The Society for Ambulatory Anesthesia: 18th Annual Meeting Report

The Society for Ambulatory Anesthesia (SAMBA) 18th Annual Meeting was presented in conjunction with the Fifth International Congress on Ambulatory Surgery held May 8–11, 2003, in Boston, MA. The Congress was co-hosted by SAMBA and the Federated Ambulatory Surgery Association and presented by the International Association for Ambulatory Surgery (IAAS). The event provided an outstanding international educational and cultural experience with a wider selection of program topics for the members of the involved organizations to attend. Rebecca S. Twersky, MD, (Brooklyn, NY) organized the anesthesia track of the program. More than 60 educational sessions, including multidisciplinary panels and specialty breakout sessions, plus optional workshops, were featured in this in-depth program. Scientific poster sessions presented information on recent research in anesthetic management, surgical management, patient safety, and quality improvement as well as business operations management. Highlights of the meeting included the presentation of the IAAS Nicoll Memorial Lecture delivered by SAMBA Past President Burton S. Epstein, MD, (Washington, DC) who addressed the audience on “Exploring the World of Ambulatory Surgery.” Dr. Epstein became the fourth person to have this honor bestowed upon him by the international community of ambulatory surgery. The lecture is named after James H. Nicoll, MB, a pioneer of modern day surgery, who first described pediatric day case surgery in 1909 and performed 8988 operations as day cases at the Royal Glasgow Hospital in Scotland. Another meeting highlight was the presentation of the SAMBA Distinguished Service Award to Raafat S. Hannallah, MD, (Washington, DC) in recognition of his lifetime of outstanding contributions and distinguished service to the specialty of ambulatory anesthesia. The anesthesia track of the program began on Wednesday, May 7, with an Advanced Cardiac Life Support workshop, which continued on Thursday, May 8. On Thursday, May 8, two 3-h workshops on difficult airway management were presented by course director Andrew Herlich, DMD, MD, (Philadelphia, PA) accompanied by Robert G. Krohner, DO, (Pittsburgh, PA), Brian M. Parker, MD, (Cleveland, OH), and Linda I Wat, MD (Loma Linda, CA). The ambulatory anesthesia track on Friday, May 9, began with a 2-h panel session titled “Sedation Analgesia in the Ambulatory Setting: Where Are We Now and Where Are We Going?” Burton S. Epstein, MD, (Washington, DC) was the moderator for this multidisciplinary panel, which presented an understanding of the concept of sedation/analgesia in an outpatient or remote setting, the current drugs and techniques, and the implications for anesthesia management. Walter G. Maurer, MD, (Cleveland, OH) led a discussion titled “Sedation/Analgesia in the Ambulatory Setting: From Local Standby to ‘Big MAC’.” He described the continuum of sedation and emphasized that the new era of using deep sedation is rapidly developing. Therefore, it is required to prevent the potential hazards of entering a state deeper than originally intended. He described the use of combinations of propofol and remifentanil. He suggested that the sedation/analgesia techniques should be cost-effective not only with respect to drug costs, but also with respect to the duration of hospital stay as well as patient and surgeon satisfaction. This talk was followed by a presentation by Greg Zuccaro, MD, (Cleveland, OH) who spoke on “Sedation and Analgesia for the Gastroenterologists.” He provided us a gastroenterologist’s perspective of sedation for gastrointestinal endoscopic procedures. He estimated that sedation/analgesia-related costs are approximately 40% of total endoscopic costs. In addition, the costs associated with reduced efficiency of the unit due to an increase in total duration of hospital stay resulting from sedation and costs related to the escort required after sedation should also be included. He also discussed the pros and cons of propofol sedation provided by nonanesthesiologists (e.g., gastroenterologists). Charlotte Guglielmi, RN, CNOR, (Boston, MA) presented “Who Is Really Monitoring the Patient?” She discussed the role of nurses during sedation/analgesia. Finally, Talmage D. Egan, MD, (Salt Lake City, UT) discussed “Approaches and Tools to Teach Moderate and Deep Sedation to Non-Anesthesiologists.” He discussed a web-based approach to providing competency-based education and training in conscious sedation/analgesia to nonanesthesiologists. The mid-morning sessions on Friday, May 9, featured concurrent panels on pharmacology and geriatric anesthesia. Girish P. Joshi, MD, (Dallas, TX) moderated the panel, which addressed the question “Are the New Drugs Better?” The panel provided point-counterpoint presentations that compared the benefits of total IV anesthesia (TIVA) with those of inhaled anesthetics, as well as the perioperative use of opioids and opioids antagonists. Peter S. Glass, MB, ChB, (Stony Brook, NY) spoke on “Why I Prefer TIVA Rather Than Inhalational Anesthesia.” He discussed the new drug-delivery systems that calculate (through physical and pharmacokinetic principles) the dose required to achieve targeted concentrations of IV anesthetics and analgesics. He argued that patient outcomes are superior with propofol TIVA rather than inhaled anesthesia (e.g., less frequent postoperative nausea and vomiting [PONV]). In addition, TIVA is beneficial in providing anesthesia outside the operating room environment. Furthermore, he suggested that the use of TIVA prevents the increase in environment fluorocarbons associated with the use of inhaled anesthetics. This presentation was countered by Beverly K. Philip, MD, (Boston, MA) who stated that “Inhalation Anesthesia Is Superior to TIVA.” Inhaled anesthesia is easy to use and allows real-time, patient-specific monitoring and allows for a more rapid recovery as compared with propofol TIVA. In addition, the bronchodilator and muscle relaxant properties of inhaled anesthetics are beneficial. Furthermore, inhaled induction can be safely used for patients with anticipated difficult airway. She also presented recent studies reporting myocardial protective effects of inhaled anesthetics. Tong J. Gan, MD, (Durham, NC) led a discussion on the “Perioperative Use of Opioids and Opioid Antagonists.” He emphasized that opioids should be used in minimal doses, particularly in an outpatient setting so as to reduce opioid-related side effects, which may delay recovery. He also discussed the advantages of opioid antagonists such as naloxone, nalmefene, and methylnaltrexone, which have been reported to improve pain relief and reduce opioid-related side effects. Alec Rooke, MD, PhD, (Seattle, WA) moderated the geriatric ambulatory anesthesia panel titled “The Future Is Aging: Challenges in the Care of the Older Patient.” Dr. Rooke’s presentation “What Makes the Older Patient More Difficult?” discussed the physiological changes in the elderly as well as the reasons for their susceptibility to complications such as postoperative cognitive decline. He noted that inactivity during the early recovery phase might cause deconditioning in an elderly patient with borderline function. Therefore, it is important to ensure that adequate support is provided during the recovery phase. Talmage Egan, MD, (Salt Lake City, UT) spoke on the “Clinical Pharmacology of Opioids and Sedative Hypnotics: Does Age Matter?” It is well accepted that the elderly require smaller dosages of hypnotic-sedatives and opioids because of both pharmacodynamic and pharmacokinetic changes. However, the pharmacodynamic factors may have a predominate influence. Terri G. Monk, MD, (Gainesville, FL) addressed the subject of “Postoperative Cognitive Dysfunction: Is It a Problem After Ambulatory Surgery?” Recent studies report that postoperative cognitive dysfunction is observed in a significant percentage of elderly patients. However, elderly outpatients have better cognitive outcomes at discharge than elderly inpatients. Possible explanations for these differences could be related to healthier preoperative status of outpatients, shorter surgery and anesthesia duration, minimal nature of outpatient surgical procedures, and avoidance of hospitalization. “Regional Anesthesia: Simple and Cost-Effective Techniques” and “New Challenges in Health Care: Emergency Preparedness for Ambulatory Surgery” concurrently started the Friday afternoon sessions. Lucinda L. Everett, MD, (Seattle, WA) focused on the safety and efficacy of regional anesthesia in children. She stated that pediatric regional anesthesia has an excellent record of safety and efficacy. Although peripheral nerve blocks have been increasingly used in pediatric outpatient surgery, caudal block remains a useful and effective technique. She concluded that knowledge of anatomy and careful incremental dosing of local anesthetics with frequent aspiration and attention to indicators of intravascular injection may decrease the risk of complications. Stephen M. Klein, MD, (Durham, NC) then addressed “How to Provide a Successful Brachial Plexus Block and Lower Extremity Block in Adult Outpatients.” Rebecca S. Twersky, MD, (Brooklyn, NY), Donald M. Mathews, MD, (Valhalla, NY), and Donna A. Pritchard, RN, (New York City, NY) presented a review of bioterrorism threats and the impact such threats have on the ambulatory surgery facility and staff, including a look at the lessons learned from the terrorist attack on the World Trade Center. Dr. Mathews shared “Tales of 9/11” and his hospital’s experience during the event. Dr. Twersky, who moderated the session, addressed the issue of “Bioterrorism Threats: What the Clinician Needs to Know About Smallpox, Anthrax and Other Bugs.” She pointed out that although anthrax and smallpox are the most viable biological weapons, vaccine, antimicrobial therapy, and effective postexposure prophylaxis are available for these agents. Therefore, clinicians, first responders, and public health personnel remain the cornerstone of effective bioterrorism defense. Ms. Pritchard, speaking as an ambulatory surgery center (ASC) administrator, talked about how ASCs can prepare themselves for emergencies in an informative presentation on “Emergency Plans: Is Your Facility Prepared?” The final concurrent panels of the anesthesia track on Friday afternoon covered discharge issues and office-based anesthesia. Frances Chung, MD, (Toronto, Canada), the current SAMBA President, moderated a panel on “Discharge Issues and the PACU Nurse’s Perspective.” The session provided participants with an understanding of the new approaches to fast-tracking patients in day surgery, presented by Paul F. White, MD, PhD, (Dallas, TX) as well as addressing new issues in discharge criteria, presented by Dr. Chung. She emphasized that tolerance to oral fluids and voiding before discharge should not be mandatory in all outpatients. Nancy Brooks, RN, (Boston, MA) suggested that postanesthesia care unit nurses play an important role in managing postoperative problems such as pain, PONV, and lack of escort and facilitate patient discharge. Melinda L. Mingus, MD, (New York City, NY) and S. Diane Turpin, JD, (Washington, DC) teamed up to provide a “nuts and bolts” program titled “Office-Based Anesthesia: A Wave of the Future?” Dr. Mingus explained issues associated with office-based anesthesia practice include building a client base, controlling costs, and risk management of practice to maximize revenue. She emphasized that educating the office staff is important for proper patient selection and improving patient safety. Ms. Turpin led a discussion of the new guidelines that the Federation of State Medical Boards has issued to assist state medical boards in regulating the office-based practice and also discussed selected state regulations. Saturday, May 10, began with a 1-h research poster discussion session, followed by concurrent sessions. Girish P. Joshi, MD, (Dallas, TX) moderated the session “Current Topics in Acute Postoperative Pain Management” and presented the topic “COX-2 Specific Inhibitors: Do They Make a Difference in the Management of Acute Postoperative Pain?” The COX-2 inhibitors provide all the advantages of the traditional nonsteroidal antiinflammatory drugs but without the side effects, such as platelets and gastrointestinal effects. This should allow practitioners to use these drugs preoperatively and thus reduce opioid requirements and opioid-related side effects. The recommended doses for celecoxib is 400 mg before surgery followed by 200 mg bid after surgery, rofecoxib 50 mg before surgery followed by 50 mg once a day after surgery, and valdecoxib 40 mg before surgery followed by 20 mg bid after surgery. This interdisciplinary panel also provided valuable insight into the “Efficacy, Feasibility and Safety of Continuous Regional Anesthesia for Postoperative Pain,” which was presented by Stephen M. Klein, MD (Durham, NC). Denise O’Brien, RN, (Ann Arbor, MI) addressed the opportunities for nursing interventions in the treatment of pain as well as in the education of patients about postdischarge pain management. Dick de Jong, MD, PhD, (Leersum, Netherlands) provided a surgeon’s perspective of pain management after surgery. He suggested that surgeons should select surgical techniques with less postoperative pain (e.g., sequential avulsion of the long saphenous vein has less pain as compared to stripping). He also emphasized the need for multimodal analgesia techniques, particularly the use of local anesthetic techniques because of their efficacy and minimal side effects. The “Using Technology as a Clinical Tool” program was designed to help health care providers to acquire a better understanding of the latest technical advances including the use of computers in the operating room, personal data assistant (PDA), and data dictionaries. J. Lance Lichtor, MD, (Iowa City, IA) who served as a moderator of the panel, presented an insightful presentation on “The Bytes and PCs of Using Computers in Ambulatory Surgery.” He pointed out that medical literature is now easily accessible through the Internet (e.g., Medline and PubMed), which could be further enhanced by using a reference librarian. Dr. Kirk H. Shelley, MD, PhD, (New Haven, CT) shared information on PDAs in his presentation “The Palm Is Sharper than the Scalpel: OR Experiences with the PDA.” Applications found in most PDAs include calendar (day planner), contact list, calculator, to do list, note pad, and ability to synchronize with a computer. Other advanced abilities of these devices include word processor, excel spread sheets, power point presentations, database management, e-mail and short text messages, Internet surfing, music, video, digital camera, cell phone, games, and global positioning service. These devices can enhance our practice because they allow quick reference to medical information such as drug information, algorithms for management of complications, and patient information. Terri G. Monk, MD, (Gainesville, FL) spoke on the topic “Uniform Information Systems: The Data Dictionary,” during which she explained that data dictionaries allow standardization of medical terminology. This should allow us to easily obtain medical information and improve patient safety. On Saturday, May 10, in the morning, Barbara S. Gold, MD, (Minneapolis. MI) moderated the multidisciplinary panel titled “Preoperative Screening and Patient Selection: Practical Applications.” Donald M. Mathews, MD, (Valhalla, NY) spoke on “Guidelines or Gut: How Should We Conduct Preoperative Screening in 2003?” In his presentation, Dr. Mathews discussed how to use available information to determine the appropriate preoperative testing in the current climate, including application of the ASA Practice Advisory Panel on preanesthesia evaluation. In her talk titled “Adolescent Pregnancy and Outpatient Surgery,” Dr. Gold remarked that no other preoperative test raises so many medical, legal, and ethical issues as the preoperative pregnancy testing. She concluded that there is no standard for preoperative pregnancy testing. She emphasized that asking the patient in private (specifically, not in the presence of parents) should generate a reliable history regarding possibility of pregnancy. In addition, state laws govern with whom the status of pregnancy should be shared and the options available to adolescents. Alec Rooke, MD, PhD, (Seattle, WA) focused his presentation on the controversial area of laboratory testing in geriatric patients. Preoperative laboratory tests (even in the elderly) do not predict perioperative complications. Therefore, there is no benefit from routine laboratory testing. He concluded that preoperative testing should be based on the patient’s medical status and the anticipated effects of proposed surgery. Yung-Fong Sung, MD, (Atlanta, GA) moderated the panel on “Complementary Medicine.” The use of complementary medicine such as acupuncture and herbal medications is increasing in the United States. Therefore, it is required to know the effects of herbal medications on surgical patients. During this panel, Adam Perlman, MD, (Newark, NJ) addressed the “Integration of Complementary Medicine into the Conventional Medical Model,” including the principles and challenges such practice presents. Alternative medicine practices include medical based and and The and in the use of acupuncture was presented by May MD (Boston, In to changes in of acupuncture point has been to decrease in the and studies have reported the of acupuncture in pain management. May MD, (Boston, MA) spoke on the perioperative of the patient on herbal Dr. noted that many herbal are not without medications can the duration of anesthetic cause (e.g., or and increase herbal (e.g., and should be approximately a before surgery. The “Current in session provided into controversial issues pediatric anesthesia including of inhaled anesthetic and airway management and to a Raafat S. Hannallah, MD, (Washington, DC) presented a review of the Inhaled for and He concluded that was the drug of for inhaled induction in the pediatric Furthermore, rapid is is MD, (Washington, DC) discussed to an She recommended that patients are not for ambulatory surgery because of the potential of the In case of a with a it was recommended that a be to the parents) and A with an to be in or is also surgery should be for approximately Furthermore, a with history of should be In a with a it is to the presence of or of Linda J. MD, (Loma Linda, addressed the issue of Challenges in The topic “Regional Anesthesia: and was moderated by MD (Valhalla, The session covered complications of regional anesthesia and the and safety of local anesthesia techniques for regional anesthesia Stephen M. Klein, MD, (Durham, NC) addressed of Continuous Dr. spoke on the of Regional Anesthesia.” morning, May began with panels on the on International Anesthesia and which participants with the status of ambulatory surgery as well as the challenges in and They stated that the lack of of day surgery might be because of information provided to patients about the surgical and postoperative course as well as the including and the long for outpatient surgical procedures. In the panel Surgery in the The Are the from the Association for Surgery provided an on the status of day surgery in the with respect to is and is as well as they have been and they are The on the panel, MD, presented the talk How Do We Do the He emphasized the role of the in guidelines and educating all members of the regarding patient selection and preoperative He noted of the practice should complications and maximize patient satisfaction. After the early SAMBA presented the World which an Barbara S. Gold, MD, MI) an panel of MD, Andrew Herlich, MD (Philadelphia, PA), Linda J. MD (Loma Linda, and L. MD, recommended perioperative management to that could be by an in an outpatient These cases were discussed in an audience The program concluded with a session on Patient and Management in Ambulatory Surgery” moderated by A. MD L. MD, addressed of Surgery on with Ambulatory Surgery” was discussed by MD, H. MD, (Boston, MA) spoke on the of in the of The SAMBA Annual Meeting be held at the in The SAMBA meeting a educational from the of ambulatory anesthesia.

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