Clinical Program

The Division of Ambulatory Anesthesia is responsible for the delivery of anesthesia services at the Ambulatory Surgery Center (ASC). Located in the North Pavilion, the ASC is a stand-alone, nine-operating room facility with an eight-bed, 23-hour Recovery Care Center.  Originally opening in July 1998, the facility, staff and systems are uniquely dedicated to providing world-class medical center care in a convenient, community and patient-oriented manner.  This successful organization has been a model for efficiently delivering the highest level of academic medicine without the typical constraints that are found in a multi-mission tertiary facility. This has resulted in patient satisfaction scores that are consistently among the highest in the institution. Today the division provides peri-anesthesia care and postoperative pain management to over 7,000 patients a year using the latest in innovative ambulatory medicine. The Division has been leaders in pioneering many novel ambulatory anesthesia techniques.  Among these breakthroughs has been the Division’s use of advanced regional anesthesia to safely, compassionately and comfortably facilitate more complex outpatient surgery. The Division offers a wide variety of novel regional anesthesia techniques that enhance the options available to patients for both their intra-operative experience and for the management of postoperative pain. Some of these techniques include a broad array of targeted peripheral nerve blocks, continuous ambulatory infusions of local anesthetic, diverse multi-modal analgesia and paravertebral blockade for breast surgery.  The group’s ultimate goal is to offer pre-operative education, advanced operative and regional anesthetic techniques, prolonged postoperative pain management, and improved perioperative outcomes.

To help achieve these goals approximately 50% of patients last year had surgery, enhanced with regional anesthesia.  Most notable is the faculty’s emphasis on non-central, neuraxial regional anesthesia techniques for both upper and lower extremity and truncal surgery when possible (Figure 1). These peripheral regional anesthesia techniques allow targeted analgesia and the potential for stress-free recovery for our ambulatory surgery patients. The excellent postoperative analgesia that results by using single injection and continuous peripheral nerve blockade is unparalleled. Greater than 98% of the patient population at our Center rate their experience with anesthesia and pain management as very satisfied or satisfied 24-hours after surgery.

A unique care modality, pioneered and developed by the Division, is the use of home perineural catheter infusion systems for managing postoperative pain. Since opening the ASC nearly 10,000 peripheral nerve catheters have been placed, and when appropriate many of these patients have been sent home with continuous local anesthetic infusions. Part of this strategy has been a detailed patient educational program facilitated by the Center’s nurses, fellows and faculty. By using continuous catheter technique, the division is improving health outcomes, including superior analgesia and high patient satisfaction. The success of this protocol continues to be tremendous with outstanding safety, analgesic and surgical outcomes. As a by product of this success and the faculty’s international reputation the division frequently hosts anesthesiologists from all over the world who seek additional information to emulate this program. 

The Breast Imaging Center at the ASC continues to offer our breast surgery patients a dedicated facility to deliver comprehensive imaging and care in a less stressful patient centric way.  By combining radiologic services, anesthesia and surgery in the same pavilion many logistical transport issues have been eliminated. We continue to improve our protocol for breast procedures by performing paravertebral blocks not only for surgical procedures but also for diagnostic procedures including needle localization. The collaboration between Ambulatory Anesthesia and the Breast Imaging Center has provided a much less stressful, more accessible, and more efficient treatment course for breast patients. Many of our patients who undergo mastectomy and other breast procedures and who are candidates for regional anesthesia have minimal opioid requirements for pain control and experience dramatically reduced postoperative nausea and vomiting. The published success of this strategy has led other institutions and cancer centers around the world to adopt this treatment modality.

Education and Training

Division members teach residents, fellows, and medical students as part of the Department and Duke’s core educational mission. In addition, faculty are frequently invited to national and international anesthesiology conferences where they teach a broad array of topics and learners. The division also hosts visiting faculty from other institutions who wish to see the ambulatory surgery center and staff first hand. Residents begin their outpatient exposure during their CA-2 year and enhance this during their CA-3 year when they spend one month at the ASC. The rotations are designed to expose residents to a broad spectrum of ambulatory anesthesia including team integration, systems based care delivery, and advanced outpatient regional anesthesia. A popular component of this rotation is the ability to apprentice with the faculty; acting as an anesthesiology consultant and performing peripheral nerve blocks in the pre-op holding area.

The Ambulatory and Regional Anesthesia fellowship is one of the premier academic programs to gain post-graduate expertise in advanced regional anesthesiology. Each year the fellowship receives dozens of applications from highly qualified national and international applicants for the three positions. The success of the fellowship program is a major focus of the Division’s faculty and one of their proudest educational commitments. The fellowship year is spent on rotations both at the ASC and the Duke North Hospital to expose fellows to a broad array of clinical scenarios and educational diversity. Fellows have the opportunity to take advantage and learn from cutting edge leaders who make up one of the largest, highly specialized regional anesthesia faculties in the world. Each year is individualized to meet the goals and experience of each fellow. In general, fellows begin with didactic and clinical exposure to basic lower and upper extremity blocks. On a graduated basis they progress to more advanced blocks, continuous catheters and paravertebral blocks. A typical fellow can expect to perform more than 1,000 blocks over the course of the year. Throughout this experience fellows are exposed to all techniques of block placement with a major emphasis on ultrasound assisted insertion. Fellows gain broad exposure in the logistics and management of acute post-operative pain. A major component of the fellowship year is understanding the teamwork and systems necessary to implement a regional anesthesia program both at a busy outpatient center and in an academic setting. Fellows are expected to participate in research and education while they are at Duke to enhance their ability to function independently as academic faculty. Since inception more than 70% of graduates have gone on to become leaders in academic medicine.

Two examples of this academic leadership are Col. Chester Buckenmaier, MD, HS ’01-’02, and Lt. Col. Scott Croll, MD, HS ’03-’04. Since 2001 the anesthesia staff has partnered with the U.S. Army in support of the Army Regional Anesthesia Initiative. Their goal is to bring cutting-edge, advanced regional anesthesia techniques to the U.S. Armed Forces for use in times of peace and war. Drs. Buckenmaier and Croll studied these techniques in one-year fellowships at the ASC. Immediately prior to his July 2003 arrival at Duke, Dr. Croll served in Operation Iraqi Freedom at a combat support hospital near Baghdad, Iraq. Dr. Buckenmaier returned from a three-month field trial, where he demonstrated that the continuous peripheral nerve blockade techniques he mastered at Duke can be performed on the modern day battlefield for our injured soldiers. This provides the soldier continuous state-of-the-art pain control from the time of injury on a foreign soil throughout the air evacuation process, back to the continental United States. Exciting testimonies and publications continue to evolve from this incredible use of regional anesthesia. Since its inception these techniques are now wide spread throughout the armed services and thousands of soldiers have received this advanced care. Our staff takes great pride in having indirectly comforted and cared for American soldiers injured on a battlefield halfway around the world through the hands of Drs. Buckenmaier and Croll.

Research

The Division of Ambulatory Anesthesiology has broad and diverse areas of research interest. The overriding goal is to improve a patient's peri-operative experience. Research endeavors include many aspects of outpatient surgery including preoperative education, advanced anesthetic techniques, prolonged pain management and improving operative outcome. The Division also has ongoing collaborations with the departments of surgery, pulmonology, biomedical engineering, and the brain imaging center. Ongoing research involves projects studying (1) predictive measures of pulmonary function and sleep disordered breathing in outpatients (2) cerebral plasticity after regional anesthesia (3) extending local anesthesia efficacy (4) utilizing automated anesthesia information systems and outcomes data base to define patient outcome, satisfaction and economics (5) multi-drug therapy and alternative modalities for reducing postoperative nausea (6) examining the efficacy of home infusion and health care for major surgery (7) redefining the scale, scope and postoperative care of ambulatory surgery (8) developing new methodologies for needle imaging and local anesthetic delivery.

Figure 1

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Stephen M. Klein, MD

Associate Professor of Anesthesiology
Chief, Division of Ambulatory Anesthesia
Medical Director, Ambulatory Surgery Center

Faculty

Stephen M. Klein, MD
Karen C. Nielsen, MD
Stephen Melton, MD
Marcy Tucker, MD PhD

Fellows (2008-09)

Joshua Dooley, MD
Mitchell Fingerman, MD
Erin Rose, MD

Fellows (2009-10)

Patrick Armstrong, MD
Sean Dobson, MD
Jennifer Sposito, MD

CRNA Staff

Paula Alford, CRNA
Narda Croughwell, CRNA
Fred Fesel, CRNA
Robert Foy, CRNA
Becky Hobbs, CRNA
Ronald Iacone, CRNA
Carolyn Knoop, CRNA
David Lee, CRNA
Don Moede, CRNA
Mary Murphy, CRNA
Flora O’Brien, CRNA
Tammy Schaeffer, CRNA
Kena Sigman, CRNA
Susan Tomso, CRNA
Steve Ziegler, CRNA

Support Staff

Luanne Latta
Valerie Parker

Featured Publication

Steele SM, Nielsen KC, Klein SM, eds. Ambulatory Anesthesia & Perioperative Analgesia. 1st ed. New York, NY: McGraw-Hill, 2005.