Anesthesia for Office-Based Urologic Procedures

Abstract

Office-based anesthesia (OBA) and surgery is performed in a physician’s private office that is not accredited by the state or a national organization as an ambulatory surgical center (ASC) or as a hospital. While the practice of OBA has recently undergone great expansion, it is not a new idea. With the introduction of anesthesia over 150 years ago, it was common for surgeons to attend the elite at home, arriving in a carriage with a bag of “laughing gas” or a sponge and container of chloroform. Such care was only for the very wealthy. Dr. John Snow, probably the first physician anesthetist, in his book on Chloroform and Other Anaesthetics wrote that he had notes on 867 cases of dental extractions (3,021 teeth were extracted) performed in neighborhood dentists’ offices, particularly that of MR West of Broad Street, in the city (London) (Snow J. On chloroform and other anaesthetics. London: John Churchill, 1858. p. 314–5). Snow reported no “inconvenience” from chloroform administration except for rare instances of nausea and vomiting. His OBA brought Snow to the attention of a Dr. Fuller of Manchester Square who recommended that he be invited to anesthetize patients at St George’s Hospital (Keys TE. The history of surgical anesthesia. New York: Krieger, 1945. p. 32–5). He began to do so on January 28, 1847, and later was also credentialed at University College Hospital where he worked with the preeminent English surgeon, Mr. Robert Liston.

Thus, anesthesia was moved from the office to the hospital where it remained for many decades. Dr. Ralph Waters published the first report in the United States of OBA in 1919. In his practice in Sioux City, Iowa, he had “a modest office equipped with a waiting room and a small operating room with an adjoining room containing a cot on which the patient could lie down after his anesthetic” (Am J Surg 33:71–3, 1919). As concern grew over hospital costs in the 1970s, means to provide more efficient care were explored. Building on an idea from 1949, a preanesthetic assessment clinic was established at the Bronx Municipal Hospital Center in 1972 (Anaesthesia; 4:169–74, 1949; Anesth Analg; 55(3):307–10, 1976). Over 3 years, the average patient day reduction was 4 days. The groundwork was set for ambulatory surgery and for anesthesia to move outside of the conventional hospital operating room. Currently, it is estimated that more than 55 % of all ambulatory procedures in the United States are performed in freestanding facilities, 40 % in ASC and 15 % in offices, a percentage that is moving toward the office setting (Can J Anesth; 57:256–72, 2010).