Decades ago, sending a patient home the same day he or she underwent surgery was unheard of. However, ongoing advancements in surgical practices as well as improvements in postoperative care have made this the norm.
Since it was first proposed in the mid-19th century, ambulatory anesthesia has become an integral component of the surgical experience. The discovery of more effective short-acting anesthetic drugs as well as a tailored approach to care has made it possible for the specialty to support a growing demand for safe and efficient ambulatory procedures.
During an interview with the ASA Monitor, Tong Joo (TJ) Gan, MD, MHS, FRCA, MBA, Professor and Distinguished Endowed Chair, Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, shared his perspective on the growth of ambulatory anesthesiology and what the future may hold.
ASA Monitor: How has the field of ambulatory anesthesiology evolved?
Dr. Gan: Ambulatory anesthesia has undergone tremendous change since it first started. Significant growth was seen in the 1980s with the development of shorter acting drugs. Most importantly, advances in pharmacological agents used in the perioperative period allow patients to recover quicker and go home on the same day. Previously, it took patients several hours to days to emerge from anesthesia and, therefore, they were not in a position to leave the facility even though their surgery was completed. At the same time, surgical techniques were improving and becoming less invasive. A major advance was the introduction of laparoscopic surgery, which replaced many of the open procedures. Progressing surgical techniques in conjunction with advanced anesthetic management allowed for an increase in the number of surgeries conducted in the ambulatory setting.
Over the years, the percentage of surgeries done on an ambulatory basis has increased. In the 1970s, almost 90% of procedures were inpatient. And now, a majority of surgeries – I would estimate almost 70% – occur in the ambulatory setting. I expect this will continue to increase as more and more procedures shift from inpatient to ambulatory.
ASA Monitor: What do anesthesiologists need to know about ambulatory anesthesia?
Dr. Gan: In the ambulatory setting, the anesthesiologist should understand that we need to have a way to effectively manage the anesthetic while at the same time enabling the patient to go home and have a more rapid recovery. The concept of enhanced recovery after surgery or perioperative surgical home is a new paradigm to manage patients so they can recover more quickly with a lower complication rate. One of the fundamental principles of this idea is that anesthesiologists should work with surgeons and nurses as a team. The goal is to have a multimodal approach that focuses on pain control, nausea and vomiting, and fluid management as well as better surgical technique and increased post-operative mobilization. This allows for improved quality of patient recovery while also enabling more procedure types to be conducted in an ambulatory setting.
“Increasingly, we are using different types of blocks to reduce pain, which allows patients to leave the hospital, do their physical therapy, and recover in their own home.”
ASA Monitor: What challenges are associated with ambulatory anesthesiology today?
Dr. Gan: The two main challenges are pain control and the management of post-operative nausea and vomiting. Additionally, many of the drugs we provide to patients, such as opioids, have a number of side effects, including drowsiness, sedation, abdominal discomfort, constipation, and, to a certain extent, confusion. These are examples of some of the limitations of ambulatory anesthesia.
ASA Monitor: How can these issues be addressed?
Dr. Gan: Advancements continue to occur across a number of different areas. For instance, pharmacological developments have led to better, more effective analgesics. There are new, more effective antiemetics available for post-operative nausea and vomiting management. Another major advancement is the use of regional blocks. Increasingly, we are using different types of blocks to reduce pain, which allows patients to leave the hospital, do their physical therapy, and recover in their own home. There are a number of blocks available today, such as the adductor canal block for lower limb surgery. Other novel techniques that provide effective pain control after surgery include the transversus abdominis plane (TAP) block and quadratus lumborum (QL) block. There have also been improvements in ambulatory anesthesia monitoring. We are able to better monitor the depth of anesthesia with the use of bispectral index and other EEG-based monitoring. In addition to these three fronts, surgical techniques are also improving with less invasive procedures and shorter surgical times. All these advancements make it possible for more surgeries to occur in the ambulatory setting.
ASA Monitor: What are your predictions for the future of ambulatory anesthesiology?
Dr. Gan: I predict that ambulatory anesthesia will continue to increase in the future and the type of cases performed in the ambulatory setting will only go up, as surgical techniques, anesthetic drugs, and monitoring capabilities continue to advance. There is also a push for more surgical procedures to move to the ambulatory setting because it reduces healthcare costs as well as complication rates. While these are positive shifts, it is important that we also consider a comprehensive support mechanism when these patients return to their home environment. These are all important factors, especially if we are going to expand ambulatory surgery and ambulatory anesthesia into the future.
The anesthesia community should embrace ambulatory anesthesia and take more of a leadership role in charting its future because I believe our specialty can help advance ambulatory anesthesia and improve the patient experience through that surgical journey. Additionally, societies, such as the Society for Ambulatory Anesthesia and the American Society of Anesthesiologists, all have an important role to play in the advancement of ambulatory anesthesia, as they have since it first began.
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