SAMBA: Advocating for Patients as We Look Toward the Future

uring the past two decades, ambulatory anesthesiology has matured and expanded. With ambulatory surgery currently accounting for almost 80 percent of all surgical procedures performed in the United States, it has become undisputedly the dominant mode of surgical practice in North America as well as in many of the world’s other developed nations. Several factors have contributed to the phenomenal growth of outpatient surgery, including economic pressures, technological advances that allow minimally invasive surgery and new, short-acting drugs and anesthetic agents that have dramatically improved our ability to prevent and treat postoperative nausea and vomiting (PONV) and to manage postoperative pain. Nonetheless PONV and pain remain two of the most common causes of unanticipated hospital admission after planned outpatient surgery.

Perhaps the most striking characteristic of PONV is that it is so intensely aversive. Indeed Cicero proclaimed that he “would rather be killed than again suffer the tortures of seasickness.” (Interestingly the word “nausea” is derived from the Greek word for ship, and seasickness has been a major military concern dating back to ancient Greece).¹ In the contemporary setting, emetic symptoms are among the least desirable negative sequelae of anesthesia and surgery,² outdistancing even pain as events to be assiduously avoided.

Fortunately considerable progress has been made in our ability to manage PONV, especially in the immediate postoperative period. Identification of risk factors³ for PONV has permitted a targeted approach to antiemetic prophylaxis because it is not cost-effective to administer prophylactic therapy to all patients.⁴ In high-risk patients, however, there is increasing evidence that better prophylaxis is achieved by using a combination of agents that act at different receptors.⁵

Although we have made great strides in eliminating PONV in our postanesthesia care unit and step-down units, postdischarge nausea and vomiting remain problematic. Therapies showing promise in this domain include the ondansetron orally disintegrating tablet (ODT), transcutaneous acupoint electrical stimulation of the P6 point (effective for nausea) and application of a transdermal scopolamine patch.

Concomitant with more extensive and potentially more painful surgical procedures being performed on an outpatient basis, there is increased need for adequate postoperative pain management, particularly after discharge home. Nevertheless studies document that postoperative pain frequently is not managed effectively, owing to improper application of available information and analgesic therapies.⁶ The goal of pain management should be to minimize pain not only at rest but also during mobility and physical therapy. Multimodal analgesia techniques incorporating the use of local anesthetics, COX-2 inhibitors⁷ and opioids have become standard practice. This multimodal therapy should be initiated before surgical incision and continued until inflammation has resolved. Furthermore many clinical studies report the safety and efficacy of continuous perineural infusions maintained at home after discharge. Concerns about continuous peripheral nerve blockade, however, include patient injury as a result of an insensate extremity, especially after discharge home. Additionally other potential risks include catheter migration and local anesthetic toxicity as well as masking of a surgery-related nerve injury or compartment syndrome. The availability of longer-acting, slow-release preparations that incorporate local anesthetics into liposomes (or microspheres), which extend the duration of analgesia, should obviate these concerns. Future multimodal analgesic techniques also may include the use of alpha₂-adrenergic agonists, N-methyl-D-aspartate receptor antagonists (e.g., ketamine) and anticonvulsants (gabapentin and pregabalin). Additionally bradykinin and substance-P antagonists, leukotriene synthesis blockers and glucocorticoids also may be included in balanced analgesia regimens. Clearly it is essential that pain be managed as a continuum from the preoperative period through the postdischarge period.

The mission of the Society for Ambulatory Anesthesia (SAMBA) is to advance the highest quality of science, education and patient care in the outpatient arena. To this end, SAMBA has been extraordinarily proactive in its support of education and research, realizing that these activities provide the foundation for clinical advances. In May 2000, our organization presented the first SAMBA Outcomes Research Award of $100,000 to Lee A. Fleisher, M.D., currently Chair of the Department of Anesthesia at the University of Pennsylvania in Philadelphia. Dr. Fleisher investigated the impact of location of care and patient factors on the rate of complications and readmission after outpatient surgery.⁸ Not surprisingly the study determined that age in excess of 85 years, prior inpatient hospital admission within six months, invasive surgery and surgical venue were predictive of unanticipated admission and other adverse outcomes, including death. These findings are suggestive that not all ambulatory facilities, i.e., hospitals, freestanding surgicenters or office-based operating rooms, are created equal in terms of their ability to successfully manage complicated patients having lengthy, relatively invasive procedures.

In this context, it is important to appreciate that 15 percent of all elective surgeries performed in the United States in 2002 were conducted in offices. Indeed office-based anesthesia is currently the fastest growing segment of anesthesiology practice in our country. Startling death rates associated with office-based anesthesia and surgery have been reported, however. The death rate for office-based surgery in Florida a few years ago was estimated at 1:8,500 procedures, and it has been disclosed that the mortality for liposuction may be as high as 1:5,000 procedures.⁹ Recently Vila and colleagues¹⁰ reviewed all adverse incidents reported to the Florida Board of Medicine from April 2000 until April 2002. Despite the implementation of corrective action measures by the Board of Medicine for office-based surgery in 2000, the investigators found a more than 10-fold increase in rates of adverse incidents (66:100,000 versus 5.3:100,000) and death (9.2:100,000 versus 0.78:100,000) when comparing offices and ambulatory surgical centers, respectively.

There are multiple reasons for these alarming findings, and most of them pertain to the lack of regulatory control that is characteristic of private offices where it is not uncommon to have clerical staff administer sedative-hypnotics and opioids under the “guidance” of the operating physician (who often may be a dermatologist rather than a surgeon). Indeed only a small minority of states have regulations pertaining to office-based surgery. Therefore SAMBA and ASA have joined together to ensure the same level of safety in offices as in hospitals or accredited surgical centers. To accomplish this goal, patients and procedures must be appropriately matched to venue, and anesthesia care must be delivered only by those with expertise in the specialty.

Our understanding about the relative risk of ambulatory surgery is rather primitive. This is an area where assumptions and presumptions abound, and science is sparse. Valid risk-assessment strategies are still in their inchoate stages, and we have much to learn about such potentially devastating complications as postoperative cognitive dysfunction. Thus we are pleased to announce that SAMBA’s second Outcomes Research Award in the amount of $150,000 was presented recently to Karen C. Nielsen, M.D., and her investigative group at Duke University, Durham, North Carolina, who will explore the role of dexamethasone and anesthesia depth on the incidence of postoperative cognitive dysfunction.

For more than 19 years, SAMBA has provided a forum for anesthesiologists to ask questions, discuss problems and find solutions. Members have access to a quarterly printed newsletter, a monthly electronic newsletter, a Web site <www.sambahq.org> and two major educational meetings every year wherein experts and neophytes alike can exchange information and share experiences. These are challenging but exciting times, and you are invited to learn more about our vibrant organization with nearly 5,000 members from countries throughout the world. We welcome your support in transforming our goals and dreams into reality.

References:

1. McGoldrick KE. Postoperative nausea and vomiting. In: Afifi A, Rosenbaum S, eds. Problems in Anesthesia (Vol. 12, No. 3): PACU and Anesthetic Management. Philadelphia, PA: Lippincott Williams & Wilkins, Inc; 2000:274-286.

2. Macario A, Weinger M, Carney S, Kim A. Which clinical anesthesia outcomes are important to avoid? The perspective of patients. Anesth Analg. 1999; 89:652-658.

3. Apfel CC, Laara E, Koivuranta M, et al. A simplified risk score for predicting postoperative nausea and vomiting: Conclusions from cross-validations between two centers. Anesthesiology. 1999; 91:693-700.

4. Gan TJ, Meyer T, Apfel CC, et al. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg. 2003; 97:62-71.

5. Scuderi PE, James RL, Harris L, Mims GR. Multimodal management prevents early postoperative vomiting after outpatient laparoscopy. Anesth Analg. 2000; 91:1408-1414.

6. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003; 97:534-540.

7. Joshi GP, Viscus E, Gan TJ, et al. Effective treatment of laparoscopic cholecystectomy pain with intravenous followed by oral COX-2 specific inhibitor. Anesth Analg. 2004; 98:336-342.

8. Fleisher LA, Pasternak LR, Herbert R, Anderson GF. Inpatient hospital admissions and death after outpatient surgery in elderly patients. Arch Surg. 2004; 139:76-72.

9. Rao RB, Ely SF, Hoffman RS. Deaths related to liposuction. N Engl J Med. 1999; 340:1471-1475.

10. Vila H, Soto R, Cantor AB, Mackey D. Comparative outcomes analysis of procedures performed in physician offices and ambulatory surgery centers. Arch Surg. 2003; 138:991-995.

Kathryn E. McGoldrick, M.D., is Professor and Chair of Anesthesiology, New York Medical College, and Director of Anesthesiology, Westchester Medical Center, Valhalla, New York.