ASA annual meeting highlights top 10 risks of providing anesthesia in ambulatory setting

Editor's Note

There are certain patients and clinical situations that may require anesthesiologists to say no to performing surgery in the outpatient/ambulatory setting, Anesthesiology News April 4 reports. At the 2023 annual meeting of the American Society of Anesthesiologists (ASA), BobbieJean Sweitzer, MD, a professor of medical education at the University of Virginia and a past president of the Society for Ambulatory Anesthesia, presented “what she believes to be” the top 10 reasons anesthesiologists should reconsider providing anesthesia in ambulatory and office-based settings.

Dr Sweitzer emphasizes that this list comes from the increasing complexities and risks involved with certain outpatient procedures, especially as they are now being performed on sicker patients and for more intricate clinical cases. The list is as follows:

1. Heart failure: Patients with heart failure, particularly those with nonischemic and ischemic types, pose a higher mortality risk in the ambulatory setting.
2. Frailty: Increasing frailty, even in nonelderly patients, correlates with higher rates of complications, particularly pulmonary issues.
3. Cardiac implantable electronic devices: These devices indicate serious underlying cardiac conditions that could increase perioperative risks.
4. Congenital heart disease: Adults with congenital heart diseases, especially those with conditions like pulmonary arterial hypertension, face significant risks in outpatient settings.
5. Heart murmurs: Such patients should be carefully evaluated with echocardiograms to assess the severity and type of underlying disease to minimize perioperative risks.
6. Recent acute coronary syndromes: Guidelines recommend postponing elective noncardiac surgical procedures for at least 60 days post-myocardial infarction.
7. Coronary stents: For patients with recent coronary stent placements, there are strict waiting periods before undergoing ambulatory surgery, typically 1 month for bare metal stents and 3 months for drug-eluting stents.
8. Stroke/transient ischemic attack: Performing surgical procedures within 30 days after a stroke significantly increases the risk of perioperative strokes, except in necessary cases like carotid endarterectomies.
9. ASA Physical Status IV: These patients have higher rates of postoperative mortality and procedure cancellations, even for low-risk surgical procedures.
10. GLP-1 and SGLT-2 inhibitors: These weight loss drugs increase the risk of regurgitation and aspiration due to delayed gastric emptying. They should be stopped well before undergoing procedures that require moderate to deep sedation or general anesthesia.

Dr Sweitzer stresses the importance of assessing each case's complexity and risk, as well as considering both the provider's comfort and the facility's capabilities, to determine the suitability for ambulatory procedures. For further reading on what to consider when adding a cardiac service line to an ambulatory surgery center, check out the article, “Key items for cardiovascular, peripheral vascular service lines.”