ANESI'H ANALC;

1982.61 921-6

Criteria for Selection of Ambulatory Surgical Patients

and Guidelines for Anesthetic Management:
A Retrospective Study of 1553 Cases
Howard W. Meridy, MD"

MERIDY,H. W.: Criteria for selection of ambulatory surgical patients and guidelines for anesthetic management: a
retrospective study of 1553 cases. Anesth Analg 1982;61:921-6.

The charts of 1553 patients who were anesthetized for ambulatory surgery were analyzed retrospectively to determine
the effect of the type of surgery, the age of the Patient, the use of premedication, the duration of anesthesia, and the
anesthetic technique on the duration of recovery and the rate of complications. In a 4-month period in 1979, 1073
patients were treated, and another 480 Patients were treated during a 2-month period in 1980. Aside from patients
undergoing dental surgery, the surgical procedure and the extremes of age affected neither the duration of recovery
(193 k 97 minutes) nor the rate of complications (2.45%). The use of premedicants other than narcotics did not
prolong recovery. There was no relationship between anesthesia time and the duration of recovery. Patients who
received local anesthesia had a significantly shorter recovery period than the whole population, and significantly fewer
patients receiving local anesthesia had to be admitted to the hospital. Thus, arbitrary limits placed on the type of
surgery. age of the patient, the duration of the procedure, and the use of certain premedication appear to be
unwarranted.

Key Words: ANESTHESIA: outpatient.

I N RECENT YEARS, there has been a proliferation

of hospital-based and free-standing ambulatory
surgical centers throughout the United States. Day
care surgery in a hospital-based setting has been
practiced at Hartford Hospital since the 1950s, with
22,031 ambulatory surgical patients having been cared
for between October 1975 and October 1981, repre-
senting approximately 20% of all surgical cases.
This increase in the number of patients has raised
serious questions about the criteria for selection of
suitable candidates for ambulatory surgery and guide-
lines for their anesthetic management. Type of sur-
gery, age, use of premedication, duration of anesthe-
sia, and anesthetic technique have all been proposed
as criteria for patient selection and guidelines for
anesthetic care (1-6). Nevertheless, it has not been
possible to define precisely the factors that contribute
to a successful outcome of ambulatory surgery.
This retrospective study reviews 1553 patients who
underwent surgery and anesthesia at Hartford Hos-
* Associate Anesthesiologist.
Received from the Department of Anesthesiology, Hartford
Hospital, 80 Seymour Street, Hartford Connecticut 06106. Accepted
for publication June 23, 1982.
Reprint requests to Dr. Meridy.
pita1 in the One-Day Surgery Unit, which opened as
a self-contained unit in 1979. The purpose of this
review is to determine what effects-if any-age, use
of premedication, duration of anesthesia, and anes-
thetic technique may have had on the outcome, i.e.,
the duration of the recovery as well as the rate and
nature of complications incurred. To assess the value
of 1 year of experience in operating the newly estab-
lished, self-contained unit, two time spans, 1 year
apart, were selected.
Methods
Two sets of data were compiled: (a) records of 1073
patients treated from September through December
1979, and ( b ) records of 480 patients treated in Sep-
tember and October 1980. Surgical procedure, age,
sex, premedication, anesthetic agent, and technique
were recorded. Duration of anesthesia, determined as
the time spent in the operative suite, and recovery
time, defined as the amount of time between leaving
the operative suite and discharge from the unit, were
recorded. All data were coded and processed with an
IBM 34 series computer, where they were stored,
sorted, and analyzed. Statistical analysis included lin-
ear regression to determine correlation, the unpaired
ANESTHESIA AND ANALGESIA
V o l 6 1 , No 1 1 , November 1982 921
 GUIDELINES FOR OUTPATIENT ANESTHESIA
Student’s t-test to compare mean values, and the chi-
square test to determine significant differences in
frequency.
The first set of 1073 patients consisted of 802
females and 271 males with ages ranging from 4 to 92
years, mean age of 37 years. The second set of 480
patients included 317 females and 163 males with
ages ranging from 9 months to 87 years, mean age of
37 years (Fig 1). All patients were A.S.A. physical
status I or 11.
Results
The surgical procedures performed were grouped
into seven categories: general (16.2%), ophthalmologic
(3.4%), urologic (7.6%), gynecologic (34.2%), otolar-
yngologic (9%),dental (15%),and orthopaedic (14.6%).
The relation between the surgical procedure and the
length of the anesthesia time can be seen in Table 1.
Ophthalrnologic procedures approached the mean an-
esthesia time for the entire population. General and
dental surgical, otolaryngologic, and orthopaedic pro-
cedures were significantly longer, whereas gyneco-
logic and urologic procedures were significantly
shorter. The mean anesthesia time for 1073 patients
anesthetized in 1979 was 46 * 23 minutes with a
range of 2 to 170 minutes. For the second series of
480 patients anesthetized in 1980, the mean anesthesia
time was 45 k 24 minutes with a range of 2 to 215
minutes.
Recovery time is used as one of the measures of
outcome in this study. The mean recovery time for
the patients in the first set was 193 -+ 97 minutes in
contrast to the significantly shorter mean recovery
1979
NO. OF
PATIENTS
0 10 20 30 40 50 60 70 80 90
ACE
FIG I .
922 ANESTHESIA AND ANALGESIA
Vol61, No 1 1 , November 1982
time of the second set which was 164 f 86 minutes
( p < 0.001). The relation between the surgical pro-
cedure and the mean recovery time can be seen in
Table 1. Recovery time for gynecologic and otolar-
yngologic patients did not differ from that of the
entire population. Patients recovering from dental
surgery had a significantly longer recovery period.
The recovery period of 40% of these patients was
greater than 294 minutes. Patients recovering from
general surgical, orthopaedic, urologic, and ophthal-
mologic procedures had a significantly shorter recov-
ery period. The recovery period of 52% of these
patients was less than 143 minutes.
The data in Table 1indicate that there is no striking
relationship between anesthesia time and recovery
time. Orthopaedic procedures, which required the
longest anesthesia time, resulted in a recovery time of
155 minutes, which was less than the mean of all cases
studied. Furthermore, as anesthesia time is increased,
there is no increase in the duration of recovery, as
shown in Fig 2.
The relation between the anesthetic techniques and
surgical procedures is seen in Fig 3. Analysis of the
anesthetic agents administered revealed that 76% of
the patients received general anesthesia preceded, in
almost all cases, by a thiopental induction. General
anesthesia agents administered were: nitrous oxide/
oxygen 11%,halothane/nitrous oxide/oxygen 22%,
enflurane/nitrous oxide/oxygen 42%, and narcotic/
nitrous oxide/oxygen 25%. Halothane/nitrous oxide/
oxygen was the most frequently selected anesthetic in
the younger age group. In the older age group, local
anesthesia was most frequently selected, whereas in
1980
N O . OF
PATIENTS
0 10 20 30 40 50 60 70 80 90
ACE
Age distribution.
 MERIDY
'L I001
the middle age group, there was an even distribution
of anesthetic agents used.
The relation between anesthetic techniques and the 90 -
duration of recovery (Table 2) reveals that those
patients who received enflurane had a significantly 80 -
longer recovery period than the population as a whole.
Twenty-five percent of patients receiving enflurane
anesthesia had a recovery period greater than 294
70 -
minutes. Patients who received local anesthesia (i.e.,
field block or intravenous regional block) had a sig-
60 -
3
W

c?
nificantly shorter recovery period. Sixty percent of
patients receiving local anesthesia had a recovery I
U
50 -
+
period less than 143 minutes. u 40-
The number of patients transferred from a day care I
W
I-

z
W
TABLE 1 < 30-

Relationship between Surgical Procedure and Anesthesia

and Recovery Times
20-
Time*
Procedure No.
Anesthesia Recovery 10-

min
Dental surgical 180 57 f 1st 274 f 78$ +
General surgical 193 52 f 25t 168 f 873
Gynecologic 382 34 f 15t 203 k 90 O?

Ophthalmologic 41 49 f 19 122 k 89$

Orthopaedic 109 61 f31t 155 k 85$
Otolaryngologic 91 57 f21t 178 f 102
Urologic 77 31 f 14t 126f 76$
All procedures 1073 46 k 23 193 f 97 H A L O T H A N E N20 O 2 gl.1 NA?.CSTIC'N20102

* Values are means f SD. TYPE OF S U R G I C A L PROCEDURE

t Differed significantly ( p < 0.005)from mean (46 f 23). FIG 3. Relationship between anesthetic technique and surgical
4 Differed significantly ( p < 0.001) from mean (1 93 f 97). procedures.

TABLE 2
Relationship between Anesthetic Agents and Recovery Time
Time'
Anesthetic agents No.
Anesthesia Recovery
~ ~~ ~ ~

min
NzO/Oz 97 30f 10 185f85
Halothane/N,O/OZ 170 50 f 21 206 f 100
Enflurane/NZ0/02 301 56 f 22 236 f 881
Narcotic/NZ0/02 231 38 & 19 202 f 93
Local 274 43 f 25 136 +. 863
All agents 1073 46 f 23 193 f 97
* Values are means k SD.
t Significantly longer than mean ( p < 0.001).
$ Significantly shorter than mean ( p < 0.001).

L . , , . , . , . unit to an inpatient setting can serve as an index of

0
40 80 120 160 200 outcome. The percentage of 1553 patients treated at
ANESTHESIA TIME (minutes) our one-day surgery unit who were transferred to the
FIG 2. Effect of anesthesia time on recovery time. Slope =
hospital was 2.44%. It is demonstrated in Table 3 that
intercept = 190.5;
-0.1092; r = -0.2360. of the 38 transfers, 0.64% were judged secondary to

ANESTHESIA AND ANALGESIA

Vol 61, No 1 1 , November 1982 923
 GUIDELINES FOR OUTPATIENT ANESTHESIA

anesthesia and 1.8%for surgical reasons. Eighty-seven
percent of the patients transferred to the hospital
received some form of general anesthesia whereas
13% received local anesthesia.
Of those patients admitted to the hospital because
of anesthetic complications, all received general an-
esthesia. Even though 76% of the patients studied
received general anesthesia, the number of compli-
cations in this group is larger than would be expected
by random chance according to chi-square test ( p <
0.05). Although the mean anesthesia time (63 f 30
minutes) for those patients who were admitted was
significantly longer than the mean anesthesia time for
the entire population, 71% of these patients had an
anesthetic that lasted less than 60 minutes.
The age of the patient might influence the duration
of anesthesia, recovery, and the incidence of compli-
cations. In Fig 4 is shown that the duration of anes-
thesia varied little with age. However, the duration of
recovery was influenced by age. The younger age
TABLE 3
Types of Complications Resulting in Hospital Transfer
Anesthesia related No Of
pat,ents Surgery related
Nausea and vomiting 8 Pain
Epistaxis 1 Bleeding
Atrial flutter 1 Temperature
Observation
Surgical misadventure
Errors in diagnosis
groups had Longer recovery times with the longest
times associated with the 10- to 19-year-old group.
Twenty-seven percent of the 10- to 19-year-old group
had a recovery period greater than 294 minutes. O n
the other hand, it was the 20- to 49-year-old group
that comprised 70% of the patients who were trans-
ferred to an inhospital setting.
Premedication received by 1553 ambulatory surgi-
cal patients is listed in Table 4. Approximately 25%
of the patients received a hypnotic and/or narcotic
and 40% received atropine. The effect of the use of
premedication on the duration of recovery time is
measured by comparing the mean recovery time of
those patients who received a premedicant with those
who did not. The data from this comparison (Table 4)
show that premedication had a marginal effect on
recovery times, with patients given narcotics having
significantly longer recovery times than unmedicated
patients.
Discussion
The criteria for the selection of a patient for am-
bulatory surgery and the guidelines for anesthetic
management are normally based on the type of sur-
i:;::s gery, age of the patient, need for premedication,
~~ ~ length of anesthesia, and/or technique (1-6). The
9 question raised by this study is whether or not the
4
surgical or anesthetic stress will alter the patient's
3
2
physiologic status to such a degree that he will be
3 unable to return home the same day following his
7 anesthetic and surgical experience. From the data
presented here and from other studies of one-day
surgical patients (1,2, 6-S), there is a basis to evaluate
the criteria that are currently in use.

Type of Surgery
240-

r7
All types of surgical procedures on patients of

-
a,
3
.-
t
Lo
180- TABLE 4
Relationship between Premedication Received by 1553
E
v
Patients and Recovery Time
~~ ~ _ _ _ _ ~ ___ __-
w 120- Type No Recovery time'
2
I- min

60 - No premedication
Diazepam
1015
98
179 & 113
168 f 104
Pen tobarbital 25 231 *88

I
Narcotics (meperidine and 388 208 & 101 t
0 1 . . morphine)
20 40 60 80 100 Hydroxyzine 92 192 k 120
AGE ( y e a r s )
* Values are means f SD.
FIG 4. Relationships between age and anesthesia time and age t Differs
significantly from patients not receiving any pre-
and recovery time. medication ( p < 0.001 ).

ANESTHESIA AND ANALGESIA

924 Vol61, No 11, November 1982
 MERIDY
A.S.A. physical status I or I1 were accepted by our
unit as long as the surgeon was confident that his
patient would be physically and mentally able to
return home the same day. Except for dental surgical
procedures, there was no association between the type
and duration of surgery and the outcome, as deter-
mined by prolonged recovery and the rate of over-
night hospital admission. It is recognized that a high
morbidity follows dental surgery (7, 9-11) even if
only local analgesia is used. The duration of recovery
could be prolonged because these procedures are
associated with considerable pain, bleeding, nausea,
and vomiting, and may have required the use of
postoperative narcotics and antiemetics.
Age of Patient
Our data confirm the finding that the extremes of
age are not a deterrent in the selection of ambulatory
surgical patients (4, 5). Nevertheless, we found that
certain age groups have less favorable ambulatory
surgical experiences.
Although it is not unusual that the younger age
group was managed primarily with halothane and the
older age group with local anesthesia, it was surprising
to observe that the 10- to 20-year age group had the
longest anesthetics and recovery times. As a large
percentage of this group of patients underwent dental
extraction with its aforementioned sequelae, there is
a rational explanation for this finding. Furthermore,
it was not the patients at the extremes of the age range
that experienced the greatest rate of complications, as
the majority of those patients with complications were
in the 20- to 49-year age group.
Use of Prernedication
The use of premedication in the ambulatory surgi-
cal patient is often a controversial issue. Many anes-
thesiologists believe that little or no premedication
should be given because it may either be unnecessary
or prolong the recovery period even to the point of
admission to the hospital (1, 4, 5, 12). Others, how-
ever, feel that premedication may be in the best
interest of good patient care. Clark and Hurtig (3)
concluded that premedication with meperidine and
atropine did not prolong recovery to street fitness
after outpatient surgery. Furthermore, they (3) felt
that the addition of preanesthetic medication offered
the anesthesiologist a patient who was less anxious,
would undergo a smoother and safer induction and
maintenance, and would not have a prolonged recov-
ery state.
The data in Table 4 show that the preoperative
administration of hypnotic and tranquilizing drugs
did not markedly prolong recovery whereas premed-
ication with narcotics did. Thus, some premedicants
can be given to ambulatory surgical patients without
prolonging recovery.
Duration of Anesthesia
It has been suggested that the surgical procedures
carried out in day care units be of short duration (less
than 1 hour) in order that recovery periods no longer
than 3 hours be achieved (1, 13). The findings in our
study suggest that the length of anesthesia did not
affect the length of the recovery period. Although
there was approximately a 100-fold range in anesthe-
sia times, there was only a 40% difference in recovery
times. Furthermore, there was no correlation between
the duration of anesthesia and recovery time. Proce-
dures that resulted in hospital admission had a mean
anesthesia time significantly longer than the popula-
tion as a whole, yet the majority of those patients had
an anesthesia time of less than 60 minutes. Therefore,
placing an arbitrary upper limit on the duration of
anesthesia does not seem to be indicated.
Effect of Anesthetic Agents
The notion that a specific anesthetic agent or tech-
nique is ideal for outpatient anesthesia is confusing at
best (1, 2, 4-6, 12). In our study, patients receiving
local anesthesia had a significantly shorter recovery
period than those who received general anesthesia,
and significantly fewer patients receiving local anes-
thesia were admitted to the hospital. This finding
supports the views of those who feel that, when
suitable, local anesthesia is preferred for ambulatory
surgical patients (1).
Whereas there can be little disagreement that the
anesthetic agents chosen for induction and mainte-
nance in the ambulatory surgical patient should pro-
vide the safest induction possible, ideal surgical con-
ditions, rapid recovery, and minimal postoperative
morbidity (4), few authors agree on the specific an-
esthetic agent that will best provide these conditions
(1, 2, 4-6, 12). In our study, no one general anesthetic
technique appeared superior to any other.
Effect of Experience of 1 Year
Our retrospective study reveals that there is a sta-
tistically significant shorter recovery period for pa-
tients treated in 1980. As age, length of anesthesia,
and anesthetic technique do not seem to affect the
ANESTHESIA AND ANALGESIA
V o l 6 1 , No 1 1 , November 1982 925
 GUIDELINES FOR OUTPATIENT ANESTHESIA
duration of recovery, this might reflect the experience
gained in postoperative management by our anesthe-
sia and nursing personnel during the 1st year of
operation of our self-contained ambulatory unit.
Morbidity
The number of patients requiring admission to the
hospital in this study is comparable to the rate quoted
for hospital-based, one-day surgical units (1). How-
ever, the percentage of hospital transfers is higher
than that cited by free-standing centers (5, 14). The
reason for this difference may reside in a bias built
into the criteria for hospital transfer. Perhaps, free-
standing centers transfer patients to the hospital for
life-threatening complications only whereas hospital-
based units might admit patients to the inpatient
service with greater frequency for patient conveni-
ence, as well as for life-threatening complications.
In conclusion, it has been shown that ambulatory
surgical care is appropriate for a wide variety of
surgical procedures, patients of varying age who are
A.S.A. physical status I or 11, and a wide spectrum of
anesthetic technique. Arbitrary limits placed on the
age of the patient, duration of the procedure, and the
use of premedication other than narcotics appear to
be unwarranted as recovery appears to be governed
primarily by the nature of the surgery.
ACKNOWLEDGMENTS
The author wishes to thank Bruce Lomasky for the programming
and use of his computer; Ellis Golub, PhD, for his expert assistance
ANESTHESIA AND ANALGESIA
926 V o l 6 1 , No 1 1 , November 1982
in managing the statistical analysis; and James C. Rouman, M D and
lames J. Richter, MD, PhD for their review of the manuscript.
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