Skip to main content

Patrick K. Sullivan, MD
With
James Fletcher, MD, Douglas Blake, MD, Richard Zienowicz, MD, Arnold-Peter Weiss, MD, Edward Akelman, MD

As seen in Medicine and Health / Rhode Island
magazine, Vol. 84, No. 4, April 2001.

Recent increases in office-based procedures have been stimulated in part by concerns surrounding patient comfort, convenience and privacy. This rise has also been catalyzed by the need for greater efficiency and cost containment. These goals should be realized in an environment that meets or exceeds the standards for patient safety established for conventional hospital-based operating facilities and ambulatory surgical centers. Currently the medical literature has few reports on office-based procedures’ morbidities and mortalities. We present a single center experience of over 5,000 cases over a 43 consecutive month period with no major morbidities and no mortalities. The use of a standardized regimen of anesthesia/analgesia for all procedures allows us to infer that the techniques used in this particular office-based setting are effective, reproducible, and most importantly – safe.

In recent years there has been a tremendous increase in the amount of ambulatory surgical procedures. Proponents of office-based surgery cite patient convenience, privacy, comfort and efficiency as advantages. The rise in outpatient surgery is due in part to the increasing cost of inpatient surgical services. The proliferation of office-based surgery has paralleled this rise. Although several papers detail the safety of a variety of surgical procedures at numerous ambulatory surgery facilities,1,2 few researchers have described office-based surgical practices.

Studies have shown that large surveys of surgeons report preoperative laboratory evaluation, monitoring, and the use of anesthetic agents are similar regardless of the surgical setting.3

The use of office-based anesthesia has recently come under more intense scrutiny. Many states have not formally regulated the administration of office-based anesthesia. Currently many institutions as well as legislatures are closely investigating the use of anesthesia and sedation for procedures performed outside the operating rooms of hospitals.

We detailed the experience of one office-based operatory based on the experience of five surgeons over a period of 43 consecutive months.

A retrospective review of the entire operative volume of one office-based operatory was performed. The two-suite operatory is located adjacent to a major hospital. Five surgeons performed all procedures over a 43-month period. Reports were made for all morbidities in a peer-reviewed forum and recorded along with the outcome of each incident. The type of procedure by major category is detailed in Table 1.

Carpal tunnel release 1543
Trigger finger release 542
Suction lipectomy 206
Facelift 182
Abdominoplasty 73
Augmentation mammoplasty 275
Surgery for gynecomastia 26
Other procedures 2452
TOTAL 5299

All procedures were performed by or under the supervision of an anesthesiologist with an anesthesiologist or certified registered nurse anesthetist (CRNA) in attendance at all times.

The standardized protocol for deep sedation involves the administration of midazolam .03 mg/kg and fentanyl 0.7-1.0 mg/kg with ketamine 0.3-0.5 mg/kg prior to local anesthesia or block.

Prior to the start of the case, anesthetic blocks were performed as follows in conjunction with a standardized sedation protocol.

PROCEDURE TECHNIQUE OF BLOCK
Abdominoplasty Posterior rib blocks with 0.25% bupivicaine and 0.5% lidocaine with 1/200,000 epinepherine in conjunction with ilioinguinal and iliohypogastric blocks in selected patients
Breast Augmentation Anterior intercostal blocks with 0.25% bupivicaine and 0.5% lidocaine with 1/200,000 epinepherine
Gynecomastia Anterior intercostal blocks with 0.25% bupivicaine and 0.5% lidocaine with 1/200,000 epinepherine
Hand procedures Bier block with 1% lidocaine or field block with 0.5% lidocaine and 0.5% bupivicaine

During the procedure, propofol infusion at 50mcg/kg/min with small incremental doses of fentanyl, ketamine and midazolam was utilized as needed for amnesia and patient comfort.

Antiemetic prophylaxis for all major procedures is standardized and includes the administration of metaclopromide 10mg/droperidol 1.25mg iv at the beginning of the procedure. In addition, patients with histories of nausea and/or emesis were given ondansetron 4mg iv.

There were no incidents in all cases of unintended admissions secondary to problems related to anesthesia. The incidence of postoperative nausea and vomiting was rare. There were no conversions to general anesthetic or intubations in the series. The complications reported for all procedures are listed in Table 3.

Needle miscount Radiographs obtained and no needles detected in patient
Staph a. infection in a breast expander removal of expander
Hematoma after surgery for gynecomastia evacuated
Hematoma after abdominoplasty vessel located and cauterized, hematoma evacuated
Hematoma after abdominoplasty hematoma evacuated
Extrusion after placement breast implant implant removed
Pneumothorax after augmentation mammoplasty valve placed, x-ray taken and valve removed in recovery
Pneumothorax after augmentation mammoplasty valve placed, x-ray taken and valve removed in recovery
Hematoma after augmentation mammoplasty hematoma evacuated
Hematoma after face lift hematoma evacuated
Shortness of breath after carpal tunnel release patient evaluated in emergency department and cardiology consulted by primary medical doctor, patient ruled out for myocardial infarction (MI)

Discussion

Recent reports have detailed the safety of ambulatory surgery in the perioperative period in an office-based setting for large populations of patients based on mortality.4 There have also been accounts of major morbidity and mortality within one month of surgery demonstrating low incidence of complications.5

There are reports of the efficacy of sedation regimens in an office-based setting6-8 and reports of the safety and techniques for local and regional blocks.9-11 To date, however, the literature lacks accounts of outcomes in the office-based setting based on the utilization of these techniques.

Our experience of over 5,000 cases with no major morbidities and no mortalities mirrors the data for series of ambulatory experience.1 The use of a standardized sedation regimen and routine blocks for all patients as described allows us to infer that our particular protocol has an extensive record of efficacy and safety.

This series of patients is currently unique to the literature, as no large series of office-based surgical procedures detailing technique and morbidity exists.

References

  1. Natof NE. Complications associated with ambulatory surgery. JAMA 1994; 244:1116-8.
  2. Meridy HW. Criteria for selection of ambulatory surgical patients and guidelines for anestheic management: a retrospective study of 1553 cases. Anesth Analg 1982;61: 921-6.
  3. Courtiss EH, et al. Anesthetic practices in ambulatory aesthetic surgery. Plast Reconstr Surg 1994; 93: 792-801.
  4. D’Eramo EM. Mortality and morbidity with outpatient anesthesia: the Massachusetts experience. J Oral Maxillofac Surg 1999; 57:531-6.
  5. Warner MA, et al. Major morbidity and mortality within 1 month of ambulatory surgery and anesthesia. JAMA 1993;270:1437-41.
  6. Tang J, et al. Hypnoanesthesia for office surgery. J Clin Anesth 1999;11:226-30.
  7. Tang J, et al. Use of propofol for office-based anesthesia: Effect of nitrous oxide on recovery profile. J Clin Anesth 1999;11:226-30.
  8. Friedberg BL. Propofol-ketamine technique: dissociative anesthesia for office surgery (a 5-year review of 1264 cases). Aesthetic Plast Surg 1999;23:70-5.
  9. McDowell AJ, Whitlow DR. Reversible, titrated deep sedation for major office surgery. Plast Reconstruct Surg 1977;59:21-3.
  10. Desnoyers Y, et al. Anaesthesia for facial rhytidectomy. Canad Anaesthetists Society J 1979;26:222-4.
  11. Kean H, Mayer R. Anesthesia techniques and facial plastic surgery. Transactions – Penn Acad Ophthalmol Otolaryngol 1974;2:45-8.

James Fletcher, MD, is chief resident, Department of Plastic Surgery, Brown Medical School.
Douglas Blake, MD, is Assistant Clinical Professor of Surgery (Anesthesiology), Brown Medical School.
Richard J. Zienowicz, MD, is Associate Professor of Plastic Surgery, Brown Medical School.
Lee Edstrom, MD, is Professor of Plastic Surgery, Brown Medical School.
Arnold -Peter Weiss, MD, is Professor,of Orthopaedic Surgery, Brown Medical School.
Edward Akelman, MD, is Professor,of Orthopaedics, Brown Medical School, and Chief, Division of Hand, Upper Extremity & Microvascular Surgery, Rhode Island Hospital.
Patrick Sullivan, MD, is Associate Professor of Plastic Surgery, Brown Medical School.