Manual of Office-based Anesthesia Procedures. Edited by Fred E. Shapiro, D.O. Philadelphia, Lippincott Williams & Wilkins, 2007. Pages: 200. Price: $44.95.
Office-based anesthesia (OBA) is arguably the fastest growing practice area in anesthesia, with the American Society of Anesthesiologists estimating 10,000,000 office procedures performed in 2005. Despite, or perhaps because of, its rapid ascendancy, OBA is still poorly represented in academic medicine. Few residency programs offer training in OBA, and there are no textbooks devoted to the subject. Dr. Fred Shapiro and his colleagues at the Department of Anesthesia, Harvard Medical School (Boston, MA), attempt to correct this trend with the first manual devoted to the OBA practice. Its opening sentence proclaims it to be “the first definitive step-by-step guide to office based anesthesia.” Unfortunately, it falls a little short of this rather lofty goal but represents a good first start in this exciting and rapidly growing field.
This 200-page, 5 × 8½-inch softcover manual is divided into 17 chapters, with the majority coauthored by residents or fellows in the Harvard anesthesia system. Like most multiauthored books, there is a certain degree of repetition; a little disappointing here, given that the lead author/editor coauthored 10 of the 17 chapters. Several of the chapters are only two to three pages long and could have easily been consolidated to help minimize this repetition. Other editorial housekeeping items are fairly minor, with the occasional typo, inadvertent italics, and mislabeled figures (chapter 13). A more glaring concern is the authors’ rather extensive use of boxes to separate and highlight important points throughout the book. Although the information is usually quite good, the boxes are untitled and require searching in the body of the text to put into context.
The first four chapters serve to introduce the topic and should have been consolidated to avoid overlap. They cover the basic principles of OBA and the advantages of an office practice. They introduce the recurring themes emphasized throughout the book: safety, convenience, and patient comfort. The second chapter on statistics offers lots of dry facts and numbers on types of office procedures being performed but little help in tying things together.
The book begins in earnest with chapter 5; an excellent collection of the American Society of Anesthesiologists guidelines, standards, and position statements pertaining to OBA. The exceedingly important definition of levels of sedation gets, and deserves, a significant portion of this chapter. Chapter 6 is also a well-written and -organized synopsis of preoperative evaluation of the office-based patient, with a number of good tables on medications (standard and herbal). Unfortunately, the controversial topic of whether to anesthetize patients with known or suspected difficult airways in the office is not covered.
Chapter 7, “Anesthesia Techniques: Which Is the Safest Choice,” is an excellent chapter, though perhaps poorly titled. It deals less with the relative merits of monitored anesthesia care versus general anesthesia and more with the controversy over whether surgery in the office is riskier than surgery at the hospital or ambulatory surgery center. Although the relevant literature is well represented, the limited quality of these studies could have been further emphasized. The authors do conclude by highlighting the need for more and better data.
Chapter 9 is an excellent summary of anesthetic agents used in office-based procedures, although their dosages of midazolam (2.5–7.5 mg) might not result in the rapid patient discharge that OBA demands. I particularly liked the sample cases describing how they actually perform various anesthetics for different procedures. However, the discussion on bypassing the postanesthesia care unit by choosing the correct inhalation agent strikes me as somewhat irrelevant in the office setting. I suspect that most office practices today (and many ambulatory surgery centers, too) have a single recovery approach, with the patient going to one spot until discharged home no matter what “phase” the patient is declared postoperatively.
Chapters 11–13 highlight the issues around the common OBA procedures involving cosmetic, dental, and ophthalmology surgery and gastrointestinal procedures. These are well-written descriptions of the most common procedures and their anesthetic implications. I think this section is one of the high points of the book. Traditional pain management is well covered in chapter 15, but the next chapter on alternative pain control, although well written, is a bit impractical for the fast-paced world of OBA. The book closes with a broad description of postanesthesia care unit issues. The chapter is comprehensive and well written but is not really tailored to OBA.
This handbook’s purported goal was to offer a step-by-step guide to starting an office-based practice, but a few things got left out. There is almost nothing on the financial aspects of OBA. How do I bill? Who pays for drugs? What about equipment? Which are the most lucrative cases? How do I get clients (surgeons)? There is also little specific information on accreditation issues. Which accreditation body should I use and what is the difference? What are the standards for deep venous thrombosis prophylaxis or nurse administered propofol? Are there differences in documentation and quality assurance? In fact, the “step-by-step” how-to guide is a little lacking and/or nonspecific.
The legislative side of OBA is also given short shrift here. I realize that the OBA field is in a constant state of change and transition, making any attempt at listing current state laws and regulations out of date before the book’s ink is dry. However, a discussion on the history of OBA and even some of the obstacles in pushing for state regulation would have been appreciated. The Florida and New Jersey stories are particularly interesting and deserve to be told.
In summary, this book represents the first attempt at consolidating the information in the dynamic field of OBA. Although the chapters on specific anesthetics and types of surgery are very well done, there is too much repetition and nonspecific information surrounding these chapters for me to enthusiastically recommend this book. As a manual, it serves as a good resource for basic recommendations and techniques in OBA, but the definitive textbook on OBA still needs to be written.
Mayo Clinic, Rochester, Minnesota. walsh.michael1@mayo.edu
