NEW ORLEANS—Success in ambulatory surgery largely boils down to conducting the right procedure on the right patient in the right setting. At the 2022 meeting of the American Society of Anesthesiologists, BobbieJean Sweitzer, MD, a professor of medical education at the University of Virginia, in Charlottesville, discussed the questions that she uses to discern between ambulatory surgery–appropriate patients and those who may be better cared for in a hospital.
“Traditionally, ambulatory surgery was reserved for healthy people undergoing low-risk procedures. But now we’re doing total joint replacements, major spine surgeries and cardiac interventions, and the patients are older and sicker than ever. Plus, we’re extremely busy because so many procedures were delayed due to COVID-19,” Sweitzer said.
As a recent past president of the Society for Ambulatory Anesthesia, Sweitzer has given a lot of thought to the subpopulation of surgical patients undergoing ambulatory surgery specifically, and has come up with 10 questions that are easy to ask, easy to answer and reveal the information a clinician needs to determine whether the patient is right for ambulatory surgery.
1. Have you or a family member had a significant problem with anesthesia?
This question is a bit of a throwaway, Sweitzer said, because every patient gets asked that question. But she’s not looking for complications like nausea and vomiting. “We’re looking for things like malignant hyperthermia, allergies to anesthesia medications, difficult airways and unexpected postoperative admission.”
2. What medications do you take?
The reasons to ask this question are threefold. First, certain medications need to be held the day of surgery or several days ahead. Second, the medications a patient takes tell you a lot about their health; for example, if they take blood pressure medication, they have hypertension—even if it’s under control. Third, some medications, like insulin, indicate the patient might be at higher risk for complications, “either due to the medications themselves or the diseases they treat,” Sweitzer said.
3. Have you been hospitalized in the last 30 days?
A recent hospital stay indicates the patient has been very ill and may not be a good candidate for ambulatory surgery at this time. “Also, patients can pick up colonized bacteria in the hospital, or developed a blood clot there; it’s not just what they walked in with, but what they walked out with,” Sweitzer said.
4. Do you need help eating, bathing or getting dressed?
An inability to carry out tasks of daily living unassisted is a marker for frailty, which can help clinicians identify patients at higher risk based on characteristics aside from age. A recent study showed that a dependent ASA class II patient is as high risk as an independent ASA class III patient. “Basically, with dependency on others, you move them into the next highest level of risk category,” Sweitzer said.
5. Have you had a myocardial infarction (MI) in the last 60 days?
This is the standard established by the American College of Cardiology (ACC) and American Heart Association (AHA) for surgical patients undergoing noncardiac surgery. “They specifically state that all but lifesaving surgery should be delayed until 60 days after an MI. Even at 90 days, the risk of complications is three times higher than baseline risk of patients with CAD [coronary artery disease],” Sweitzer said.
6. Have you undergone cardiac catheterization or received a coronary stent within the last six months?
Again, this standard was set by the ACC and AHA, with the caveat that surgery may be acceptable after three months if it’s truly necessary. “But it’s my opinion and that of others that between three and six months, there’s still enough risk that those patients are not appropriate for ambulatory surgery,” Sweitzer said. She noted that patients who receive bare metal stents need to delay surgery for only 30 days, “but patients usually don’t know what kind of stent they got; also, these days, almost all patients get drug-eluting stents. So, if they say yes to this question, I know to ask further questions.”
7. Can you walk four blocks briskly or up two flights of stairs without shortness of breath?
The capacity for exercise is strongly predictive of how well patients will do in surgery. Those who can walk four blocks or up two flights of stairs without difficulty “need no further cardiac testing,” Sweitzer said. She advises using a time frame for this question: When was the last time you walked up two flights of stairs? “Some of this is contextual. If I’m interviewing an 18-year-old college student and they say they can walk four blocks, I don’t ask any further; but if the patient is 94 and says they can do that, I’ll ask when was the last time they did.”
8. Have you had a stroke in the last three months?
Until a few months ago, the recommendation was to delay surgery nine months in stroke patients, but a well-regarded study recently shortened that delay to three months (JAMA Surg 2022;157[8]:e222236, editorial e222237). “I’m convinced after seeing this most recent study that three months is an adequate time period,” Sweitzer said.
9. Are you on dialysis?
Patients on dialysis are at significantly higher risk for complications; they are also prone to electrolyte and volume problems. “You want them cared for in a place with easy access to laboratory values, which we don’t often have in ASCs [ambulatory surgery centers],” Sweitzer said.
10. What other medical problems do you have?
Open-ended questions can pave the way for patients to discuss the medical issues that are most important to them. “There are so many esoteric, bizarre conditions, we can’t possibly ask about every issue a patient might have. At some point, we just have to trust them; for many patients you can just ask, ‘What’s wrong with you?’” Sweitzer said.
Extra credit question for cataract patients: Can you get to the clinic and lie flat for 45 minutes?
Even though cataract patients tend to be older and have comorbidities, cataract surgery is such a low-risk procedure, usually requiring only topical or regional anesthesia without sedation, that the benefits of sight restoration typically outweigh the risk for adverse events. “I’m really passionate about getting patients through cataract surgery because it is so low risk, and restoring sight is so important,” Sweitzer said.
—By Monica J. Smith
Sweitzer receives funding from the International Anesthesia Research Society and UpToDate.
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Patient presents with an epiglottic cyst for microlarangoscopy biopsy excision in an outpatient freestanding ASC. I canceled this case but not without a disagreement with the ENT surgeon. Thoughts on the appropriateness of scheduling this case and subsequent cancelation due to a dangerous post op swelling in PACU.