4:00PM Office-based Gynecologic Procedures
Speaker: Keith Isaacson, MD, Associate Professor of Obstetrics,
Gynecology and Reproductive Biology, Harvard Medical School; Medical Director,
Minimally Invasive Gynecological Surgery Unit, Newton Wellesley Hospital;
Attending Physician, Brigham & Women’s Hospital; Attending Physician,
Boston IVF; CIMIT Site Miner, Newton-Wellesley Hospital, kisaacson@partners.org
Moderator: John C. Petrozza, MD, Chief,
Massachusetts General Hospital Fertility Center; Chief, Vincent Reproductive
Medicine and IVF Division, jpetrozza@partners.org
Gynecologists
are spending more time in the office and less time in the operating room, and
today’s residents receive less surgical training than in the past. More and more surgical procedures are being
performed in the doctor’s office instead of in the OR. The increasing number of office-based
procedures necessitates new equipment and new training strategies, both
designed specifically for the office setting.
Many
factors contribute to the current popularity of office-based gynecologic
procedures. First, performing a
procedure in the office as opposed to the OR saves time. According
to Dr. Keith Isaacson, of
Office-based
procedures can create health risks if not performed with proper attention to
safety. Fatal problems can arise if
doctors and staff are not properly trained, if patients are not selected
carefully, and if emergency equipment and drugs are not readily available.
Office-based
procedures are not going to go away, so the gynecological community should seek
to ensure that they are safe. Gynecology
residents are not currently trained to perform procedures in the office, and
these techniques, which are not difficult, should become part of their curriculum. Guidelines should be established to help
gynecologists identify patients who should not be anesthetized in the office,
and offices should always be equipped to manage severe emergencies, such as
cardiac and respiratory failure.
Finally, surgical equipment designed specifically for the office should
be developed.
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4:30 PM
Office-based Anesthesia
Moderator: Nathaniel M. Sims,
MD, Founder, Massachusetts General Hospital (SimsLab);
affiliated with the MGH Departments of Anesthesia and Critical Care, PHS
Biomedical Engineering, CIMIT, and PHS Signature Initiatives / Patient Safety, nsims@partners.org
Overview of Office Based
Anesthesia
Fred E. Shapiro, DO, Instructor-in-Anaesthesia,
Harvard Medical School; Department of Anesthesiology, Critical Care and Pain
Medicine, Beth Israel Deaconess Medical Center, fshapiro@bidmc.harvard.edu
Many
office-based procedures require significant anesthesia, which can be risky if
not administered properly, and a number of patients have died during surgery
from cardiac arrest or malignant hyperthermia.
Many of the victims were healthy people undergoing elective, often
cosmetic, procedures.
Anesthesia
in the office is often referred to as the “Wild West of Healthcare” because
office-based procedures are sometimes performed without needed safety equipment
and because they are poorly regulated.
Ten million office-based procedures were performed in the
Many states
and professional associations are attempting to use accreditation as a means of
ensuring that office-based procedures are performed safely. Although there is some controversy, certain
studies have suggested that procedures not involving general anesthesia
performed in accredited facilities are as safe as similar procedures performed
in the hospital. Researchers are
currently attempting to create new anesthetics designed specifically for the
office. Dexmedetomidine
is a new anesthetic that seems to work effectively for surgeries involving the
face.
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Technology Implications
of Office-based Anesthesia Safety
Beverly K. Philip, MD, Professor of Anaesthesia,
The office
environment is not designed for surgery, yet it is the site of millions of
procedures, many performed without an anesthesiologist. With few regulations in place, practitioners
must hold themselves responsible for safety.
It is
crucial that all office surgeons have the correct equipment to monitor the
anesthetized patient. Many anesthesia
machines used in private practice are old, and guidelines should be established
that delineate when machines become obsolete.
Patient information (vital signs, etc.) should be collected and stored
in a useful format. Often, the riskiest
time for a patient is right before and right after surgery, when the patient is
not necessarily receiving a doctor’s full attention, so improved patient
monitoring is needed during these times as well.
Above all,
the office-based practice should be able to cope with emergencies. It is not uncommon for small surgeries to
lead to dire complications. All staff
must be trained to respond appropriately to an emergency. Dialing 911 should not be the back-up
plan. The practice must possess
emergency equipment. A defibrillator and
a reliable two-way communications device, for example, should always be on
hand. There must be a reliable source of
oxygen, a reliable source of suction, emergency drugs, and an electrical
generator in case the power fails. The
building must have a clear path of egress for a patient on a stretcher. Perhaps the greatest danger posed by
office-based surgery lies in the presumption that no serious problems will
occur.
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Regional Anesthesia in the Office Based Setting
Lisa Warren, MD, Director, Ambulatory Anesthesia,
Massachusetts General Hospital Department of Anesthesia and Critical Care, lwarren2@partners.org
Regional
anesthesia is widely used in ambulatory care but is rarely used in office
settings. It usually results in fewer
complications and in quicker patient discharges, but because it can be
difficult to administer safely, it seems destined to remain a technique used in
the hospital and not in the office.
Of the
different types of regional anesthesia, distal blockades, which can be used to
numb the upper or lower extremities, would be the easiest to perform in an
office. Spinal and epidural blockades
cause more nausea and sometimes cause life-threatening hemodynamic
instability.
The risks
of regional anesthesia should not be downplayed. It can cause bleeding, infection, nerve
damage, and local toxicity, which can be fatal.
Office practitioners have also hesitated to use the technique because
they are uncomfortable sending a patient home with an insensate limb, which
could be injured if not minded properly.
Recent
advances have made regional anesthesia safer.
Ultrasound machines now allows doctors to guide anesthesia needles more
precisely than in the past. Biomarkers,
such as epinephrine, help them avoid injecting drugs into blood vessels. Single-enantiomer
drugs are replacing racemic mixtures, and these new
drugs appear to be safer. In the past, a
patient experiencing toxicity and cardiac arrest was put immediately on a
bypass machine, but now, in some cases, a lipid emulsion can be used to help
reverse the toxicity. Despite these
advances, the skill and the potentially serious consequences of regional
anesthesia preclude its widespread adoption in the office, at least for now.
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Panel
discussion – click here to view