Il punto di vista dedll'anestesista

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
anesthesiaanesthesia
Claudio MelloniClaudio Melloni
Direttore Anestesia e RianimazioneDirettore Anestesia e Rianimazione
Ospedale di Faenza(RA)Ospedale di Faenza(RA)

Office based anesthesia:il
punto di vista
dell’anestesista
Claudio Melloni
DIRETTORE Anestesia E Rianimazione
Ospedale di Faenza

Lo stato dell’arte dell’OBA
ASA e Samba survey:
American Society of Anesthesiologists/Society for Ambulatory
Anesthesia: Office Anesthesia Survey. Spring 1997. Park Ridge, IL,
American Society of Anesthesiologists/Society for Ambulatory
Anesthesia.
almeno 25% degli intervistati pratica
OBA

Mercato Office Based Surgery
L’OBA non ha sempre accompagnato
l’OBS
Molte branche chir fanno tutto da
soli:oftalmologia,flebectomia,osteotomia
pedidia,isteroscopia,laparoscopia,odont
ostomatologia…eseguite in locale
Colonscopia,esofagogastro..ecc locale
+ sedazione

OBA
Si sa,tra le righe,che molti sono stati i
fornitori di anestesia improvvisati in
ambiente
chirurgico;ragionieri,segretarie,estetiste,
Ota,IP,medici generici….…
In +,i chirurghi praticano AL da soli…. E
non manca una ricca biblio
sull’argomento.

AL da parte dei chirurghi ….
Cohn MS, Seiger E, Goldman S: Ambulatory phlebectomy using the tumescent
technique for local anesthesia. Dermatol Surg 1995; 21:315 8.‑
Cartwright PC, Snow BW, McNees DC: Urethral meatotomy in the office using topical
EMLA cream for anesthesia. J Urol 1996; 156:857 8.‑
Green SN, Yarian DL, Masciulli LM, Leff SR: Office repair of retinal detachment using
a lincoff temporary balloon buckle. Ophthalmology 1996; 103:1804 10.‑
Wood WA, Waynej: Office based surgery in podiatry. J Am Podiatr Assoc 1981;‑
71:591 4.‑
McDonald HPjr: Office ambulatory surgery in urology. Urol Clin North Am 1987;
14:27 30.‑
Gimpelson Rj, Courtiss EH, Goldwyn RM, Joffe JM, Hannenberg AA: Office
hysteroscopy anesthetic practices in ambulatory aesthetic surgery. Clin Obstet
Gynecol 1992; 35:270 81.‑
Leach GE: Local anesthesia for laser prostatectomy. J Endourol 1995; 9:159 61.‑
Guardate quest’ultimo:
Lewis LA: Methoxyflurane analgesia for office surgery. journal of Dermatologic
Surgical Oncology 1984; 10:85 6.‑

Definizione di OBADefinizione di OBA
sedesede
Poiché l’anestesia costituisce un continuum di
profondità,dalla anest locale alla sedazione
cosciente alla sedazione profonda e infine all’AG
Poiché l’anestesia costituisce un continuum di
profondità,dalla anest locale alla sedazione
cosciente alla sedazione profonda e infine all’AG
OBA indica solo la sede in cui si effettua
l’anestesia,non quale anestesia si impiega……..
OBA indica solo la sede in cui si effettua
l’anestesia,non quale anestesia si impiega……..

Obblighi dell'anestesistaObblighi dell'anestesista
aderenza a:aderenza a:
Guidelines
for
Ambulatory
Anesthesia and
Surgery
Guidelines
for
Ambulatory
Anesthesia and
Surgery
Standards for
Postanesthesia Care'
Standards for
Postanesthesia Care'
Basic Standards for
Preanesthesia Care
Basic Standards for
Preanesthesia Care

AnestesiaAnestesia
IncoscienzaIncoscienza
AnalgesiaAnalgesia Rilassamento
muscolare
Rilassamento
muscolare

AnestesiaAnestesia
componenticomponenti
IncoscienzaIncoscienza
analgesiaanalgesia protezione Stressprotezione Stress

Componenti A.G:Componenti A.G:
questione di punti di vista....questione di punti di vista....
rilassam.musc
7%
protezione stress
21%
Analgesia
29%
incoscienza
43%
rilassam.musc
7%
protezione stress
21%
Analgesia
29%
incoscienza
43%

Anestesia come continuumAnestesia come continuum
transizione talora inevitabile....transizione talora inevitabile....
anestesiaanestesia
sedazione
pesante
sedazione
pesante
sedazione
leggera- cosciente
sedazione
leggera- cosciente

MuscleMuscle
relaxationrelaxation
Control ofControl of
stressstress
responseresponse
UnconsciousnessUnconsciousness
Hypnotics + inhalation agentsHypnotics + inhalation agents
Muscle relaxantsMuscle relaxants
AnalgesicAnalgesic
drugsdrugs
Modern balanced anesthesiaModern balanced anesthesia

MuscleMuscle
relaxationrelaxation
Control ofControl of
stressstress
responseresponse
UnconsciousnessUnconsciousness
Inhalation agents
Muscle relaxantsMuscle relaxants Analgesic drugsAnalgesic drugs
NeurolepticsNeuroleptics
Hypnotics and BDZs
Drugs for general anesthesiaDrugs for general anesthesia

Moderna anestesia bilanciataModerna anestesia bilanciata
Stanno insieme?Stanno insieme?
IpnosiIpnosi AmnesiaAmnesia AnalgesiaAnalgesia
Rilassamento
muscolare
Rilassamento
muscolare
protezione
stress
protezione
stress
protezione
riflessi
protezione
riflessi
Assenza di
movimento
Assenza di
movimento
????

Il bilanciamento
dell'anestesia
Il bilanciamento
dell'anestesia
AnestesiaAnestesia
depressione
respiratoria
depressione
respiratoria
depressione
cardiovascolare
depressione
cardiovascolare

Linee guida ASA per office
anesthesia
Guidelines for Office-Based Anesthesia
http://www.asahq.org/publicationsandServices/standards/12.pdf
Guidelines for Qualifications of Anesthesia Providers in the Office-Based Setting
http://www.asahq.org/NEWSLETTERS/2000/01_00/statement0100.html
Guidelines for Ambulatory Anesthesia and Surgery
http://www.asahq.org/publicationsAndServices/standards/04.pdf
Guidelines for Nonoperating Room Anesthetizing Locations
Position on Monitored Anesthesia Care
Statement on Regional Anesthesia
Statement on the Anesthesia Care Team
http://www.asahq.org/publicationsAndServices/standards/16.html
Basic Standards for Preanesthesia Care, Standards for Basic Anesthesia Monitoring, and
Standards for Postanesthesia Care
http://www.asahq.org/publicationsAndServices/standards/02.pd
fContinuum of Depth of Sedation Definition of General Anesthesia and Levels of sedation/Analgesia

Linee guida SIAARTI utili per
office anesthesia
LINEE GUIDA PER LA SICUREZZA IN ANESTESIA LOCO-REGIONALELINEE GUIDA PER LA SICUREZZA IN ANESTESIA LOCO-REGIONALE
Commissione SIAARTI/AAROI,sull’anestesia in day surgery.
» Coordinatore: M. SOLCA
– G.BETTELLI, M.LEUCCI, C.MATTIA, V.A.PEDUTO, E.RECCHIA, P.RUJU, I.SALVO,
A.TERREVOLI
RACCOMANDAZIONI CLINICO-ORGANIZZATIVE PER L’ANESTESIA IN DAY-
SURGERY
Raccomandazioni per l’anestesia nel Day Hospital
Raccomandazioni per il monitoraggio di minima del paziente durante
anestesia.I Edizione febbraio 1990,II Edizione giugno 1996.
RACCOMANDAZIONI PER LA VALUTAZIONE ANESTESIOLOGICA
IN PREVISIONE DI PROCEDURE DIAGNOSTICHE - TERAPEUTICHE IN
ELEZIONE
Ecc,ecc

Courtiss EH, Goldwyn RM, Joffe JM, Hannenberg AA.
Anesthetic practices in ambulatory aesthetic surgery. Plast
Reconst Surg 1994;93:792-801.
Inchiesta tra i chirurghi plastici USA
13% respiratory arrest, 8% unplanned
intubations, 3% intravascular injection of
local anesthetic and 1% mortality
However, closer examination of the anesthetic techniques
performed and the personnel in the office, the most frequent
anesthetic technique performed was monitored anesthesia care
(MAC) (92%) with a nurse or anesthesiologist being present only
70% of the time. General anesthesia was administered by 54%
of the practitioners and either the nurse or the anesthesiologist
were always present. Interestingly, central neuroaxis blockade
was performed by 10% of practitioners and the anesthesiologist
was never present; instead 12% of the time the surgeon was in
charge of the patient and 5% of the time a nurse. This might be
the cause of the problems [8]

Courtiss EH, Goldwyn RM, Joffe JM, Hannenberg AA.
Anesthetic practices in ambulatory aesthetic surgery. Plast
Reconst Surg 1994;93:792-801.
0 20 40 60 80 100
%
MAC
Anest o CRNA
SPI
0 2 4 6 8 10 12 14
%
arresto resp
intubaz non
elettiva
iniez intravasc
mortalità Anestesista assente;
spi effettuata dai chir
Complicanze nell’ufficio Responsabilità…………
Ma…

Complicazioni delle endoscopia digestiva
0.13-0.08%
Mortalità 0.7-1/10.000
50% delle KO e 65% dei decessi
dovuti a probl cardioresp

I closed claims USA
ASA

ASA closed claims database
Ci sono 2 fonti di dati :
La % di claims da MAC è cresciuta dall
1.4% % del 1970 al 6.4% del 1990
I danni derivati dalla MAC sono simili a
quelli della AG:morte 34%,danno
cerebrale permanente 19%

Caratteristiche dei pazienti nella pratica office
Domino, KB: Office-Based Anesthesia: Lessons Learned from the Closed Claims Project. ASA
Newsletter 65(6): 9-11, 15, 2001.
ient Characteristics
Ambulatory Anesthesia
(n=753)
Office-Based
(n=14)
Age (mean in years) 41 45
Female (%) 58 64
ASA 1-2 (%) 82 89
Elective surgery (%) 97 100
Anesthesia Type
General (%) 66 71
MAC (%) 10 14
Surgical procedure
Dental (%) 3 21
Plastic surgery (%) 32* 21*
Other (%) 64† 14†
* P <0.05 Ambulatory vs. Office-Based
† P <0.01 Ambulatory vs. Office-Based
Percentages do not equal 100% due to rounding

Gravità delle lesioni nella pratica in ufficio
vs quella ambulatoriale
Domino, KB: Office-Based Anesthesia: Lessons Learned from the Closed Claims Project. ASA
Newsletter 65(6): 9-11, 15, 2001.
0
10
20
30
40
50
60
70
%
non
invalidante/temporanea
invalidante/permanente morte
ambulatoriale
office
Ambulat: 753
Office :14
Casistica tot.ASA
closed claims:5490
**

Meccanismo del danno
Domino, KB: Office-Based Anesthesia: Lessons Learned from the Closed Claims Project.
ASA Newsletter 65(6): 9-11, 15, 2001.
(n=666)*
Office-Based
(n=12)
Type of Event n (%) n (%)
Respiratory 150 (22) 6 (50)
Cardiovascular 67 (10) 1 (8)
Equipment 74 (11) 1 (8)
Drug-related 58 (9) 3 (25)
Block-needle trauma 41 (6) 1 (8)

Prevedibilità con monitoraggio migliore
Domino, KB: Office-Based Anesthesia: Lessons Learned from the Closed Claims Project.
ASA Newsletter 65(6): 9-11, 15, 2001.
0
10
20
30
40
50
60
70
80
90
si no
ambulatoriale
office
Casistica tot.ASA closed claims:5490
Ambulat: 753 Office :14
*

Responsabilità e indennizzo
Context of Care
Payment
Proportion
Median
Payment
Range (Min-
Max)
(n=695)*
59%† $85,000‡
$34-
$14,700,00
0
Office-Based (n=13)* 92%† $200,000‡
$10,000-
$2,000,000
* Includes only claims where payment data are known
† P < 0.01 Ambulatory vs. Office-Based by the Chi Square test with z-test
‡ < 0.05 Ambulatory vs. Office-Based by the Mann-Whitney U. rank of payments

Problemi dell'officeProblemi dell'office
L’anestesia è divenuta + sicura…L’anestesia è divenuta + sicura…
Migliorato monitoraggio(linee guida)Migliorato monitoraggio(linee guida)
Farmaci più sicuriFarmaci più sicuri
Conoscenza migliore dei rischiConoscenza migliore dei rischi
Aumentata disponibilità degli anestesisti(numerica….)Aumentata disponibilità degli anestesisti(numerica….)
Ma.....Ma.....
nell'office le risorse ospedaliere non ci sono!nell'office le risorse ospedaliere non ci sono!
Ed è la capacità ed esperienza del personale che garantisce la sicurezza!Ed è la capacità ed esperienza del personale che garantisce la sicurezza!

Cause di danno
MAC??
Errori da farmaci,in partic.oppioidi nei paz
ambulatoriali…..
Queste tendenze avvertono chir ed anest dei
rischi e chiedono che entrambi definiscano
bene quali pazienti e quali procedure siano
approriate per la struttura office…..
Si deve assolutamente evitare di soggiacere
alle pressioni economiche di
risparmio/guadagno ricorrendo alla office chir
!

Attività ASA e SAMBA:Task Force
on OBA
Attività ASA e SAMBA:Task Force
on OBA
Committee on ambulatory surgical careCommittee on ambulatory surgical care
ASA OBA guidelines 1999ASA OBA guidelines 1999
OBA Practice manual ottobre 2000OBA Practice manual ottobre 2000
ASA workshops su OBA:nov 1999,Luglio 2002ASA workshops su OBA:nov 1999,Luglio 2002
ASA OBA training workshops genn 2000,aprASA OBA training workshops genn 2000,apr
Legame con le principali associaz di certificazione e
scientifiche:JCAHO,AAHC,AAASF,ACS,ASPS,NPSF,MHAUS,FSMB,OIG….
Legame con le principali associaz di certificazione e
scientifiche:JCAHO,AAHC,AAASF,ACS,ASPS,NPSF,MHAUS,FSMB,OIG….

Office based anesthesiaOffice based anesthesia
sfida del nuovo millenniosfida del nuovo millennio
Gli standard assistenziali non devono essere
inferiori a quelli ambulatoriali o ospedalieri
Gli standard assistenziali non devono essere
inferiori a quelli ambulatoriali o ospedalieri
La sfida per gli anestesisti è quella di
trasportare l’esperienza e i modelli di pratica
acquisiti nelle sale op ospedaliere agli
ambienti office…
La sfida per gli anestesisti è quella di
trasportare l’esperienza e i modelli di pratica
acquisiti nelle sale op ospedaliere agli
ambienti office…

ASA Guidelines for Office base
anesthesia
Amministrazione e governo clinico
Qualità dell'assistenza
Struttura e sicurezza
Monitoraggio , attrezzatura
Emergenza e trasferimentiEmergenza e trasferimenti

Lista dei controlli da effettuare per sedazione/anestesia al di fuori della
sala op.
Comunicazioni;telefono,interfono…
Illuminazione
Prese elettriche;quantità e tipo….
Farmaci presenti in sede e quali invece da portare
Ci sono monitoraggi e funzionano?
Carrello di emergenza ;il personale lo usa?
C’è spazio dove indurre AG?se l’AG è indotta in un luogo diverso da quello
dell’intervento,attrezzatura e farmaci devono essere mossi con il paziente?
Il personale conosce le procedure di emergenza?anestetiche?
Ci sono pericoli specifici per il personale anestesiologico e/ o il paziente?(radiazioni)
Dove avviene la fase di risveglio/ripresa?
Fonti di ossigeno
Aspiratore(potente)
» Apparecchiature isolate o a muro
» Arrivano al paziente?

Vena sicura

Flussometri(O2),Pompe
siringa,capnometro…..

Pulsossimetria,capnometria

Ossigenazione,Defibrillatore,ai
rways……….

Ossigenare a tutti i costi

Ossigenazione in tutti i modi

anestesia,prese
filtrate,cavi..batterie

Un poco di monitor……..

Pubblicità sanitaria

Valigie e trasporto,prese
filtrate

Pompa siringa,airways

Carrello farmaci e
materiali,piano appoggio

Guidelines for non operating room
anesthetizing locations (approved by
House of Delegates Oct 19,1994) ,
Park Ridge,Il. American Society of
Anesthesiologists 2001.

GUIDELINES FOR NONOPERATING ROOM
ANESTHETIZING LOCATIONS
(Approved by House of Delegates on October 19, 1994,and last amended on October 15, 2003)
O2 +riserva.centralizzato meglio
Aspiratore
Scarico dei gas se anest inalatoria
Pallone autoespansibile con O2 90%
Farmaci anest adeguati in tipo e quantità
Monitoraggio adeg agli standard
Se anest inalatoria,app.anest controllato
Prese elettr. qb+gr.continuità.Se chir bagnata,sicurezza cavi,terra e interruttore isol.
Illuminaz adeg per anest e chir + riserva
Spazio adeg
Personale adeg
Carrello emerg con def ,farmaci,cpr
Personale di supporto
Comunicaz bidirez
Rispetto dei codici di sicurezza abitaz
Assistenza postanest adeguata nel trasporto e personale

Criteri per la dimissione dei pazienti dopo sedazione o
AG:Texas Children hosp,1998.
Osservazione per almeno 30 min.dopo la procedura
Vie aeree pervie e respirazione adeguata
Sveglio e reattivo…
Polso e pressione stabili
Assenza di sanguinamento
Assenza o minima nausea
ASSENZA DI VOMITO
Assenza o minimo dolore o dolenzia
vedi Tolia……………….

Principio fondamentale
Gli standard di assistenza
anestesiologica non
cambiano cambiando
ambiente

Fondamentali 1
Staff professionale e amministrativo adeguato
Staff di pulizia e mantenimento
Valutazione preop
» test e consulti
Pianificazione anestetica accettata dal paz e dalla direzione medica
della sede
Responsabilizzazione medica della dimissione del paziente
Pazienti che ricevono anche solo sedazione oltre alla anaestesia
locale devono essere accompagnati da un adulto responsabile per il
domicilio
Istruzioni scritte per I pazienti

Fondamentali 2
Equipaggiamento adeguato:
Spazio sufficiente
Prese elettriche adeguate
Illuminazione buona
Fonte di alimentazione alternativa:gruppo di continuità,batterie…..
Fonte di ossigeno sufficiente per la durata della procedura e oltre
Possibilità di ventilazione positiva
Carrello di emergenza con defibrillatore e farmaci appropriati
Aspirazione(indipendente dalle fonti di energia)
Se anestesia inalatoria :aparecchio di anestesia + SCARICO GAS
Monitoraggio di base adeguato
Controllo dei regolamenti di sicurezza locali;regionali,statali……

Fondamentali nascosti
Rivedere protocolli e procedure
Trasferimento in caso di ospedalizzazione
Capacità dei chirurghi e del personale
Commisurazione alle procedure proposte

Raccomandazioni ulteriori per i
chirurghi:1 &….
Sicurezza innanzitutto piuttosto che risparmio o convenienza
Storia clinica completa e test di laboratorio appropriati
Se il paz non è a posto o presenta qualche problema medico particolare e rimangono
dubbi……….non operare
L’anestesia deve essere somministrata da un anestesista esperto o da un IP
specializzato in anestesia
Procedure come liposuzioni abbondanti o interventi combinati con tempi op prolungati
…………meglio ricovero e monitoraggio postop per almeno 24 h
Stabilire un valido team fra chir e anest.
Il chirurgo deve possedere I privilegi di staff per l’intervento ambulatoriale in un
ospedale ragionevolmente vicino
L’intervento da effettuarsi deve rientrare nell’area specifica di competenza.
Protocolli e procedure per tutti I tipi di emergenze chirurgiche

chirurghi: & 2….
Tenere archivio ordinato per tutti I tipi di intervento ,dei consensi ;ecc
Educazione dei pazienti pre e postop per ogni specifico intervento
Assumi o collabora solo con pesonale infermieristico e anestesiologico qualificqto.in
base alla teroria del legame più debole;il chir è forte tanto quanto il suo impiegqto
più debole
Aggiorna e controlla tutta l’attrezzatura a rotazione con sistemi di supporrto per le
cose vitali come l’apparecchio di anestesia e l’O2
Dotarsi di tutti gli strumenti di sicurezza e degli standard
assistenziali:ossimetri,capnografi,riscaldatori ,sistemi pneumatici anti dvt,ecc
Valuta periodicamente le prestazioni :chir,anest,IP;ecc conferenze
mortalità/morbidità
* il personale operatorio chiave deve essere certificato
in BLS e ALS
Educazione continua !!!!

Criteri di selezione dei pazienti
Figure

Home -> Professional Resources
Since Sept. 1, 2000, physician's offices that do more than local anesthesia or sedation procedures have
been required to register with the Board of Medical Examiners (BME), pay a registration fee and comply with
certain rules.
Offices that are already accredited by the joint Commission on Accreditation of Healthcare Organizations,
the American Association for the Accreditation of Ambulatory Surgery Facilities, or the Accreditation for
Ambulatory Health Care are exempted.
The BME has adopted the ASA standards and guidelines (see http://www.asahq.org). Therefore, the same
safety measures used in hospitals are incorporated into the office setting. The following are highlights of
the rules:
preoperative evaluation,
informed consent (including informing the patient if care is shared with other non-physician providers),
intraoperative monitoring,
secondary power source in the OR,
properly serviced and maintained equipment with service logs for 7 years,
emergency drugs and equipment for CPR and malignant hyperthermia,
transfer agreements in case of emergency.
In addition, the operating surgeon or anesthesiologist shall maintain current competency in ACLS or
PALS. At a minimum, at least two persons, including the surgeon or anesthesiologist, shall maintain current
competency in basic life support.
Physicians must notify the board within 15 days if a procedure performed results in an unanticipated and
unplanned transport of the patient to a hospital for observation or treatment for a period in excess of 24
hours, or a patient's death intraoperatively or within the immediate postoperative period. Immediate
postoperative period is defined as 72 hours.
The Board of Medical Examiners voted to adopt the proposed rules at its meeting on March 31, 2000.
Download the BME rules:

Sistema raccomandato per valutazione preop.
(ASA task force on preanesthesia evaluation)
CATEGORIA
CHIRURGICA υ
1 2 3 4 5
CLASSE
ANESTETICA:
π
1 giorno intervento giorno intervento giorno intervento Medico curante
prima del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
2 giorno intervento giorno intervento Medico curante
prima del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
3 Medico curante
prima del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
4 Medico curante
prima del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento
Anestesista prima
del giorno
dell’intervento

Valutazione preoperatoria:
flow chart
p a z s a n o
s p e c i a l i s t i c a g e n e r a l e
c o n s u l e n z a m e d i c a
p a z a m m a l a t o
e s a m i d i l a b
e c g
R X
S c r e e n i n g p r e o p e r a t o r i o
c o m p u t e r i z z a t o
C h i r u r g o : p a t o l o g i a c h i r u r g i c a
t i p o d i i n t e r v e n t o
Valutaz.anestesiologica

Utilizzo di un questionario come screening tool
1 Have you ever had a heart attack?
2 Have you ever had heart trouble?
3 Have you ever had heart failure?
4 Have you ever had fluid in your lungs?
5 Do you have a heart murmur?
6 Did you have rheumatic fever as a child?
7 Do you ever have chest pain, angina, or chest tightness?
8 Have you ever been treated for an irregular heart beat?
9 Do you have high blood pressure?
10 Do you ever have difficulty with your breathing?
11 Do you have asthma, bronchitis, or emphysema?
12 Do you cough frequently?
13 Does climbing one flight of stairs make you short of breath?
14 Does walking one city block make you short of breath?

Utilizzo di un questionario come screening tool
15 Do you now or have you recently smoked cigarettes? If yes, how many packs per day?
For how many years?
16 Do you have liver disease, or a history of jaundice or hepatitis?
17 Do you drink more than three drinks of alcohol per day? If yes, how many per week?
18 Do you have indigestion, heartburn, or a hiatus hernia?
19 Do you have a history of thyroid problems?
20 Do you have diabetes?
21 Do you have a kidney problem?
22 Do you have numbness or weakness of your arms or legs?
23 Do you have epilepsy, blackouts, or seizures?
24 Have you had problems with blood clots, or excessive bleeding?
25 Do you have any other important medical problems? Please list.
26 Have you ever had an anaesthetic? If yes, when was your last one?
27 Have you or any member of your family had a reaction to an anaesthetic?
28 Do you have arthritis or pain in your neck or jaw?
29 Do you have dentures, capped or loose teeth?
30 Do you think you may be pregnant?
31 Have you taken prednisone, steroid medication, or cortisone-like drugs in the past year?
32 Please list any food or medication allergies that you have:
33 Please list any medications you are currently taking:
34 Please list any operations you have had in the past:
35 If this is the day of surgery, when did you last eat or drink?

Preop process modelPreop process model
from the Cleveland Clinic Foundationfrom the Cleveland Clinic Foundation
Demographics
and type of
surgery
Demographics
and type of
surgery
Computer assisted
Health screening
Computer assisted
Health screening
Lab,EKG,RXLab,EKG,RX
surgery team
H&P+lab follow
upew Sub-Point
surgery team
H&P+lab follow
upew Sub-Point
NewGen.Int
Med concult
NewGen.Int
Med concult
medic.spec.consultation
medic.spec.consultation
Surg.office
health
y unhealthy
Express criteria satisfied
Day of
surgery
yes
no
Preop
anesth
cleara
nce

Consenso e disposizioni pre e
postop.
Gentilissimo sig………………..
come il collega chirurgo dott…………………..Le avrà già spiegato,per la riuscita
ottimale dell’intervento è importante attenersi scrupolosamente alle raccomandazioni elencate che la preghiamo di
leggere,firmare,e conservare per il giorno dell’intervento,quando la riconsegnerà compilata
all’anestesista.RingraziandoLa anticipatamente della collaborazione,
-----------------------------
Si prega di leggere attentamente e riempire con i dati richiesti lo spazio sopra i puntini(data,città, nome,
cognome,intervento,firma).
Data:………………….
Città:………………….
Io sottoscritto……………………………………………………….
acconsento che l'intervento di …………………………………………………………………..
venga eseguito in anestesia generate e /o locale come spiegato dall’anestesista dott……………………...
Dichiaro di attenermi alle seguenti disposizioni:
I)non ho assunto alcun cibo nelle 6 ore precedenti l'intervento,ne' liquidi nelle due ore
precedenti;(quindi liquidi quali bevande non alcooliche,the zuccherato,coca cola,ecc sono consentiti)
2)di non guidare alcuna automobile o motocicletta o bicicletta, od utilizzare qualsiasi
macchinario nelle 24 ore seguenti I'anestesia,
3)di non assumere alcoolici nelle 24 ore seguenti l'anestesia;
4)di farmi riaccompagnare alla mia residenza da un adulto responsabile;
5)di rimanere in compagnia di un adulto responsabile una volta tornato al domicilio;
6) di non assumere alcuna decisione importante ne' firmare documenti
importanti(testamento,assicurazioni ecc.)nelle 24 ore seguenti;
7)di vestirmi in modo pratico il giorno dell’intervento ,cosicchè il vestiario possa essere facilmente rimosso e
indossato e riposto in un armadietto;

Questionario postoperatorio I e II
giornata

L'ufficio deve accreditarsi??L'ufficio deve accreditarsi??
a chi si deve rivolgere ?a chi si deve rivolgere ?
richiesta
volontaria
richiesta
volontaria
deve rispondere a
tutti gli organismi
certificanti?
deve rispondere a
tutti gli organismi
certificanti?
obbligo di leggeobbligo di legge deregulation......deregulation......
anestesia itinerante??anestesia itinerante??

Accreditamento degli office
chirurgici
Ente Num
offices
accredit
Costo($) Supervisione anest
JCAHO
Joint Commission on
Accreditation of Heakthcare
organizations
40 3975 LIP
AAAASF
American Association for
Accreditation of Ambulatory
surgical facilities
>600 1000-3700 Anesthesiologist,MD
supervis
AAAHC
Accreditation Association
for Ambulatory Health Care
160 3000-4000 MD,DDS,MD supervis

A quale ente certificatore
rivolgersi?
JCAHO AAAHC AAAASF
Grande esperienza
ospedaliera
Validi per le sedi
ambulatoriali
Esperienza limitata a
office per chir
plastica
Nuovi standard
richiedono molte sedi
per feedback
Nuovi standard
anestesiologici
appena emessi
Nuovi standard
anestesiologici
appena emessi;altri
standard richiedono
aggiornamento

Osservazioni finali sulla collaborazione
anestesiologico/chirurgica……….
Joas (1) emphasizes, “The comfort of both patient
and surgeon is of significant concern to the
anesthesiologist to maintain good will and
continued case flow from the surgeon.” Similarly,
Koch has pointed out, “Disputes regarding
anesthesia care are on quite uneven playing fields.
For instance, if a technique departs from what the
surgeon prefers or if there is a difference in
opinion about the prudence of proceeding with the
particular case the surgeon can just as easily
invite a colleague or an alternate provider

Critica alla collaborazione anestesista/chirurgo
Difficile da accettare?ma così funzionano I consulenti:se il
curante non è d’accordo con il consiglio diagnostico-
terapeutico del consulente,…….chiama un altro consulente !
Buone relazioni con il chirurgo essenziali,ma non
dimenticate mai la sicurezza !
L’anestesista protegge il paz dallo stress chirurgico
Osservare gli standard !
Anche se ciò può significare cancellare il caso e prendersi
gli insulti del chirurgo!
In caso di dubbio pensate al paziente e alla vostra
responsabilità professionale e al rischio della vostra
autonomia……..

OBA come miglioramento ?
L’anestesista diviene il medico del perioperatorio….non ci
sono altri consulenti,……..
l’industria svilupperà apparecchi e monitor sempre + compatti
l’ambiente office richiederà sempre + attenzione da parte
degli anestesisti:pazienti giovani e/o sani….
in ospedale o centro di day surg esiste un sistema di
protezione e consulenza;in office il sistema è l’anestesista
Necessità di capacità organizzative e di comunicazione e non
solo per l’anestesista …..
innovazione spinta dall’esperienza

Consider outsourcing anesthesiology
services
Source: Cosmetic Surgery Times
By: Steven Bloch, M.D.
Originally published: January 1, 2006

THANK YOU FOR YOURTHANK YOU FOR YOUR
ATTENTIONATTENTION

FINE II

Etichettatura delle siringhe!!!

Principi fondamentaliThe fundamental principle that must govern OBA is that patient safety cannot be sacrificed for any of the aforementioned
four major considerations—i.e., the standard of anesthetic care does not decrease because of venue change (11). Indeed,
because OBA is a subset of ambulatory anesthesia, the ASA guidelines for ambulatory anesthesia and surgery as well as
the more recently adopted guidelines for office-based anesthesia must be followed. The two sets of guidelines emphasize
the need for
1.Adequate professional and administrative staff, as well as housekeeping and maintenance personnel.
2.Preoperative evaluation with necessary tests and consultations as medically indicated.
3.The development of an anesthesia plan acceptable to the patient, the administration or medical direction of same, as well
as the discharge of the patient remain physician responsibilities.
4.Patients who receive other than unsupplemented local anesthesia must be discharged with a responsible adult and
provided written postoperative and follow-up instructions.
Because the office facilities vary considerably, anesthesiologists must ensure that the facility is adequately equipped, with
the following as a minimum:
5.Sufficient space and electrical outlets plus adequate illumination must be provided, including backup power (this is listed
first because space is something for which anesthesiologists frequently must fight in the office as well as the hospital or
ASF).
6.A reliable source of oxygen adequate for the length of the procedure plus a backup supply, the latter to be at least
equivalent to an E cylinder, and the ability to administer positive pressure ventilation.
7.Emergency cart with defibrillator and appropriate drugs.
8.A reliable source of motor-driven suction.
9.If inhaled anesthetics are to be used, an anesthesia machine equivalent to that of the hospital operating room and a
system for scavenging waste anesthetic gas must be available.
10.Basic monitoring of oxygenation (pulse oximetry), ventilation (minute ventilation for general anesthesia and capnography
for intubation), circulation (blood pressure every 5 min and continuous electrocardiogram display), and temperature (when
clinically significant changes in temperature are intended, anticipated, or suggested) is essential.
11.All applicable building and safety codes and facility standards must be observed and federal, state, and local laws
obeyed.

Because the office facilities vary considerably, anesthesiologists must ensure that the facility
is adequately equipped, with the following as a minimum:
5.Sufficient space and electrical outlets plus adequate illumination must be provided,
including backup power (this is listed first because space is something for which
anesthesiologists frequently must fight in the office as well as the hospital or ASF).
6.A reliable source of oxygen adequate for the length of the procedure plus a backup supply,
the latter to be at least equivalent to an E cylinder, and the ability to administer positive
pressure ventilation.
7.Emergency cart with defibrillator and appropriate drugs.
8.A reliable source of motor-driven suction.
9.If inhaled anesthetics are to be used, an anesthesia machine equivalent to that of the
hospital operating room and a system for scavenging waste anesthetic gas must be available.
10.Basic monitoring of oxygenation (pulse oximetry), ventilation (minute ventilation for
general anesthesia and capnography for intubation), circulation (blood pressure every 5 min
and continuous electrocardiogram display), and temperature (when clinically significant
changes in temperature are intended, anticipated, or suggested) is essential.
11.All applicable building and safety codes and facility standards must be observed and
federal, state, and local laws obeyed.

Principi fondamentali 2
Less obvious, but equally important, is the need to review
policies and procedures, including transfer protocols in the event
that hospitalization is required. Similarly, the capabilities of both
the facility and the surgeon must be equal to the task of handling
the proposed procedure.
Moss (12), who led the fight to regulate OBA and surgery in New
Jersey, has addressed the issue of cost required to meet
reasonable standards: “The $2500 pulse oximeter or the
$15,000 refurbished anesthesia machine spread over years of
use and thousands of patients makes the per-patient cost
insignificant.” He also emphasized the need for complete
evaluation of an office before agreeing to provide OBA. Although
physical plant, anesthesia equipment, and monitors are obvious
considerations, support staffing, capability of the surgeon, facility
protocols, and policies must also be evaluated.

Raccomandazioni ASA,ASAPS e
ASPS
1. Be accredited by a national or state recognized
accrediting agency/organization such as the American
Association for Accreditation for Ambulatory Surgery
Facilities (AAAASF), Accreditation Association for
Ambulatory Health Care (AAAHC), or the Joint
Commission on the Accreditation of Healthcare
Organizations (JCAHO).
2. Be certified to participate in the Medicare program
under Title XVIII.
3. Be licensed by the state in which the facility is
located.
regular inspections and report to their state agencies,
provide ongoing staff training, credential their
personnel, and have emergency equipment on hand
such as crash carts.

chirurghi
What can we do as individual plastic surgeons within our clinical practices in addition to our major organizations’ efforts to enhance
patient safety in outpatient surgery settings? We are encouraged to consider the following:
* Patient safety comes first before cost and convenience. In the final analysis, this is more important than any mandate or
moratorium.
* A complete medical history is taken, including any appropriate laboratory tests. If the patient is not healthy or has any extenuating
medical problems, the patient needs a proper medical evaluation. If any doubt remains, do not operate.
* Anesthesia should be administered by a skilled licensed professional, either an anesthesiologist or a certified registered nurse
anesthetist.
* Procedures such as large-volume liposuction and combination procedures with prolonged anesthesia and operative time should
be considered for inpatient surgery or postoperative monitoring in an accredited facility for at least 24 hours. (Use common sense
and good surgical judgment.)
* A total operating team effort emphasizing communication between the anesthesia personnel and surgeon should be established
to promote safety.
* The surgeon should have staff privileges to perform the specific procedure being done in the outpatient setting at a hospital within
reasonable proximity. Procedures should only be done if they are in the surgeon’s specific area of expertise.
* Have specific policies in place for all types of potential outpatient surgery emergencies.
* Maintain appropriate documentation of medical history and informed consent.
* Provide uniform preoperative and postoperative patient education for specific procedures.
* Hire only qualified nursing and anesthesia personnel. Use the “weak link theory” in your practice. You are only as strong as your
weakest employee.
* Update and test all operating room equipment on a rotating basis, with backup support available for vital equipment failures such
as anesthesia equipment and the oxygen delivery system.
* Provide the elements of patient safety and current standard of care including humidifiers, oximeters, capnography, warming
blankets, and pneumatics/compression leg garments.
* Periodically evaluate the surgical team’s performance, including surgeons, anesthesiologists, and nurses, in peer review
morbidity and mortality conferences.
* Strongly suggest that key operative personnel are certified in advanced cardiac life support and maintain updated continuing
medical education in outpatient surgery advances.

Porterfield and Franklin Porterfield HW, Franklin LT.
The use of general anesthesia in the office
surgery facility. Clin Plast Surg 1983;10:289-
294. reviewed their 16 years of experience in office-based
plastic surgery procedures. They performed 13 080 cases under
local anesthesia with or without sedation and 5038 under
general anesthesia. They concluded that to maintain a low
admission rate of 0.02% it is essential to have adequate and
rational selection criteria, based on the patients' medical health
and the surgical procedure. They included ASA I or II patients
and procedures without extensive blood loss which were
completed within a time frame that allowed the patient to awaken
adequately and leave the facility by late in the afternoon [10].

Davis [11] Davis JE, Sugioka K. Selecting the
patient for major ambulatory surgery. Surgical
anesthesiology evaluations. Surgical Clinics of
Northamerica 1987;67(4):721-732 selected surgical
procedures based on the intensity of postoperative surgical care. He
divided the surgical procedures into four levels (I-IV) (Figure 1) [11].
Those procedures appropiate for office-based surgery and anesthesia
belong to level I, where no postoperative care is needed. However, the
line of demarcation can shift to the right, and surgical procedures
belonging to level Ia or II can be included in the office, depending on the
surgical and anesthetic skills, on the office-resources, on the proximity
to a hospital and, most importantly, on the patient's medical health. This
means that surgical procedures performed in the office can belong
either to level I, Ia or II. Tobin also considered that the extent of the
surgery should be determined more by the nature of the recovery period
than by the surgical procedure itself and patients should be in excellent
health with no significant medical problems [2].

Limits of the office setting
Why is it so critical to perform an adequate selection of the
patient and the surgical procedure? Because there are of course
some limits in the office setting. First, based on the limited scope
of the office-unit (as well as in the free-standing facility), both the
staff and medical capabilities are less extensive than those
within a hospital. Second, the service is likely to be available on
limited basis. Urgent care would be referred to an hospital
emergency department. Finally, the office surgical suite is
designed to treat patients whose stay is normally less than 4 h. It
is not designed to ‘even occasionally’ hold a patient for a 24-h
observation (such as in a free-standing unit or a hospital). In
those exceptional cases, the patient would be referred to a
hospital of reference (Figure 2) [9].

Diapo della aggressività interventi da
anest ambulat e schemi per ospedale

Mortalità durante OBA
1.A 3-yr-old boy developed a seizure followed by cyanosis during laser removal
of port wine stains. No oxygen was available.
2.Malignant hyperthermia occurred in a 28-yr-old woman having breast
augmentation. Temperature was 107°F (41.67 °C) on arrival in the emergency
room. No dantrolene was available.
3.A 51-yr-old man underwent a 9.5-hr combined liposuction, penile enlargement,
and face-lift. He was kept in the office overnight under the care of an agency
nurse, who noted 2 h later that the patient was in respiratory distress and that the
oxygen tank was empty. Paramedics were contacted 30 min later. Not
surprisingly, the patient was dead on arrival at a local hospital 40 min later.
Se queste procedure fossero state effettuate in un unità di day surg o
ospedale………………………
IL probl ha preso tanta cosnsistenza che The risks associated with OBA were
considered so great in the United Kingdom that, on July 21, 2000, the
administration of general anesthesia in a dentist’s office was banned. Dentists
and oral surgeons were given 18 mo to transition their practices to a hospital
setting. Considering the emphasis on cost-containment by governmental
agencies, the decision to move patients to the more expensive hospital setting
must reflect great concern of the United Kingdom authorities concerning the OBA
risk to patients.

Morti in ufficio……..
10San Francisco Examiner 17 August
1993. [Context Link]
11The San Diego Tribune 13 January
1989. [Context Link]

Medicina preventiva vs
trattamento delle complicanze
Preventive medicine is always preferable to rescue
from complications. In addition to adhering to the
standards summarized above, careful patient
selection is the best way to avoid complications. In
particular, patients with comorbid disease, especially
chronic obstructive pulmonary disease, epilepsy,
heart disease, and obesity, must be evaluated
carefully and completely, so specialty consultation can
be included when indicated. When in doubt, referral of
these patients to a more complete facility than a
surgeon’s office is strongly advised, even though such
a decision may produce friction—even an acrimonious
confrontation—with the referring surgeon, the patient,
or both.

Many surgeons administer intravenous sedation, but for procedures requiring general or regional anaesthesia, they seek the assistance of an anaesthesiologist
or certified registered nurse anaesthetist (CRNA) [12•]. The CRNA is often the surgeon's choice if, in the surgeon's opinion, the procedure requires only a slightly
deeper level of sedation than the surgeon is accustomed to administering himself. For procedures requiring general anaesthesia in the USA (except New
Hampshire), the anaesthesia is administered by an anaesthesiologist, a CRNA supervised by an anaesthesiologist, or a CRNA supervised by the surgeon. In
most other developed countries such as Australia or the UK, a specialist anaesthetic medical practitioner must be present if general anaesthesia is administered.
Anaesthetic techniques
The range of anaesthetic techniques in office-based practice is the same as in hospital-based practice, especially ambulatory surgery. The overriding concern is
rapid discharge. Recovery facilities and personnel in the office setting are usually incapable of monitoring patients who are heavily sedated, have a long-lasting
spinal block, or are suffering from severe pain or nausea. The majority of office-based anaesthesia is monitored anaesthetic care (MAC). Improvements in
monitoring capability, notably continuous pulse oximetry and expired CO2 display, provide the anaesthesiologist a better understanding of the patient's response
to sedative and analgesic medications [13•]. Today's anaesthesiologist can more safely provide deep levels of sedation in appropriate patients, however, as in any
anaesthetizing location, the critical threshold of patient unresponsiveness must not be crossed unwittingly. An anaesthesiologist can deliberately breach the
boundary between MAC and general anaesthesia in appropriate patients if airway equipment is available and both the patient and the surgeon understand the
risks. For procedures requiring general anaesthesia in the office, the laryngeal mask airway is a significant technological improvement, not only for routine use but
also for the emergency ventilation of patients with an unanticipated difficult airway [14].
Anaesthetic drugs
The close control offered by rapidly acting and rapidly eliminated drugs is especially useful in the office setting. Midazolam, propofol, ketamine, and methohexital
are the sedative hypnotics we use. A propofol infusion combined with an opioid and sometimes midazolam or ketamine provides an easily adjusted depth of
sedation or general anaesthesia [15,16]. A new short-acting benzodiazepine, Ro 48-6791, is being developed and might play a role in office-based anaesthesia
[17].
Analgesics administered in office-based anaesthesia include non-steroidal anti-inflammatory drugs and opioids. A short period of relatively profound intraoperative
analgesia can be produced using fentanyl, alfentanil, or remifentanil. In the US, remifentanil is infused for both MAC and general anaesthesia, but in Australia it is
approved for use only in artificially ventilated patients. There is no major difference between these drugs in the speed of recovery after relatively short
anaesthetics; however, recovery from longer anaesthetics should be significantly faster using remifentanil [16]. The haemodynamic response to surgical stimuli is
suppressed better by remifentanil than by alfentanil, so remifentanil might be preferable in patients at risk of myocardial ischaemia [18]. When administering
remifentanil, provision for postoperative analgesia must be made because pain is one of the chief reasons for delayed discharge from ambulatory surgical
centres, and is the third most common reason for return hospital visits [19,20]. Although the respiratory depression and nausea associated with opioids can be
particularly troublesome in the office setting (where postoperative care of a patient can delay the following cases), parenteral or oral opioids are the mainstay of
postoperative analgesia.
The use of muscle relaxants in office-based surgery is the same as in any ambulatory surgical setting. A rapid-onset short-duration non-depolarizing
neuromuscular junction blocking drug, ORG 9487, is being developed and might prove ideal for office-based anaesthesia [21].
Inhalational agents are playing an increasing role in office anaesthesia as anaesthesiologists move into this practice. Offices must provide suction for scavenging
volatile anaesthetics or the anaesthetic machine must have a charcoal filter. Sevoflurane and desflurane potentially offer a rapid emergence [22,23], an attractive
feature in office-based anaesthesia, but these agents are associated with a higher incidence of emergence delirium [22,23]. This delirium can be disquieting for
other patients and can tax the limited personnel available in the office setting. Sevoflurane has remarkable cardiovascular stability and is significantly less irritating
to the airway than the other halogenated agents [24,25]. If choosing a single halogenated agent for office-based anaesthesia (a reasonable possibility in order to
minimize equipment weight and bulk) sevoflurane is a logical choice.
Equipment and facilities
Anaesthesiologists must be circumspect when asked to provide anaesthesia in a new office location [26]. They assume responsibility for the equipment, facilities,
and drugs required to provide safe anaesthesia, and must develop a contingency plan for equipment or power failure. A reliable means of transporting a patient to
the nearest hospital in the event of a disaster should be outlined, and the hospital emergency room director should be made aware of the plans to provide
anaesthesia in the office.
Physiological monitoring of the patient must meet or exceed the relevant local standards for anaesthetic monitoring [27,28]. Procedures performed under MAC in
the informal setting of the physician's office require heightened vigilance by the anaesthesiologist. A review of the ASA closed claims project database revealed
that claims involving MAC have increased from 1.6% of the total claims in the 1970s to 6% in the 1990s [29••]. The severity of these claims is similar to those
occurring under general anaesthesia, including death (34%) and permanent brain damage (19%). Overall, the data from this project suggest that improved
monitoring, notably pulse oximetry and end-tidal CO2 detection, has decreased patient morbidity, as reflected by a decrease in ventilatory complications relative

Cause della insufficienza
rianimativa
Attrezzature di rianimazioine inadeguate
Monitoragio insufficientemspecie
puilsossimetria
Erore umano
Lento riconoscimento dell’evento
Mancanza di esperienza
Sovradosaggio gfarmacologico
Inadeguata valutazione preop.
Inadeguiata valutaz postop

Qualificazioni mediche
Specializzazione
Partica ospedlaiera nella discipilina
Possibilità di ricovero?

Surgical Facility Standards
Plastic surgery performed under anesthesia, other
than minor local anesthesia and/or minimal oral
tranquilization, should be performed in a surgical
facility that meets at least one of the following criteria:
* accredited by a national or state-recognized
accrediting agency/organization such as the American
Association for Accreditation of Ambulatory Surgery
Facilities (AAAASF), the Accreditation Association for
Ambulatory Health Care (AAAHC), or the Joint
Commission on Accreditation of Healthcare
Organizations (JCAHO)
* certified to participate in the Medicare program
under Title XVIII
* licensed by the state in which the facility is located.

Patient Safety in Office-Based Surgery
Facilities: II. Patient Selection
[COSMETIC SECTION: COSMETIC
SPECIAL TOPIC]
Iverson, Ronald E. M.D.; Lynch, Dennis
J. M.D.; ASPS Task Force on Patient
Safety in Office-based Surgery Facilities

Selezione dei pazienti
preoperative patient history should include personal
health history, identification of comorbidities, social
history, family history, medication regimen
(prescription and nonprescription), allergies (drug,
latex, tape) and reaction, review of the body systems,
and availability of a responsible adult to assist with
postoperative instructions and care. The physical
examination is essential for assessing the patient’s
clinical status preoperatively and should include an
estimate of general health and appearance;
measurement of height and weight; assessment of
vital signs, including the heart and lung; and an
examination of the anatomical area of the surgery. A
sample preoperative history and physical form is
shown in

identifying comorbidities that are relevant to the
procedure or that may predispose the patient to
intraoperative or postoperative complications. When
evaluating the patient, particular attention should be
given to factors such as age, weight, and history of
other illnesses, including diabetes mellitus, cardiac
diseases, and respiratory conditions. The physician
should evaluate the patient for a history of (or
potential for) venous thromboembolism, and when
indicated, should consult the appropriate ASPS
Practice Advisory and/or Clinical Practice Guideline
for thrombosis risk ratings and thromboprophylaxis
measures. 3,4 The surgeon should refer patients with
significant comorbidities to medical specialists when
indicated.

On the basis of the patient’s preoperative history and physical examination
results, pertinent tests should be ordered, including:
electrocardiogram in patients over 45 years of age
electrocardiogram at any age when known cardiac conditions are present
complete blood count/blood chemistries, as needed, for detailed evaluation of
specific diagnosis, such as anemia, diabetes mellitus, hypertension, diuretic
therapy
additional tests as appropriate, depending on the patient’s status as
determined through the medical history and physical examination or because
of the specific procedure being performed (see ASPS Clinical Practice
Guideline for specific procedures; http://www.plasticsurgery.org/psf/
psfhome/clinprac/index.htm).

The ASA House of Delegates approved “Guidelines for Office-
Based Anesthesia” in October of 1999
(http://www.asahq.org/ProfInfo/offbasedguide.htm ). These
comprehensive guidelines focus on the delivery of safe
anesthesia care in doctor’s offices by anesthesiologists and
certified registered nurse anesthetists. The ASA Task Force on
Office-Based Anesthesia has recently created a manual that
provides practical advice for surgeons and anesthesiologists
interested in setting up and maintaining a safe office-based
surgery environment. The ASPS and ASAPS have taken an
unprecedented stance by mandating that all outpatient plastic
and cosmetic surgery must be done in an accredited facility.
Over a 3-year period that began in June of 1999 and will end in
July of 2002, members must transition to perform outpatient
surgeries in accredited and/or licensed facilities that meet at
least one of the following criteria 2,3

Conclusioni
La oba sta crescendo rapidamente ed è necessario regolamentarla come hanno
fatto alcuni stati USA California, Florida,e New Jersey,Tezxas :I dugbbi sorti circa
la qualità dell’assistenza devono essere dissolti da regolamentazioni appropriate
e ragionevoli che coinvolgano i professionisti consnetano La scelta di eseguire
interventi in ambulatorio piuttosto che in strutture più attrezzate deve basarsi su
considerazioni tecniche legate alal propria professionalità ed allo stto fisico del
paziente piuttosto che su consideraziomni economiche.La costo effiacci è soloiun
fattore e devono prevalere considerazioni di qualità e scicurezza Negli USA è
stata fondata ed è attiva una società (Society for Office-Based Anesthesia)che ha
lo scopo di milgiorare continuamente la qualkità dell’assistenza e e la sicurezza
dei pazienti e iniziative analoghe devono esser intraprese in Italia per la
salvagiardia dei cittadini,mma anche dei professionisti
E’ probabile che il sistema assicurativo debba farsi carico anche della OBS e
OBA e non posa necesasriamente proporre tariffe basse
Per il mioguioramento dellapartica cgirurgica ed anestesiologica ambulatoriale è
necassrio seguire delel linee guida nazionali ed internazionali e formare dei
professionisti esperti in questo settore ,cher non può che essere un continuum
assistenziale che riguarda tutto il perioepratorio

Diapo di esempi attrezz e monitor….

Classi di aggressività
chirurgica…………

Questionario…

Schemi schede anest;quest
preop;;;;;vedi milano ;;;;;;

Materiale occorrente nel carrello della rianimazione:
Materiale numero
pallone di Ambu 1
maschera di gomma nera:
numero 5 1
numero 4 1
numero 3 1
maschera monouso trasparente
grande 1
media 1
cateter mount 1
filtro antibatterico 1
tubi endotracheali :
numero 7.5 1
“ 7 1
“ 6.5 1
tubi di Guedel calibro 31
“ “ “ “ “ 2 1
manici da laringoscopio con pile:
2
lame da laringoscopio
media curva 1
grande “ 1
media retta 1
grande “ 1
siringhe da 20 ml 2
siringhe da 10 ml 2
siringhe da 5 ml 2
siringhe da 2 o 2.5 ml 2
rotoli di cerotto di seta;
largo 1
stretto 1

Farmaci per carrello della rianimazione:
Materiale numero
ADRENAliNA 2
Aleudrin o Alupent 2
Aminofillina 2
ATROPINA 2
Bentelan 2
Bicarbonato di sodio 8.4% 2
Calcio
catapresan 2
Cordarone 2
Dobutamina 2
dopamina(revivan) 2
Emagel 2
Isoprenalina 2
isoproterenolo 2
Lanoxin 2
Lasix 2
Levicor 2
Lidocaina 2
Solumedrol 2
Trimeton 2
Uraprene 2
Valium 2
Venitrin 2
Visken 2
CATETERI E.V VIALON:
22G 2
20 G 4
18G 4
16 G 2
DEFLUSSORI FLEBOCLISI4

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