Patient Selection for Adult Ambulatory Surgery: A Narrative Review

Abstract

With migration of medically complex patients undergoing more extensive surgical procedures to the ambulatory setting, selecting the appropriate patient is vital. Patient selection can impact patient safety, efficiency, and reportable outcomes at ambulatory surgery centers (ASCs). Identifying suitability for ambulatory surgery is a dynamic process that depends on a complex interplay between the surgical procedure, patient characteristics, and the expected anesthetic technique (eg, sedation/analgesia, local/regional anesthesia, or general anesthesia). In addition, the type of ambulatory setting (ie, short-stay facilities, hospital-based ambulatory center, freestanding ambulatory center, and office-based surgery) and social factors, such as availability of a responsible individual to take care of the patient at home, can also influence patient selection. The purpose of this review is to present current best evidence that would provide guidance to the ambulatory anesthesiologist in making an informed decision regarding patient selection for surgical procedures in freestanding ambulatory facilities.

Pro-Con Debate: Are Patients With a Cardiovascular Implantable Electronic Device Suitable to Receive Care in a Free-Standing Ambulatory Surgery Center?

“…They are usually categorized with an ASA physical status of IV, and they are thus not suitable for a procedure in a free-standing ASC. 1 Due to inadequate support and lack of personnel, a free-standing ASC may not be equipped to manage the potential perioperative complications, such as unanticipated cardiac arrhythmia and hemodynamic compromise. Consultation and ancillary services may not be readily available.…”

Medical disease and ambulatory surgery, new insights in patient selection based on medical disease

“…However, there is little evidence to support that hypertension increases adverse events in patients undergoing ambulatory surgery. Thus, delaying surgery until hypertension is controlled is unlikely to be beneficial, at least as long as the blood pressure is less than 180/110 mmHg [37 ▪ ].…”

Ambulatory surgical patients and sleep apnea

“…2). 1,22 There are limited studies on OSA patients undergoing upper airway surgery in the ambulatory setting. These procedures are concerning because of the possibility of upper airway swelling and bleeding leading to an exacerbation of OSA-related complications.…”

“…20 With the increasing prevalence of obesity and OSA in the surgical population and the associated postoperative cardiopulmonary complications associated with this diagnosis, it is imperative to appropriately triage patients scheduled for ambulatory surgery in order to avoid perioperative complications and decrease postoperative unplanned hospital admissions. 21,22 Selection of patients for ambulatory surgery should take into account the presence and severity of patient comorbidities, the anesthetic technique, the procedure, and anticipated postoperative opioid requirements and whether the surgical center is free standing or hospital based and has the capability to offer advanced treatment if the need arises. 1,22 Patients with a positive screen on one of the previously mentioned questionnaires (ie, presumed diagnosis of OSA) should be informed of the associated perioperative risks.…”

“…21,22 Selection of patients for ambulatory surgery should take into account the presence and severity of patient comorbidities, the anesthetic technique, the procedure, and anticipated postoperative opioid requirements and whether the surgical center is free standing or hospital based and has the capability to offer advanced treatment if the need arises. 1,22 Patients with a positive screen on one of the previously mentioned questionnaires (ie, presumed diagnosis of OSA) should be informed of the associated perioperative risks. Although concrete evidence is lacking, most experts believe that if patients with presumed OSA have medical comorbidities optimized, there is no need to delay surgery for further testing for sleep apnea or initiation of PAP therapy.…”