Office based anesthesia complications

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Office based anesthesia
:complications
Claudio Melloni
Direttore UO Anestesia e Rianimazione
Ospedale di Faenza(RA)

Courtiss EH, Goldwyn RM, Joffe JM, Hannenberg AA.
Anesthetic practices in ambulatory aesthetic surgery. Plast
Reconst Surg 1994;93:792-801.
Inchiesta tra i chirurghi plastici USA
13% respiratory arrest, 8% unplanned
intubations, 3% intravascular injection of
local anesthetic and 1% mortality
However, closer examination of the anesthetic techniques
performed and the personnel in the office, the most frequent
anesthetic technique performed was monitored anesthesia care
(MAC) (92%) with a nurse or anesthesiologist being present only
70% of the time. General anesthesia was administered by 54%
of the practitioners and either the nurse or the anesthesiologist
were always present. Interestingly, central neuroaxis blockade
was performed by 10% of practitioners and the anesthesiologist
was never present; instead 12% of the time the surgeon was in
charge of the patient and 5% of the time a nurse. This might be
the cause of the problems [8]

Courtiss EH, Goldwyn RM, Joffe JM, Hannenberg AA.
Anesthetic practices in ambulatory aesthetic surgery. Plast
Reconst Surg 1994;93:792-801.
0 20 40 60 80 100
%
MAC
Anest o CRNA
SPI
0 2 4 6 8 10 12 14
%
arresto resp
intubaz non
elettiva
iniez intravasc
mortalità Anestesista assente;
spi effettuata dai chir
Complicanze nell’ufficio Responsabilità…………
Ma…

Complicazioni delle endoscopia digestiva
0.13-0.08%
Mortalità 0.7-1/10.000
50% delle KO e 65% dei decessi
dovuti a probl cardioresp

1989 ASGE Survey of Endoscopic sedation
and monitoring practice(Gastrointest Endoscopy 1990;36:s13-18)
0 20 40 60 80 100
>75%
50-75%
up to 33%
none
% dei paz sedati durante endoscopia
UK
ASGE

Attitudini degli endoscopisti nei confronti della
sedazione(e anticolinergici..
0
10
20
30
40
50
60
70
80
Midazolam Diazemuls Diazepam Petidine scopolamine atropine topical anesth topical anesth
occas
UK USA

Volume 97(9);September 2004:pp 800-
805
Who Is Willing to Undergo
Endoscopy Without Sedation:
Patients, Nurses, or the Physicians?
Madan, Anand MD; Minocha, Anil MD,
FACG.

Chi preferisce subire l’endoscopia senza sedazione? Madan
A,Minocha A Who Is Willing to Undergo Endoscopy Without Sedation: Patients, Nurses, or
the Physicians? 2004; 97:800-805
0
10
20
30
40
50
60
70
80
90
100
%
pazienti:desiderio di
sedazione
medici IP della Gastro IP altri reparti
prima della
procedura
dopo la procedura
127 patients, 117 nurses,
and 51 physicians
Patients with a high
school
or associates degree
were less likely
to forego sedation.

problemi durante e dopo la procedura
LUGAY M,OTTO G,KONG M,MASON DJ, WILETS I. Recovery Time and Safe Discharge of Endoscopy Patients
After Conscious Sedation .Gastroenterology Nursing 19;1996:194-200
0
5
10
15
20
25
30
35
40
45
%
pain hypertensione Hypotension bradycardia O2
desaturation
weakness abdom.pain dizziness
intraprocedure
adverse occurrences
postprocedure
adv.occurr.
Relaz significativa fra eventi avversi intra e post
69%(228)

Ko of endoscopic procedures.
Freeman ML, Timothy Hennessy J, Cass OW, Phelley AM. Carbon dioxide retention and oxygen
desaturation during gastrointestinal endoscopy. Gastroenterology 1993; 93: 331-339.
Freeman ML. Sedation and monitoring for gastrointestinal endoscopy. Gastrointest Endosc Clin N
Am 1994; 94: 475-499.
0
10
20
30
40
50
60
70
80
90
100
%
fentanyl midaz desaturaz need o2 ipetens tachic
egd
colonscopy
ercp

Fattori di rischio;eventi sentinella nella endoscopia
digestiva?
Desaturaz arteriose
Wengrower 7%
Rosenberg 2(con O2)-35%( senza O2)
Freeman 40-70%
Bouchut :0.4 con O2, 68% senza
Tachicardia:
Freeman 30-40%
Rosenberg 30%

Rischio di aritmie cardiache
36% paz con mal cardiache
25% paz.con mal.resp.
16% paz apparentemente sani (Gupta
Milit.Med 1990)

Fattori di rischio per eventi avversi nella endoscopia in
sedazione cosciente
Iber et al. (1993)
» Mal maggiori
» > 70 anni
» ERCP.
Nagengast (1993)
Ischemia card
mal cerebrovascolare
Disfunz polm
Obesità patol.
severa anemia
sanguinamento gastrointest.
Insuff renale o epatica

Anormalità resp.e anestesia topica
Mc Nicholas WS, Coffey M, Mc Donnel T, O'Regan R, Fitzgerald MX. Upper airway obstruction
during sleep in normal subjects after selective topical oropharyngeal anesthesia. Am Rev Respir Dis
1987;135:1316-9
0
2
4
6
8
10
12
14
16
18
20
controlli anest
orofaringea
anest.nasale
Apnea ostruttiva+
ipopnea
apnea
centrale+ipopnea
apnee e ipopnee
tot
9 normal subjects
20-28 y.
Pressure sensitive receptor mechanism,
afferent limb originating in the upper
airway

O2 per l’endoscopia digestiva tratto sup
(Block R, Jankovski J, Johnston D, Wormsley K. The administration of supplementary oxygen to
prevent hypoxia during upper alimentary endoscopy. Endoscopy 1993;25:269-73
O2 NO
O2 SI
Senza O2
Con O2

Saturazione O2 e premed con BDZ
SaO2 89-92%;
» Bell Scand J Gastroenterol 1990
Ulteriore riduz durante introduz dello strumento
specie nei primi 3-4 min dopo premed. (Lieberman
Gastroenterology 1985)
BDZ+oppioide O2 desat ancora + spiccata (40%)
+fattori di rischio (age>65,Cold…);
» Hart & Classen Endoscopy 1990)
» Cousins Scand J gastroenterol 1990)

Fattori contributori alla desaturazione in O2 durante
endoscopia digestiva
Ostruzione del faringe
Compressione tracheale
Distensione gastrica
farmaci
Anest loc.

Complicazioni che avvengono
dopo chir amb.
Le Ko postop dopo chir amb possono avere
inizio durante la procedura,nella RR o dopo la
dimissione.
In una RASSEGNA DI 40 CENTRI,86%
DELLE Ko avvenivano dopo il
termine della chir!
Dunque è necessario stretta vigilanza e
elevato livello di assistenza durante il periodo
postop (Natof, 1985a)

Mortalità e morbilità della oba
/obs
Office based anesthesia /office based
surgery

PERUGIA: CONDANNATI MEDICI PER
PAZIENTE MORTA DURANTE
LIPOSUZIONE
PERUGIA, 11 MARZO - Si è concluso con la condanna di tutti gli
imputati il processo davanti alla Corte d' Appello di
Perugia a 3 medici per la morte di una paziente dopo
un intervento di liposuzione.
In serata i giudici di secondo grado hanno infatti condannato ADG a 2 anni di
reclusione, S A a 1 anno e 4 mesi ed AP a 1 anno di reclusione.
Tutti sono stati ritenuti colpevoli di omicidio colposo.
Francesca De Tommaso morì nel 1993 dopo essersi sottoposta ad un
intervento di liposcultura per eliminare 3 chilogrammi di grasso. I 3 medici
erano stati processati in primo grado dal pretore di Ancona che aveva inflitto 2
anni di reclusione a DG ed A ed 1 anno e 4 mesi a P. La sentenza era poi
stata parzialmente riformata dalla Corte d' Appello del capoluogo marchigiano
e quindi annulla dalla Cassazione che aveva rinviato il processo alla Corte
d'Appello di Perugia.

PRATO Liposuzione, Nas sequestrano studio
non autorizzato
PRATO, 18 OTTOBRE 2002 - Un locale utilizzato per
interventi chirurgici di liposuzione è stato sequestrato
dai carabinieri del Nas di Firenze in uno studio medico
di Prato. Il locale - che era stato affittato da un
chirurgo di Pisa - non avrebbe avuto alcuna
autorizzazione per gli interventi di quel tipo. I
carabinieri hanno sequestrato anche tutte le
apparecchiature e le attrezzature e hanno denunciato
il medico e il rappresentante legale dello studio per
esercizio medico in locali non autorizzati.

Il chirurgo: «Una disgrazia»
Morte dopo la liposuzione. Il dottor P:in tv:
«L’intervento era perfettamente riuscito».
L’autopsia conferma: la giovane commerciante è stata uccisa da
un’embolia. Francavilla, tanti mazzi di fiori davanti al negozio di
Mariana .
Articolo di:
Il Messaggero, Cronaca, Provincia Chieti, 19-02-2002
FRANCAVILLA — E’ stata una tromboembolia polmonare ad
uccidere Mariana Bellomo, la giovane mamma deceduta a
Francavilla sabato mattina. A confermarlo è stato l’esame autoptico
effettuato dal dottor Armando Colagreco dell’istituto legale di Chieti.
Quattro, forse addirittura cinque, gli emboli killer che hanno
stroncato la vita di Mariana, 24 anni, madre di una bimba di appena
2 anni. E R P il medico che l’ha operata, va in tv e dice di non
sentirsi responsabile: «L’intervento era perfettamente riuscito, ed è
stato fatto rispettando tutte le procedure dal punto di vista
sanitario».

Chiesto il rinvio a giudizio per C G, il medico
fiorentino che operò Bernadette Fontana, uccisa da
un'infezione.Morta per liposuzione
"Omicidio volontario"
FIRENZE - Sapeva che avrebbe potuto uccidere. Sapeva che
qualcuno, prima o poi, sarebbe morto a causa sua. Ma il sapere tutto
questo non l'ha messa in guardia contro il pericolo che correva, e che avrebbe
fatto correre agli altri. Per questo CG, il medico di Firenze che lo scorso anno fece
un intervento di liposuzione su una donna che poì morì per un'infezione post-
operatoria, è colpevole. Colpevole a tutti gli effetti. Per il pubblico ministero Paolo
Canessa che ha condotto l'inchiesta sul caso, si tratta senza ombra di dubbio di
omicidio volontario e per questo ne chiede il rinvio a giudizio: se il giudice accoglierà
la richiesta del pm, Costanza Greco dovrà rispondere dell'omicidio di Bernadette
Fontana, la donna di 48 anni morta per una grave infezione dopo essere passata
sotto i ferri del medico fiorentino.

Ma non è finita qui. La dottoressa G.è anche accusata di lesioni colpose e lesioni
volontarie gravi per aver provocato in quello stesso periodo di tempo, fra il 18 e il 20
marzo 1999, analoghe infezioni post-operatorie ad altre due pazienti, L. B., 39 anni,
e P. F., 44 anni. Anche loro andarono dalla G.nella speranza di togliersi quei chili di
troppo. Ma, dopo essersi sottoposte all'intervento di liposuzione al "Centro servizi
Edonè" di Firenze che, tra l'altro, secondo l'accusa, non aveva neanche
l'autorizzazione della Regione, se ne sono tornate a casa con un'infezione in eredità.
ILpm Canessa è arrivato a contestare il reato di omicidio e di lesioni volontarie al
medico dopo aver valutato anche altre ipotesi: la G.infatti inizialmente sembrava
avere avuto un comportamento colposo. Ma dopo l'infezione provocata alla prima
donna, L.B., la .G non prese precauzioni per evitare anche alle altre pazienti
conseguenze disastrose. E continuò a operare senza mascherina
chirurgica, a non sterilizzare la sala operatoria, a non prevedere
nessuna profilassi antibiotica, utilizzando infine cannule per
aspirazione e medicinali non adeguatamente sterilizzati. Per questo
alla colpa si è aggiunta nella convinzione degli inquirenti una responsabilità
volontaria della G.

Mortalità nella office surgery
Morello DC,Colon GA, Fredricks S,Iverson RE,Singer R Patient Safety in Accredited Office
Surgical Facilities. Plast Reconstr Surg, Volume 99(6).May 1997.1496-1500
7 casi ( 0.0017 %, 1 / 57,000)
1 decesso 3 gg dopo lifting facciale e frontale
2 decessi da occlusione della LAD ,1 durante mastoplast addit.e 1
4 h dopo rinoplastica.
3 decessi da complicanze intraop:1 /133,558
» ipossia cerebrale durante addominoplastica ,con decesso dopo 11 gg:
– Un pnx iperteso durante mastoplastica con decesso 4 h più tardi
– Un arresto cardioresp (con decesso più tardi) durante decompressione
tunnel carpale

Incidenza di complicanze a confronto:office based vs day
surg.centers
Warner, M. A., Shields, S. E., and Chute, C. G. Major morbidity and mortality within 1 month of
ambulatory surgery and anesthesia.J.A.M.A. 270: 1437, 1993
Natof, H. E. Complications associated with ambulatory surgery. J.A.M.A. 244: 1116, 1980
emorragia infezione Trasf in
ospedale
mortalità
Morello 0,24% 0.09% 0.03% 0,0017%
1/57000
Natof 0.55% 0.74% 0.12% 0
Warner 0,0087
1/11273
14 MI 7 SNC 5 emb polm 5 insuff resp

Morello DC,Colon GA, Fredricks S,Iverson RE,Singer R Patient
Safety in Accredited Office Surgical Facilities. Plast Reconstr Surg,
Volume 99(6).May 1997.1496-1500
Questionario inviato ai 418
AAAASF,uffici chir accreditati
Ripetizione del questionario alcune
settimane a dopo a chi non aveva
risposto
241 risposte :57.7 %
(organizzazione curata da una ditta
esterna , Chalana, Inc).

Casistica
Morello DC,Colon GA, Fredricks S,Iverson RE,Singer R Patient Safety in Accredited Office
Surgical Facilities. Plast Reconstr Surg, Volume 99(6).May 1997.1496-1500
400,675 interventi in 5 anni (Jan1, 1989 - Dec 31, 1993)
» 253,355 estetici (63.2 %) ,147,320 ricostruttive (36.8 %).
Complicazioni : 1877 (1/ 213 ), 0.47 %
» Emorragie(ematomi intra-postop):965 ,1 /415 (0.24 %).
» Episodi ipertensivi :414 ,1 /968 0.1 %).
» Infezione (infezione maggiore o sepsi ) 350 , 1/1145 (0.09 %).
» Ipotensione intra e postop :148 ,1 / 2707 (0.04 %).
» Ritorno in sala op entro 24 h: 530 casi, 1/ 756 , (0.13 %, )
» Ospedalizzazione precauzionale 126 casi, 1/ 3180 (0.03 %)

Complicanze della office chirurgia plastica
From: Keyes: Plast Reconstr Surg, Volume 113(6).May 2004.1760-1770

Aritmie cardiache

Alterazioni della PA Intraop.

Trombosi venosa profonda/embolia
polmonare

Pneumotorace

Worthington LM, Flynn PJ, Strunin L. Death in the dental
chair — an avoidable catastrophe? British Journal of
Anaesthesia 1998; 80:131-132.
Attualmente circa 300 000 paz con GA per proc dentarie
MINORI in UK.
2 decedono .
» Anaesthesia most commonly consists of a mixture of oxygen, nitrous oxide and halothane
and is administered in general dental practices, community dental surgeries and hospitals.
dei 26 paz deceduti durante anest per dent. 1984–1993
(informaz da British Dental Association)
> 50% bambini <16 anni
L’eziol era equamente distribuita fra difficoltà resp e collasso
cc improvviso
Il decorso tipico era arresto card improvviso senza segni premonitori con
resuscitazione impossibile ;all’autopsia nulla !

Mortality on the dental chair (UK) :1984-1993 Seel D. Dental
General Anaesthesia. Report of a Clinical Standards Advisory Group Committee on General
Anaesthesia for Dentistry. London: Department of Health, 1995
Poswillo D. General anaesthesia, sedation and resuscitation in dentistry. Report of an Expert
Working Party for the Standing Dental Advisory Committee. London: Department of Health, 1990.
O2 /N2O/aloth
Mortalità 9/ 1.000.000, i.e 1/111.0000
50 % <16 anni
Cause;resp diff e improvviso collasso cc.

Decessi sulla sedia del dentista in UK
Coplans MP, Curson I..eaths associated with dentistry.British Dental Journal 1982; 153:357-363.
Coplans MP, Curson I.Deaths associated with dentistry.and dental disease. Anaesthesia1993; 48:435-438
Seel D. Dental General Anaesthesia. Report of a Clinical Standards Advisory Group Committee on General Anaesthesia for Dentistry. London: Department of Health, 1995
Poswillo D. General anaesthesia, sedation and resuscitation in dentistry. Report of an Expert Working Party for the Standing Dental Advisory Committee. London: Department of
Health, 1990
0
10
20
30
40
50
60
70
80
90
100
tot numb.
1970-79 1980-89 1990-99
GA
.
15 million GA

Decessi da chirurgia dentaria e maxillo-faciale
0/416. 561 paz (1989), 147 medici,AG,sedazione e/o
locale :871 episodi sincopali (nessuno in AG...)
» D'Eramo EM. Morbidity and mortality with outpatient anesthesia.
The Massachusetts experience. J Oral Maxillofac Surg
1992;50:700-704.
1/274.000
» Tomlin PJ. Death in outpatient dental anesthetic practice.
Anaesthesia 1974;29:551-570.
1 / 229 730
» Coplans MP, Curson I. Deaths associated with dentistry. Br Dent
J 1982;153:357-369.
» Variabilità delle cifre………….

Jastak JT, Peskin RM. Major morbidity or mortality from
office anesthetic procedures: a closed-claim analysis of 13
cases. Anesth Prog. 1991 Mar-Apr;38(2):39-44.
A closed-claim
analysis(cartelle,deposizioni,informazioni,autopsie,pro
c legali) dei decessi legati all’anestesia e danni
permanenti nel contesto dell’ambulatorio dentistico
In cooperaz con il principale assicuratore della
categoria (dentisti, chir maxillo faciali, anestesisti del
settore)
Un totale di 13 casi fra 1974 e 1989

Risultati dell’analisi dei closed-claim delle morti anestetiche
nell’ambulatorioi dentistico
La maggioranza dei paz erano ASA status II o III.
Molti con patologie preesistenti:obesità patologica,mal
cardiache,epilessia,COPD………
Ipossia da ostruz delle vie aeree e/o depress resp la
causa + frequente
La maggior parte delle volte evitabili……
Estremi di età e ASA >1 indicano rischio
aum nel contesto dell’anest. office
dentistica!

Eventi dannosi in ufficio
0 10 20 30 40 50
%
eventi resp
probl cardiovasc
probl.attrezz
probl con farmaci
traumi da aghi
??
Errori di dosaggio,allergia,IM
Broncospasmo,depressione resp severa,ipossia,fallita o errata intubaz,ostruzione…

Mortalità in odonto

General Anesthesia in Dentistry da Nkansah PJ, Haas
DA, Sato MA. Mortality incidence in outpatient anesthesia for dentistry
in Ontario. Oral Surg Oral Med Oral Pathol 1997;83:647.
Poswillo
report

Anesthesia providers and hospital-based surgical procedures,1970-1996.
from Cromwell J. Barriers in achieving a cost-effective workforce mix: lessons from
anesthesiology. J Health Policy Law 1999;24:1333.

Linee guida della American Academy of Oral and
Maxillofacial Surgery (AAOMS)
Parameters and pathways: clinical practice guidelines for oral and maxillofacial surgery,
version 2.0. Philadelphia: W.B. Saunders, 1995
Parametri assistenziali che riflettono il consenso di gruppi di
praticanti(società,associazioni…) :strategie di trattamento dei pazienti,con
» Linee guida
» Criteri clinici
» Standard
» American Academy of Oral and Maxillofacial Surgery (AAOMS) e ASA :documentazione delle
sedazioni:
» Registrazione di tutti I farmaci,dosaggi,segni vitali,monitoraggi e sedi di iniezione parenterali
Parameters and pathways: Clinical practice guidelines for oral and maxillofacial surgery,
version 3.0. Philadelphia: W.B. Saunders, 2000
Revisione e aggiornamento ;
» Personale
» Documentazione
» Assistenza postop.
Sedazione aggiornata come “time-oriented anesthesia record" cioè documenta
farmaci,dosi;vie;monitoraggio (ECG,PA,SaO2)continuo con orari.

Linee guida della ASA per la sedazione 1996
Practice guidelines for sedation and analgesia by non-
anesthesiologists.Anesthesiology 1996; 84:459-471
Registrazione simultanea dei:
» livelli di coscienza
» funzione resp
» emodinamica
» prima,durante la procedura ad intervalli regolari,;nella fase di ripresa e al
momento della dimissione
Anche la chir maxillo faciale ha poi definito più precisamente I ciriteri per il
monitoraggio postop e la dimissione
Invece di “ segni vitali stabili prima della dimissione”
Ora specificamente raccomanda "determinazione e documentazione della
ossigenazione,ventilazione,circolazione e temperatura stabili prima della
dimissione”
Nel 2000 è stato stabilito che il chirurgo determini che “il paziente è ritornato al suo
stato basale fisico e mentale di prima dell’intervento e non è più a rischio di
depressione cardiorespiratoria”
In passato la formula era “il paziente risponde appropriatamente”

Personale aggiuntivo
1 persona preparata e competente per BLS
(il chirurgo deve essere ALS se somministra sedazione…)
2 persone con BCLS o equivalente in caso di AG
+ recentemente ASA e American Association of Pediatrics (AAP) hanno definito le
quqlifiche :AAPnelle linee guida ultime
Definisce la presenza oltre al chirurgo di una altra persona in caso di sedazione
profonda la cui unica responsabilità sia di osservare costantemente “i segni vitali del
paziente,la pervietà delle vie aeree e la’deguatzza della ventilazione e per
somministrare farmaci”
Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.
Pediatrics 1992;89:1110-1115
Nell’ ASA "Statement of Qualifications of Anesthesia Providers in the Office-Based
Setting," (1999),è scritto che"ASA believes that anesthesiologist participation in an
office-based surgery is optimally desirable as an important anesthesia safety standard
and will always support such a standard. It does not oppose however regulatory
requirements that, where necessary, speak merely in terms of `physician supervision‘”

Collaborazione su indicazioni per
pazienti in ambito OBS/OBA
ASA Committee on Ambulatory Surgical Care
Society for Ambulatory Anesthesia (SAMBA)
stanno sviluppando policies to safeguard the
increasing numbers
Anesthesia Patient Safety Foundation
Dipartimenti della salute e società di
anestesia locali per creare dei legami con le
società di accreditamento
interazione con American College of
Surgeons (ACS).

Cause di morte durante liposuzione.
Grazer F, deJong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr
Surg 2000;105:436-46.
Embolia polmonare 23%
Perforazione visceri addominali 14,6%
Anestesiologiche 10%
Embolia grassosa 8,5%
Insuff cardioresp 5,4%
Infez massiva 5,4%
Emorragia 4,6%
Sconosciuta o confidenziale 28,5%
Mortalità globale 19,1 per 100.000,ossia
1/5000

Complicazioni delle liposuzioni per area trattata
Grazer F, deJong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast
Reconstr Surg 2000;105:436-46.
72
39
3
14
8 6
addome
natiche,estr.i
nf
estr sup
dorso sup
dorso inf
testa,collo

Mortalità da liposuzione
.Grazer F, deJong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast
Reconstr Surg 2000;105:436-46.
sede Morti tot Morti % Sede chir %
office 62 47,7% 45%
Day surg 39 30% 29%
Sala op
ospedale
22 17% 26%
sconosciuta 7 5,4%

21 luglio 2000,UK.,eadings21 luglio 2000,UK.,eadings
Vietata AG nello studio dentisticoVietata AG nello studio dentistico
18 mesi di tempo per la transizione in
ambiente ospedaliero.
18 mesi di tempo per la transizione in
ambiente ospedaliero.

August 10, 2000, Florida Board
of Medicine
August 10, 2000, Florida Board
of Medicine
90 days moratorium on Office
surgery
90 days moratorium on Office
surgery
..."there is an immediate danger to
the health,safety and welfare of
patients"....
..."there is an immediate danger to
the health,safety and welfare of
patients"....

Conclusioni
In ambulatorio non si puo fare di tutto
Selezione dei pazienti
Selezione delle procedure chir;
– Selezione degli operatori………
–Il rischio clinico e le possibili sequele
medico legali sono maggiori!

Numeratore/denominatore:Casistica/co
mplicanze……..

Problemi dell'officeProblemi dell'office
L’anestesia è divenuta + sicura…L’anestesia è divenuta + sicura…
Migliorato monitoraggio(linee guida)Migliorato monitoraggio(linee guida)
Farmaci più sicuriFarmaci più sicuri
Conoscenza migliore dei rischiConoscenza migliore dei rischi
Aumentata disponibilità degli anestesisti(numerica….)Aumentata disponibilità degli anestesisti(numerica….)
Ma.....Ma.....
nell'office le risorse ospedaliere non ci sono!nell'office le risorse ospedaliere non ci sono!
Ed è la capacità ed esperienza del personale che garantisce la sicurezza!Ed è la capacità ed esperienza del personale che garantisce la sicurezza!

Cause di danno
MAC??
Errori da farmaci,in partic.oppioidi nei paz
ambulatoriali…..
Queste tendenze avvertono chir ed anest dei
rischi e chiedono che entrambi definiscano
bene quali pazienti e quali procedure siano
approriate per la struttura office…..
Si deve assolutamente evitare di soggiacere
alle pressioni economiche di
risparmio/guadagno ricorrendo alla office chir
!

Attività ASA e SAMBA:Task Force
on OBA
Attività ASA e SAMBA:Task Force
on OBA
Committee on ambulatory surgical careCommittee on ambulatory surgical care
ASA OBA guidelines 1999ASA OBA guidelines 1999
OBA Practice manual ottobre 2000OBA Practice manual ottobre 2000
ASA workshops su OBA:nov 1999,Luglio 2002ASA workshops su OBA:nov 1999,Luglio 2002
ASA OBA training workshops genn 2000,aprASA OBA training workshops genn 2000,apr
Legame con le principali associaz di certificazione e
scientifiche:JCAHO,AAHC,AAASF,ACS,ASPS,NPSF,MHAUS,FSMB,OIG….
Legame con le principali associaz di certificazione e
scientifiche:JCAHO,AAHC,AAASF,ACS,ASPS,NPSF,MHAUS,FSMB,OIG….

Office based anesthesiaOffice based anesthesia
sfida del nuovo millenniosfida del nuovo millennio
Gli standard assistenziali non devono essere
inferiori a quelli ambulatoriali o ospedalieri
Gli standard assistenziali non devono essere
inferiori a quelli ambulatoriali o ospedalieri
La sfida per gli anestesisti è quella di
trasportare l’esperienza e i modelli di pratica
acquisiti nelle sale op ospedaliere agli
ambienti office…
La sfida per gli anestesisti è quella di
trasportare l’esperienza e i modelli di pratica
acquisiti nelle sale op ospedaliere agli
ambienti office…

Criteri di selezione dei pazienti
Figure

Home -> Professional Resources
Since Sept. 1, 2000, physician's offices that do more than local anesthesia or sedation procedures have
been required to register with the Board of Medical Examiners (BME), pay a registration fee and comply with
certain rules.
Offices that are already accredited by the joint Commission on Accreditation of Healthcare Organizations,
the American Association for the Accreditation of Ambulatory Surgery Facilities, or the Accreditation for
Ambulatory Health Care are exempted.
The BME has adopted the ASA standards and guidelines (see http://www.asahq.org). Therefore, the same
safety measures used in hospitals are incorporated into the office setting. The following are highlights of
the rules:
preoperative evaluation,
informed consent (including informing the patient if care is shared with other non-physician providers),
intraoperative monitoring,
secondary power source in the OR,
properly serviced and maintained equipment with service logs for 7 years,
emergency drugs and equipment for CPR and malignant hyperthermia,
transfer agreements in case of emergency.
In addition, the operating surgeon or anesthesiologist shall maintain current competency in ACLS or
PALS. At a minimum, at least two persons, including the surgeon or anesthesiologist, shall maintain current
competency in basic life support.
Physicians must notify the board within 15 days if a procedure performed results in an unanticipated and
unplanned transport of the patient to a hospital for observation or treatment for a period in excess of 24
hours, or a patient's death intraoperatively or within the immediate postoperative period. Immediate
postoperative period is defined as 72 hours.
The Board of Medical Examiners voted to adopt the proposed rules at its meeting on March 31, 2000.
Download the BME rules:

Sistema raccomandato per valutazione preop.
(ASA task force on preanesthesia evaluation)
CATEGORIA
CHIRURGICA υ
1 2 3 4 5
CLASSE
ANESTETICA:
π
1 giorno intervento giorno intervento giorno intervento Medico curante
prima del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
2 giorno intervento giorno intervento Medico curante
prima del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
3 Medico curante
prima del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
4 Medico curante
prima del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento

Valutazione preoperatoria:
flow chart
p a z s a n o
s p e c i a l i s t i c a g e n e r a l e
c o n s u l e n z a m e d i c a
p a z a m m a l a t o
e s a m i d i l a b
e c g
R X
S c r e e n i n g p r e o p e r a t o r i o
c o m p u t e r i z z a t o
C h i r u r g o : p a t o l o g i a c h i r u r g i c a
t i p o d i i n t e r v e n t o
Valutaz.anestesiologica

Utilizzo di un questionario come screening tool
1 Have you ever had a heart attack?
2 Have you ever had heart trouble?
3 Have you ever had heart failure?
4 Have you ever had fluid in your lungs?
5 Do you have a heart murmur?
6 Did you have rheumatic fever as a child?
7 Do you ever have chest pain, angina, or chest tightness?
8 Have you ever been treated for an irregular heart beat?
9 Do you have high blood pressure?
10 Do you ever have difficulty with your breathing?
11 Do you have asthma, bronchitis, or emphysema?
12 Do you cough frequently?
13 Does climbing one flight of stairs make you short of breath?
14 Does walking one city block make you short of breath?

Utilizzo di un questionario come screening tool
15 Do you now or have you recently smoked cigarettes? If yes, how many packs per day?
For how many years?
16 Do you have liver disease, or a history of jaundice or hepatitis?
17 Do you drink more than three drinks of alcohol per day? If yes, how many per week?
18 Do you have indigestion, heartburn, or a hiatus hernia?
19 Do you have a history of thyroid problems?
20 Do you have diabetes?
21 Do you have a kidney problem?
22 Do you have numbness or weakness of your arms or legs?
23 Do you have epilepsy, blackouts, or seizures?
24 Have you had problems with blood clots, or excessive bleeding?
25 Do you have any other important medical problems? Please list.
26 Have you ever had an anaesthetic? If yes, when was your last one?
27 Have you or any member of your family had a reaction to an anaesthetic?
28 Do you have arthritis or pain in your neck or jaw?
29 Do you have dentures, capped or loose teeth?
30 Do you think you may be pregnant?
31 Have you taken prednisone, steroid medication, or cortisone-like drugs in the past year?
32 Please list any food or medication allergies that you have:
33 Please list any medications you are currently taking:
34 Please list any operations you have had in the past:
35 If this is the day of surgery, when did you last eat or drink?

Preop process modelPreop process model
from the Cleveland Clinic Foundationfrom the Cleveland Clinic Foundation
Demographics
and type of
surgery
Demographics
and type of
surgery
Computer assisted
Health screening
Computer assisted
Health screening
Lab,EKG,RXLab,EKG,RX
surgery team
H&P+lab follow
upew Sub-Point
surgery team
H&P+lab follow
upew Sub-Point
NewGen.Int
Med concult
NewGen.Int
Med concult
medic.spec.consultation
medic.spec.consultation
Surg.office
health
y unhealthy
Express criteria satisfied
Day of
surgery
yes
no
Preop
anesth
cleara
nce

Consenso e disposizioni pre e
postop.
Gentilissimo sig………………..
come il collega chirurgo dott…………………..Le avrà già spiegato,per la riuscita
ottimale dell’intervento è importante attenersi scrupolosamente alle raccomandazioni elencate che la preghiamo di
leggere,firmare,e conservare per il giorno dell’intervento,quando la riconsegnerà compilata
all’anestesista.RingraziandoLa anticipatamente della collaborazione,
-----------------------------
Si prega di leggere attentamente e riempire con i dati richiesti lo spazio sopra i puntini(data,città, nome,
cognome,intervento,firma).
Data:………………….
Città:………………….
Io sottoscritto……………………………………………………….
acconsento che l'intervento di …………………………………………………………………..
venga eseguito in anestesia generate e /o locale come spiegato dall’anestesista dott……………………...
Dichiaro di attenermi alle seguenti disposizioni:
I)non ho assunto alcun cibo nelle 6 ore precedenti l'intervento,ne' liquidi nelle due ore
precedenti;(quindi liquidi quali bevande non alcooliche,the zuccherato,coca cola,ecc sono consentiti)
2)di non guidare alcuna automobile o motocicletta o bicicletta, od utilizzare qualsiasi
macchinario nelle 24 ore seguenti I'anestesia,
3)di non assumere alcoolici nelle 24 ore seguenti l'anestesia;
4)di farmi riaccompagnare alla mia residenza da un adulto responsabile;
5)di rimanere in compagnia di un adulto responsabile una volta tornato al domicilio;
6) di non assumere alcuna decisione importante ne' firmare documenti
importanti(testamento,assicurazioni ecc.)nelle 24 ore seguenti;
7)di vestirmi in modo pratico il giorno dell’intervento ,cosicchè il vestiario possa essere facilmente rimosso e
indossato e riposto in un armadietto;

Questionario postoperatorio I e II
giornata

THANK YOU FOR YOURTHANK YOU FOR YOUR
ATTENTIONATTENTION

FINE II

Rao, R. B., Ely, S. F., Hoffman, R. S. Deaths related to
liposuction. N. Engl. J. Med. 340: 1471, 1999

There are three basic types of outpatient surgical
facilities: (1) the hospital controlled ambulatory facility;
(2) the free-standing ambulatory surgical facility; and
(3) the surgical suite in the physician's office.
Selection criteria in the office setting
Can we perform any kind of surgical procedure in the
office? The answer is no. The selection criteria in this
setting are similar to standard ambulatory surgery.
However, liability and risk office-based practice are
greater, compared to the other types of outpatient
surgical facilities (hospital controlled ambulatory
facility and free-standing ambulatory surgical facility).

Domino, KB: Office-Based Anesthesia: Lessons Learned from
the Closed Claims Project. ASA Newsletter 65(6): 9-11, 15, 2001.
Budget-driven decision-making threatens the safety of office-based
surgery. Anaesthesia has become remarkably safe because of several
factors, including improved monit-oring, safer drugs, heightened
awareness of anaesthetic risks, and perhaps most importantly, the
increased availability of anaesthesiologists [31••]. In an office, where the
hospital resources of emergency personnel and equipment are
unavailable, it is the training of the personnel providing the anaesthesia
which ensures patient safety. Whereas most office anaesthesia is MAC
and therefore might appear to be less dangerous than general
anaesthesia, data from the USA closed claims project indicate a rising
percentage of claims after MAC in the 1990s [29••]. A sobering statistic
is the increase in medication error deaths in the USA caused by
anaesthetic and analgesic (primarily opioids) drugs in outpatients over
the decade between 1983 and 1993 [32•]. These trends warn the
anaesthesiologist and surgeon of the increased risk of office-based
anaesthesia, and demand that both the surgeon and anaesthesiologist
agree on which patients and which procedures are appropriate for their
facility. Compromising patient safety because of pressures to perform
relatively inexpensive office surgery must be scrupulously avoided.

Procedures performed under MAC in the informal
setting of the physician's office require heightened
vigilance by the anaesthesiologist. A review of the
ASA closed claims project database revealed that
claims involving MAC have increased from 1.6% of
the total claims in the 1970s to 6% in the 1990s [29••].
The severity of these claims is similar to those
occurring under general anaesthesia, including death
(34%) and permanent brain damage (19%). Overall,
the data from this project suggest that improved
monitoring, notably pulse oximetry and end-tidal CO2
detection, has decreased patient morbidity, as
reflected by a decrease in ventilatory complications
relative to cardiac complications [30•].

Patients filing claims for adverse anesthesia
events in the office-based setting exhibited
similar demographic characteristics to patients
filing claims in other ambulatory settings
[Table 1]. Most were middle-aged, ASA
Physical Status 1 or ASA Physical Status 2
women undergoing elective surgery under
general anesthesia. Dental and plastic
surgery were the most common procedures
performed in the office-based group. Both
ambulatory groups were generally younger
and healthier than inpatients in the Closed
Claims database.2

Severity of Injury
The severity of injury for office-based claims was greater than for
other ambulatory anesthesia claims [Figure 1]. Most (62 percent)
ambulatory anesthesia claims were for a temporary and
nondisabling injury, compared to 21 percent of office-based
claims (P <0.01). In contrast, 64 percent of office-based
claims were for death, compared to 21 percent of
ambulatory anesthesia claims (P <0.01). Although these
data may reflect decreased patient safety in the office-based
setting , the lack of denominator data (e.g., the number of
cases performed in each setting) prevents the estimation of
risk or safety. In addition, the data may reflect a difference
in patient liability profile and propensity to sue in the office-
based versus ambulatory care settings.

Mechanism of Injury
The "damaging event" is the particular aspect of anesthesia management that led
to patient injury. The most common damaging events in the Closed Claims
database overall (including inpatient and pain claims) are respiratory system (22
percent), cardiovascular system (11 percent) and equipment-related (10 percent)
events. The damaging events in office-based claims involved mostly respiratory
system events (50 percent) and drug-related events (25 percent) [Table 2]. The
respiratory system damaging events in office-based claims included airway
obstruction, bronchospasm, inadequate oxygenation-ventilation and esophageal
intubation. The drug-related damaging events included wrong dose or drug,
malignant hyperthermia and allergic drug reaction. Although there was a trend for
an increase in respiratory system events in the office-based claims compared to
other ambulatory anesthesia claims, this difference was not statistically
significant [Table 2]. The injury in office-based claims against anesthesiologists
occurred through intra-anesthesia in most claims (64 percent), in the recovery
phase in 14 percent and after discharge in 21 percent of claims. The location of
the damaging event was similar in other ambulatory anesthesia claims, although
there was a trend for fewer injuries occurring after discharge (7 percent of
ambulatory claims).

Preventability of Injury
In contrast to injuries in ambulatory anesthesia
claims, a higher proportion of injuries in office-based
claims were judged by the Closed Claims reviewers
as being potentially preventable by better monitoring
[Figure 2]. More than 46 percent of office-based
injuries were judged to be preventable by better
monitoring, in contrast to only 13 percent of
ambulatory anesthesia claims (P<0.01). All the
potentially preventable office-based injuries resulted
from adverse respiratory events in the recovery or
postoperative periods, which were judged to be
preventable by use of pulse oximetry. This profile is
quite different from injuries occurring during other
ambulatory anesthesia claims.

Liability and Payment
There was a trend to judge the anesthesia care as sub-standard more frequently
in the office-based claims than in other ambulatory claims. Fifty percent of office-
based claims had received care that was clearly substandard compared to 34
percent of ambulatory anesthesia claims (difference not statistically significant).
Although anesthesia care met standards in 36 percent of office-based claims,
postoperative care after discharge was substandard in several of these claims.
Payment was made in a greater proportion of office-based claims than
ambulatory claims (92 percent versus 59 percent, respectively [Table 3]). In
addition, the payment amounts were greater for office-based claims (median
payment of $200,000) than for other ambulatory anesthesia claims (median
payment of $85,000). This is not surprising since the payment amount correlates
with severity of injury, and office-based claims involved more severe injuries. 3
There was, however, a broad range of payment in both groups reflecting patient
demographics, severity of injury, standard of care and regional differences (Table
3). In summary, office-based claims (although few in number due to the delay in
entering the database) had a greater severity of injury and higher proportion and
amount of payment than claims from other ambulatory anesthesia settings. In
addition, a greater proportion of injuries in office-based claims were judged to be
preventable by monitoring, especially in the postoperative period. These
preliminary data suggest that safety efforts involving office-based
anesthesia should focus on improving care in the recovery and
postoperative phases.

Caratteristiche generali degli standard e linee guida
utili per anestesia

Harvard University Hospitals in Boston [3]. These patient care
practice guidelines were followed by the development of
Standards for Basic Intraoperative Monitoring by the American
Society of Anesthesiologists [4]. The standards were promoted
as uniform practice guidelines for anesthesia care. In an effort to
standardize clinical monitoring during anesthesia care across the
country, these guidelines were applied to the operating room and
any other alternative sites where anesthesia care would be
delivered. As well as the standard monitoring of
electrocardiography, pulse rate and blood pressure,
capnography, pulse oximetry and temperature monitoring also
became national standards. Individual practice site requirements
were also defined (Table 2). It is vital that each anesthesia care
site meet established standards. General ethical and responsible
practice metho-dologies were presented in the American Society
of Anesthesiologist's Guidelines for the Ethical Practice of
Anesthesiology [5]. The guidelines are also independent of site.

The Joint Commission on Accreditation of Healthcare Organizations
mandates one uniform standard for anesthesia care in all locations
within a healthcare facility, including operating rooms and alternative
sites. ‘The standards ... apply when any patients, in any setting, receive,
for any purpose, by any route, general, spinal, or other major regional
anesthesia; or sedation (with or without analgesia) for which there is
reasonable expectation that in the manner used the sedation/analgesia
will result in the loss of protective reflexes for a significant percentage of
a group of patients.’ [5]. The Director of Anesthesiology has complete
facility-wide responsibility for the quality of anesthesia care provided
whether delivered by an anesthesiologist or other provider. The
American Society of Anesthesiologists has also developed guidelines for
non-anesthesiologists providing sedation and analgesia both inside and
outside the operating room (Table 3) [6]. Guidelines have been
developed by other medical and dental organizations for the care of
patients undergoing procedures requiring sedation or anesthesia [7-11].
These include endoscopic procedures by gastroenterologists,
electroconvulsive therapy by psychiatrists, and invasive procedures
performed on pediatric patients. The Academy of Pediatrics was one of
the first professional organizations to develop guidelines for the
administration of sedation by its members

Although there have often not been specific, new policies developed for
anesthesia care in alternative sites, the World Wide Web has provided
widespread availability and easy dispersion of patient care policies and
guidelines already in place. Both the Canadian Anaesthetists' Society (Guidelines
for the Practice of Anaesthesia Outside a Hospital [12•]) and the Australian and
New Zealand College of Anaesthetists have developed policies for alternative
site anesthesia care [13] for patient monitoring, anesthetic equipment, sedation
for specific procedures and patient recovery.
It is clear that guidelines for anesthetic practice must provide the same quality of
patient care for patients being cared for outside the operating room as for those
undergoing operating room care. This includes all aspects of patient care,
including pre-procedural evaluation and post-anesthesia care and recovery. The
care standards must be uniform even if alternative sites do not have dedicated
recovery facilities and personnel. The American Society of Post-Anesthesia
Nurses has guidelines requiring one-to-one nursing for patients requiring life
support (mechanical ventilation, vasopressors) with a second nurse available,
and one-to-two nursing for stable cases after major procedures and for pediatric
patients [14]. One-to-three nursing is appropriate for uncomplicated adults. In
most countries, the Department of Anesthesia has overall administrative
responsibility for recovery facilities. Not only must recommended national
physician organizational guidelines be met, but all facilities must also conform to
hospital standards developed and published by national standards organizations.

Etichettatura delle siringhe!!!

Principi fondamentaliThe fundamental principle that must govern OBA is that patient safety cannot be sacrificed for any of the aforementioned
four major considerations—i.e., the standard of anesthetic care does not decrease because of venue change (11). Indeed,
because OBA is a subset of ambulatory anesthesia, the ASA guidelines for ambulatory anesthesia and surgery as well as
the more recently adopted guidelines for office-based anesthesia must be followed. The two sets of guidelines emphasize
the need for
1.Adequate professional and administrative staff, as well as housekeeping and maintenance personnel.
2.Preoperative evaluation with necessary tests and consultations as medically indicated.
3.The development of an anesthesia plan acceptable to the patient, the administration or medical direction of same, as well
as the discharge of the patient remain physician responsibilities.
4.Patients who receive other than unsupplemented local anesthesia must be discharged with a responsible adult and
provided written postoperative and follow-up instructions.
Because the office facilities vary considerably, anesthesiologists must ensure that the facility is adequately equipped, with
the following as a minimum:
5.Sufficient space and electrical outlets plus adequate illumination must be provided, including backup power (this is listed
first because space is something for which anesthesiologists frequently must fight in the office as well as the hospital or
ASF).
6.A reliable source of oxygen adequate for the length of the procedure plus a backup supply, the latter to be at least
equivalent to an E cylinder, and the ability to administer positive pressure ventilation.
7.Emergency cart with defibrillator and appropriate drugs.
8.A reliable source of motor-driven suction.
9.If inhaled anesthetics are to be used, an anesthesia machine equivalent to that of the hospital operating room and a
system for scavenging waste anesthetic gas must be available.
10.Basic monitoring of oxygenation (pulse oximetry), ventilation (minute ventilation for general anesthesia and capnography
for intubation), circulation (blood pressure every 5 min and continuous electrocardiogram display), and temperature (when
clinically significant changes in temperature are intended, anticipated, or suggested) is essential.
11.All applicable building and safety codes and facility standards must be observed and federal, state, and local laws
obeyed.

Principi fondamentali 2
Less obvious, but equally important, is the need to review
policies and procedures, including transfer protocols in the event
that hospitalization is required. Similarly, the capabilities of both
the facility and the surgeon must be equal to the task of handling
the proposed procedure.
Moss (12), who led the fight to regulate OBA and surgery in New
Jersey, has addressed the issue of cost required to meet
reasonable standards: “The $2500 pulse oximeter or the
$15,000 refurbished anesthesia machine spread over years of
use and thousands of patients makes the per-patient cost
insignificant.” He also emphasized the need for complete
evaluation of an office before agreeing to provide OBA. Although
physical plant, anesthesia equipment, and monitors are obvious
considerations, support staffing, capability of the surgeon, facility
protocols, and policies must also be evaluated.

Raccomandazioni ASA,ASAPS e
ASPS
1. Be accredited by a national or state recognized
accrediting agency/organization such as the American
Association for Accreditation for Ambulatory Surgery
Facilities (AAAASF), Accreditation Association for
Ambulatory Health Care (AAAHC), or the Joint
Commission on the Accreditation of Healthcare
Organizations (JCAHO).
2. Be certified to participate in the Medicare program
under Title XVIII.
3. Be licensed by the state in which the facility is
located.
regular inspections and report to their state agencies,
provide ongoing staff training, credential their
personnel, and have emergency equipment on hand
such as crash carts.

Porterfield and Franklin Porterfield HW, Franklin LT.
The use of general anesthesia in the office
surgery facility. Clin Plast Surg 1983;10:289-
294. reviewed their 16 years of experience in office-based
plastic surgery procedures. They performed 13 080 cases under
local anesthesia with or without sedation and 5038 under
general anesthesia. They concluded that to maintain a low
admission rate of 0.02% it is essential to have adequate and
rational selection criteria, based on the patients' medical health
and the surgical procedure. They included ASA I or II patients
and procedures without extensive blood loss which were
completed within a time frame that allowed the patient to awaken
adequately and leave the facility by late in the afternoon [10].

Davis [11] Davis JE, Sugioka K. Selecting the
patient for major ambulatory surgery. Surgical
anesthesiology evaluations. Surgical Clinics of
Northamerica 1987;67(4):721-732 selected surgical
procedures based on the intensity of postoperative surgical care. He
divided the surgical procedures into four levels (I-IV) (Figure 1) [11].
Those procedures appropiate for office-based surgery and anesthesia
belong to level I, where no postoperative care is needed. However, the
line of demarcation can shift to the right, and surgical procedures
belonging to level Ia or II can be included in the office, depending on the
surgical and anesthetic skills, on the office-resources, on the proximity
to a hospital and, most importantly, on the patient's medical health. This
means that surgical procedures performed in the office can belong
either to level I, Ia or II. Tobin also considered that the extent of the
surgery should be determined more by the nature of the recovery period
than by the surgical procedure itself and patients should be in excellent
health with no significant medical problems [2].

Limits of the office setting
Why is it so critical to perform an adequate selection of the
patient and the surgical procedure? Because there are of course
some limits in the office setting. First, based on the limited scope
of the office-unit (as well as in the free-standing facility), both the
staff and medical capabilities are less extensive than those
within a hospital. Second, the service is likely to be available on
limited basis. Urgent care would be referred to an hospital
emergency department. Finally, the office surgical suite is
designed to treat patients whose stay is normally less than 4 h. It
is not designed to ‘even occasionally’ hold a patient for a 24-h
observation (such as in a free-standing unit or a hospital). In
those exceptional cases, the patient would be referred to a
hospital of reference (Figure 2) [9].

Figure

Diapo della aggressività interventi da
anest ambulat e schemi per ospedale

Mortalità durante OBA
1.A 3-yr-old boy developed a seizure followed by cyanosis during laser removal
of port wine stains. No oxygen was available.
2.Malignant hyperthermia occurred in a 28-yr-old woman having breast
augmentation. Temperature was 107°F (41.67 °C) on arrival in the emergency
room. No dantrolene was available.
3.A 51-yr-old man underwent a 9.5-hr combined liposuction, penile enlargement,
and face-lift. He was kept in the office overnight under the care of an agency
nurse, who noted 2 h later that the patient was in respiratory distress and that the
oxygen tank was empty. Paramedics were contacted 30 min later. Not
surprisingly, the patient was dead on arrival at a local hospital 40 min later.
Se queste procedure fossero state effettuate in un unità di day surg o
ospedale………………………
IL probl ha preso tanta cosnsistenza che The risks associated with OBA were
considered so great in the United Kingdom that, on July 21, 2000, the
administration of general anesthesia in a dentist’s office was banned. Dentists
and oral surgeons were given 18 mo to transition their practices to a hospital
setting. Considering the emphasis on cost-containment by governmental
agencies, the decision to move patients to the more expensive hospital setting
must reflect great concern of the United Kingdom authorities concerning the OBA
risk to patients.

Morti in ufficio……..
10San Francisco Examiner 17 August
1993. [Context Link]
11The San Diego Tribune 13 January
1989. [Context Link]

Medicina preventiva vs
trattamento delle complicanze
Preventive medicine is always preferable to rescue
from complications. In addition to adhering to the
standards summarized above, careful patient
selection is the best way to avoid complications. In
particular, patients with comorbid disease, especially
chronic obstructive pulmonary disease, epilepsy,
heart disease, and obesity, must be evaluated
carefully and completely, so specialty consultation can
be included when indicated. When in doubt, referral of
these patients to a more complete facility than a
surgeon’s office is strongly advised, even though such
a decision may produce friction—even an acrimonious
confrontation—with the referring surgeon, the patient,
or both.

Many surgeons administer intravenous sedation, but for procedures requiring general or regional anaesthesia, they seek the assistance of an anaesthesiologist
or certified registered nurse anaesthetist (CRNA) [12•]. The CRNA is often the surgeon's choice if, in the surgeon's opinion, the procedure requires only a slightly
deeper level of sedation than the surgeon is accustomed to administering himself. For procedures requiring general anaesthesia in the USA (except New
Hampshire), the anaesthesia is administered by an anaesthesiologist, a CRNA supervised by an anaesthesiologist, or a CRNA supervised by the surgeon. In
most other developed countries such as Australia or the UK, a specialist anaesthetic medical practitioner must be present if general anaesthesia is administered.
Anaesthetic techniques
The range of anaesthetic techniques in office-based practice is the same as in hospital-based practice, especially ambulatory surgery. The overriding concern is
rapid discharge. Recovery facilities and personnel in the office setting are usually incapable of monitoring patients who are heavily sedated, have a long-lasting
spinal block, or are suffering from severe pain or nausea. The majority of office-based anaesthesia is monitored anaesthetic care (MAC). Improvements in
monitoring capability, notably continuous pulse oximetry and expired CO2 display, provide the anaesthesiologist a better understanding of the patient's response
to sedative and analgesic medications [13•]. Today's anaesthesiologist can more safely provide deep levels of sedation in appropriate patients, however, as in any
anaesthetizing location, the critical threshold of patient unresponsiveness must not be crossed unwittingly. An anaesthesiologist can deliberately breach the
boundary between MAC and general anaesthesia in appropriate patients if airway equipment is available and both the patient and the surgeon understand the
risks. For procedures requiring general anaesthesia in the office, the laryngeal mask airway is a significant technological improvement, not only for routine use but
also for the emergency ventilation of patients with an unanticipated difficult airway [14].
Anaesthetic drugs
The close control offered by rapidly acting and rapidly eliminated drugs is especially useful in the office setting. Midazolam, propofol, ketamine, and methohexital
are the sedative hypnotics we use. A propofol infusion combined with an opioid and sometimes midazolam or ketamine provides an easily adjusted depth of
sedation or general anaesthesia [15,16]. A new short-acting benzodiazepine, Ro 48-6791, is being developed and might play a role in office-based anaesthesia
[17].
Analgesics administered in office-based anaesthesia include non-steroidal anti-inflammatory drugs and opioids. A short period of relatively profound intraoperative
analgesia can be produced using fentanyl, alfentanil, or remifentanil. In the US, remifentanil is infused for both MAC and general anaesthesia, but in Australia it is
approved for use only in artificially ventilated patients. There is no major difference between these drugs in the speed of recovery after relatively short
anaesthetics; however, recovery from longer anaesthetics should be significantly faster using remifentanil [16]. The haemodynamic response to surgical stimuli is
suppressed better by remifentanil than by alfentanil, so remifentanil might be preferable in patients at risk of myocardial ischaemia [18]. When administering
remifentanil, provision for postoperative analgesia must be made because pain is one of the chief reasons for delayed discharge from ambulatory surgical
centres, and is the third most common reason for return hospital visits [19,20]. Although the respiratory depression and nausea associated with opioids can be
particularly troublesome in the office setting (where postoperative care of a patient can delay the following cases), parenteral or oral opioids are the mainstay of
postoperative analgesia.
The use of muscle relaxants in office-based surgery is the same as in any ambulatory surgical setting. A rapid-onset short-duration non-depolarizing
neuromuscular junction blocking drug, ORG 9487, is being developed and might prove ideal for office-based anaesthesia [21].
Inhalational agents are playing an increasing role in office anaesthesia as anaesthesiologists move into this practice. Offices must provide suction for scavenging
volatile anaesthetics or the anaesthetic machine must have a charcoal filter. Sevoflurane and desflurane potentially offer a rapid emergence [22,23], an attractive
feature in office-based anaesthesia, but these agents are associated with a higher incidence of emergence delirium [22,23]. This delirium can be disquieting for
other patients and can tax the limited personnel available in the office setting. Sevoflurane has remarkable cardiovascular stability and is significantly less irritating
to the airway than the other halogenated agents [24,25]. If choosing a single halogenated agent for office-based anaesthesia (a reasonable possibility in order to
minimize equipment weight and bulk) sevoflurane is a logical choice.
Equipment and facilities
Anaesthesiologists must be circumspect when asked to provide anaesthesia in a new office location [26]. They assume responsibility for the equipment, facilities,
and drugs required to provide safe anaesthesia, and must develop a contingency plan for equipment or power failure. A reliable means of transporting a patient to
the nearest hospital in the event of a disaster should be outlined, and the hospital emergency room director should be made aware of the plans to provide
anaesthesia in the office.
Physiological monitoring of the patient must meet or exceed the relevant local standards for anaesthetic monitoring [27,28]. Procedures performed under MAC in
the informal setting of the physician's office require heightened vigilance by the anaesthesiologist. A review of the ASA closed claims project database revealed
that claims involving MAC have increased from 1.6% of the total claims in the 1970s to 6% in the 1990s [29••]. The severity of these claims is similar to those
occurring under general anaesthesia, including death (34%) and permanent brain damage (19%). Overall, the data from this project suggest that improved
monitoring, notably pulse oximetry and end-tidal CO2 detection, has decreased patient morbidity, as reflected by a decrease in ventilatory complications relative

Cause della insufficienza
rianimativa
Attrezzature di rianimazioine inadeguate
Monitoragio insufficientemspecie
puilsossimetria
Erore umano
Lento riconoscimento dell’evento
Mancanza di esperienza
Sovradosaggio gfarmacologico
Inadeguata valutazione preop.
Inadeguiata valutaz postop

Qualificazioni mediche
Specializzazione
Partica ospedlaiera nella discipilina
Possibilità di ricovero?

Surgical Facility Standards
Plastic surgery performed under anesthesia, other
than minor local anesthesia and/or minimal oral
tranquilization, should be performed in a surgical
facility that meets at least one of the following criteria:
* accredited by a national or state-recognized
accrediting agency/organization such as the American
Association for Accreditation of Ambulatory Surgery
Facilities (AAAASF), the Accreditation Association for
Ambulatory Health Care (AAAHC), or the Joint
Commission on Accreditation of Healthcare
Organizations (JCAHO)
* certified to participate in the Medicare program
under Title XVIII
* licensed by the state in which the facility is located.

Patient Safety in Office-Based Surgery
Facilities: II. Patient Selection
[COSMETIC SECTION: COSMETIC
SPECIAL TOPIC]
Iverson, Ronald E. M.D.; Lynch, Dennis
J. M.D.; ASPS Task Force on Patient
Safety in Office-based Surgery Facilities

Selezione dei pazienti
preoperative patient history should include personal
health history, identification of comorbidities, social
history, family history, medication regimen
(prescription and nonprescription), allergies (drug,
latex, tape) and reaction, review of the body systems,
and availability of a responsible adult to assist with
postoperative instructions and care. The physical
examination is essential for assessing the patient’s
clinical status preoperatively and should include an
estimate of general health and appearance;
measurement of height and weight; assessment of
vital signs, including the heart and lung; and an
examination of the anatomical area of the surgery. A
sample preoperative history and physical form is
shown in

Questionario…

identifying comorbidities that are relevant to the
procedure or that may predispose the patient to
intraoperative or postoperative complications. When
evaluating the patient, particular attention should be
given to factors such as age, weight, and history of
other illnesses, including diabetes mellitus, cardiac
diseases, and respiratory conditions. The physician
should evaluate the patient for a history of (or
potential for) venous thromboembolism, and when
indicated, should consult the appropriate ASPS
Practice Advisory and/or Clinical Practice Guideline
for thrombosis risk ratings and thromboprophylaxis
measures. 3,4 The surgeon should refer patients with
significant comorbidities to medical specialists when
indicated.

On the basis of the patient’s preoperative history and physical examination
results, pertinent tests should be ordered, including:
electrocardiogram in patients over 45 years of age
electrocardiogram at any age when known cardiac conditions are present
complete blood count/blood chemistries, as needed, for detailed evaluation of
specific diagnosis, such as anemia, diabetes mellitus, hypertension, diuretic
therapy
additional tests as appropriate, depending on the patient’s status as
determined through the medical history and physical examination or because
of the specific procedure being performed (see ASPS Clinical Practice
Guideline for specific procedures; http://www.plasticsurgery.org/psf/
psfhome/clinprac/index.htm).

The ASA House of Delegates approved “Guidelines for Office-
Based Anesthesia” in October of 1999
(http://www.asahq.org/ProfInfo/offbasedguide.htm ). These
comprehensive guidelines focus on the delivery of safe
anesthesia care in doctor’s offices by anesthesiologists and
certified registered nurse anesthetists. The ASA Task Force on
Office-Based Anesthesia has recently created a manual that
provides practical advice for surgeons and anesthesiologists
interested in setting up and maintaining a safe office-based
surgery environment. The ASPS and ASAPS have taken an
unprecedented stance by mandating that all outpatient plastic
and cosmetic surgery must be done in an accredited facility.
Over a 3-year period that began in June of 1999 and will end in
July of 2002, members must transition to perform outpatient
surgeries in accredited and/or licensed facilities that meet at
least one of the following criteria 2,3

Conclusioni
La oba sta crescendo rapidamente ed è necessario regolamentarla come hanno
fatto alcuni stati USA California, Florida,e New Jersey,Tezxas :I dugbbi sorti circa
la qualità dell’assistenza devono essere dissolti da regolamentazioni appropriate
e ragionevoli che coinvolgano i professionisti consnetano La scelta di eseguire
interventi in ambulatorio piuttosto che in strutture più attrezzate deve basarsi su
considerazioni tecniche legate alal propria professionalità ed allo stto fisico del
paziente piuttosto che su consideraziomni economiche.La costo effiacci è soloiun
fattore e devono prevalere considerazioni di qualità e scicurezza Negli USA è
stata fondata ed è attiva una società (Society for Office-Based Anesthesia)che ha
lo scopo di milgiorare continuamente la qualkità dell’assistenza e e la sicurezza
dei pazienti e iniziative analoghe devono esser intraprese in Italia per la
salvagiardia dei cittadini,mma anche dei professionisti
E’ probabile che il sistema assicurativo debba farsi carico anche della OBS e
OBA e non posa necesasriamente proporre tariffe basse
Per il mioguioramento dellapartica cgirurgica ed anestesiologica ambulatoriale è
necassrio seguire delel linee guida nazionali ed internazionali e formare dei
professionisti esperti in questo settore ,cher non può che essere un continuum
assistenziale che riguarda tutto il perioepratorio

Diapo di esempi attrezz e monitor….

Office based anesthesia complications

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