Advances in Ambulatory Anaesthesia

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Advances in Ambulatory Anaesthesia

• Dr.R.Muthukumaran M.D.,D.A.,
• Thanjavur

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• simple procedures on healthy outpatients
• major procedures in outpatients with complex
  preexisting medical conditions.
• less than 10 to over 70 of all elective
  surgical procedures.
• development of ambulatory anesthesia as a
  respected subspecialty
• establishment of the Society for Ambulatory
  Anesthesia
• development of postgraduate subspecialty training
  programs

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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

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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.

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• The first freestanding outpatient surgical
  facility was built and managed by an
  anesthesiologist, Wallace Reed, to provide
  surgical care to patients whose operations were
  deemed too demanding for a surgeon's office yet
  did not require overnight hospitalization

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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

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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

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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)

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Duration of Surgery

• lasting less than 90 minutes
• lasting 3 to 4 hours

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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 gt40 kg/m2) is no longer
  considered an exclusionary criterion for day-case
  surgery.

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Susceptibility to Malignant Hyperthermia

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

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Extremes of Age

• elderly elderly patient (gt100 years) should not
  be denied ambulatory surgery solely on the basis
  of age
• ex-premature infants (gestational age lt 37 weeks)
  recovering from minor surgical procedures under
  general anesthesia have an increased risk for
  postoperative apnea, persists until the 60th
  postconceptual week
• no relationship between apnea and intraoperative
  use of opioid analgesics or muscle relaxants.-IV
  caffeine

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Contraindications to Outpatient Surgery

• Potentially life-threatening chronic illnesses (
  brittle diabetes, unstable angina, symptomatic
  asthma)
• Morbid obesity complicated by symptomatic
  cardio-respiratory 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

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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

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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.

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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

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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
  (lt24 hours).

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Pharmacologic Preparation

• Anxiolysis and Sedation
• Barbiturates -residual sedation
• Benzodiazepines - diazepam 0.1 mg/kg PO midazolam
  0.5mg/kg PO or 1mg IV
• a-Adrenergic Agonists - a2 agonist clonidine,
  dexmeditomidine-anaesthetic analgesic sparing
  effect-decrease emergence delirium of
  sevoflurane-reduce emesis-facilitate glycemic
  control- reduce cardio-vascular complication
• ß-Blockers -atenolol,esmolol attenuate
  adrenergic responses-prevent cardiovascular events

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Pharmacologic Preparation

• Pre-emptive (Preventative) Analgesia
• Opioid (Narcotic) Analgesics
• Anesthetic sparing-minimize hemodynamic response
• PONV, urinary retention -delay discharge
• Nonopioid Analgesics
• 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

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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

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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

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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

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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

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General Anesthesia

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

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Regional Anesthesia

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

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Intravenous Regional Anesthesia

• short superficial surgical procedures (lt60
  minutes)
• Ropivacaine vs. lignocaine
• Adjuvants ketorolac 15 mg, clonidine 1 µg/kg,
  dexmedetomidine 0.5 µg/kg, gabapentin 1.2 mg,
  dexamethasone 8 mg.

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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

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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

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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.

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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 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

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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

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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
  patient-controlled sedation.
• Methohexital -intermittent boluses 10-20 mg or as
  a variable-rate infusion 1-3 mg/min
• The a2-agonists clonidine and dexmedetomidine

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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

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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 antagonist- palonosetron 75 µg 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, a2-agonists,
  glucocorticoids, ketamine, and local anesthetics

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Newer analgesic therapies

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

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Fast-Tracking Multimodal Approaches to Minimize
Side Effects

• low-dose ketamine 75-150 µg/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.
• instillation of 30 mL of 0.5 bupivacaine into
  the joint space reduces postoperative opiate
  requirements and permits earlier ambulation and
  discharge. The addition of adjuvants- morphine
  1-2 mg, ketorolac 15-30 mg, clonidine 0.1-0.2 mg,
  ketamine 10-20 mg, triamcinolone 10-20 mg
• TENS

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Guidelines for ambulatory surgical facilities

• Employment of appropriately trained and
  credentialed anesthesia personnel
• Availability of properly maintained anesthesia
  equipment appropriate to the anesthesia care
  being provided
• As complete documentation of the care provided as
  that required at other surgical sites
• Use of standard monitoring equipment according to
  the ASA policies and guidelines
• Provision of a PACU or recovery area that is
  staffed by appropriately trained nursing
  personnel and provision of specific discharge
  instructions
• Availability of emergency equipment (e.g., airway
  equipment, cardiac resuscitation)
• Establishment of a written plan for emergency
  transport of patients to a site that provides
  more comprehensive care should an untoward event
  or complication occur that requires more
  extensive monitoring or overnight admission of
  the patient
• Maintenance and documentation of a quality
  assurance program
• Establishment of a continuing education program
  for physicians and other facility personnel
• Safety standards that cannot be jeopardized for
  patient convenience or cost savings

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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

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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

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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

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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
• Nausea and Vomiting
• 2-Minimal
• 1-Moderate
• 0-Severe
• Pain
• 2-Minimal
• 1-Moderate
• 0-Severe
• Surgical Bleeding 
• 2-Minimal
• 1-Moderate

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