Office Based Anesthesia: An Entirely Different Animal

I’ve been meaning to post my initial thoughts about providing anesthesia in a medical office as I’ve started to move into this arena several months ago. Again, I’ve been a full-fledged CRNA for 2 years now and I’ve been very interested with moonlighting in as many different settings as I can find just because I find the experience to be fascinating. You get to see how various facilities practice medicine and believe me when I say you get exposed to a wide variety of approaches, some good and some highly questionable. However, despite that, as an anesthesia provider, you always have to remember to go back to the basics and to remain vigilant when providing care, particularly when you’re working in an outpatient setting. Nowhere is this more evident than in an office-based setting.

I thought my foray into a stand alone surgery center last year as a new grad was a little hairy, but I have to say, providing anesthesia in a medical office? Now that’s an entirely different story. There are no anesthesia machines. There are no PACU nurses. There’s A nurse, but usually this nurse plays a “jack of all trades” role within this setting; meaning he/she admits the patient and acts as both the circulating/scrub nurse for the proceduralist. Obviously, other than you, there aren’t any other anesthesia providers in the office. You are on your own. All I have access to is a vital signs monitor, an O2 tank, an ambu-bag and my drugs. It’s no wonder why one ought to have a heightened sense of vigilance when providing care to a patient in an office.

I think what makes this experience so unusual as opposed to working in an outpatient surgery center for the first time is that not only do you not have any personnel backup should you run into an airway situation, but you also don’t have access to an anesthesia machine, which makes the situation all the more harrowing because let’s say you DO run into a situation where you have to place an LMA or intubate with an ETT, the thought of having to manage a patient’s airway with just an ambu-bag and no support just sounds downright scary…and it is…

At this particular office, I work with neurologists who perform ultrasound-guided regional blocks on patients who have chronic pain issues. Anyone who has ever provided care to patients with chronic pain understands the complexity of providing anesthesia care to them. It’s a tough situation to be in because oftentimes, the procedure is relatively short (~15-45 min in duration) and the patient has a high tolerance for opioids. Couple that with the aforementioned lack of equipment and personnel support and you can see how you’re pushing the boundaries of providing care.

For these cases, it’s not uncommon for these patients to receive 7-8 mg of versed and 500 mcg of fentanyl. It’s just amazing how much these patients require in order to tolerate the blocks that are being administered. And of course, these patients have to be recovered in PACU before being discharged. Perhaps it’s because I’m inculcated with the culture of hospital care, but the thought of providing that amount of versed and fentanyl in a short period of time and then discharging patients afterward…well, there’s a bit of cognitive dissonance there…

This is an experience that I will have to continue to ponder. It seems as though more and more procedures and surgeries are being performed in an outpatient setting and it makes sense for anesthesia providers to be there in order to provide a service in order to remain viable…it’s an interesting and challenging transition, to say the least…

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