PSUR 602

Outpatient Anesthesia
Qeena C. Woodard, DPM
Diplomat, American Board of Podiatric Medicine
Diplomat, American Board of Podiatric Surgery
2012

Outpatient Anesthesia
Future of Elective Surgery
Decrease costs while maintain Quality of
Care
Admit s/p <3%
2005: 20% surgery procedures performed in
Doctors offices

Non-hospital based surgery

Satellite/surgery center/doctors office
Some insurance companies penalize for
surgery in the hospital vs. office

Outpatient Anesthesia
Considerations
General Medical health of the patient
Psychosocial considerations
Specifics of surgical procedure
Limitation of the surgical facility or
health care provider
Post-op care easily managed at home
Low rates of post-op complications

General Medical Health

Originally ASA class I or II only for
outpatient procedures
Originally only if patient is under 70
Now : pre-op labs and ASA III or IV
medically stable, there are few
limitations

Psychosocial Considerations
Patient and family understand the
care afterwards
The patient needs a responsible
companion for the first 24 hours to
assist
Social service counseling may be
needed

Surgical Procedure
Minor procedures with minimal
physiologic derangement
Low morbidity
Minimal post-op bleeding, infection,
unresponsive pain, and airway
compromise
Length of surgery
Long operations should be early in day

Facility
A facility in association with hospital
is better to manage and respond to
patient needs and complications

Patient Factors

Dietary restrictions
Pre-op screening
Physical status
Age

Dietary Restrictions
Pre-op fasting of 8 12 hours without
an IV needed
NPO after midnight is a routine order
Chronic medications taken with sip of
H2O minimal 2h prior
Fasting 2h clear liquid

Pre-op Screening

Medical and family history

Arrival time before surgery
Loose clothing
No jewelry, no makeup
Any surgery in the past 2 months

Physical Status
ASA I and II are optimal patients
ASA III and IV are appropriate if their
systemic diseases are medically
managed and stable
There is no cause and effect
relationship between preexisting
disease and incidence of
complications

AGE
Very Old
Chronological age is not a deterrent
Physiologic age is important

Very Young
Infants are best handled as inpatients
Premature children have more
difficulties in respiration

Inappropriate Candidates
Infant who was born premature and
is younger than 50 weeks postconceptual age
Any infant with respiratory problems
Any history of SIDS in the family
Any patient with malignant
hyperthermia

Inappropriate Candidates

Uncontrolled seizures
Morbidly Obese patients
Substance abusers
Uncooperative patient
No responsible person at home

Anesthesia Outside the OR

Must have appropriate anesthesia
machines and monitors and
emergency equipment
Standards
BP and HR measured every 15 minutes
EKG continuously monitored
If general anesthesia
Ventilation must be continuously monitored

Pre-op Medications
Benzodiazepines: decrease anxiety,
increase sedation
Diazepam (Valium) 2-5mg po
Midazalam (Versed) 2mg IV
Propofol 5mg IV

Opiods: increase sedation, control

HTN during GA, decrease pain s/p
procedure
Fentanyl

Procedures Outside the OR

Extra Corporeal Shock Wave
Lithotripsy
Radiologic procedures
Angiogram
MRI/CT
Radiation therapy

Electroconvulsive therapy
Dental and Podiatric surgery

Transport of patients
Member of the anesthesia team
should always be present
Hypoxemia and drop in BP is seen
commonly in transport
Especially after Spinal Anesthesia

Stretcher must have IV pole and O2

tank

Post-op Recovery Room

Post anesthesia care unit (PACU)
Post anesthesia recovery (PAR)
Recovery room (RR)

Pulse oximeter and EKG continuously

utilized
Pain management is continued

Post-op Recovery Room

Anesthesia Report must go with the
patient
Meds and medical history included
All meds given in the OR

Careful observation is needed

BP, HR, Ventilation and Temperature
Monitored every 5 minutes for the
first 15 minutes then every 15
minutes until discharged to SDS

Discharge Criteria
Oriented to assess physical condition
Airway reflex must be sufficient to prevent
aspiration
Ventilation, BP and HR are constant for
hour
Cessation of shivering
Monitor hour after last dose of opiod or
sedative
Monitor 15 minutes after ceasing 02
Ingestion of fluids/void

Aspiration Pneumonia

cimetidine
Ranitidine
Sodium Citrate
Omeprazole

CV Complications
Hypotension
ANS will divert flow to brain, heart and
kidneys
Monitor blood loss causing hypotension
May develop MI or cardiac dysrythmia

CV Complications
Hypotension
Monitor
Disorientation
Nausea
Angina
Urine output
HR

CV Complications
Hypotension
Treatment
Fluid bolus (250 ml of Lactated Ringers)
Vasopressor (5 15 mf IV of ephedrine)

CV Complication
Hypertension
Common causes in Recovery Room
Pain
Hypercarbia
Bladder distension

If healthy patient a moderate HTN is

normal and not harmful
30% increase in BP

CV Complications
Hypertension
Treatment
Hydralazine (5 20 mg IV)
Slow onset (15 minutes)

Propranolol (0.5 mg)

Does not increase intracranial pressure and
it improves cardiac ischemia

Dysrhythmias
PVC
Common post-op
Check for
Hypokalemia
Hypoxia
Hypercarbia

If MI is a concern treat with Lidocaine

(1.5 mg/kg IV)

Dysrhythmias
Atrial Fibrillation
Common post-op
Treat with Beta blockers
Verapamil (2.5 5.0 mg)
Digoxin (0.25mg)

Oliguria
Less than .5 ml/kg/hour of urine
Monitor for hypovolemia, ureter
ligation, renal vein compression
Avoid diuretics initially
Give fluid bolus
May need to give Urecholine- dilates
ureter so pt can void

Hypoxemia
Causes
Atelectasias
Airway obstruction
Pneumothorax
Pulmonary Embolism

Treat with 100% O2 first

Hypothermia
Common
Warm the patient
May need to give a vasodilator due
to reflex vasoconstriction
Monitor for malignant hyperthermia

Conclusion
Reasons for Admission
Infection- deep space abscess
Hemostasis- find the bleed (specifically after
tourniquet removal)
Environmental concerns- stairs, babysitting young
children who can fall on post-op foot, big dogs, etc.
Pain (unsolved with meds)- dont send pt home
with narcotics
Life & Death
Constitutional symptoms
Failed outpatient treatment

Dr. Woodard
1: Cardinal manifestations of anesthesia,
mallampati classifications asa classes
2: Psns vs sns receptors ne vs ach, stages of
anesthesia
3: CHF consequences, SBE, RA pts (cervical xray!)
4: SCIP define, preop meds, who does
what..analgesic vs sedation, nausea vomiting, ph
reducers
5: Patient criteria, post op complications, reasons
for admit
ALL : KNOW Malignant hyperthermia

Dr. Klein:
Positioning and complications of
different positions, what is needed for
stand in monitoring (one more than
Woodard), what pulse ox is for, Bp
monitoring, ekg monitoring reasons
General: Planes of anesthesia, inhaled
anesthetics, intubation : good vs bad
candidate, Propofol. Benzols and side
effects from benzols