Given Medicare’s addition of several orthopedic procedures to its fee schedule, an increasingly graying population and a post-COVID effect that has predisposed...
Ambulatory surgical facilities have pivoted quickly during the COVID-19 pandemic, which has shown clinical teams are able to make a number of changes in short order. In this new world of must-dos, though, we can't lose sight of the should-dos that will continue to push outpatient surgery forward. Advances in anesthetic techniques, pain management and post-surgical care continue to increase access to care for more patients.
Good outpatient anesthesia care is based on a "less is more" approach: apply local anesthesia when appropriate, titrate medications to the lowest amounts necessary and employ just enough airway management intervention to get the job done safely.
- Increased use of regional blocks. Local anesthesia produces longer postoperative analgesia by stopping pain receptor stimulation before it has a chance to "rev up." This practice is proactive instead of reactive, so fewer narcotics are needed to control pain after surgery.
- Better medication management. The use of propofol and multimodal anesthesia has improved efficiency and patient safety by decreasing adverse effects, improving patient satisfaction and decreasing costs. Most outpatient anesthesia providers continue to provide patient-specific dosing and titrating to effect. They also employ short-acting narcotics or other drugs such as ketamine and dexmedetomidine as appropriate to control post-op pain.
- Improved airway management. The goal of deep sedation, which is increasingly used in outpatient surgeries, is to achieve suppression of patient awareness while maintaining spontaneous breathing. This is where things can get tricky. As the depth of propofol sedation increases, so does the occurrence of airway obstruction, which can occur for a variety of reasons: respiratory depression, airway obstruction, laryngospasm, bronchospasm, regurgitation or aspiration. A huge part of the anesthesia provider's job is maintaining adequate ventilation and oxygenation via a patent airway.
Anatomy, head position and anesthetic effects all impact where and how airway obstructions occur, and also how well airway devices function. Even devices designed to alleviate obstruction often require a chin lift or jaw thrust to achieve patency. This can translate into providers in the OR and PACU having to hold the patient's head for long periods of time. In the COVID-19 era, it also means close, prolonged patient-provider contact.
Coughing is another concern that's receiving more scrutiny during the pandemic. Though not without controversy, the practice of deep extubation — removing the endotracheal tube or laryngeal mask airway (LMA) while the patient is still under anesthesia — is gaining interest. It has been shown to reduce the incidence of coughing, dysrhythmias, hypertension, laryngospasms, and intraocular or intercranial pressures.
Deep extubation also allows the surgical team to move patients to recovery before they wake up, speeding up OR turnover times. It can lead to airway obstruction, however, because the airway can still collapse due to anesthesia, so an interim airway should be placed to maintain adequate ventilation and oxygenation. Deep extubation success also relies on staff skill levels in PACUs, which vary among facilities and affect the level of post-anesthesia care that can be utilized.