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ANESTHESIA FOR DAY CARE

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

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Benefits of “Day Care” or “Ambulatory”
Surgery

 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

3
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.

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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.

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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...

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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

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

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Pre – Operative evaluation

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Recommended Laboratory tests for
ambulatory surgery

Pre –operative evaluation includes history , examination


and Laboratory testing

Age Range Men Women


< 40 yrs None Pregnancy test
40-49 ECG Hematocrit , pregnancy test

50-64 ECG Hb / Hematocrit, ECG


65-74 Hb/ Hematocritt, ECG, Bl. Hb/ Hematocritt, ECG, Bl.
Urea nitrogen, glucose Urea nitrogen, glucose

>75 Hb/ Hematocritt, ECG, Bl. Hb/ Hematocritt, ECG, Bl.


Urea nitrogen, glucose, X Urea nitrogen, glucose,
ray chest chest radiograph 10
Pre – Operative Preparation

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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.

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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.

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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.

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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

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Pharmacological methods (contd..)

 Prevention of Nausea and Vomiting


As a mutimodal regimen , combination of anti-emitic drugs are
used to prevent PONV .
 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.

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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

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Anesthesia techniques

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Anesthesia Techniques

 Various techniques for Ambulatory anesthesia –

 General Anesthesia

 Regional Anesthesia

 Monitored Anesthesia Care

 Local Anesthesia

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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

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General Anesthesia

 Induction of General Anesthesia –


Drug Dose (mg/Kg) Onset Recovery Side effects
Thiopental 3-6 Rapid Intermed. Drowsiness
Methohexital 1.5-3 Rapid Rapid Pain, excitatory
activities

Etomidate 0.15-0.30 Rapid Intermed. Pain, emesis,


myoclonus
Ketamine 0.75-1.5 Intermed. Intermed. CVS manif.,
Psychomm.
Midazolam 0.1-0.2 Slow Slow Drowsiness,
amnesia
Propofol 1.5-2.5 Rapid Rapid CVS depress.,
pain on inj.

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General Anesthesia (contd...)

 Opioid Analgesics –

 Fentanyl – 1-2 mcg/kg


 Alfentanil – 15-30 mcg/kg
 Sufentanil – 0.15-0.3 mcg/kg
 Remifentanil – 0.5-1 mcg/kg

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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 8-
10 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.

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General Anesthesia (contd...)

 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 Concentration (%) Onset Recovery Side effects


Halothane 0.5-1.5 Slow Slow Sedation,
arrhythmias
Enflurane 0.75-1.5 Intermed. Intermed. Shivering
Isoflurane 0.5-1 Intermed. Intermed. Coughing
Desflurane 3-6 Very rapid Very rapid Coughing,
tachycardia
Sevoflurane 1-2 Rapid Rapid Flammable

N2O 50-70 Very rapid Very rapid Nausea,


Vomiting

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Regional Anesthesia

 Modes of Regional Anesthesia –

 Epidural and spinal techniques

 Intravenous regional anesthesia

 Peripheral Nerve Blocks

 Local Infiltration techniques

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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.

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Regional Anesthesia (contd..)

Disadvantages of RA in ambulatory surgery:

(a) Takes time and new separate setup to be organized,


(b) Patients active co-operation is needed
(c) Risk of complications : Nerve damage, TNS after Spinal
anaesthesia.
(d) Variable failure rate (up to 10% with PNB)
(e) Urinary retention with Spinal Anaesthesia.

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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.

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Regional Anesthesia (contd..)

Peripheral Nerve Blocks


Procedure Technique Advantage Disadvantage

Hernia Repair Field Block Good post operative Supplementation


pain relief
Spinal Speed PDPH; urinary
Little supplementation retention; delayed
mobilization
Cataract extraction Peribulbar block Reduces confusion and Ocular complications
discharge time
Knee surgery 3-in-1 block Good analgesia Failed blocks

Spinal Speed ; little PDPH; urinary


supplementation retention; delayed
mobilization
Foot surgery Popliteal block, ankle Good analgesia Failed blocks
blocks
Hand surgery Bier’s block, brachial Analgesia Failed plexus blocks
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R.A. v/s G.A.

 Comparison of regional and general anaesthesia


Technique Advantage Disadvantage
General Anesthesia Fast PONV
No Failures Confusion

Regional Anesthesia Prolonged analgesia Prolonged motor block


Reduced PONV PDPH
Reduced confusion Slow onset
High Failure rate

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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.

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Monitored Anesthesia Care (contd..)

 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 (1-
3mg/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

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Concept of “Fast – Tracking”

Bypassing the PACU has been termed


“Fast-Tracking” after ambulatory
surgery.

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Criteria used to determine fast-track
eligibility after ambulatory anesthesia

 Level of Conciousness –
 Awake and oriented 2
 Arousable with minimal stimulation 1
 Responsive only to tactile stimulation 0
 Physical activity –
 Able to move all extremities on command 2
 Some weakness in movement of extremities 1
 Unable to voluntarily move the extremities 0
 Hemodynamics –
 BP < 15% of the baseline MAP 2
 BP between 15-30% of the baseline MAP 1
 BP > 30% below the baseline MAP 0
 Respiration –
 Able to breathe deeply 2
 Tachypnea with good cough 1

Dyspneic with weak cough 0 contd…

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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.

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Assessment of Recovery
Discharge Criteria

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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

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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.
 Phase II / Intermediate recovery –
 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
 Phase III / late recovery –
 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.
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Steward Score

 Consciousness
Awake 2
Responding to stimuli 1
Not responding 0

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

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

* Six points are required for discharge.

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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 1
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.

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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 1
Blood pressure and pulse within 40% of baseline 0

 Activity level
Patient must be able to ambulate at preoperative level

Steady gait, no dizziness, or meets preoperative level 2


Requires assistance 1
Unable to ambulate 0

 Nausea and vomiting


Minimal: successfully treated with oral medication 2
Moderate: successfully treated with intramuscular medication 1
Severe: continues after repeated treatment 0

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Post-anaesthesia Discharge Scoring
System for assessing home readiness
(contd.)
 Pain
 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 2
Unacceptable 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 1
Severe: more than three dressing changes required 0

* Nine points are required for discharge.

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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

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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.

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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

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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.

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Application of Ambulatory
anesthesia in specific
population

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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.

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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.

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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.

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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.

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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.

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Patient with Asthma or COPD

 Asthma, chronic obstructive pulmonary disease and smoking all


predict adverse perioperative events, but patients with well-
controlled 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.

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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.

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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)

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GUIDELINES FOR AMBULATORY
ANESTHESIA AND SURGERY

I. ASA Standards, Guidelines and Policies should be adhered to in all settings


except where they are not applicable to outpatient care.
II. 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.
III. 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.”

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GUIDELINES FOR AMBULATORY
ANESTHESIA AND SURGERY

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.

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GUIDELINES FOR AMBULATORY
ANESTHESIA AND SURGERY

VII. Minimal patient care should include:


A. Preoperative instructions and preparation.
B. 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.
C. Preoperative studies and consultations as medically indicated
D. An anesthesia plan developed by an anesthesiologist, discussed with and accepted by the
patient and documented.
E. 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.
F. Discharge of the patient is a physician responsibility
G. Patients who receive other than unsupplemented local anesthesia must be discharged with a
responsible adult.
H. Written postoperative and follow-up care instructions
I. Accurate, confidential and current medical records

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