rate, depth, or quality. While this method of intraoperative monitoring is sensitive, it does not appear to be particularly popular among OMSs. The study by D'Eramo reported only 36% of practitioners used a precordial stethoscope, compared to a 93% utilization rate for blood pressure and pulse oximetry monitoring [1]. The stethoscopes become less reliable in situations of increased ambient noise or excessive patient movement that can displace the bell of the stethoscope. Nevertheless, the esophageal stethoscope can provide additional clinical information regarding a patient's respiratory status. It may be most useful when treating small children (or others at increased risk of rapid respiratory compromise) and obese patients, in whom it can sometimes be difficult to observe chest rise and other signs of ventilatory effort.
Personnel Preparedness
Specific guidelines, in addition to individual state law specifications, regarding the appropriate number of personnel and specifics of their training requirements when administering outpatient anesthesia exist and should be adhered to strictly. Familiarity with the equipment used for monitoring, as well as emergency equipment and setup, medications, and dosages, is crucial for the administration of safe outpatient anesthesia. In addition to emergency equipment setup and operation, the treating team should practice, at frequent intervals, emergency scenario response to ensure preparedness and to anticipate and prevent adverse events. A recent study of anesthesia providers demonstrated better performance when hands‐on simulation training in anesthetic emergencies had been provided [13]. In addition, frequent scheduled and unscheduled drug and equipment inventory examinations and testing for expiration dates and malfunctions should be implemented routinely.
Equipment and Emergency Supplies
Some of the most common emergency drugs and equipment that may be needed in an outpatient anesthesia setting are listed in Table 1.3. Emergency drugs are available from the manufacturer in appropriate dilutions that are prepackaged into syringes designed for single‐patient use. Though there is an increased cost when purchasing emergency drugs in this form, it allows a practitioner to select and administer an emergency drug as needed without delay and potentially minimizing calculation errors.
Table 1.3. Emergency drugs and equipment
| Emergency equipment: | |
| Defibrillator | |
| Suction (portable) | |
| Oxygen tank with backup | |
| Face mask (non‐rebreathing with bag valve mask) | |
| Laryngoscope with light source, blades, extra batteries | |
| Endotracheal tubes, cuffed/uncuffed | |
| Laryngeal mask airway | |
| Oral airways | |
| Nasal airways | |
| MacGill forceps | |
| Tracheostomy/cricothyroidotomy set | |
| Emergency drugs: | |
| Epinephrine | Atropine |
| Vasopressin | Succinylcholine |
| Nitroglycerin | Glycopyrrolate |
| Adenosine | Lidocaine |
| Labetalol | Metoprolol |
| Esmolol | Diphenhydramine |
| Lorazepam or diazepam | Hydrocortisone |
| Glucagon | 50% Dextrose |
| Naloxone | Flumazenil |
| Albuterol MDI | Aspirin |
Postoperative Monitoring
When the surgical and anesthetic procedure is completed, the patient is discharged to a postoperative area where patient recovery from anesthesia is typically overseen by someone other than the surgeon. Due to the short‐acting nature of most anesthetic drugs currently in use, most patients begin to awaken by the end of the surgical procedure. Some patients may still be significantly sedated upon arriving to the recovery area, however, due to differences in patient response to anesthesia. Vital signs should continue to be monitored postoperatively. A trained staff member should be physically present in the immediate recovery area at all times and should observe the patient's condition, including skin color, respiratory rate and effort (chest rise), response to verbal or physical stimulation, and any signs of agitation or inability to be roused. Once patients are reasonably awake, they may be joined by a family member or friend, if space permits in the recovery area.
INCIDENCE OF COMPLICATIONS IN AMBULATORY ANESTHESIA
Though little historical data are available, it appears that ambulatory anesthesia has increased in safety over the past several decades. A recent large study reported an incidence of outpatient anesthetic complications of 1.45%, compared to a 2.11% complication rate for inpatient anesthesia [15]. Improvements in equipment design for the provision of anesthesia and patient monitoring as well as improvements in engineering controls, safety practices, and practitioner training have contributed to the overall low rate of anesthetic complications. Some of the more common complications of anesthesia, such as nausea and vomiting, have relatively low morbidity although the institutional costs may be high. Other complications such as respiratory or cardiac arrest are so morbid that significant effort has been made to adequately prevent and manage them despite their very low incidence. A proportion of complications are due to underlying patient factors such as patient age and medical comorbidities over which the practitioner has little control, but evidence has also shown that many complications are the result of operator error, equipment malfunction, or system failure. Preventable complications offer an opportunity for the individual clinician and the specialty as a whole to make improvements that increase patient safety and anesthetic success.
NEUROLOGICAL COMPLICATIONS
Syncope
Syncope, one of the most common anesthetic complications, typically occurs in the preoperative setting, but may be observed occasionally postoperatively as well (Algorithms 1.1, 1.2). Syncope is defined as transient loss of consciousness with spontaneous return to consciousness. In a study by D'Eramo, syncope was the most frequently observed