Oui ou Non? Controversies in Ambulatory Anesthesia

By Adaora M. Chima, MBBS, MPH, from the IARS, AUA and SOCCA 2019 Annual Meetings*

It was a congenial battle of the wills during the SAMBA Innovative Session: Wait, You Can’t Do That: Or Can You? Controversies in Ambulatory Anesthesia as Drs. Girish Joshi, Niraja Rajan, and Richard Urman debated opposing positions on three important issues in ambulatory perioperative care – guidelines requiring escorts for patients discharged in ambulatory setting, NPO guidelines for ambulatory anesthesia, and the need for upper age limits in ambulatory care settings.

The first debate centered around guidelines requiring that escorts accompany patients when discharged from the ambulatory setting, with Dr. Urman serving as the moderator for the discussion.

Dr. Niraja Rajan held the position that patient escorts are essential to discharge planning in the ambulatory setting. Impaired driving and increased risk of accidents have been demonstrated for up to 17 hours in the recovery period following sedation or general anesthesia, especially with the use of benzodiazepines. A survey of postoperative patients also revealed >90% incidence of amnesia when asked to recall postoperative instructions given at discharge. Thirty-one percent reported requiring the help of a caregiver.

Available guidelines are inconsistent in describing the role of and indication for escorts and support persons on discharge. However, they consistently maintain that the anesthesiologist make the determination of the need for an escort. In two case studies discussed during the session, the anesthesiologist was legally held responsible for injuries sustained following independent discharge while the surgeon was held responsible in the other.

She concluded her argument by recommending the creation of decision pathways to determine the need for an escort or medical transportation based on type of procedure, anesthesia technique, baseline mental and physical status, comorbidities and the discharge disposition.

In his counter argument, Dr. Urman pointed out that a strict requirement for an escort could result in delays and cancellations and can create an undue burden on the patient and/or the escort, who might need to be excused from work or incur undue cost to be present. There is also a paucity of robust data supporting the role of escorts in ambulatory care discharge, and an inconsistency in available guidelines. He cited studies that showed that single agent sedation with low dose propofol did not have a prolonged cognitive effect. The debate raised new questions regarding the definition/role of an escort, medical transportation and the care needed in the patient’s disposition destination. Moderated by Dr. Joshi, all speakers agreed that definitions and roles have to be clarified, and decisions regarding escorts should made on a case-by-case basis.

This was followed by a lively debate on NPO guidelines for ambulatory anesthesia. Dr. Rajan took the podium first, holding the position that the current guidelines are appropriate and need not be modified. She reviewed the evolution of NPO guidelines over the past century and the underlying rationale. The current guidelines became mainstream in the 1980s and are driven by concerns regarding residual gastric volume, aspiration risk and its ensuing complications. She noted that these recommendations were put forth for healthy patients. Although there are many risk factors contributing to aspiration risk, most cases of aspiration happen under light anesthesia and are not solely attributable to gastric volume. Point-of-care ultrasound is a tool that can be used for objective assessment of NPO status. She argued that liberalizing the current guidelines could introduce inconsistencies in implementation and potentially result in aspiration.

Dr. Girish Joshi countered by highlighting the fact that the guidelines are based on outdated animal studies performed over 40 years ago, which do not take into account the array of comorbidities that could be complicated by poor hydration. Studies have shown that a significant portion of patients will abstain from both fluids and solid food to comply with fasting instructions, presenting with poor hydration on the day of surgery. Multiple studies also show that water ingested within the 30 minutes – 1 hour period before surgery is associated with increased GI emptying. It is also associated with decreased incidence of PONV and improved hydration has been associated with decreased opioid requirement. Dr. Joshi shared his experience with liberalized pre-operative fluid intake and urged the audience to consider encouraging fluid intake during the pre-operative fast period. Members of the audience indicated by show of hands a willingness to explore clear fluid intake within an hour of surgery if requested by patients.

The last item of debate focused on the need for upper age limits in ambulatory care settings. Dr. Urman proffered the opinion that age should be considered a determinant when making the decision of the setting for care, in addition to other factors. He supported this stance by citing findings that increase in age is associated with cognitive dysfunction, which is associated with an increased risk in adverse events. The increased incidence in comorbidities in the elderly also results in an increased risk in complications that an ambulatory setting may not be equipped to manage.

According to Dr. Joshi, who had published findings on this topic in 2017, age alone is a poor predictor of postoperative outcome. Frailty and cognition are better predictors of the risk of postoperative adverse events. Multiple peer-reviewed publications have proposed that frailty rather than age be used as a predictor.

Ultimately, this informative session reiterates that guidelines are only as effective and generalizable as the evidence they are based on. Anesthesiology is not an absolute science and our responses to questions will often begin with, “It depends….”

*Coverage from SAMBA Innovative Session: Wait, You Can’t Do That: Or Can You? Controversies in Ambulatory Anesthesia at the IARS 2019 Annual Meeting