be ASA physical status one or two to have surgery at an ambulatory surgical center.

You probably don't want to put an ASA physical status class 4 patient to sleep if you don't think that you'll be able to extubate. But if you can do it on the regional, maybe that's still appropriate for an ambulatory setting. And I would say we are seeing more and more ASA, you know, three patients at least going to these ambulatory settings because there's a pressure to get that done. So people are going to be seeing this for sure. Mm-hmm.

And key concept three, anesthesiologists should be aware of local policies and procedures.

including a method for preoperative screening of patients. There is often insufficient evidence for national guidelines regarding patient selection, but two themes are that obstructive sleep apnea in a patient with non-optimized comorbid conditions may not be appropriate, and those with a BMI greater than 50 are at an increased risk of complications. Again, this doesn't mean you can't, but those are the sort of the clearest guidelines we have that there's evidence that that might carry additional risk.

All right. So again, I wish I could give you a clear cut list of who's appropriate and who isn't, but I can't. The good news is that the ABA cannot either. So their questions tend to be more general on the topic. Ready to try some out? Let's do it.

All right, question one. A 59-year-old female with obesity, obstructive sleep apnea, high blood pressure, and diabetes presents to an ambulatory surgery center for a distal toe amputation. The patient refuses regional anesthesia and you proceed with general anesthesia. Which of the patient's risk factors is most likely to result in unplanned postoperative hospital admission? A, obstructive sleep apnea, B, high blood pressure, or C, obesity?

Yeah. So, you know, you, as you mentioned, as you were going through key concept three, extreme obesity and OSA are both things that can cause increased risk of complications. Um, and that of course can lead to an unplanned admission. Um, this says obesity, it doesn't say morbid obesity, it doesn't say super morbid obesity. So, you know, maybe that's a clue that they're not pushing us towards that. We know high blood pressure though, certainly not, uh,

great is not in and of itself as much of a risk factor as the other two. So if nothing else, you're deciding between OSA and obesity. And I think I'd go with OSA here because we know that in and of itself is, and the obesity is more of a spectrum and they haven't given us a lot of details there. And I think that's right. One of those questions where there is maybe not one correct answer, but there is a clear better answer. And that is obstructive sleep apnea. Question two, which of the following patients should be classified as ASA physical status three?

A, a 56-year-old female with well-controlled diabetes and a BMI of 42. B, a 36-year-old healthy female G1P0 at 34 weeks gestation. C, a 72-year-old male status post PCI placement for an MI two months ago.

Yeah, I think this is a tricky question. We can definitely eliminate B. Obviously, a healthy woman doesn't become an ASA3 just by being pregnant. And so we're left with A and C. I think that, you know, I see residents sometimes will put this person who is a well-controlled diabetic and obese as an ASA2. That's incorrect. Having, and this patient actually has a BMI of 42, so morbid obesity and another diagnosis like diabetes definitely is an ASA3. So that patient is

Then you come to the 72-year-old who had an MI and a stent two months ago. And what's tricky here is, you know, you could make the argument this is an ASA4. This patient clearly had some pathology that was very much a threat to life, had an MI requiring a stent.

At the same time, you could argue that if this patient is now has a stent, is revascularized and is no longer at constant threat, that maybe they would be an ASA3 also. So I think it's a little tricky there. I think if I had to go, I'd go with A because I think two reasons. One, I think that the ABA wants you to know that morbid obesity is

even in and of itself, but certainly with some other even well-controlled conditions can make a patient an ASA3 because that's something people don't always get right. And also because that's a pretty classic description. So I think those are the reasons why probably A is the right answer here.

That's right. And I think for C, the 72-year-old male status post PCI, I think a good rule of thumb is that any myocardial infarction within three months or stent platements within three months should be sort of a cutoff in your head. And they fall within that timeframe, which would keep them at a higher risk. Yeah, I think that makes sense. They're kind of not out of the danger zone yet.

Yeah, and I stuck this question in here just because ASA physical status is tested. I think it's sort of most appropriately tested in the ambulatory setting where you're sort of deciding these things and whether they're appropriate or not. Would you mind giving just a really quick rundown of one through five to refresh everyone? Sure.

Yeah, absolutely. So one, of course, is a normal, healthy patient. Two is a patient with mild systemic disease. So remember that systemic disease. So a patient with like an ankle fracture that doesn't make them an ASA2, right? But a patient with just kind of, you know, well-controlled diabetes, a patient with hypertension.

Okay. These are patients who, if just those standalone things are ASA twos and ASA three is a patient with severe systemic disease. This could be a single disease like diabetes. That's really out of control, right? That patient with, you know, an amputation from their diabetes with a, you know, um, um, A1C level, you know, 13% or something just completely uncontrolled, or it could be several, uh, less severe things. So obesity, hypertension, diabetes, um, um,

And then four is a patient with severe systemic disease that is a constant threat to life. So again, that patient with coronary artery disease, if they just have coronary artery disease and it's well-controlled and they don't have angina, you know, it's an ASA3. But that patient who just had an MI from their coronary artery disease, clearly theirs is bad enough that it's threatening their life. They could have died from that MI. That's what bumps them up to be a four. A patient with severe aortic stenosis who's

who's symptomatic, that's a constant threat to life. And so those would be ASA4 patients. And then an ASA5 patient is a patient who is not going to survive without the procedure. So they're going to die if they don't have this done right now. So that could be the patient in pericardial tamponade who is dying, right? They need to have that drained right now or they will die. And then there is actually a 6, which is a brain dead patient who's awaiting organ donation.

Perfect. And there's also the E that you can add on the end of any of those. So it's not that if you have an emergent surgery, you're automatically ASA 5, you could be a perfectly healthy patient who needs an emergency surgery. That makes you a 1E.

Exactly. So, for example, that ankle fracture, right? If you have an open ankle fracture, you have to get that operated on now. But if you're totally healthy and you just, you know, got hit in the ankle by a car, I mean, you probably have more going on than just that, but let's just say that's what happened, right? You're a 1E.

Perfect. Question number three, you have been asked by your anesthesia group to begin providing anesthesia services in an office-based surgery practice. Which of the following is most accurate? A, general anesthesia should not be performed in this setting. B, patient selection should be similar to that of an ambulatory surgery center. Or C, office-based surgery centers have the same regulations as ambulatory surgery centers.

So, you know, even if you don't really know, I think you can think your way through this. First of all, general anesthesia does not have to be ET tube, right? If you're not responsive, so you're in a dental office and you're getting your wisdom teeth out and you're getting enough to make you unresponsive, then you're not going to get enough.

then you're having general anesthesia, right? And so absolutely general anesthesia can be performed in an office-based practice. And so that's out as an answer. Patient selection should be similar to that of an ambulatory surgery center. You know, we kind of talked about that in the key points. You do, in general, want to think of these as places where you don't want those sicker patients.

You might be thrown off a little here by thinking, well, the office even less so. But right. If you're already selecting for the patients who you think you can do it without having to need a hospital admission, then it's probably pretty similar. So you're thinking B could be it. Let's look at C. Office based surgery centers have the same regulations as ambulatory surgery centers. Right off the bat, you should be able to think yourself. I can't imagine that could be true. Right. Someone in their own office.

It's got to be different than a state-regulated ambulatory surgery center. And so I would say probably, though I will admit I don't know that for a fact, I'm going to guess that's not true, and that leaves B. Yep, C is not true, and you're right. Patient selection should be similar. Question four, which of the following is least likely to be a good candidate for surgery at an ambulatory center?

A, an 86-year-old male with high blood pressure undergoing a cystoscopy. B, a 55-year-old female status post liver transplant one year ago undergoing cataract surgery. Or C, a 47-year-old female status post drug-eluting stent placement two months ago undergoing a ventral hernia repair. Great. So...

You might see that 86-year-old and think, oh, too old, high blood pressure, old guy, no way. But remember, if that's all he's got, right, 86, he's got some high blood pressure, he's an ASA2, and he's having a cystoscopy, which is a pretty low-risk procedure. So he should be fine, right? The chances of him having major issues, that can be done under...

Certainly could be done under just sedation. It could be done with an LMA. It could be done with a spinal, though you're probably not doing that in a – well, you could do it in an ambulatory center. But anyway, it could be done in a lot of different ways. Probably be done even just with very light sedation. And so that is fine. A 55-year-old female after a liver transplant a year ago who's having cataract surgery. Cataract surgery is the least – the least –

stressful procedure you can have. The recommendations here are that there should be no testing of any kind, no matter what, for patients having cataracts. You don't even need to know what else they have going on. It's like going to the store. You don't need to worry about it from a patient standpoint.

comorbidity standpoint. So that should be fine. And then the 47-year-old woman who had a drug-eluting stent placed two months ago, we just talked about a patient like her in the last question who is really an ASA4 if she had that MI two months ago. And so an eventual hernia repair is not a small procedure. So both a more risky procedure and a patient who's an ASA4, probably not a good candidate.

That's right. And I think the only other clue there, if you really need anything more, is when you have a drug-eluting stent that's just placed a couple months ago, you probably want to be concerned about continuation of anticoagulation. So any case that might require stopping that probably needs a place that is in an ambulatory surgery center. Yeah.

All right, great. Let's move on to the second subcategory, anesthetic management. Again, one of the main goals of ambulatory surgery is reduction in perioperative complications and expeditious recovery. Those are our goals. A lot of what the ABA stresses in this area is how to use or not use medications and or techniques to achieve those two goals. So key concept four, the two most common causes of delayed discharge in an ambulatory surgery setting are pain and postoperative nausea and vomiting.

Key concept five, the APFEL simplified risk score for postoperative nausea and vomiting is one of the validated ways to assess for this potential complication. Each positive risk factor increases the probability of PONV by 20%. If there's no risk factors, the rate's still about 10%. And the risk factors in this risk score are female sex, non-smoking status, history of PONV or motion sickness, and postoperative opioid use.

In key concept six, regional anesthesia has been shown to speed up discharge time by decreasing postoperative pain and reducing the incidence of postoperative nausea and vomiting.

partially because you need fewer opioids or other medications if you have less pain. Yeah. And I'll just say that that, I can't tell you how many times I have seen and heard about that AFL score coming up. I mean, you really need to know those risk factors and the risk associated with each one. So you start at 10%, each one gives you an additional 20%. That, it comes up all the time on tests.

All right. Question five, which of the following policies is most likely to result in longer discharge times from the postoperative anesthesia care unit in an ambulatory surgery center? A, the use of midazolam preoperatively in anxious patients. B, the use of regional anesthesia for lower extremity orthopedic surgeries. Or C, the use of prophylactic antiemetics only in patients with multiple risk factors.

So as you said earlier, post-op nausea and vomiting, one of the major reasons for delayed discharge. So only giving anti-medics to patients with multiple risk factors means you're missing those patients who have a 10% and a 20%, I mean, 10% and a 30% risk of this, right? So if you're only giving to people with two or more risk factors.

You're missing 30% of people who are going to have post-op nausea and vomiting. That's a big problem. So that's probably it. Let's just look quickly. The other ones, giving Priyamidaz, we've all seen patients wake up just fine. That's not going to delay them from getting out after their procedure. And the use of regional anesthesia obviously is going to help, not hurt. That's right.

Question number six, which of the following anesthesia techniques should be avoided in the ambulatory setting? A, neuraxial techniques because motor block will delay discharge. B, clonidine because it causes hemodynamic instability. Or C, succinylcholine because of a risk of malignant hyperthermia.

Yeah, so you certainly can use Sux, though. Of course, if you're going to be using Sux or volatile anesthetics, you need to have dantrolene. So as long as you have dantrolene, you are able to use it. And of course, the chances are very low of getting malignant hyperthermia, obviously.

So certainly okay to use. Norexial, we already talked about. You want to be thoughtful about the norexial techniques that you use. Doing a spinal with a bunch of bupivacaine and morphine and fentanyl and epi, probably not a great call. But you certainly can do norexial blocks as long as you're careful about what you use. And then clonidine, again, a little bit different.

Got to be careful here if someone's on clonidine at home, giving them their home clonidine, fine. I think we may be talking more about using clonidine like in blocks in a neuraxial technique, which can certainly cause some significant hemodynamic instability, significant hypotension, and so probably best to avoid.

Yeah, I think they probably are getting at using clonidine as an adjuvant here, but really goes for any medications. Just use that judgment. Is this something that will increase complication risk, make discharge trickier? And if so, use something else. Question seven, which of the following techniques would best reduce the risk of postoperative nausea and vomiting in a patient with multiple risk factors presenting for surgery in an ambulatory surgery center?

A, using etomidate during induction of anesthesia. B, giving NSAIDs and acetaminophen as first-line agents for postoperative pain. Or C, reducing volatile anesthetic concentration by supplementing with nitrous oxide. So they've been nice to us here. They gave us two things that are going to increase your risk of post-apnoecy and vomiting. So etomidate is a more pro-emetic than propofol. And so giving etomidate instead of propofol is going to put you at higher risk.

reducing volatile anesthetic concentration, but supplementing it with nitrous, right, is going to, it's certainly not going to help and it might hurt, that nitrous may increase your risk. But using NSAIDs and acetaminophen if they let you reduce opioid use is going to help. So multimodal, because it helps you reduce opioids and opioids can cause post-op nausea and vomiting, that's going to be your right answer. Perfection. Stay with us. We'll be right back.

Thank you.

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Which is least likely to reduce his risk of post-operative nausea and vomiting? A, reducing the dose of neostick menius for reversal.

B, inducing and maintaining anesthesia with propofol, or C, allowing for clear liquid intake into two hours prior, limiting clear liquid intake until two hours prior to surgery. And I think I misspoke. There is no access to Sugamidex at this surgery center. Okay. So no access to Sugamidex, which means we may have to use nilcigmine and glycopyrrolate. And so...

So there is this thought out there that neostigmine is pro-emetic and that using less of it will help, but that is probably not true. You're going to need to use the dose of neostigmine that you need to use for a reversal, and a small reduction in the dose is unlikely to make a difference. So I think that's probably not – that probably is our answer because it's saying which is least likely to reduce post-op nausea and vomiting, and that is not going to make much of a difference, if any. Okay.

Inducing and maintaining anesthesia with propofol, that will, of course. Propofol is anti-emetic. And then allowing clear liquid intake, again, is a good idea, right? So patients who are allowed to have clear liquid intake, some Gatorade, for example, up until two hours prior to surgery, that is helpful. And that's why it's part of the ERAS pathways in a lot of places. So that is not our answer. So again, A, reducing the neosigmine dose is unlikely to help here.

That's right. And I think this is one of those questions that hangs around. I've seen in a couple of places that it's probably less and less relevant at this point because we use less and less eostigmine. And it's one of those facts that it used to be thought that it increases the risk of postoperative nausea and vomiting. And that was sort of a

proven not to be true, but it's still tested. In terms of C allowing for a clear liquid intake, not only is it seen in ERAS protocols, but the Society for Ambulatory Anesthesia has as a recommendation adequate hydration as a way of reducing the risk of postoperative nausea and vomiting.

And as we saw, the majority of these questions tend to be about post-op nausea and vomiting, but just be looked out for any way in which you can reduce PONV, minimize post-operative pain, reduce complications rates, and keep discharge times quick, and that'll steer you towards the right answer. Anything else you'd like to talk in particular regarding anesthesia management before we cover discharge?

No, I think we covered some good stuff. Let's do it. Let's move on. All right. Discharge. Key concept seven. Discharge scoring systems have been devised to facilitate timely and safe transfer of patients from post-anesthesia care units to the home setting.

One of the most common, the ALDRETI scoring system includes activity, respiration, circulation, consciousness, and oxygen saturation. And you get up to two points for each. And I want to point out here that nausea and vomiting is not part of it. Key concept eight, the patient must be discharged by the anesthesiologist and the surgeon or those designated to fulfill that role for them, be given clear discharge instructions, and have an adult escort them home.

Key concept nine, post-anesthesia care is divided into two phases. Phase one is immediate recovery and requires intensive monitoring until the patient fully recovers from anesthesia, while phase two is for less acute care that includes preparation for discharge. Many ambulatory anesthetic techniques allow for fast tracking to phase two PACU care straight from the OR if an ALGEDD score of nine or 10 is met.

And I think with these few main points, you'll be able to sweep up these types of questions that are typically asked. They all sort of fall into the knowledge from these key points. Great. Anything you want to add before we hit some questions? No, let's do it. All right. Question nine. Which of the following is true regarding the discharge of patients following procedures in the ambulatory setting? A, ongoing bleeding is not a contraindication to discharge.

B, an anesthesiologist not previously involved in the care of a patient can discharge them home. And C, a patient in phase two of an Algedredi score of 10 can be discharged home alone.

All right, so we're looking at which of the following is true. Ongoing bleeding, not a contraindication of discharge. Okay, we know that. Right, can't be right. You're not going to send someone home who's actively bleeding. So that's wrong. The next one, an anesthesiologist not previously involved in the care of the patient can discharge them home. I mean, anyone who's practiced anesthesia knows we do this all the time. You don't have to have been the anesthesiologist of the case. If you are an anesthesiologist...

You absolutely can assess and decide to discharge a patient home from the PACU. So that's going to be the right answer. Let's just look at C. A patient in phase two with an Alderady score of 10 can be discharged home alone. No, right? They can't be discharged home alone. You have to have an adult to escort you home. So that's wrong. Yeah. They try to get you different ways. It doesn't matter how healthy you are. It doesn't matter how small the procedure adult escort is required home.

Question number 10, a resident on their first ambulatory rotation asks you for the definition of fast tracking in a post-anesthesia care unit. The most appropriate reply is A, fast tracking is going directly from the operating room to phase two in the PACU. B, fast tracking is reducing the amount of time a patient spends in phase one in the PACU. And C, fast tracking is discharging the patient home from phase one care in the PACU.

So this is one of those things you either know or you don't, and it is A, going straight from the operating room to phase two. So skipping phase one. And these are the patients, you know, who move themselves over, right? Like they're awake, they move themselves over from the OR bed to the stretcher and are talking awake, like as if they never had anesthesia. These are the patients who obviously can go straight to phase two. So that's the answer.

Absolutely. And I know it's repetitive with a key concept, but really this is one of those things, like you said, it's only tested in one way. And this question comes up. Question 11, which of the following criteria is not present in both the post-anesthesia discharge scoring system and the ALGREDI scoring system? A, blood pressure, B, nausea and vomiting, or C, activity level?

Yeah. And so you mentioned this earlier, it's nausea and vomiting is not part of the Alderete scoring system. So that's all you would need to know. Even if you didn't know anything about the post-anesthesia discharge scoring system, it's not, you know, it's not in there in the Alderete. Activity level and blood pressure are in both.

That's right. And the post-anesthesia discharge scoring system is vital signs, activity level, nausea, vomiting, pain, and surgical site bleeding. So a little bit different. And I think the question I see most often is the sort of gotcha of, did you remember that the Aldretti scoring system doesn't include nausea and vomiting? Because you really would think that something does when it's one of our chief concerns, especially for discharge from an ambulatory setting. Yep.

In question 12, a 36-year-old female underwent an upper extremity surgery under regional anesthesia at an ambulatory surgery center. How does her discharge criteria differ than if she had the surgery at a hospital under general anesthesia? A, her oxygen saturation does not need to be checked before discharge. B, she does not need to void before discharge. Or C, there needs to be an adult escort to take her home. Yeah, so...

This is, I think, actually a little tricky, right? So you might say, well, it was done under regional. Presumably she didn't have any sedation, so she shouldn't need her oxygen checked, right? Because she never had an ET tube or anything like that. But vital signs are part of all these scoring systems, and so they do need to get checked, even if you didn't have anything except regional. Right.

Certainly even maybe even more so you need to be able to avoid if you had regional, I guess depends on what kind of regional. But I would say that's pretty likely. And then adults escort you home. And I think, you know, it probably depends, honestly, from place to place. But if you all you had was, let's say, you know, an upper extremity arm block for an upper extremity surgery.

or an ankle block for a foot surgery or something, there's really no reason you need an adult to escort you home if you had no sedation at all. So I bet there's some places that still require it, but there are probably some that allow it.

Yeah, and so in this case, the correct answer is that there does need to be an adult to escort, take you home. One of the key points is that no matter what you've had in ambulatory surgery setting, you'll need an adult to take you home, even if it was just a regional nerve block. Oh, that's interesting. I must have misunderstood this question. So it's saying if she had her upper extremity surgery under regional at an ambulatory center, how does it differ than if she had had the surgery at a hospital under general? So it differs...

So are you? Yeah, go ahead. Yeah, I think the question here is saying because she was at an ambulatory surgery center, how is it different than if she had been at a hospital setting under general anesthesia? So if you're I think it may not be the best question, but it's testing the knowledge that you need an adult escort to take you home if you are at an ambulatory surgery center. But not if you're at a hospital.

Um, maybe the, maybe it's an implication that you might be staying overnight, that you are in the inpatient setting versus the outpatient setting. I think the other way to get here is the, do you need to void before discharge? And the other thing that you're seeing more and more is that that's not a necessary thing for discharge. So...

Okay. So let's go back. Let's go back over so we don't confuse everybody. So because I got confused. All right. So the you definitely if you're getting discharged from the hospital after surgery, need an adult to escort you home. But I think you must be right, Tim. Maybe what they're getting at here is you're not going home. Maybe you could. So if you're staying in the hospital, you obviously don't need an adult. But the answer is that.

And that was what was a little confusing to me. So good, you do need an adult escort to your home, whether or not you have regional or general. Okay. And then you no longer, though this did used to be a part of discharge criteria, you no longer necessarily need to void before discharge. So that's going to be in both settings, not necessarily part of your discharge criteria. And then you will get your oxygen checked in both. Correct. Okay. Okay.

All right. Anything else to add from your end?

I don't think so. What's next? So hopefully a pretty straightforward set of things to remember from that section. Know the definition of fast tracking. Know that nausea and vomiting isn't an algecide. Send them home with an adult and you'll be set. Right. Onto the last section, office-based anesthesia. There's probably no portion of above discussion that doesn't also apply to office-based anesthesia, but there's a few further specifics here. One

One of the overarching themes tested here is that because of the differences in accreditation and regulations, anesthesiologists must be much more judicious in ensuring the anesthetizing location is safe. With that in mind, key concept 10,

is that an office-based setting must have standard ASA monitoring capability, an oxygen source, suction, resuscitation equipment, and emergency medications. There should also be a backup power source, a plan for hospital admission if needed, fire prevention and preparedness, and controlled substance handling and storage methods.

Those are the guidelines for what needs to be present. You should always check that those are present before you sign up to take care of patients in a particular outpatient or office-based setting. Key concept 11, office-based anesthetic complications tend to be more severe than those in an ambulatory surgery center and are most often the result of inadequate monitoring, over-sedation, and thromboembolism.

In Key Concept 12, the major advantages of office-based anesthesia care are further reduction in cost, even when compared to ambulatory surgery centers and patient convenience. Let's dive right into the questions. Question 13, which of the following is true about office-based anesthesia? A, only ASA physical class 1 and 2 patients may be cared for in this setting. B, reimbursement policies may differ between states.

Or C, the costs of running an office-based center are similar to an ambulatory surgery center. Even if you don't know anything, you've got to imagine that reimbursement policies have to be different between states. It's such a common thing for there to be variation. But we already have said ASA 1 and 2 are not the only patients. Certainly no longer. There probably was a time when it was true, but certainly no longer. So, for example, you could have an ASA 4 patient having a cataract in an office-based setting. And

And then the cost of running an office-based center, as you just said, are significantly lower than in an ambulatory center, which is the appeal of this for practitioners. Yep. Question 14. Which of the following is true regarding the care of a 36-year-old in an office-based setting? A. Dantrolene does not have to be available if volatile anesthetics and succinylcholine are not stocked. B. After successful recovery, the patient may be discharged by an appropriately trained PACU nurse.

C, a plan for unexpected hospital admission is not necessary if general anesthesia is not used. Great. So...

The question is asking which of the following is true. All right. So let's look at does dantrolene not have to be available if volatiles and sucks are not stocked? I would think that's probably accurate. Why would you need dantrolene if you're not using any triggers of malignant hyperthermia? So that's probably correct. Let's look at the others, though. After successful recovery, the patient may be discharged by an appropriately trained PACU nurse.

That's a little tricky because there are discharge by nurse criteria out there, but that is really a delegation of the authority of the anesthesiologist to the nurse. So I think what this is getting at is can the nurse just do it on her own without that authority? And the answer to that is no. And finally, a plan for unexpected hospital admission is not necessary if general anesthesia is not used. So you always need to have a plan for unexpected hospital admission regardless of what kind of anesthesia you're doing. And so that answer is incorrect.

That's right. And the reasoning there is accurate for all of those. And if you remember back to that key concept, in terms of what needs to be present, dantrolene is not one of them. It's a good question that you see often because it just seems like something you should have around, like a local anesthetic product.

toxicity kit and a melanohepidemia kit, but if you're not putting patients at potential risk without triggering substances, it does not need to be present per regulation policies. Question 15, you arrive at a new office-based anesthesia location that you will be practicing at. Which of the following must you check are present? A, a local anesthetic toxicity kit, B, an anesthesia machine or backup ventilator, or C, a backup power source?

Yeah. So you said in your, in your intro to this section that you do have to have a backup power source. And so that is true. And that makes sense, right? Anything you're going to be doing is probably going to need power. You can't have someone who you need to use any power-based source who you're going to lose it. And then, you know, what are you going to do? So that is a requirement, a local anesthetic toxicity kit. Obviously you don't need it if you're not using local anesthetics. So, you know, that can't be a requirement for everywhere. Uh,

And then an anesthesia machine or backup ventilator, again, you don't need it if you're not using an anesthesia machine or ventilator, if you're just doing regional anesthesia, for example.

Perfect. And our last question for the day. Question 16. An office-based center performs plastic surgery under local anesthesia or light sedation with benzodiazepine and opioids. Which of the following is not required to be immediately accessible in the center? A. A malignant hyperthermia kit. B. A fire prevention plan. Or C. A suction device.

And so, again, we talked about this, but malignant hyperthermia kits don't need to be present if you're not using any malignant hyperthermia triggers. And they mentioned local anesthetics and light sedation with benzos and opioids. So no sucks, no inhaled anesthetics. So you don't need that. So that's going to be your answer. A fire prevention plan you always need. And a suction device is certainly necessary.

something that I don't actually know that that's part of the requirements, but it certainly makes sense that it should be because you're going to want that no matter what. And it is part of the requirements. One of the things that must be available to you. Fabulous. All right. That's it. Those are the categories. Those are the questions. Great. I think that was a great review, Tim. Thank you. And I think that's going to be really helpful for folks. Let's turn to the portion of our show where we make random recommendations. Do you have something you would like to share with the audience that you'd recommend they check out?

I do. It might not apply to everybody. I gave this recommendation to someone else recently, and I forget who it was. But for the longest time, I had used Garmin watches that were sort of at the lowest end of their product line, specifically for runners for me.

And I thought that the high-level ones were for true pro athletes, if you're getting sponsored, if you're making a profession out of this. And I upgraded to a 4Runner 955, and I absolutely love it. And I think anyone that...

exercises uh you know more than a few times a week uses a watch in that setting you will enjoy the extra features that it comes with um it works a little bit better i think what ends up happening is they probably develop most of the software on the higher end so not only do you have more features but they tend to have fewer bugs and just work so much smoother than the lower end lines um

I love it. I'm never going back. I'm in the Garmin ecosystem. I think probably the same advice applies for whether it's a Polar or Suntour or whatever you use, but worth the upgrade if you use your activity watch often. Nice. That's awesome. You think much better than an Apple Watch.

Yeah. And I'm on the Apple platform, so nothing against Apple. But I think if you are athletic, get a dedicated watch for that. Okay. Well, Garmin, you're not sponsoring us, but we're open to having those talks if you want to reach out.

I'm going to – so if you don't listen to Conan O'Brien Needs a Friend, you should. It's an incredibly funny podcast by Conan O'Brien called Conan O'Brien Needs a Friend. A variety of things, but mostly he interviews celebrities and with his assistants and his –

producer, all of whom are very funny. But the ones I recommend specifically that I just was like dying laughing are the three different times he's had Kevin Nealon on. He and Kevin are friends.

And they have just an incredibly funny interaction, make fun of each other nonstop. And I was just like I was listening to it while I was working out and I had to stop working out because I was laughing so hard I couldn't breathe. So there are three different ones. If you just Google Conan, Kevin Nealon, they'll come up. It's first one's called Kevin Nealon, then Kevin Nealon returns and then Kevin Nealon returns again. And they're just absolutely worth it. All right, Tim, thank you so much. I will see you soon.

Thank you and see you next time. All right. Hopefully you got as much out of that as I did. That was really fantastic. Let us know what you thought. Go to the website, akrak.com, where you can leave a comment. Others can learn from what you have to say. If you are a fan of the show, you can follow us. We're on Twitter. We are on Facebook. We are on Reddit. And we are on Instagram.

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Even if it's just a dollar or two that you pledge, it makes a big difference and we really appreciate it. You can also make donations anytime by going to paypal.me slash akrak or looking up J. Walpaw on Venmo. Thank you so much to those who have already made donations and become patrons. We really appreciate it. Thanks as always to our fantastic Akrak crew.

Sonia Amanat is our tech lead. Taylor Duggan is our social media manager. And William Mao is our production assistant. Thanks so much for all you do. Our original ACRAC music is by Dr. Dennis Kuo. You can check out his website at studymusicproject.com. All right. That is it for today. For the ACRAC podcast, I'm Jed Wolpaw. Thanks for listening. Remember, what you're doing out there every day is really important.

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