Society for Ambulatory Anesthesia Updated Consensus Statement on Perioperative Blood Glucose Management in Adult Patients With Diabetes Mellitus Undergoing Ambulatory Surgery.

WHAT OTHER GUIDELINES ARE AVAILABLE ON THIS TOPIC: Since the publication of the SAMBA Consensus Statement for perioperative blood glucose management in the ambulatory setting in 2010, several recent guidelines have been issued by the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists (AACE), the Endocrine Society, the Centre for Perioperative Care (CPOC), and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) on DM care in hospitalized patients; however, none are specific to ambulatory surgery. HOW DOES THIS GUIDELINE DIFFER FROM THE PREVIOUS GUIDELINES: Previously posed clinical questions that were outdated were revised to reflect current clinical practice. Additional questions were developed relating to the perioperative management of patients with DM to include the newer therapeutic interventions.

Care of the Pediatric Patient for Ambulatory Tonsillectomy With or Without Adenoidectomy: The Society for Ambulatory Anesthesia Position Statement.

The landscape of ambulatory surgery is changing, and tonsillectomy with or without adenoidectomy is one of the most common pediatric surgical procedures performed nationally. The number of children undergoing tonsillectomy on an ambulatory basis continues to increase. The 2 most common indications for tonsillectomy are recurrent throat infections and obstructive sleep-disordered breathing. The most frequent early complications after tonsillectomy are hemorrhage and ventilatory compromise. In areas lacking a dedicated children's hospital, these cases are managed by a nonpediatric specialized anesthesiologist and general otolaryngology surgeon. In response to requests from our members without pediatric fellowship training and/or who care for pediatric patients infrequently, the Pediatric Committee of the Society for Ambulatory Anesthesia (SAMBA) developed a position statement with recommendations for the safe perioperative care of pediatric patients undergoing tonsillectomy with and without adenoidectomy in freestanding ambulatory surgical facilities. This statement identifies children that are more likely to experience complications and to require additional dedicated provider time that is not conducive to the rapid pace and staffing ratios of many freestanding ambulatory centers with mixed adult and pediatric practices. The aim is to provide health care professionals with practical criteria and suggestions based on the best available evidence. When high-quality evidence is unavailable, we relied on group consensus from pediatric ambulatory specialists in the SAMBA Pediatric Committee. Consensus recommendations were presented to the Pediatric Committee of SAMBA.

Pro-Con Debate: Are Patients With Coronary Stents Suitable for Free-Standing Ambulatory Surgery Centers?

With increasing implantation of coronary artery stents over the past 2 decades, it is inevitable that anesthesiologists practicing in the outpatient setting will need to determine whether these patients are suitable for procedures at a free-standing ambulatory surgery center (ASC). Appropriate selection of patients with coronary artery stents for a procedure in an ASC requires consideration of factors that affect the balance between the risk of stent thrombosis due to interruption of antiplatelet therapy and the thrombogenic effects of surgery, and the risk of perioperative bleeding complications that may occur if antiplatelet therapy is continued. Thus, periprocedure care of these patients presents unique challenges, particularly for extensive surgical procedures that are increasingly scheduled for free-standing ASCs, where consultation and ancillary services, as well as access to percutaneous cardiac interventions, may not be readily available. Therefore, the suitability of the ambulatory setting for this patient population remains highly controversial. In this Pro-Con commentary, we discuss the arguments for and against scheduling patients with coronary artery stents in free-standing ASCs.

Should rocuronium and sugammadex replace succinylcholine for airway emergencies in class B ambulatory anesthesia settings?

INTRODUCTION: In class B surgical facilities, where only oral or intravenous (IV) sedation is employed without the administration of volatile anesthetics, laryngospasm is among the most common airway complications. However, these facilities generally do not stock succinylcholine to avoid the cost of storing dantrolene for the treatment of malignant hyperthermia (MH). High dose IV rocuronium with sugammadex reversal has been suggested as an alternative to succinylcholine for airway emergencies. The aim of this paper was to evaluate the clinical utility, patient safety, and financial implications of replacing succinylcholine with rocuronium and sugammadex in lieu of stocking dantrolene in class B facilities. EVIDENCE ACQUISITION: A systematic review of the literature concerning neuromuscular blockade for airway emergencies in class B settings in adult patients was conducted. The MEDLINE and EMBASE databases were searched for published studies from January 1, 1990, to October 1, 2021. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used to assess the certainty of evidence. EVIDENCE SYNTHESIS: The search strategy yielded 1124 articles. After review, 107 articles were included, with 49 graded as "strong" evidence to provide recommendations for the posed questions. CONCLUSIONS: The use of succinylcholine in isolation without volatile agents has a low incidence of triggering MH. Laryngospasm is a common airway emergency that requires immediate treatment to avoid morbidity and mortality. Both succinylcholine and rocuronium-sugammadex provide adequate treatment of airway emergencies and rapid return of spontaneous ventilation, but succinylcholine has a superior economic and clinical profile.

Pro-Con Debate: Are Patients With a Cardiovascular Implantable Electronic Device Suitable to Receive Care in a Free-Standing Ambulatory Surgery Center?

Migration of surgical and other procedures that require anesthesia care from a hospital to a free-standing ambulatory surgery center (ASC) continues to grow. Patients with cardiac implantable electronic devices (CIED) might benefit from receiving their care in a free-standing ASC setting. However, these patients have cardiovascular comorbidities that can elevate the risk of major adverse cardiovascular events. CIEDs are also complex devices and perioperative management varies between devices marketed by various manufacturers and require consultation and ancillary services, which may not be available in a free-standing ASC. Thus, perioperative care of these patients can be challenging. Therefore, the suitability of this patient population in a free-standing ASC remains highly controversial. Although applicable advisories exist, considerable discussion continues with surgeons and other proceduralists about the concerns of anesthesiologists. In this Pro-Con commentary article, we discuss the arguments for and against scheduling a patient with a CIED in a free-standing ASC.

Patient Selection for Adult Ambulatory Surgery: A Narrative Review.

With migration of medically complex patients undergoing more extensive surgical procedures to the ambulatory setting, selecting the appropriate patient is vital. Patient selection can impact patient safety, efficiency, and reportable outcomes at ambulatory surgery centers (ASCs). Identifying suitability for ambulatory surgery is a dynamic process that depends on a complex interplay between the surgical procedure, patient characteristics, and the expected anesthetic technique (eg, sedation/analgesia, local/regional anesthesia, or general anesthesia). In addition, the type of ambulatory setting (ie, short-stay facilities, hospital-based ambulatory center, freestanding ambulatory center, and office-based surgery) and social factors, such as availability of a responsible individual to take care of the patient at home, can also influence patient selection. The purpose of this review is to present current best evidence that would provide guidance to the ambulatory anesthesiologist in making an informed decision regarding patient selection for surgical procedures in freestanding ambulatory facilities.

Preoperative Care for Cataract Surgery: The Society for Ambulatory Anesthesia Position Statement.

Cataract surgeries are among the most common procedures requiring anesthesia care. Cataracts are a common cause of blindness. Surgery remains the only effective treatment of cataracts. Patients are often elderly with comorbidities. Most cataracts can be treated using topical or regional anesthesia with minimum or no sedation. There is minimal risk of adverse outcomes. There is general consensus that cataract surgery is extremely low risk, and the benefits of sight restoration and preservation are enormous. We present the Society for Ambulatory Anesthesia (SAMBA) position statement for preoperative care for cataract surgery.

Management of postoperative nausea and vomiting in adults: current controversies.

PURPOSE OF REVIEW: Postoperative nausea and vomiting (PONV) continue to plague the surgical patient population with an adverse impact on postoperative outcomes. The aim of this review is to critically assess current evidence for PONV management, including studies evaluating baseline risk reduction and antiemetic prophylaxis, to provide a pragmatic approach to prevention and treatment of PONV in routine clinical practice. RECENT FINDINGS: Multiple recent reviews and guidelines have been published on this topic with some limitations. In the current ERAS era, all patients irrespective of their PONV risk should receive two to three antiemetics for prophylaxis. Patients at a high risk of PONV [i.e. prior history of PONV, history of motion sickness, high opioid requirements after surgery (e.g. inability to use nonopioid analgesic techniques)] should receive three to four antiemetics for prophylaxis. SUMMARY: This review provides a practical approach to PONV prevention based on recent literature.

Dexmedetomidine as an Adjunct for Regional Anesthetic Nerve Blocks.

PURPOSE OF REVIEW: This article will review current evidence related to the use of dexmedetomidine as an adjuvant for regional anesthesia. RECENT FINDINGS: Adjuvants, frequently used during regional anesthesia, act synergistically with local anesthetics thus enhancing the quality of regional anesthesia while minimizing adverse effects. These adjuvants may be administered via different routes including topical, perineural, neuraxial, and systemic. Recent studies indicate that dexmedetomidine prolongs the duration of intravenous regional anesthesia, peripheral nerve blocks, and spinal analgesia. Controversy regarding potential neurotoxicity of perineural dexmedetomidine in patients with diabetic neuropathy requires further evaluation.

The high-risk patient for ambulatory surgery.

PURPOSE OF REVIEW: This article describes the processes for identifying high-risk patients at the time of ambulatory procedure scheduling, enabling the implementation of multidisciplinary collaborative pathways for prehabilitation and optimization, allowing for risk mitigation and improvement in outcomes. This review is particularly relevant because of the current proliferation of ambulatory surgery with more complex procedures being performed on an outpatient basis on patients who may be American Society of Anesthesiologists Physical Status 3 or greater. RECENT FINDINGS: Increased longevity and rising prevalence of obesity have resulted in patients with a wide variety of comorbidities presenting for complex ambulatory procedures with the expectation of rapid recovery and same-day discharge to home. Recent literature highlights the importance of patient preparation, value-based healthcare, patient outcomes, and the role of anesthesiologists as perioperative physicians. SUMMARY: The focus of this article is on general principles and establishment of best practices based on current evidence and a brief description of anesthetic management of specific comorbidities. This review will provide guidance to the practicing anesthesiologist on identifying, stratifying, optimizing, and managing high-risk patients in the ambulatory setting.

COVID-19: Role of Ambulatory Surgery Facilities in This Global Pandemic.

Coronavirus disease 2019 (COVID-19) has now become a global pandemic. This has led the United States to declare a national emergency and resulted in a ban on all elective diagnostic and therapeutic procedures as well as elective surgery in inpatient and outpatient settings. Ambulatory surgery facilities (ASF) that perform only elective procedures are thus likely to be closed. However, these facilities may be able to assist acute care hospitals as essential (urgent and emergent) surgeries and diagnostic and therapeutic procedures will still need to be performed. The aim of this article is to explore the potential contribution of ASFs in the current health care crisis. It is important to understand that COVID-19-related information is continually evolving, and thus, the discussion provided here is subject to change.

Intravenous Regional Anesthesia Using a Forearm Tourniquet: A Safe and Effective Technique for Outpatient Hand Procedures.

Background: Bier block provides anesthesia of an entire extremity distal to the tourniquet without necessitating direct injection at the surgical site. This avoids obscuring anatomy with local anesthetic and anesthetizes a wide area, allowing for multiple procedures and incisions. We hypothesize that a low-volume Bier block with forearm tourniquet, rather than a traditional brachial tourniquet, is a safe, well-tolerated, and effective anesthesia technique. Methods: All cases in which adult patients underwent hand procedures using Bier block anesthesia by a single surgeon over a 4-year period were reviewed. Data collected included patient demographics, procedure(s) performed, complications, tourniquet time and settings, procedure and in-room time, and supplemental medications administered. Results: In all, 319 patients were included, 103 from a university hospital and 216 from an ambulatory surgery center. The most commonly performed procedures were carpal tunnel release (205 cases) and trigger digit release (83 cases). Most patients received a 125-mg dose of lidocaine for the Bier block; many also received additional sedatives. Twenty-three patients received no additional medications. No patients required conversion to general anesthesia. One complication (0.3%) occurred, with paresthesias and tinnitus that resolved without intervention. The average tourniquet time was 24 minutes (SD = 4.3 minutes). Patients were discharged at a median of 49 minutes postoperatively, and 9.1% of patients received supplemental analgesics prior to discharge. Conclusions: Regional anesthesia achieved with a forearm tourniquet and intravenous local anesthetic provides adequate pain control, permits timely discharge home, and has a low complication rate. It should be considered for use in outpatient hand procedures.

Malignant Hyperthermia-Susceptible Adult Patient and Ambulatory Surgery Center: Society for Ambulatory Anesthesia and Ambulatory Surgical Care Committee of the American Society of Anesthesiologists Position Statement.

This document represents a joint effort of the Society for Ambulatory Anesthesia (SAMBA) and the Ambulatory Surgical Care Committee of the American Society of Anesthesiologists (ASA) concerning the safe anesthetic care of adult malignant hyperthermia (MH)-susceptible patients in a free-standing ambulatory surgery center (ASC). Adult MH-susceptible patients can safely undergo a procedure in a free-standing ASC assuming that proper precautions for preventing, identifying, and managing MH are taken. The administration of preoperative prophylaxis with dantrolene is not indicated in MH-susceptible patients scheduled for elective surgery. There is no evidence to recommend an extended stay in the ASC, and the patient may be discharged when the usual discharge criteria for outpatient surgery are met. Survival from an MH crisis in an ASC setting requires early recognition, prompt treatment, and timely transfer to a center with critical care capabilities.

Common controversies surrounding anesthesia for procedures in the Interventional Pulmonology Suite.

The number of anesthetics for both simple diagnostic and complex therapeutic procedures being performed in non-operating room locations (NORA) in dedicated Interventional Pulmonology Suites have been increasing in the past few years. Anesthesiologists must be familiar with the demands necessitated by the procedures performed by the interventionists and tailor the anesthetic to create a still field while carefully considering the patient's altered pharmacokinetics and reduced cardio-pulmonary function and choose a technique that allows prompt recovery and early discharge in these patients, many of whom are elderly and frail. In this article we will address controversies surrounding the use of topical analgesia in patients already anesthetized by a TIVA technique and the questions of choice of muscle relaxants and reversal agents and standard of monitoring during these procedures.

Bedside ultrasound assessment of gastric content in children noncompliant with preoperative fasting guidelines: Is it time to include this in our practice?

Ultrasound assessment of gastric contents and volume is gaining popularity in adults and children. At present, a preoperative verbal check is used to determine the fasting status. Due to fear of delay or cancellation of surgery, parents may not disclose noncompliance with fasting guidelines. Pulmonary aspiration of gastric contents is a potential cause of morbidity and mortality. Ultrasound assessment of gastric contents is noninvasive and easy to learn. We present a series of three cases to demonstrate how the use of ultrasound to assess gastric contents in children can provide an objective means for decision-making and impact anesthetic management when preoperative fasting status is uncertain.