ANESTHESIOLOGY
EXIMIUS
ANESTHETIC CONSIDERATIONS FOR AMBULATORY ANESTHESIA
DR. ERWIN A. TAGUINOD, DPBA
ADVANTAGES OF AMBULATORY SURGERY:
1. Greater control over scheduling
2. Greater privacy and convenience
3. Increased efficiency and consistency in nursing staff and support
personnel
4. Decreased cost to the patient
Most surgical procedures are performed in:
a. In-hospital procedures as outpatient
b. Hospital-based ambulatory surgery centers
c. Free-standing ambulatory centers
d. Office-based surgery facilities
Examples of advanced procedures successfully carried out in ambulatory
settings:
• Laparoscopic major gastric surgery: cholecystectomy,
fundoplication, gastric banding, gastric sleeve
• Laparoscopic major gynecologic surgery: hysterectomy
• Minimally invasive low back surgery
• Breast surgery
• Bladder/prostate cancer surgery
• Cruciate ligament repair
• Major plastic surgery: breast reduction, abdominal fat reduction
• Thyroidectomy
• Tonsillectomy
The anesthesiologiost, before delivery of anesthesia care is responsible
for:
1. Reviewing the available medical record
2. Interviewing and performing a focused examination of the
patient to discuss and assess
3. Ordering and reviewing pertinent available tests and
consultation necessary
4. Ordering appropriate preop meds
5. Ensuring that consent has been obtained
6. Documenting in the chart that the above has been performed
Approaches to screening patients:
1. Facility visit prior to the day of surgery
2. Office visit prior to the day of surgery
3. Telephone interview/no visit
4. Review of health survey/no visit
5. Preoperative screening and visit on the morning of surgery
6. Computer-assisted information gathering
7. The use of telemedicine technology
8. Nurse-assisted interview
The goal to determine who is fit for outpatient surgery, then optimize
these patients.
Depends on the type of facility, patient population, procedure to be
done.
Selection criteria will differ for the type of ambulatory unit involved.
*Laboratory examinations should be obtained for medical indications
only
*“Routine” testing of no value
*Information gained from a thorough history and PE and clear
communication with perioperative team is of considerable benefit
Contributory factors in preventable adverse events:
• Poor airway assessment
• Communication problems
• Inadequate preoperative evaluation
TRANSCRIBERS Marky, Josh, Reima
JANUARY 2020 2021
Exclusion from Day Surgery
Age and medical exclusions:
o ex-preterm infant < 60 weeks of post-conceptual age
1
o Inadequately controlled systemic disease (e.g. epilepsy, asthma)
o Active viral or bacterial infection (esp. respiratory)
o Complex congenital heart disease
o Cardiac murmur that has not been investigated
o Poorly controlled diabetes mellitus
o Sickle cell disease
Surgical and anaesthetic exclusions:
o Inexperienced surgeon or anaesthetist
o Prolonged procedure (>1 hour)
o Significant risk of excessive preoperative haemorrhage
o Opening a body cavity
o Difficult airway
o Sleep apnoea
o Malignant hyperthermia susceptibility
o Unlikely relief of pain by oral analgesia after discharged home
Social exclusions
o Parents incapable or reluctant to care for child at home
o Unsupported single parent with other children
o Inadequate housing conditions
o No telephone
o Inadequate post operative transport
o Arrangements (public transport unacceptable)
o Long journey (> 1 hour)
Patient inappropriate for outpatient surgery:
Pediatric:
a. Formerly premature infants of less than 50 weeks post-
conceptual age
b. Infants with respiratory disease
c. Infants with cardiovascular diseases
d. Children with fever, cough, sore throat, onset of worsening urti
Adult:
a. Patients expected to have major blood loss
b. ASA III or IV patients whose systemic disease is unstable or
requires monitoring
c. Morbily obese patients
d. Patients with a need for complex pain management
e. Patients with fever, wheezing, nasal congestion, coughing, urti
Independent risk factors for cardiac complications:
• High-risk surgery
• History of ischemic heart disease
• History of congestive heart failure
• History of cerebrovascular disease
• Preoperative treatment with insulin
• Preoperative serum creatinine >2.0 mg/dL
Practical Screening Tool
• Poor exercise tolerance (<4 metabolic equivalents or METS) is an
independent predictor of serious perioperative complications.
• The likelihood of serious complications is inversely related to the
number of blocks walked or flight of stairs climbed
Independent predictors of adverse cardiac events:
• age above 68 years
• Active congestive heart failure
• BMI >/= 30 kg/m3
• Emergency surgery
• Previous cardiac intervention
• Cerebrovascular disease
• Operative duration >3.8 hours
• Administration of one or more units of PRBCs
EDITOR
1 of 4
 ANESTHETIC CONSIDERATIONS FOR AMBULATORY ANESTHESIA EXIMIUS
2021
0000

Key points: (AHA/ACC guidelines) Pulmonary disease

• Ambulatory procedures are considered low risk with reported Focus on:
cardiac mortality of <1% o Need for home oxygen
• In the absence of “active cardiac conditions” interventions o Use of inhalers (incl rescue meds)
based on cardiovascular testing in patients would rarely result in o Ability to walk up to 2 flights of stairs
a change in management and it would be appropriate to o Frequency of coughing and secretions
proceed with planned surgery Useful tests:
o Preoperative x-ray
Difficult airway o ABG
• Depends on available resources including advanced airway o Spirometry incl vital capacity & FEVI
equipment Vital capacity of less than 1.5-2 meters or an adult FEVI of less than 1-1.5
• Access to personnel with experience dealing with difficult liters indicates increased likelihood of the need for ventilator support and
airways inpatient conversion postop
• Ensure adequate NPO
• Ascertain potential difficult airway Smoking
• Increases risk of perioperative complications
Cardiovascular disease
o Pneumonia
• Routine cardiac testing is not recommended
o Unplanned intubation
• Exceptions: decompensated or new onset heart failure, unstable o Mechanical ventilation
or severe angina, a recent MI (within 60 days), symptomatic
o Cardiac arrest
arrhythmias and severe aortic or mitral stenosis
o MI
o Stroke
Ischemic heart disease
o Sepsis
• The function of ventricles and portion of the myocardium at risk o Infection
predict a further cardiac event, not the age of the infarction
o Septic shock
• Delay atleast 60 days
• Aspirin, statin, beta-blocker
Obstructive sleep apnea
Associated with:
Coronary Intervention
o Increased age, obesity, and presence of redundant pharyngeal
• Recommendation to delay surgery
tissues
• Angioplasty: two weeks
o Snoring, episodes of apnea, tiredness despite normal night’s
• BMS: 4-6 weeks
sleep
• DES: 12 months
• CABG: 4 weeks
Approaches to managing patients with OSA in an ambulatory setting
• Access to CPAP after discharge and optimized comorbidities à
Arrhythmias
proceed with ambulatory surgery with CPAP in the
• Rule out of MI, ischemia, drug toxicity, or metabolic causes
postoperative period
• Further evaluation needed for AV block, atrial fibrillation with
• Unable or unwilling to use CPAP after discharge à proceed with
rapid ventricular response, new onset symptomatic bradycardia,
ambulatory surgery if postoperative pain relief provided without
newly recognized ventricular tachycardia
opioids
• Risk of stopping or continuing anticoangulants considered
• If patient comorbidities not optimized à not suitable for
individually
ambulatory surgery
• Upper airway surgery à per surgeon’s and anaesthesiology's
ICDs/Pacemakers
discretions
• Discuss with patient’s cardiologist a perioperative plans
• Consider placing defibrillator pads
OSA (ASA guidelines)
• Minimize surgical electrocoagulation
• Not discharged from the recovery area to an unmonitored
setting until no longer at risk for postop respiratory depression
Hypertension
• Observed no longer breathing room air in an unstimulated
• Stable hypertension acceptable (resting values 180 systolic, 110
environment
diastolic)
• Newly diagnosed, high values or unstable high values need
further evaluation
• Medications should be continued (ACEi, ARBs)

Valvular abnormalities
• A preoperative echocardiogram (done within a year) needed to
evaluate the value in symptomatic or physically inactive patients
when symptoms cannot be assessed.

TRANSCRIBERSx Marky, Josh, Reima EDITOR 2 of 4

 ANESTHETIC CONSIDERATIONS FOR AMBULATORY ANESTHESIA EXIMIUS
2021
0000

Postop pain analgesia

• Topical drops
• Wound infiltration
• PNBs
• Caudal blocks
• Nsaids, paracetamol
• Oral opioids

Discharge criteria
• Awake, alert, oriented, responsive
• Minimal pain
• No active bleeding
• Vital signs stable
• Minimal nausea
• No vomiting
• Can perform sustained five second head lift
• 02 saturation of 94% on room air

Obese patients
• BMI >30 and <50 without comorbidities
• Comorbidities and ASA status

Diabetes mellitus
• FBS should tested preoperatively
• Accepted value: <180 mg/dL or 10mmol/l (Association
of clinical endocrinologists, 2015)

Insulin recommendations for day of surgery

INSULIN MEDICATION INSTRUCTIONS

Insulin pump Set to basal rate

Long acting, peakless insulins 75-100% morning dose

Intermediate acting insulins
(NPH) 50-75% of morning dose

Fixed combination insulins 50-75% of morning dose Home instructions:

• For the next 24 hours:
Short or rapid acting insulins Hold the dose o may feel a little sleepy
o rest at home, no strenuous activity
Pregnancy o Have a responsible adult
• Elective surgery during 1st and 3rd trimester is discouraged o May not:
• Malignancy or a condition that will deteriorate unless treated, o Drive
acceptable o Operate heavy machinery
• Ambulatory setting, if fetal monitoring is available o Make any important decisions

Breastfeeding patients Postoperative pain management:

• Breastmilk contains low levels of anesthetic agents within 24
hours of GA, breastfeeding can continue unchanged
• Repeated and high doses of benzodiazepines and opioids may
accumulate to dangerous levels in breastmilk, suggesting
mothers pump and discard milk before breastfeeding
ESRD
• Allowed if dialysis is done prior
• No acidosis, volume overload, electrolyte abnormalities
• Some advocate checking Potassium levels
Multimodal therapy, which combines two or more analgesics to treat
postoperative pain, is often used.
Complications and challenges of ambulatory anesthesia recovery
• Inadequate analgesia
• Postoperative nausea and vomiting (PONV)
• Postdischarge nausea and vomiting (PDNV)
• Rebleeding from surgical site
Strategies to reduce risk of PONV
• Use regional anesthesia (avoid gen. anesthesia)
• Propofol for induction and maintenance
• Avoid nitrous oxide
• Avoid volatile anesthetics

TRANSCRIBERSx Marky, Josh, Reima EDITOR 3 of 4

 ANESTHETIC CONSIDERATIONS FOR AMBULATORY ANESTHESIA EXIMIUS
2021
0000

• Minimization of intraoperative and postoperative opioids

• Minimization of neostigmine
• Adequate hydration

Home instructions:
• Medications – include specific instructions and schedule of
intake
• Diet – progress slowly to regular diet; start with clear fluids
(water, gatorade)
• When to call doctor
• Names and numbers of persons to call, in case
• Additional instructions

Future Doctors, always remember:

“How much you earn does not define your worth.”

TRANSCRIBERSx Marky, Josh, Reima EDITOR 4 of 4