Anesthesia Alert: Keeping Pace With Change

Abulatory 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; and regurgitation or aspiration. A huge part of the anesthesia provider's job is maintaining adequate ventilation and oxygenation via a patient 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.

In the early days of outpatient surgeries, most of the emphasis was on identifying patients who could be candidates for surgical care outside a traditional hospital. Usually, the patients were quite healthy. Today, the patient populations are broader, and the surgeries are more involved. The country's 5,800 ambulatory surgery centers provide a large range of increasingly complex procedures, particularly in the field of spine and orthopedics.

More involved procedures can be performed in the ambulatory setting because of advances in minimally invasive surgical technology. Less damage to tissues typically results in less pain, less blood loss, decreased postoperative care, fewer complications and shortened healing time. And because the quality of care is going up while case costs remain lower than the same surgeries performed in acute care facilities, outpatient surgeries are expected to continue to grow. The research firm Sg2 predicts that 85% of surgeries will be performed in the outpatient setting by 2028.

Growth isn't just about numbers. It's about evolution. Has anesthesia kept up with the progress surgeons have made? Adopting new tools and techniques isn't easy. After all, the biggest barrier to change is current practice. The LMA, for example, was originally intended as an alternative for hand-mask ventilation. It has also proved to be an alternative to elective endotracheal intubations, especially in outpatient anesthesia, and an option for securing a difficult airway. The LMA is widely used today, but it took about 10 years for providers to embrace it, despite its ease of use, lower anesthetic requirements and other benefits. As outpatient surgery caseloads increase, the pace of change must accelerate to deliver higher level and more efficient care.

Of course, concerns about costs come into play. Value analysis committees are tasked with comparing a new device's cost to the equipment it replaces. The challenge with this approach is that the product being replaced has likely been on the market for decades and the price is low. Even if a new device works well and providers want it to help them do their jobs to the highest standard, it can be difficult to access it. If staff can't obtain a solution in a timely way, they may end up using workarounds to achieve their goals.

To stent airways open, for example, a survey of 293 anesthesia providers indicated that 52.8% had used nasal airways orally because the longer tubing of a nasal airway reaches lower into the pharynx than a traditional oral airway. This off-label practice indicates the need for a new option in airway management and newer devices exist to address this issue. This is a good example of a desire for change outpacing implementation.

As ambulatory surgery practices mature, surgical facilities must remember that being nimble, innovative and responsive to the needs of patients and staff is what has helped make them successful. They can be the leaders in adopting new approaches, tools and technologies that improve patient outcomes and satisfaction, while also easing staff burden, shortening turnaround times and reducing expenses. OSM