Ohio. "It depends on the procedure and if anesthesia feels like they
can be managed at our facility."
Who's suitable for an ambulatory procedure? It helps to follow
American Society of Anesthesia (ASA) admission guidelines
(osmag.net/SKh8fU), which say that "patients with a high burden of
comorbidities, particularly those with poorly stabilized medical
conditions, are not suitable for ambulatory surgery." You should
also have your own guidelines for BMI limits, cardiac history
(including myocardial infarction, heart failure or a history of hyper-
tension) and chronic respiratory history (especially chronic
obstructive pulmonary diseases and asthma).
"If there is a question," says one administrator, "the anesthesia
provider or medical director usually have the final say." But some-
times, laments another, "anesthesia challenges and overrules our BMI
policy."
As older and sicker patients undergo more complex surgical proce-
dures in an ambulatory setting, the ASA says patient selection has
become the cornerstone of safe and efficient perioperative care.
"Who's a good candidate? Who's not? It should be less of an argument
and more of a discussion," says Dr. Daley. "To do that, you need crite-
ria — some evidence to back up what you're talking about. There's a
line. You can say, 'This guy's probably going to be okay, this guy's
not.'"
Take a 2-hour shoulder arthroscopy with complex rotator cuff repair.
The patient has an unusual EKG finding that could be indicative of an
ischemic event and a vague heart history. The surgeon wants to do the
case. "There's nothing wrong with him. No chest pain," he says. But Dr.
Daley sees things differently. "You're in a situation where you feel that
something is probably not right. If you contacted the patient's cardiolo-
gist, you probably wouldn't hear back until the end of the day."
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