Ambulatory Anesthesiology Division

The ambulatory division traces its inception to 1998. The field of ambulatory surgery was just beginning when a small group of Duke anesthesiologists, surgeons, nurses, and staff joined forces to form the first stand-alone Duke Ambulatory Surgery Center (ASC), separate from the main, inpatient hospital. The current chief of both ambulatory anesthesiology for the Duke University Health System and the Ambulatory Anesthesiology Division for Duke Anesthesiology, Dr. Stephen Klein, was a member of that small team who embarked on this ambitious mission. Motivated to provide high quality, patient centered, innovative care, Dr. Susan Steele, the first division chief, was recruited to lead the development of the new center. Capitalizing on her passion for patient care, team building and regional anesthesia, along with founding members, Drs. Roy Greengrass, Stephen Klein and Karen Nielsen, the center became known internationally for contributions to the field of regional anesthesiology, research, education, and equipment development. Today, this spirit of patient care and innovation continues. With newer members, Drs. Michael Kent, Alex Cravanas and Michael Doden, the division is using its knowledge and past experience to build the care pathways for the Duke University Health System’s future. The planned expansion of ambulatory surgery and the development of several free-standing centers will provide the division the opportunity to grow Duke’s ambulatory surgery footprint and continue leading the field.

Much of the Ambulatory Anesthesiology Division’s success can be attributed to the introduction of a new model of care, in which a dedicated perioperative team, comprised of anesthesiologists, surgeons, and highly trained nurses, works together to ensure a seamless patient experience. From the outset, Ambulatory Surgery Center (ASC) faculty and staff have treasured the spirit of comradery and teamwork fostered amongst this common goal. The Duke Ambulatory Anesthesiology Division consider themselves not only part of a department and division, but part of a broader health system ASC team.

As members of this team, the Ambulatory Anesthesiology Division has been instrumental in the application of regional anesthesia to help facilitate patient care and procedures once necessitating inpatient hospital admission to be performed in the ambulatory setting. Members of this division developed the B. Braun Continuous Peripheral Nerve Block Catheter System. With this technology, Duke’s original stand-alone ASC became the first center in the nation to send patients home with continuous peripheral nerve blocks to manage postoperative pain. Duke’s ambulatory division was amongst the first to institute paravertebral nerve blocks in the outpatient setting to enable complex breast surgeries, such as mastectomies to be performed as an ambulatory surgical procedure. Additionally, it was one of the first to perform ambulatory total joint arthroplasty procedures, and now, an entire team and center is dedicated to same day, outpatient total knee and hip arthroplasty procedures. With the implementation of specific regional anesthesia techniques, spine surgery is now being performed awake and/or with light sedation in the ambulatory environment. The Ambulatory Anesthesiology Division and the entire Duke ASC team, across multiple outpatient surgery centers, have repeatedly demonstrated that extensive procedures can be carried out successfully on an outpatient basis with carefully coordinated teamwork and attention to acute pain management.

Delivering compassionate, efficacious, and efficient patient-centered care is the mission of the Ambulatory Anesthesiology Division and the entire ASC team. As experts in ambulatory and regional anesthesia, the division’s practice is tailored to quickly return patients home to their families and a normal lifestyle, with excellent surgical outcomes and high patient satisfaction.  The ambulatory division’s past, present and future are unified in their dedication to perioperative teamwork, openness to change and wholehearted commitment to improving patient care.

Dr. Susan M. Steele, a regional and cardiac anesthesia fellowship trained anesthesiologist, established the Duke Regional Anesthesia Fellowship Program in July 1997; the program was one of the few regional anesthesia fellowship curricula available in the country. Drs. Steele and Karen Nielsen were part of the Regional Anesthesia Fellowship Program directors group from its inception in 2002, which established the first regional anesthesia fellowship training guidelines. These guidelines were later published in the Regional Anesthesia and Pain Medicine journal (Reg Anesth Pain Med 2005;30:218-225).

Dr. Stephen M. Klein assumed the role of fellowship program director from 2006 to 2009. Dr. Nielsen, also a regional anesthesia fellowship trained anesthesiologist, assumed the role of fellowship program director in July 2009 and served until June 2017. The fellowship blossomed under Dr. Nielsen’s direction. Trainees who have completed the highly-acclaimed fellowship have received an unrivaled education in advanced regional anesthesia with a strong focus on the outpatient setting. As outpatient surgery grew in popularity and efficiency, this fellowship grew as well into one of the strongest regional anesthesia fellowships in the country and in the world. For instance, the Duke Ambulatory Surgery Center started to send patients home with continuous peripheral nerve catheters after outpatient surgery in 1998.

Michael L. Kent, MD, MSQM
Fellowship Director

Graduates of the original Institutional Committee for Graduate Medical Education (ICGME) Fellowship are spread across the world, including Canada, Brazil, Chile, Saudi Arabia, Great Britain, Pakistan, and India. This fellowship cultivated a successful educational exchange between Duke’s ambulatory anesthesiology training program and the military. This collaboration served our country well in caring for soldiers in the Afghan and Iraqi conflicts. The current fellowship program director, Dr. Michael L. Kent, is a product of the military collaboration. He is fellowship trained at Walter Reed National Military Medical Center under Dr. Chester C. Buckenmaier III, (past fellow from 2001-2002) and is now practicing with the Ambulatory Anesthesiology Division at Duke. This is another example of the far reaching excellence that has resulted from the educational endeavors through our fellowship program.

In March of 2017, the prior ICGME Fellowship Program became an Accreditation Council of Graduate Medical Education (ACGME) Regional Anesthesiology and Acute Pain Medicine Fellowship Program. This fellowship was one of the first nine programs in the country to achieve the status of an ACGME-accredited program in regional anesthesiology and acute pain medicine. From the beginning, the fellowship program was and still is an excellent training opportunity for participants. Positions in the fellowship (we offer five per year) are sought after heavily by some of the brightest and best. In addition, the fellowship has provided a powerful platform for our team to train and develop relationships with the finest regional anesthesiology and acute pain medicine physicians in the world.

Faculty within the Ambulatory Anesthesiology Division have a long history of providing unrivaled education to interns, residents and fellows. While focused on high efficiency methodologies, the division’s longitudinal expertise in regional anesthesiology and acute pain medicine provides a critical educational experience for developing physician anesthesiologists. In particular, as the originating site for the Regional Anesthesiology and Acute Pain Medicine Fellowship in 1997, Dr. Michael Kent recently took the reigns as the fellowship program director and maintains the collaborative educational mission between the ambulatory, pain, and regional anesthesiology divisions.

All faculty members have an extensive teaching history in national courses/workshops, textbook creation, and internal lecture series/journal clubs. The Ambulatory Anesthesiology Division maintains a very active role in the ASA, SAMBA, ASRA, and AAPM societies. Additionally, the division aggressively participates and leads educational activities across ambulatory surgical sites focused on nursing, patient and caregiver educational content.

The Ambulatory Anesthesiology Division maintains a robust history of medical investigation, especially within the field of regional anesthesiology and acute pain medicine. Led by pioneers in the field, Drs. Susan Steele and Roy Greengrass, the Duke Ambulatory Surgical Center was one of the first sites in the country to investigate and deploy the use of peripheral nerve catheters for postoperative analgesia.

The Ambulatory Anesthesiology Division currently focuses on a broad array of research topics focused on delivery patient centered care. These topics include:

1. The use of patient reported outcomes to predict both acute and chronic postsurgical outcomes
2. The development of digital health tools to facilitate remote patient evaluation and support
3. The measurement of postoperative pulmonary function following outpatient shoulder surgery
4. Investigating national trends in outpatient surgery with a focus on stratifying patients groups that may be considered in new ambulatory markets
5. The development of outpatient total joint and spine surgery pathways to facilitate same day discharge in an ambulatory surgery center setting
6. Participate as a supporting site in regards to the application of intravenous methadone for postoperative analgesia
7. Comparing varying regional anesthesiology techniques in forefoot surgery

Key Publications

1. Evans H, Steele SM, Nielsen KC, Tucker MS, Klein SM. Peripheral nerve blocks and continuous catheter techniques. Anesthesiol Clin North Am. 2005 Mar;23(1):141-62. doi: 10.1016/j.atc.2004.11.003. PMID: 15763416.
2. Klein SM, Melton MS, Grill WM, Nielsen KC. Peripheral nerve stimulation in regional anesthesia. Reg Anesth Pain Med. 2012 Jul-Aug;37(4):383-92. doi: 10.1097/AAP.0b013e3182576647. PMID: 22683706.
3. Klein SM, Evans H, Nielsen KC, Tucker MS, Warner DS, Steele SM. Peripheral nerve block techniques for ambulatory surgery. Anesth Analg. 2005 Dec;101(6):1663-1676. doi: 10.1213/01.ANE.0000184187.02887.24. PMID: 16301239.
4. Melton MS, Nielsen KC, Tucker M, Klein SM, Gan TJ. New medications and techniques in ambulatory anesthesia. Anesthesiol Clin. 2014 Jun;32(2):463-85. doi: 10.1016/j.anclin.2014.02.003. Epub 2014 Apr 18. PMID: 24882131.
5. Nielsen KC, Melton MS, Gebhard RE, Greengrass RA. Recurrence of breast cancer after anaesthesia. Lancet. 2020 Aug 8;396(10248):376. doi: 10.1016/S0140-6736(20)30487-6. PMID: 32771098.
6. Melton MS, Li YJ, Pollard R, Chen Z, Hunting J, Hopkins T, Buhrman W, Taicher B, Aronson S, Stafford-Smith M, Raghunathan K. Unplanned hospital admission after ambulatory surgery: a retrospective, single cohort study. Can J Anaesth. 2021 Jan;68(1):30-41. English. doi: 10.1007/s12630-020-01822-1. Epub 2020 Oct 14. PMID: 33058058.
7. Kent ML, Hurley RW, Oderda GM, Gordon DB, Sun E, Mythen M, Miller TE, Shaw AD, Gan TJ, Thacker JKM, McEvoy MD; POQI-4 Working Group. American Society for Enhanced Recovery and Perioperative Quality Initiative-4 Joint Consensus Statement on Persistent Postoperative Opioid Use: Definition, Incidence, Risk Factors, and Health Care System Initiatives. Anesth Analg. 2019 Aug;129(2):543-552. doi: 10.1213/ANE.0000000000003941. PMID: 30897590; PMCID: PMC6640123.
8. Kent ML, Tighe PJ, Belfer I, Brennan TJ, Bruehl S, Brummett CM, Buckenmaier CC 3rd, Buvanendran A, Cohen RI, Desjardins P, Edwards D, Fillingim R, Gewandter J, Gordon DB, Hurley RW, Kehlet H, Loeser JD, Mackey S, McLean SA, Polomano R, Rahman S, Raja S, Rowbotham M, Suresh S, Schachtel B, Schreiber K, Schumacher M, Stacey B, Stanos S, Todd K, Turk DC, Weisman SJ, Wu C, Carr DB, Dworkin RH, Terman G. The ACTTION-APS-AAPM Pain Taxonomy (AAAPT) Multidimensional Approach to Classifying Acute Pain Conditions. Pain Med. 2017 May 1;18(5):947-958. doi: 10.1093/pm/pnx019. PMID: 28482098; PMCID: PMC5431381.

Please contact the Ambulatory Anesthesiology Division’s staff assistant, Luanne Latta, at 919-681-9941 or luanne.latta@duke.edu with inquiries.