Ambulatory Anaesthesia

Dr .Sachin Anand , Mod By:Dr Meera Kharbanda

Benefits of Ambulatory Surgery

Patient preference, especially 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 (greater efficiency) Shorter surgical waiting lists Lower overall procedural costs Less preoperative testing and postoperative medication

Facility Design

Hospital integrated: Ambulatory surgical patients are managed in

the same surgery facility as inpatients. Outpatients may have separate preoperative preparation and recovery areas.

Hospital-based: A separate ambulatory surgical facility within a

hospital handles only outpatients.

Freestanding: These surgical and diagnostic facilities may be

associated with a hospital or medical center but are housed in separate buildings that share no space or patient care functions. Preoperative evaluation, surgical care, and recovery occur within this autonomous unit.

Office-based: These operating and/or diagnostic suites are

managed in conjunction with physicians offices for the convenience of patients and health care providers.

Safety in Day Case Anaesthesia

Safety in day cases is optimised by: Patient selection. Procedure selection Anaesthetic choice. (GA Vs. LA etc.) Discharge planning. These are the anaesthetic issues most specific to day case anaesthesia. Clear evidence and policy exist.

Procedures Suitable for Ambulatory Surgery

Dental -Extraction, restoration, facial fractures Dermatology -Excision of skin lesions General -Biopsy, endoscopy, excision of masses, hemorrhoidectomy, herniorrhaphy, laparoscopic cholecystectomy, adrenalectomy, splenectomy, varicose vein surgery Gynecology -Cone biopsy, dilatation and curettage, hysteroscopy, diagnostic laparoscopy, laparoscopic tubal ligations, uterine polypectomy, vaginal hysterectomy Ophthalmology -Cataract extraction, chalazion excision, nasolacrimal duct probing, strabismus repair, tonometry

Procedures Suitable for Ambulatory Surgery

Orthopedic -Anterior cruciate repair, knee arthroscopy, shoulder reconstructions, bunionectomy, carpal tunnel release, closed reduction, hardware removal, manipulation under anesthesia and minimally invasive hip replacements Otolaryngology -Adenoidectomy, laryngoscopy, mastoidectomy, myringotomy, polypectomy, rhinoplasty, tonsillectomy, tympanoplasty Pain clinic -Chemical sympathectomy, epidural injection, nerve blocks Plastic surgery -Basal cell cancer excision, cleft lip repair, liposuction, mammoplasty (reductions and augmentations), otoplasty, scar revision, septorhinoplasty, skin graft Urology -Bladder surgery, circumcision, cystoscopy, lithotripsy, orchiectomy, prostate biopsy, vasovasostomy, laparoscopic nephrectomy and prostatectomy

Minimally invasive outpatient procedures

parathyroidectomy and thyroidectomy, laparoscopically assisted vaginal hysterectomy, removal of ectopic tubal pregnancy, and ovarian cystectomy, as well as laparoscopic cholecystectomy and fundoplication, laparoscopic adrenalectomy, splenectomy, and nephrectomy, lumbar microdiscectomy, and video-assisted thoracic surgery superficial procedures (mastectomy)

Duration of Surgery

lasting less than 90 minutes lasting 3 to 4 hours

Recommendations for the Perioperative Care of Patients Selected for Day Care Surgery
1. Procedures suitable for day care surgery must entail: 1.1 A minimal risk of post operative haemorrhage. 1.2 A minimal risk of post operative airway compromise. 1.3 Post operative pain controlled by out patient management techniques. 1.4 No special post operative nursing requirements that cannot be met by the hospital in the home or district nursing facilities. 1.5 A rapid return to normal fluid and food intake. 1.6 Early commencement of procedures for which a long recovery period is likely.

2. Patient requirements for day care surgery include: 2.1 Willingness, understanding, an ability to follow discharge instruction. 2.2 Place of residence within one hour from medical attention. 2.3 ASA I or II. Medically stable ASA III or IV may be accepted following consultation with the anaesthetist. 2.4 Normal term infants > six weeks of age or expremature infants of > 60 weeks post-conceptual age.

3. Social requirements for day care surgery include: 3.1 A responsible person to transport the patient in a suitable vehicle. 3.2 A responsible person staying at least overnight.Mentally able. 3.3 Patient /responsible person understands instructions and intends to comply particularly with regard to public safety. 3.4 Remain within one hour of medical attention until the morning following. 3.5 Ready access to a telephone. 3.6 Advice as to when to resume activities such as driving and decision making.

Patient Characteristics

ASA physical status I or II ASA physical status III (and even some IV) The risk of complications can be minimized if preexisting medical conditions are stable, for at least 3 months before the scheduled operation. Even morbid obesity (BMI >40 kg/m2) is no longer considered an exclusionary criterion for day-case surgery.

Susceptibility to Malignant Hyperthermia

Admission solely on the basis of MH susceptibility is no longer considered appropriate Non-triggering anesthetics ( local anesthesia)

Extremes of Age

elderly elderly patient (>100 years) should not be denied ambulatory surgery solely on the basis of age ex-premature infants (gestational age < 37 weeks) recovering from minor surgical procedures under general anesthesia have an increased risk for postoperative apnea, persists until the 60th postconceptual week

Contraindications to Outpatient Surgery

Potentially life-threatening chronic illnesses ( brittle diabetes, unstable angina, symptomatic asthma) Morbid obesity complicated by symptomatic cardiorespiratory problems ( angina, asthma) Multiple chronic centrally active drug therapies (monoamine oxidase inhibitors such as pargyline and tranylcypromine) and/or active cocaine abuse Ex-premature infants less than 60 weeks postconceptual age requiring general endotracheal anesthesia No responsible adult at home to care for the patient on the evening after surgery

Controversial exclusion criteria.

Morbid obesity Significant sleep apnoea Fragile diabetes COPD Severe asthma Significant epilepsy Patients prone to malignant hyperpyrexia Alcohol abuse

Preoperative assessment

The three primary components of a preoperative assessment history (86%), physical examination (6%), and laboratory testing (8%) Computerized questionnaires -telephone interview by a trained nurse -guide preoperative laboratory testing

Preoperative assessment

All paperwork (consent form, history, physical examination, and laboratory test results) should be reviewed before the patient arrives for surgery Appropriate patient preparation before the day of surgery can prevent unnecessary delays, absences (no shows), last-minute cancellations, and substandard perioperative care.

Preoperative Preparation

Patients should be encouraged to continue all their chronic medications up to the time that they arrive at the surgery center. Oral medications can be taken with a small amount of water up to 30 minutes before surgery

Preoperative Preparation

Non-pharmacologic Preparation - economic-lack side effects high patient acceptance - preoperative visit educational programs -videotapes written and verbal instructions regarding arrival time and place, fasting instructions, and information concerning the postoperative course, effects of anesthetic drugs on driving and cognitive skills immediately after surgery, and the need for a responsible adult to care for the patient during the early post discharge period (<24 hours).

Pharmacologic Preparation

Anxiolysis and Sedation

Barbiturates -residual sedation Benzodiazepines - diazepam 0.1 mg/kg PO midazolam 0.5mg/kg PO or 1mg IV -Adrenergic Agonists - 2 agonist clonidine, dexmeditomidine-anaesthetic & analgesic sparing effectdecrease emergence delirium of sevoflurane-reduce emesisfacilitate glycemic control- reduce cardio-vascular complication -Blockers -atenolol,esmolol attenuate adrenergic responses-prevent cardiovascular events

Pharmacologic Preparation

Pre-emptive (Preventative) Analgesia

Opioid (Narcotic) Analgesics

Anesthetic sparing-minimize hemodynamic response PONV, urinary retention -delay discharge Surgical bleeding-gastric mucosal & renal tubal toxicity a fixed dosing schedule beginning in the preoperative period and extending into the post discharge period. addition of dexamethasone to a COX-2 inhibitor leads to improvement in postoperative analgesia

Nonopioid Analgesics

Pharmacologic Preparation

Prevention of Nausea and Vomiting

Pharmacologic Techniques
Butyrophenones droperidol- dexamethasone Phenothiazines -prochlorperazine Antihistamines dimenhydrinate, hydroxyzine Anticholinergics atropine, glycopyrrolate, TDS Serotonin Antagonists ondensetron,palanosetron Neurokinin-1 Antagonists- aprepitant

Nonpharmacologic Techniques
Acupuncture, Acupressure and TENS at the P-6 acupoint - with the Relief Band

Pharmacologic Preparation

Prevention of Aspiration Pneumonitis no increased risk of aspiration in fasted outpatients routine prophylaxis for acid aspiration is no longer recommended -pregnancy, scleroderma, hiatal hernia, nasogastric tubes, severe diabetics, morbid obesity H2-Receptor Antagonists Proton Pump Inhibitors

Pharmacologic Preparation

NPO Guidelines
Prolonged fasting does not guarantee an empty stomach at the time of induction Hunger, thirst, hypoglycemia, discomfort Preoperative administration of glucose-containing fluids prevents postoperative insulin resistance and attenuates the catabolic responses to surgery while replacing fluid deficits

Basic Anesthetic Techniques

General Anesthesia Regional Anesthesia - Spinal and Epidural Intravenous Regional Anesthesia TIVA- combination of propofol and remifentanil -TCI Peripheral Nerve Blocks Local Infiltration Techniques Monitored Anesthesia Care

General Anesthesia

Airway management Induction- barbiturates, benzodiazepines, ketamine, propofol Inhaled anaesthetics- sevoflurane, desflurane Opiod analgesics fentanyl 1-2 g/kg , alfentanil 15-30 g/kg , sufentanil 0.15-0.3 g/kg , remifentanil 0.5-1 g/kg. Muscle relaxants- succinylcholine, mivacurium, Antagonists- nalaxone, succinylcholine, flumazenil, neostigmine, atipamezole, caffeine IV, modafinil, sugammadex

Regional Anesthesia

Mini-dose spinal- lignocaine 10-30 mg , bupivacaine 3.5-7 mg , ropivacaine 5-10 mg , fentanyl 10-25 g , sufentanil 5-10 g Epidural- 3% 2-chloroprocaine- back pain from muscle spasm - EDTA CSE

Intravenous Regional Anesthesia

short superficial surgical procedures (<60 minutes) Ropivacaine vs. lignocaine Adjuvants ketorolac 15 mg, clonidine 1 g/kg, dexmedetomidine 0.5 g/kg, gabapentin 1.2 mg, dexamethasone 8 mg.

Peripheral Nerve Blocks

Brachial plexus -axillary, subclavicular, or interscalene block Three-in-one block - femoral, obturator, and lateral femoral cutaneous nerves Deep and superficial cervical plexus blocks Continuous perineural techniques -PCA Ultrasound guidance

Local Infiltration Techniques

simple wound infiltration (or instillation) use of a local anesthetic at the portals and topical application at the surgical site instillation of 30 ml of 0.5% bupivacaine into the joint space perioperative administration of IV lidocaine improved patient outcomes

Monitored Anesthesia Care

The combination of local anesthesia and/or peripheral nerve blocks with intravenous sedative and analgesic drugs is commonly referred to as MAC and has become extremely popular in the ambulatory setting The standard of care for patients receiving MAC should be the same as for patients undergoing general or regional anesthesia and includes preoperative assessment, intraoperative monitoring, and postoperative recovery care.

Monitored Anesthesia Care

MAC is the term used when an anesthesiologist monitors a patient receiving local anesthesia or administers supplemental drugs to patients undergoing diagnostic or therapeutic procedures Anesthetic drugs are administered during procedures under MAC with the goal of providing analgesia, sedation, and anxiolysis and ensuring rapid recovery without side effects

Monitored Anesthesia Care

Systemic analgesics are often used to reduce the discomfort associated with the injection of local anesthetics and prolonged immobilization Sedative-hypnotic drugs are used to make procedures more tolerable for patients by reducing anxiety and providing a degree of intraoperative amnesia

Monitored Anesthesia Care

sedative-hypnotic drugs have been administered during MAC -barbiturates, benzodiazepines, ketamine, and propofol intermittent boluses- variable-rate infusion, target-controlled infusion, and even patientcontrolled sedation. Methohexital -intermittent boluses 10-20 mg or as a
variable-rate infusion 1-3 mg/min

The 2-agonists clonidine and dexmedetomidine

Cerebral Monitoring

EEG-derived indices - The bispectral index (BIS), physical state index (PSI), spectral and response entropy, auditory evoked potential (AEP) index, and cerebral state index (CSI) The BIS, PSI, and CSI values are dimensionless numbers that vary from 0 to 100, with values less than 60 associated with adequate hypnosis under general anesthesia and values greater than 75 typically observed during emergence from anesthesia

Fast-Tracking
Multimodal Approaches to Minimize Side Effects

PONV-

droperidol 0.625-1.25 mg IV, dexamethasone 4-8 mg IV, ondansetron 4-8 mg IV, long-acting 5-HT3 antagonistpalonosetron 75 g IV, and NK-1 antagonist - aprepitant, a transdermal scopolamine patch, or an acu-stimulation device - SeaBand, Relief Band Non-opioid analgesics -NSAIDs, cyclooxygenase-2 [COX-2] inhibitors, acetaminophen, 2-agonists, glucocorticoids, ketamine, and local anesthetics

Newer analgesic therapies

continuous local anesthetic infusions, nonparenteral opioid analgesic delivery systems ambulatory patient-controlled analgesic techniques ( subcutaneous, intranasal, transcutaneous)

Fast-Tracking
Multimodal Approaches to Minimize Side Effects

low-dose ketamine 75-150 g/kg Non-pharmacologic factors

conventional CO2 insufflation technique /gasless technique subdiaphragmatic instillation of local anesthetic - local anesthetic at the portals and topical application at the surgical site. TENS

Discharge Criteria

Early recovery is the time interval during which patients emerge from anesthesia, recover control of their protective reflexes, and resume early motor activity Aldrete score operating room Intermediate recovery- recovery room -begin to ambulate, drink fluids, void, and prepare for discharge Late recovery period starts when the patient is discharged home and continues until complete functional recovery is achieved and the patient is able to resume normal activities of daily living

Discharge Criteria

anesthetics, analgesics, and antiemetics can affect the patient's early and intermediate recovery, the surgical procedure has the highest impact on late recovery Before ambulation, patients receiving a central neuraxial block should have normal perianal (S4 5) sensation, have the ability to plantarflex the foot, and have proprioception of the big toe

Score based recovery

Patient is moved through the unit and discharged when they achieve a set of criteria using a scoring system
Patient is moved through the unit and discharged when they achieve a set of criteria and required time length of stay in the unit.

Time based recovery

Fast tracking

Clinical pathway that involves transferring the patient from the operating room to the day surgery ward (2nd Stage recovery) and bypassing PACU (1st stage)

Discharge Scoring systems

Aldrete scoring system White et al scoring system PADSS Modified PADSS

Aldrete Scoring system

Requires a patient to reach the criteria of 9 or 10/10 before the can

Move from 1st stage to 2nd stage By pass 1st stage (by achieving the score in the operating room)

Aldrete Scoring system

Does not address

Pain Nausea Vomiting

Aldrete Scoring system

Discharge Criteria
Activity: Able to move voluntarily or on command
Four extremities Two extremities Zero extremities 2 1 0 2 1 0 2 1 0

Score

Respiration
Able to deep breathe and cough freely Dyspnoea, shallow or limited breathing Apneic

Circulation
BP +/- 20mm of pre anaesthetic level BP +/- 20-50 mm of pre anaesthetic level BP +/- 50mm of pre anaesthetic level

Discharge Criteria
Consciousness
Fully awake Arousable on calling

Score
2 1

Not responding

0
2 1 0

O2 Saturation
Able to maintain O2 saturation >92% room air Needs O2 inhalation to maintain O2 saturation >90% O2 saturation <90% with O2 supplementation

PADS
(1) vital signs, including blood pressure, heart rate, respiratory rate, and temperature (2) ambulation and mental status (3) pain and PONV (4) surgical bleeding and (5) fluid intake/output

Post-anesthesia Discharge Scoring (PADS) System

Vital Signs

2-Within 20% of the preoperative value 1 -20%-40% of the preoperative value 0-40% of the preoperative value

Ambulation

2 -Steady gait/no dizziness 1-With assistance 0-No ambulation/dizziness

2-Minimal 1-Moderate 0-Severe 2-Minimal 1-Moderate 0-Severe 2-Minimal 1-Moderate 0-Severe

Nausea and Vomiting

Pain

Surgical Bleeding

Post anaesthesia discharge score (PADS) was noted after surgery and patients are discharged only when they achieved total score of =9

Discharge of the patient from the day care unit:

1. Stable vital signs 2. Orientated. 3. Pain control 4. PONV, dizziness 5. Minimal bleeding 6. Hydration adequate, likelihood of oral intake. 7. Patients at significant risk of urinary retention must have passed urine. 8. Responsible adult 9. Written and verbal instructions. 10. Suitable analgesia provided. 11. A telephone inquiry (following day) whenever possible.

Discharge Criteria: Input & Output

Areas of controversy exist: 1. Input: oral intake prior to discharge. 2. Output: Requirement for urinary output. ie: no definite direction/guidelines in literature. Discharge sooner if requirements relaxed: Associated cost saving. Increased readmission/complication risk.

Input:

Discharge contraindicated while actively vomiting. In children: Vomiting increased by 50% if forced oral intake. Vomiting more likely after discharge. (Therefore oral intake not predictive of later vomiting.)

Is voiding necessary?

Risk factors for post operative urinary retention are

Anorectal surgery Old age Male sex Spinal anaesthesia Hernia surgery

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