Ambulatory surgery: Patient selection

The type of procedures performed in the ambulatory setting are becoming more diverse and complex. 70% of surgeries performed in the US are now performed in an outpatient setting. The safety and ease of performing anesthetic techniques make this a possibility. The importance of appropriate patient selection for these surgeries are paramount to ensure the best possible perioperative outcomes and prevent unplanned hospital admission, delayed discharge, readmission, or patient dissatisfaction. Patients who are suitable for ambulatory surgery include patient with ASA status 1 or 2, patients having uncomplicated surgery (e.g, cataract surgery, cystoscopy, lipoma resections), patients for whom regional anesthesia may be an appropriate anesthetic technique, and patient who have appropriate disposition and caregiver availability post-operatively.

Additionally, procedures that can be carried out on an outpatient basis include surgeries with low-risk for intraoperative and post-operative bleeding, surgeries with minimal tissue damage and thus minimal pain control requirements, surgeries that require minimal post-operative care, and procedures with minimal surgical time. A 2014 study on orthopedic outpatient patient found that the number one reason for rehospitalization was poor pain control [1].

Predictors of high post-operative morbidity and mortality include patient with high BMI-at risk of OSA, airway obstruction, laryngospasm and desaturation—patients with COPD or other respiratory compromise, previous cardiac surgery, hypertension, previous TIA or stroke, prolonged surgery, advanced age where these patient are prone to prolonged post-operative observation, and may have unreliable social situations, and high ASA status (>3) [2]. See specific issues addressed in references below.

Patient selection algorithm for patients with OSA

Joshi GP et al. Society For Ambulatory Anesthesia Consensus Statement On Preoperative Selection of Adults Patients with Obstructive Sleep Apnea Scheduled for Ambulatory Surgery. Anesth Analg 2012; 115: 1060-8

Patient selection algorithm for obese patients

Joshi GP, et al. Selection Of Obese Patients Undergoing Ambulatory Surgery: A Systematic Review Of the Literature. Anesth Analg 2013; 117: 1082-91

Perioperative Cardiac Assessment

Fleisher L A et al. 2014 ACC/AHA Guideline On Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: Executive Summary. Circulation. 2014;130:2215-45

Patient Selection algorithm for patients with implantable defibrillators.

Crossley GH et al. The Hearty Rhythm Society (HRS)/ American Society of Anesthesiologists (ASA) Expert Consensus Statement on the Perioperative Management of Patients with Implantable Defibrillators, Pacemakers and Arrhythmia Monitor. Heart Rhythm 2011; 8: 1114-54