Presented : Dr. Nitin Bhalla, P.G. Student, Department of Anesthesiology and Critical care, Dr. S.N. Medical College, Jodhpur.

Introduction to Ambulatory Surgery

Ambulatory anesthesia is administered with the dual goals of rapidly and safely establishing satisfactory condition for the performance of therapeutic or diagnostic procedures while ensuring rapid, predictable recovery with minimal post operative sequelae.


Benefits of “Day Care” or “Ambulatory” Surgery
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Patient preference, esp. children and the elderly Lack of dependence on the availability of hospital beds Greater flexibility in scheduling operations Low morbidity and mortality Lower incidence of infection Lower incidence of respiratory complications Higher volume of patients Shorter surgical waiting lists Lower overall procedural costs Less preoperative testing and postoperative medications


Patient selection criteria for ambulatory anaesthesia

ASA physical status  ASA status I, II and medically stable ASA status III  The risk of complication can be reduced if pre-existing medical conditions are under good control for at least 3 months before operation. Age  Premature infants < 46 weeks of postconceptional age are at increased risk and are not an ideal candidate for Ambulatory surgery.  Anemia is a sinificant independent risk factor , particularly for infants less than 43 weeks of post conceptional age.  Elderly outpatients may experience a higher incidence of perioperative CVS event and slow recovery of fine motor skills and cognitive functions.


Patient selection criteria for ambulatory anaesthesia

Social Factors 1.The patient must be prepared to have the procedure performed as a day case, 2. live close to the hospital, and 3. Should have a responsible, able, adult carer at home with them for 24 hours postoperatively Surgical procedure - Ideally, surgical procedures for the ambulatory patient should be completed in a reasonable amount of time, should not require blood transfusion and should not create excessive fluid shifts. Duration of Surgery – in the ambulatory setting should be less than 90 minutes.


Medical contraindications for day case anesthesia
Morbid obesity • Body mass index > 35 kg/m2 or weight > 125 kg Cardiovascular disease • Poorly controlled angina, arrhythmia or cardiac failure • Hypertension > 180/100 mm Hg • Significant valvular or congenital heart disease • Myocardial infarction or stroke within 6 months Respiratory disease/airway • Poorly controlled asthma or chronic obstructive pulmonary disease (patients taking oral corticosteroids, with poor exercise tolerance or with a peak expiratory flow rate < 200 litres/minute are unlikely to be suitable) 1 • Severe restrictive lung disease (e.g. kyphoscoliosis) • Previous failed intubation • Significant obstructive sleep apnoea Continued...


Medical contraindications for day case anesthesia (contd.)
Metabolic/endocrine/haematological • Poorly controlled diabetes or insulin dependent 1 • Active liver disease • Anaemia (haemoglobin < 10 g/dl) 1 • Haemophilia/anticoagulation 1 • Cholinesterase deficiency 1 • Hypo- or hyperkalaemia (acceptable range 3–6 mmol/litre) Renal disease • Patients requiring renal support 1 Neuromuscular disease • Myasthenia gravis • Significant multiple sclerosis • Malignant hyperpyrexia susceptibility • Poorly controlled epilepsy • Parkinson’s disease interfering with daily activity • Significant motor neuron disease Acute substance abuse


Operative procedures suitable for Ambulatory surgery
Specialty Dental Dermatology General Gynecology ophthalmology Orthopedic Otolaryngology Pain clinic Plastic surgery Urology Type of Procedure Extraction , restoration, facial fractures Excision of skin lesions Biopsy, endoscopy, excision of masses, hemorrhoidectomy, herniorrhaphy, laproscopic procedures, varicose vein surgery Cone biopsy, dilatation and curettage, hysteroscopy, laparoscopy, polypectomy, tubal ligation, vaginal hysterectomy Cataract extraction, chalazion excision, NLD probing, Strabismus repair, tonometry AC repair, arthroscopy, bunionectomy, carpal tunnel release, closed reduction, hardware removal, manipulation under anesthesia Adenoidectomy, laryngoscopy, mastoidectomy, myringotomy, polypectomy, rhinoplasty, tonsillectomy, tympanoplasty Chemical sympathectomy, epidural injection, nerve blocks BCC excision, cleft lip repair, liposuction, mammaplasty, otoplasty, scar revision, septorhinoplasty, skin grafting Bladder surgery, circumcision, cystoscopy, lithotripsy, orchiectomy, prostate biopsy, vasovasostomy


Pre – Operative evaluation


Recommended Laboratory tests for ambulatory surgery
Pre –operative evaluation includes history , examination and Laboratory testing
Age Range < 40 yrs 40-49 50-64 65-74 Men None ECG ECG Women Pregnancy test Hematocrit , pregnancy test Hb / Hematocrit, ECG

Hb/ Hematocritt, ECG, Bl. Hb/ Hematocritt, ECG, Bl. Urea nitrogen, glucose Urea nitrogen, glucose Hb/ Hematocritt, ECG, Bl. Hb/ Hematocritt, ECG, Bl. Urea nitrogen, glucose, X Urea nitrogen, glucose, ray chest chest radiograph



Pre – Operative Preparation


Aims of Pre – Operative Preparation

Aims –  Reducing the risk inherited in Ambulatory Surgery.  Improving patient outcome.  Making the surgical experience more pleasant to the patient.  Minimizing patient anxiety.  Reduce potential post operative problems.


Non Pharmacological Methods
Non – Pharmacological techniques should be aimed to allay anxiety and fear of the patient regarding the operative procedure. Patient should also be instructed (written and verbal) regarding the arrival time and place, fasting instructions and information concerning the post operative course, limitation in driving skills, and the need for a responsible adult to care for the patient during post operative period.

Benefits of Non Pharmacological methods –  Economical  Lacks undesirable side effects.  High patient acceptance and motivation. Non-Pharmacological methods –  Patient Interview.  Instructional preoperative video tapes.  Music before surgery  Self hypnotic relaxation techniques.  Play oriented pre-operative teaching, Books, pamphlets, and video programs – specifically in pediatric patients.


Pharmacological methods

Anxiolysis and Sedatives

Benzodiazepines –  Midazolam - drug of choice. (I.M., I.V., PO)  Oral Temazepam and alprazolam α 2 adrenergic agonists –

Clonidine - residual post operative sedation is concerned factor. Dexmedetomidine - Shorter duration of action and highly selective α 2 agonist.

Pharmacological methods (contd..)

Analgesics –

Opioid Analgesics –  Relive anxiety, Decreases anesthetic doses, minimize hemodynamic response, provide post operative pain relief.  Shorter acting – Fentanyl, alfentanil, Remifentanil, Sufentanil NSAID’s –  As mutiimodal analgesic technique, in combination, it facilitates early recovery and reduces discharge time.  For maximal benefit in ambulatory surgery, NSAID’s s/b administered on “fixed” dosage shedule.  More selective COX – 2 inhibitors s/b used.  Oral – Rofecoxib, Celecoxib, Valdecoxib  Parentral - Parecoxib

Pharmacological methods (contd..)

Prevention of Nausea and Vomiting As a mutimodal regimen , combination of anti-emitic drugs are used to prevent PONV
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Droperidol – Low dose ( < 10mcg/kg) Metoclopramide – 20 mg iv / 0.2 mg/kg iv Dimenhydrinate and Hydoxyzine – 0.5 mg/kg. Ondansetron, granisetron, dolasetron, tropisetron Neurokinin – 1 antagonists Dexamethasone – 4 to 8 mg iv Acupuncture and acupressure.


Pharmacological methods (contd..)

Prevention of Aspiration Pneumonitis  H2 receptor antagonists –  Ranitidine – 150 mg p.o. ; 50 mg iv  Pantoprazole – 40 mg iv  Antacids – Sodium Citrate 15-30 ml po.  Prokinetic - Metoclopramide – 10-20 mg iv  NPO


Anesthesia techniques


Anesthesia Techniques

Various techniques for Ambulatory anesthesia –

General Anesthesia Regional Anesthesia Monitored Anesthesia Care Local Anesthesia


Qualities of an ideal day care anaesthetic agent
• • • • • • • • • Fast predictable onset Fast predictable elimination Easily titratable depth of anaesthesia No active metabolites No accumulation Stable in solution in water/volatile liquid at room temperature No pain on injection/non-irritant on inhalation Good side-effect profile No PONV


General Anesthesia

Induction of General Anesthesia –
Drug Thiopental Methohexital Dose (mg/Kg) 3-6 1.5-3 Onset Rapid Rapid Recovery Intermed. Rapid Side effects Drowsiness Pain, excitatory activities Pain, emesis, myoclonus CVS manif., Psychomm. Drowsiness, amnesia CVS depress., pain on inj.

Etomidate Ketamine Midazolam Propofol

0.15-0.30 0.75-1.5 0.1-0.2 1.5-2.5

Rapid Intermed. Slow Rapid

Intermed. Intermed. Slow Rapid

General Anesthesia (contd...)

Opioid Analgesics –
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Fentanyl – 1-2 mcg/kg Alfentanil – 15-30 mcg/kg Sufentanil – 0.15-0.3 mcg/kg Remifentanil – 0.5-1 mcg/kg


General Anesthesia (contd...)

Sufentanil with N2O has lower incidence of nausea and P.O. pain as compared with fentanyl with N2O. Emergence and recovery of psychomotor functions are faster with alfentanil as compared to Fentanyl. Also Afentanil is associated with lower incidence of PONV as compared to Fentanyl or Sufentanil. Remifentnil is an ultra-short acting opioid with a half life of 810 minutes and a context sensitive half life of 4 minutes regardless of duration of infusion. In elderly patients, TIVA with remifentanil and propofol is associated with more rapid recovery than a standard Fentanyl-Isoflurane technique.

General Anesthesia (contd...)

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Inhaled Volatile anesthetic agents –
Most commonly used for the maintance of anesthesia. Fast patient recovery and earlier discharge. Volatile anesthetic agents that can be used for ambulatory anestheisa are – Sevoflurane, Desflurane and Isoflurane. Sevoflurane – induction of anesthesia in adults as well as in pediatric patients. Desflurane – Emergence faster than other inhalation agents; Rapid recovery of cognitive and psychomotor function; Better postural control than after propofol. Associated with higher incidence of vomiting in early p.o. period Use of N2O as an adjuvant is beneficial.

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General Anesthesia (contd...)
Drug Halothane Enflurane Isoflurane Desflurane Concentration (%) Onset 0.5-1.5 0.75-1.5 0.5-1 3-6 Slow Intermed. Intermed. Recovery Side effects Slow Intermed. Intermed. Sedation, arrhythmias Shivering Coughing

Very rapid Very rapid Coughing, tachycardia Rapid Rapid Flammable

Sevoflurane 1-2 N2O 50-70

Very rapid Very rapid Nausea, Vomiting


Regional Anesthesia

Modes of Regional Anesthesia –

Epidural and spinal techniques Intravenous regional anesthesia Peripheral Nerve Blocks Local Infiltration techniques


Regional Anesthesia
Advantages to patients : (a) Improved quality of recovery i. Less pain (mainly with CPNB) ii. Less PONV iii. Less unplanned hospital admission (b) Able to observe the procedure (c) Communication with surgeon during the procedure, (d) Option to receive no or light sedation. (e) Earlier mobilization. Advantages to surgeon and Hospital : (a) Fast tracking of recovery, (b) Less requirement of post op. surgery staff, (c) Less requirement of drugs, so chance of adverse reaction is less, (d) Economical.


Regional Anesthesia (contd..)

Disadvantages of RA in ambulatory surgery: (a) (b) (c) Takes time and new separate setup to be organized, Patients active co-operation is needed Risk of complications : Nerve damage, TNS after Spinal anaesthesia. (d) Variable failure rate (up to 10% with PNB) (e) Urinary retention with Spinal Anaesthesia.


Regional Anesthesia (contd..)

Spinal Anesthesia –  Although simple and most reliable reg. anesthetic tech., is associated with higher incidence of side effects.  For Ambulatory Anesthesia , short acting local anesthetics (Lidocaine and procaine) is preferred over the bupivacaine and tetracaine.  Recommendations – Isobaric lidocaine, or combination of small dose of hypobaric lidocaine (1% ; 20-25mg) combined with fentanyl (10-25mcg) or sufentanil.  For ambulatory surgeries lasting for > 2 hours, Intrathecal bupivacaine can be used.  Associated with – delayed ambulation, dizziness, urinary retention, and impaired balance. Epidural Anesthesia - is technically more difficult to perform, slower onset of action, potential for intravascular / intrathecal injection, greater chances of incomplete sensory block.

Regional Anesthesia (contd..)
Peripheral Nerve Blocks
Procedure Hernia Repair Technique Field Block Spinal Advantage Good post operative pain relief Disadvantage Supplementation

Speed PDPH; urinary Little supplementation retention; delayed mobilization Reduces confusion and Ocular complications discharge time Good analgesia Speed ; little supplementation Good analgesia Analgesia Failed blocks PDPH; urinary retention; delayed mobilization Failed blocks Failed plexus blocks 30

Cataract extraction Knee surgery

Peribulbar block 3-in-1 block Spinal

Foot surgery Hand surgery

Popliteal block, ankle blocks Bier’s block, brachial

R.A. v/s G.A.

Comparison of regional and general anaesthesia
Advantage Fast No Failures Prolonged analgesia Reduced PONV Reduced confusion Disadvantage PONV Confusion Prolonged motor block PDPH Slow onset High Failure rate

Technique General Anesthesia

Regional Anesthesia


Monitored Anesthesia Care

MAC is the term used when an anesthesiologist monitors a patient receiving local anesthesia or administers supplemental drugs to patient undergoing diagnostic or therapeutic procedures. ASA defines MAC – instances in which an anesthesiologist has been requested to provide specific anesthesia services to a particular patient receiving local anesthesia or, in some cases, no anesthesia al all. Goal of MAC – providing analgesia, sedation, and anxiolysis and ensuring rapid recovery without side effects. Vigilant monitoring is required as patient may progress from ‘Light’ level of sedation to ‘ deep’ sedation or unconciousness.


Monitored Anesthesia Care (contd..)

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Small dose of midazolam (1-2mg) or propofol (0.5-1mg/kg) or both, followed by a propofol infusion at 25-100mcg/kg/min. Methohexital – 10-20mg bolus ; or variable rate infusion (13mg/min.) Alfentanil (0.3-0.4mcg/kg/min) + propofol (25-75 mcg/kg/min.) infusion – “Avramov and White”. Remifentanil infusion (0.05-0.15 mcg/kg/min). Ketorolac – sole or as an adjuvant to propofol. Low dose ketamine (0.25-0.5 mg/kg) with midazolam or propofol. Subanesthetic conc. Of inhaled anesthetics – (N2O -30% to 50%; Sevoflurane 0.3% to 0.6%)

α 2 agonists – clonidine or Dexmedetomidine

Concept of “Fast – Tracking”
Bypassing the PACU has been termed “Fast-Tracking” after ambulatory surgery.


Criteria used to determine fast-track eligibility after ambulatory anesthesia

Level of Conciousness –  Awake and oriented 2  Arousable with minimal stimulation  Responsive only to tactile stimulation Physical activity –  Able to move all extremities on command  Some weakness in movement of extremities  Unable to voluntarily move the extremities Hemodynamics –  BP < 15% of the baseline MAP  BP between 15-30% of the baseline MAP  BP > 30% below the baseline MAP Respiration –  Able to breathe deeply  Tachypnea with good cough 1

1 0 2 1 0 2 1 0 2

Dyspneic with weak cough



Criteria used to determine fast-track eligibility after ambulatory anesthesia (contd..)

O2 saturation status –  Maintain > 90% on room air 2  Requires supplemental O2 (nasal prongs) 1  Saturatio < 90% with supplemental O2 0 Post operative pain assessment –  None or mild discomfort 2  Moderte to severe pain req. IV analgesics 1  Persistent severe pain 0 Postoperative emetic symptoms –  None or mild nausea with no active vomiting 2  Transient vomiting or retching 1  Persistent moderate to severe nausea and vomiting 0

Total Score – 14. A Score of over 12 with no individual score less than 1 is required for fast- tracking.


Assessment of Recovery Discharge Criteria


Assessment of Recovery

Recovery includes return of normal physiological and psychomotor functions with a minimal level of morbidity associated with anaesthesia and surgery. Recovery is a continuous process, the beginning of which overlaps with the end of the surgical procedure. Patients are not fully recovered until they have returned to their preoperative physiological and psychomotor state. The process may last for days, but it can be divided into distinct phases.

Stages of Recovery

Stage of Recovery Clinical definition 1. Early recovery : Awakening and Recovery of vital reflexes 2. Intermediate recovery : Intermediate clinical recovery, home readiness 3. Late recovery : Full recovery, psychological recovery


Phases / Stages of Recovery

Phase I / Early recovery –

It is the time interval during which patients emerge from anesthesia, recover control of protective reflexes, and resumes early motor activity. During this phase of recovery, patients are cared for in the PACU. The Steward and Modified Aldrete score is commonly used to assess the fitness of patient to be transferred to the Phase II recovery area. During this period , patients are usally cared for in a reclining chair and progressively begin to ambulate, drink fluids, void, and prepare for discharge. For second-stage recovery the Excitement Score or the Post-anaesthesia Discharge Scoring System (PADS) is used This period begins when the patient is discharged home and continues until functional recovery is achieved and the patient is able to resume normal activities of daily living.

Phase II / Intermediate recovery –

Phase III / late recovery –

Steward Score

Awake Responding to stimuli Not responding 2 1 0

Coughing on command or crying Maintaining a good airway Airway needs maintenance 2 1 0

Moving limbs purposefully 2 Non-purposeful movement Not moving 0 1

* Six points are required for discharge.

Modified Aldrete Scoring System
Activity: able to move, voluntarily or on command Four extremities 2 Two extremities 1 No extremities 0 Respiration Able to breathe deeply and cough freely 2 Dyspnoea, shallow or limited breathing 1 Apnoea 0 Circulation Blood pressure within 20 mm Hg of preoperative level 2 Blood pressure within 20–50 mm Hg of preoperative level Blood pressure ± 50 mm Hg of preoperative level 0 Consciousness Fully awake 2 Arousable on calling 1 Unresponsive 0 Oxygen saturation Saturation > 92% 2 Needs oxygen to maintain saturation > 90% 1 Saturation < 90% with oxygen 0 * Nine or more points are required for recovery to be confirmed.



Post-anaesthesia Discharge Scoring System for assessing home readiness

Vital signs Vital signs must be stable and consistent with age and preoperative baseline Blood pressure and pulse within 20% of baseline 2 Blood pressure and pulse within 20–40% of baseline Blood pressure and pulse within 40% of baseline 0 1

Activity level Patient must be able to ambulate at preoperative level Steady gait, no dizziness, or meets preoperative level Requires assistance Unable to ambulate 2 1 0

Nausea and vomiting Minimal: successfully treated with oral medication 2 Moderate: successfully treated with intramuscular medication Severe: continues after repeated treatment

1 0


Post-anaesthesia Discharge Scoring System for assessing home readiness (contd.)

   

The patient should have minimal or no pain before discharge The level of pain that the patient has should be acceptable to the patient Pain should be controlled by oral analgesia The location, type and intensity of pain should be consistent with the anticipated postoperative discomfort Acceptable Unacceptable 2 1

Surgical bleeding
Postoperative bleeding should be consistent with the expected blood loss for the procedure Minimal: does not require dressing change 2 Moderate: up to two dressing changes required Severe: more than three dressing changes required 1 0

* Nine points are required for discharge.


Guidelines for safe discharge after day surgery
Vital signs must have been stable for at least 1 hour The patient must be able to: Orientate themselves in person, place and time Keep oral fluids down Void urine Dress Walk without assistance The patient must not have More than minimal nausea and vomiting Excessive pain Bleeding

Discharge criteria after Regional anesthesia

Besides the recovery criteria for general anesthesia, patients with regional anesthesia must fulfill additional criteria. These are –

Normal perianal sensation (S4-S5 ) Able to plantar flex the foot Proprioception of the big toe. Normal Blood pressure on standing and sitting.


Causes of prolonged recovery following regional and general anaesthesia
• • • • • • • Pain Nausea and vomiting Haemorrhage Cardiovascular or pulmonary dysfunction Wound drains Needing observation Lack of escort or inadequate home conditions


Post operative instructions
Both written and verbal instructions should be given regarding the post operative period before discharging the patient In general, for 24 hours after anesthesia: 1.Do not drink alcohol or use nonprescription medications. 2.Do not drive a car or operate dangerous machinery. 3.Do not make important decisions. The patient should be provided with a contact number to contact in case of any emergency.


Application of Ambulatory anesthesia in specific population


Pediatric patients

Sedative premedication is generally not offered in children younger than 12 months. Oral or rectal premedicant remains the choice in pediatric patients. Midazolam is the most commonly used anxiolytic premedicant for pediatric patients. ( dose – 0.5 mg/kg po) Ketamine , provides hyponsis without cardiorespiratory depression, and can be given per rectally or i.m.


Geriatric Patients

Perioperative functional status can be difficult to quantitate because many elderly patients have reduced preoperative function related to de-conditioning, age – associated disease or cognitive impairment. Geriatric patients tend to have decreased beta-adrenergic responsiveness and they experience an increased incidence of conduction abnormalities, bradyarrhythmias and hypertension. Hypovolemia or overperfusion are both poorly tolerated. The elderly have a two-third reduction in anaesthetic requirement because of fundamental neurophysiologic changes in the brain.

Cardiovascular Disease patients

Patients with well-controlled cardiovascular disease should not be denied the opportunity to have their surgery in the ambulatory setting. However, patients with poorly controlled angina, congestive cardiac failure, symptomatic valvular disease, uncontrolled arrhythmias or recent myocardial infarction or stroke (within 6 months) are unsuitable for elective surgery. Hypertension is associated with an increased risk of developing perioperative cardiac events and should be treated before surgery. A reasonable upper limit for blood pressure is 180/100 mm Hg.


Diabetic patient

Diabetes is a predictor of adverse intraoperative and postoperative events, but patients with good diabetic control and a good understanding of their disease should be allowed day surgery. Patients with Type 2 diabetes are, in general, more suitable for day surgery than those with Type 1 diabetes. A complication of unique concern for anaesthesiologist is the diabetic “stiff joint syndrome”. Glycosylation of collagen decreases mobility of the cervical spine and TMJ and may increase the likelihood of difficult laryngoscopy and intubation. Stiffness of the 4th and 5th interphalangeal joints (prayer sign) assessed using palm prints is a sensitive predictor of difficult intubation. It is recommended that patients receive insulin long with a continuous infusion of dextrose on arrival to the ambulatory unit.

Morbid Obesity

Obesity is often associated with cardiac disease, diminished respiratory reserve and gastro-oesophageal reflux. Body mass index greater than 35 kg/m2 is associated with perioperative anaesthetic and surgical problems, and is often used as a cut-off point for patient suitability. Desaturation and bronchospasm are frequently noted complications.


Patient with Asthma or COPD

Asthma, chronic obstructive pulmonary disease and smoking all predict adverse perioperative events, but patients with wellcontrolled disease are likely to be suitable for day surgery. A regional anaesthetic technique can be considered for the more seriously affected. Patients with poorly controlled disease, marked exercise limitation or a recent exacerbation of their condition should have their surgery postponed. Smokers should be encouraged to stop smoking.


Obstructive Sleep Apnoea
 

Out-patient surgery for OSA patients remains controversial even in developed countries. OSA patients are more likely to be difficult to intubate ; Several factors, including obesity, retrognathia and increased neck circumference contribute to the increased difficulty with intubation. The severity of OSA is determined by the apnoea-hypopnoea index which is the number of apnoeas or hypopnoeas per hour of sleep. (mild 5 – 15, moderate 15 – 30, severe > 30) Recovery room complications are also more frequent and may include hypertension, dysarrhythmias, desaturation, airway obstruction or reintubation. well-treated OSA patients having low risk procedure performed under local anaesthesia or regional anaesthesia with little or no sedation and minimal need for narcotic-based analgesia can be discharged after surgery. Pain should be managed with non-narcotic analgesics and opioid drugs should be avoided.


GUIDELINES FOR AMBULATORY ANESTHESIA AND SURGERY Committee of Origin: Ambulatory Surgical Care (Approved by the ASA House of Delegates on October 15, 2003, and last amended on October 22, 2008)


I. II. ASA Standards, Guidelines and Policies should be adhered to in all settings except where they are not applicable to outpatient care. A licensed physician should be in attendance in the facility, or in the case of overnight care, immediately available by telephone, at all times during patient treatment and recovery and until the patients are medically discharged. The facility must be established, constructed, equipped and operated in accordance with applicable local, state and federal laws and regulations. At a minimum, all settings should have a reliable source of oxygen, suction, resuscitation equipment and emergency drugs. Specific reference is made to the ASA “Statement on Nonoperating Room Anesthetizing Locations.”



IV. Staff should be adequate to meet patient and facility needs for all
procedures performed in the setting, and should consist of: A. Professional Staff 1. Physicians and other practitioners who hold a valid license or certificate are duly qualified. 2. Nurses who are duly licensed and qualified. B. Administrative Staff C. Housekeeping and Maintenance Staff V. Physicians providing medical care in the facility should assume responsibility for credentials review, delineation of privileges, quality assurance and peer review. VI. Qualified personnel and equipment should be on hand to manage emergencies. There should be established policies and procedures to respond to emergencies and unanticipated patient transfer to an acute care facility.


VII. Minimal patient care should include:
A. B. Preoperative instructions and preparation. An appropriate pre-anesthesia evaluation and examination by an anesthesiologist, prior to anesthesia and surgery. In the event that nonphysician personnel are utilized in the process, the anesthesiologist must verify the information and repeat and record essential key elements of the evaluation. Preoperative studies and consultations as medically indicated An anesthesia plan developed by an anesthesiologist, discussed with and accepted by the patient and documented. Administration of anesthesia by anesthesiologists, other qualified physicians or nonphysician anesthesia personnel medically directed by an anesthesiologist. Non-anesthesiologist physicians who are administering or supervising the administration of the continuum of anesthesia must be qualified by education, training, licensure, and appropriately credentialed by the facility. Discharge of the patient is a physician responsibility Patients who receive other than unsupplemented local anesthesia must be discharged with a responsible adult. Written postoperative and follow-up care instructions Accurate, confidential and current medical records

C. D. E.

F. G. H. I.



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