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OUTPATIENT SURGERY

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Title: OUTPATIENT SURGERY


1
OUTPATIENT SURGERY
  • Dr Abdollahi

2
Another Name
  • Ambulatory surgery
  • Day-case surgery
  • Same-day surgery
  • Come and go surgery

3
  • In the early 1900s, an american anesthesiologist,
    Ralph Waters, opened an outpatient anesthesia
    clinic in Sioux City, lowa.

4
  • This facility, which provided care for dental and
    minor surgery cases, is generally regarded as the
    prototype for the modern freestanding ambulatory
    (and office-based) surgery center.

5
  • Interestingly, there was little ,interest in
    ambulatory surgical care until the late
    1960s,when the first hospital-based ambulatory
    surgery units were developed.

6
  • Over the last 3 decades, outpatient surgery has
    grown at an exponential rate, progressing from
    the practice of performing simple procedures on
    healthy outpatients to encompassing a broad
    spectrum of patient care in freestanding
    ambulatory surgery centers. Formal
  • development of ambulatory anesthesia as a
    subspecialty occurred with establishment of the
    Society for Ambulatory Anesthesia (SAMBA)in 1984
    and the subsequent development of postgraduate
    subspecialty training programs.

7
  • By 1985, 7 million elective operations in the
    United States (over 30 of all elective surgical
    procedures) were performed on an ambulatory
    basis. Currently, more than 60of all elective
    surgery is performed in the outpatient surgical
    setting, and it is expected that this number will
    increase to more than 70 in the near future.

8
  • The growth in ambulatory surgery would have not
    been possible without the development of improved
    anesthetic and surgical techniques. The
    availability of rapid, shorter -acting
    anesthetic, analgesic, and muscle relaxant drugs
    has clearly facilitated the recovery process and
  • allowed more extensive procedures to be performed
    on an ambulatory basis, irrespective of
    preexisting medical
  • Conditions.

9
Overnight admission
  • An alternative to same- day surgical concept is
    a planned overnighte admission to the hospital
    after surgery.
  • This approach (AM admit,23 hour, short stay, come
    and stay ) is often classified as outpatient
    surgery and preserved many of its advantages.

10
  • Outpatient surgery allows a person to return home
    on the same day that a surgical procedure is
    performed.

11
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

12
FACILITY DESIGN AND SAFETY
13
Patient selection
  • Characteristic of the patient
  • type of operation
  • psychosocial aspect of the patient
  • Human and physical resource for pre post op
    care
  • Proximity to EMS
  • Resource of skill set of both anesthesiologist
    and surgeon

14
  • Surgical procedures suitable for ambulatory
    surgery should be accompanied by minimal
    postoperative physiologic disturbances and an
    uncomplicated recovery.
  • The primary predictors of prolonged stay or
    unanticipated admission after day-case surgery
    are related to the surgical procedure (e.g.,
    blood loss, pain, postoperative nausea and
    vomiting (PONV).

15
  • Operative procedures suitable for ambulatory
    surgery

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  • Patients undergoing procedures that are likely to
    be associated with postoperative surgical
    complications or major fluid shifts should be
    admitted to the hospital overnight. Although
    autologous blood transfusions are used for more
    extensive outpatient plastic surgery (e.g.,
    reduction mammoplasty, liposuction), lengthy
    rocedures
  • associated with excessive fluid shifts should be
    handled in an overnight (23-hour) recovery
    facility. Similarly, operative procedures
    requiring prolonged immobilization and
    parenteral opioid analgesic therapy are more
    ideally suited to a 23-hour stay. The
    availability of newer analgesic therapies (e.g.,
    continuous local anesthetic infusions) and
    ambulatory patient-controlled analgesia (e.g.,
    subcutaneous, intranasal, transcutaneous) may
    alter the latter recommendation in the future.

18
Duration of Surgery
  • The duration of surgery in the ambulatory setting
    was originally limited to procedures lasting less
    than 90 minutes because investigators have found
    that the operating and anesthetic time is a
    strong predictor of postoperative complications
    (e.g., pain, emesis)and delayed discharge, as
    well as unanticipated admission to the hospital
    after ambulatory surgery .

19
Patient Characteristics
  • Most patients seen in ambulatory surgical
    facilities are classified as ASA physical status
    I or II. However, because of improved anesthesia
    and surgical care, increasing numbers of
    medically stable ASA physical status III (and
    even some IV) patients are able to undergo
    operations
  • away from conventional medical centers.

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25
American Society of Anesthesiologists
(ASA)Classification of Physical Status
  •  A normal healthy patient
  • -no discernible disease animals
    entered for ovariohysterectomy, castration,
    declaw, cosmetic procedures
  •  A patient with mild systemic disease
  • -skin tumor, fracture without shock,
    cruciate repair, uncomplicated hernia,
    cryptorchidectomy, localized infection,
    compensated cardiac disease
  •  A patient with severe systemic disease
  • -fever, dehydration, anemia, cachexia,
    moderate hypovolemia
  •  A patient with severe systemic disease that is a
    constant threat to life
  • -uremia, toxemia, severe dehydration or
    hypovolemia, severe anemia, cardiac
    decompensation, emaciation, high fever
  • A moribund patient not expected to survive 24
    hrs. with or without surgery
  • -extreme shock or dehydration, terminal
    malignancy or infection, severe trauma

26
  • Age is usually not a factor in the selection of
    the patient for outpatient surgery.
  • Any infant with apnea in PACU or anemia
    regardless of age should be admitted to the
    hospital.

27
Contraindications in infant
  1. premature infant with Hct lt30 (apnea )
  2. history of RDS
  3. History of sudden death in family

28
Susceptibility to Malignant Hyperthermia
  • MH-susceptible patients can be successfully
    managed with non triggering anesthetics (e.g.,
    local anesthesia) in the outpatient setting .

29
Contraindications to Outpatient Surgery
  • 1. Serious, potentially life-threatening diseases
    that are not optimally managed (e.g., brittle
    diabetes, unstable angina, symptomatic asthma)

30
  • 2. Morbid obesity complicated by symptomatic
    cardiovascular
  • (e.g., angina) or respiratory (e.g., asthma)
    problems.

31
  • 3. Multiple chronic centrally active drug
    therapies (e.g., use of monoamine oxidase
    inhibitors such as pargyline and tranylcypromine)
    and active cocaine abuse because of the increased
    risk of intraoperative cardiovascular
    complications, including death.

32
  • 4.Ex-premature infants less than 60 weeks'
    postconceptual age requiring general endotracheal
    anesthesia

33
  • 5. Lack of a responsible adult at home to care
    for the patient on the evening after surgery.

34
PREOPERATIVE ASSESSMENT
35
Preoperative Preparation
  • Nonpharmacologic Preparationsia

36
Pharmacologic Preparation
37
opioid
  • Routine use of narcotic (opioid) analgesics for
    premedication is not recommended unless the
    patient is experiencing acute pain .

38
Prevention of Nausea and Vomiting
39
  • Butyrophenones
  • Phenothiazines
  • Gastrokinetic drugs (Metoclopramide and
    domperidone)
  • Anticholinergics
  • Dexamethasone, 4 to 8 mg intravenously,
  • Nonpharmacologic Techniques
  • Acupuncture and acupressure

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41
Prevention of Aspiration Pneumonitis
  • 1.H2 Receptor Antagonists and Proton Pump
    Inhibitors
  • 2.Antiacid
  • 3.Gastrokinetic Agents (Metoclopramide)
  • 4. NPO Guidelines

42
ANESTHETIC TECHNIQUES
  • Quality, safety, efficiency, and the cost of
    drugs and equipment are all important
    considerations in choosing
  • an anesthetic technique for outpatient surgery.

43
  • The ideal outpatient anesthetic should have a
    rapid and smooth onset of action, produce
    intraoperative amnesia and analgesia, provide
    good surgical conditions with a short recovery
    period, and have no adverse effects.

44
  • Outpatient surgery requires the same basic
    equipment as inpatient surgery for delivery of
    anesthetic drugs, monitoring, and resuscitation.
    Standard intraoperative monitoring equipment for
    outpatient operations should include an ECG,
    blood pressure cuff, pulse oximeter, and
    capnograph.
  • If nondepolarizing muscle relaxants are used, a
    neuromuscular monitor should also be available.
    Increasingly, cerebral monitors are also being
    used to improve titration of anesthetic drugs and
    facilitate faster recovery.

45
  • The choice of anesthetic technique depends on
    both surgical and patient factors. For many
    ambulatory procedures, general anesthesia remains
    the most popular technique
  • with both patients and surgeons.

46
  • Although central neuraxis blockade has
    traditionally been popular for peripheral
    extremity and lower abdominal procedures, its use
    in the ambulatory setting can delay discharge
    because of residual motor and sympathetic
    blockade.

47
  • Peripheral nerve blocks facilitate the recovery
    process by minimizing the need for postoperative
    opioid analgesics. Therefore, an increasing
    number of ambulatory cases are being performed
    with a combination of local anesthetic nerve
    blocks and intravenous sedation (so-called
    monitored anesthesia care MAC) .

48
  • Despite a higher incidence of side effects,
    general anesthesia remains
  • the most widely used anesthetic technique for
    managing ambulatory surgery.

49
General Anesthesia
  • warming devices
  • Tracheal intubation causes a high incidence of
    postoperative airway-related complaints,
    including sore throat, croup, and hoarseness

50
LMA
  • The laryngeal mask airway (LMA) was first
    introduced in 1983 as an alternative to tracheal
    intubation or a facemask for airway management.
    When compared with anesthesia with a mask and
    oral airway,
  • patients with an LMA had fewer desaturation
    episodes, fewer intraoperative airway
    manipulations, and fewer difficulties
  • in maintaining an airway .

51
  • The incidence of postoperative sore throat after
    ambulatory surgery was
  • 18 with an LMA versus 45 with a tracheal tube
    and 3 with a face mask.

52
  • The LMA frees the anesthesiologist's
  • hands for record keeping, monitoring, and drug
    administration. Hand fatigue from maintaining the
    airway with a mask is also eliminated .

53
  • Although there is no ideal anesthetic drug or
    technique for outpatients, a vast array of
    pharmacologically active drugs, when combined in
    a rational manner and carefully titrated, can
    produce the desired anesthetic conditions with an
    acceptable recovery profile and reasonable cost.

54
  • An altenative to the LMA is the cuffed
    oropharyngeal airway device. Even though this
    device is easy to insert after induction without
    muscle relaxants, its ability to maintain an
    obstruction-free airway is less adequate than
    that of other curently used airway devices.
  • Although the LMA device has been used in
    paralyzed patients undergoing laparoscopic
    surgery, most practitioners in North America
    still prefer tracheal intubation in these
    situations to minimize the risK of gastric
    distention and ensure adequate ventilation in the
    Trendelenbmg posinduction .

55
Anesthetic Drugs
  • Induction of general anesthesia is typically
    accomplished with a rapid-acting intravenous
    anesthetic. Propofol has virtually replaced the
    barbitmates for induction of anesthesia in the
    ambulatory
  • setting because of its favorable recovery profile

56
  • The most popular technique for maintenance of
    anesthesia is a combination of a volatile
    anesthetic and nitrous oxide. The extremely low
    solubility of nitrous oxide and the newer
    volatile anesthetics (sevoflurane
  • and desflurane) contributes to a more rapid onset
    and recovery from general anesthesia .

57
  • Although it has been suggested that the use of
    nitrous oxide is associated with PONY, controlled
    studies have questioned the clinical importance
    of nitrolls oxide in producing this side
    effect.When compared with a target-controlled
    infusion of propofol for maintenance of
    anesthesia, the use of
  • desflurane or sevoflurane produced similar
    anesthetic conditions with shorter emergence
    times and at a lower drug cost.

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Inhaled Anesthetics
  • Volatile anesthetics are most commonly used for
    maintenance of ambulatory anesthesia .
  • isoflurane was the most commonly used anesthetic
    for maintenance of ambulatory anesthesia before
    the introduction of the less soluble drugs
    sevoflurane and desflurane.

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61
Barbiturates
  • Thiopental (3 to 6 mg/kg) is the prototypical
    intravenous induction drug with a rapid onset and
    a relatively short duration of action as a result
    of redistribution of the drug . However,
    thiopental impairs fine motor skills for several
    hours after surgery and can produce a "hangover
    sensation.

62
  • Methohexital appears to be associated with
    shorter awakening times, but complete recovery of
    fine motor skills may still require 6 to 8 hours
    after an induction dose. when compared with
    thiopental, methohexital is associated with a
    higher incidence of pain on injection,
    involuntary muscle movement, and hiccoughing

63
  • Although propofol resulted in faster emergence
    from anesthesia and a lower incidence of PONV
    than methohexital, the barbiturate compared
    favorably with propofol when used for induction
    only in outpatient procedures lasting longer than
    90 minutes. Unfortunately, methohexital is no
    longer widely available.

64
Benzodiazepines
  • Although midazolam (0.2 to 0.4 mg/kg IV) has been
    used
  • for induction of anesthesia in outpatients, its
    onset of
  • action is slower and recovery is prolonged in
    comparison
  • to the barbiturate compounds and propofol. When
    combined with nitrous oxide and a potent opioid
    analgesic, lower doses of midazolam (0.1 to 0.15
    mg/kg) can be used to induce general anesthesia.
    If midazolam is used for induction and
    flumazenil, a specific benzodiazepine antagonist,
    is administered at the end of surgery, prompt
    recovery can be achieved after outpatient
    surgery.
  • When compared with propofol, recovery after
    flumazenil antagonism of midazolam anesthesia
    offered no clinically significant advantages.

65
Etomidate
  • Etomidate (0.2 to 0.3 mg/kg) has also been used
    for induction and maintenance (1 to 3 mg/min) of
    general anesthesia during short outpatient
    procedures. Recovery tends to be faster than
    after thiopental and compares favorably with
    methohexital. Disadvantages of etomidate include
    pain on injection, a high incidence of PONV,
    myoclonic movements, and transient suppression of
    adrenal steroidogenesis. Given its side effect
    profile, the use of etomidate should be
    restricted to clinical situations in which its
    hemodynamic stability offers a distinctive
    advantage over the other available induction
    drugs (e.g., elderly outpatients with clinically
    significant coronary artery or cerebrovascular
    disease).

66
ketamine
  • Ketamine is a unique sedative-analgesic that can
    be used
  • for both induction and maintenance of general
    anesthesia.
  • However, ketamine compares unfavorably with both
    the barbiturates and propofol for minor
    gynecologic procedures because of its prominent
    psychomimetic effects and higher incidence of
    PONV during the early postoperative period. Use
    of the more potent S()-isomer of ketamine may
    decrease some of the adverse effects associated
    with the racemic mixture in the ambulatory
    setting. Premedication with a benzodiazepine
    (e.g., midazolam, 0.05 mg/kg IV) decreases the
    incidence of ketamine-induced emergence
    reactions. Small doses of ketamine (10 to 20 mg
    IV) have
  • been used as an alternative to potent opioid
    analgesics
  • during induction of anesthesia with propofol.

67
propofol
  • Propofol is an intravenous anesthetic with an
    extremely high metabolic clearance rate Although
    propofol costs more than the barbiturate
    anesthetics do, the use of propofol may
    contribute to significant savings because of
    decreased recovery costs. When compared with
    methohexital,the use of propofol was associated
    with fewer perioperative side effects (e.g., less
    hiccoughs, nausea, and vomiting) and faster
    overall recovery times.the faster intermediate
    recovery with propofol-based anesthetics may also
    yield significant savings in nursing costs
    (e.g.,less overtime). For example, a I5-minute
    reduction in the phase I recovery room stay could
    save 1000 nursing hours in a 4,000-case per year
    ambulatory surgical .

68
  • Midazolam remains the most commonly used
    anxiolytic premedication for pediatric
    outpatients. After receiving O.5 mg/kg of
    midazolam orally, children can be easily
    separated from their parents within 30 minutes
    without prolonging the discharge time even after
    short surgical procedures.
  • ..

69
  • rectal methohexital is administered (20 to 30
    mg/kg) before volatile anesthesia, recovery times
    will be prolonged.

70
  • Rectal etomidate (6 mg/kg) or ketamine (5 to 10
    mg/kg) can roduce a rapid onset of hypnosis
    without cardiorespiratory epression in children
    undergoing outpatient procedures.Although
    ketamine (2 to 4 mg/kg intramuscularly) can be an
    extremely useful drug for induction of anesthesia
    in an uncooperativ e or mentally retarded child,
    home readiness is delayed when larger doses of
    ketamine (gt5mg/kg) are combined with volatile
    anesthetics.In addition, psychomimetic reactions
    have been reported in children after ketamine
    administration

71
Volatile anesthetics
  • Volatile anesthetics are associated with a higher
    incidence of vomiting in the early recovery
    period than propofol based anesthetic techniques .

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Opioid Analgesics
  • Opioid compounds are frequently administered in
    the immediate preinduction period to suppress
    autonomic responses to tracheal intubation and
    during the maintenance period to treat acute
    autonomic responses to painful (noxious) stimuli .

74
  • The use of small doses of potent opioids (e.g.,
    fentanyl, 1 to 2 µg/kg, alfentanil, 15 to 30
    µg/kg, sufentanil, 0.15 to 0.3µg/kg, or
    remifentanil, 0.5 to 1µg/kg) can effectively
    attenuate the cardiostimulatory response to
    laryngoscopy and intubation, as well as the skin
    incision.

75
  • Remifentanil is an ultrashort-acting opioid
    analgesic with potency similar to that of
    fentanyl. It is rapidly metabolized by
    nonspecific tissue esterases, a process that
    allows for rapid systemic elimination, with a
    half-life of 8 to 10 minutes.

76
  • Morphine, hydromorphone, oxymorphone, and
    meperidine have all been used in outpatient
    anesthesia
  • However, these opioid compounds are less popular
    than the more potent, rapid, and shorter-acting
    opioid analgesics (e.g., fentanyl, sufentanil,
    alfentanil, and remifentanil).

77
  • morphine was associated with increased nausea and
    vomiting in the
  • postdischarge period. Motion-induced emesis is a
    major concern when morphine and its more
    lipophobic congeners are used in the ambulatory
    setting.

78
Muscle Relaxants
  • Many superficial outpatient surgical procedures
    do not require the use of neuromuscular
    relaxants.
  • When remifentanil is used in combination with
    propofol for induction of anesthesia, tracheal
    intubation can be performed without any muscle
    relaxants .

79
  • Succinylcholine remains the most commonly used
    muscle relaxant to facilitate tracheal intubation
    in the
  • ambulatory setting because it has a rapid onset
    and its short duration of action obviates the
    need for reversal
  • drugs.

80
  • Use of the short- and intermediate-acting
    nondepolarizing muscle relaxants (e.g.,
    cisatracurium, mivacurium) allows reversal of
    neuromuscular blockade even after brief surgical
    procedures.

81
  • Cost-effective technique involves the use of
    succinylcholine for tracheal intubation followed
    by small (4 to 8 mg) bolus doses of mivacurium
    during the maintenance period. This relaxant
    technique minimizes the need for muscle relaxant
    reversal drugs after short laparoscopic
    procedures.

82
  • Mivacurium may be advantageous for use during the
    maintenance period because reversal is seldom
    required if the drug is properly titrated

83
Antagonist (Reversal) Drugs
  • antagonists may also produce unwanted side
    effects (e.g., dizziness, headaches, PONV) that
    should
  • be considered before routinely using these drugs.
    In addition, because their duration of action is
    often shorter than the agonist (e.g., naloxone,
    flumazenil), a "rebound of the agonist effect
    may occur.

84
Pediatric Considerations
  • In unruly, frightened, or mentally retarded
    children, preoperative sedation is required
    before taking the patient into the operating
    room. In general, sedative premedication is not
    offered to children younger than 12 months, but
    it is often used for toddlers or preschool-aged
    children.

85
  • Midazolam remains the most commonly used
    anxiolytic premedication for pediatric
    outpatients. After receiving O.5 mg/kg of
    midazolam orally, children can be easily
    separated from their parents within 30 minutes
    without prolonging the discharge time even after
    short surgical procedures.

86
REGIONAL ANESTHESIA
  • Regional anesthesia can offer many advantages for
    the ambulatory patient population .

87
Epidural and Spinal Techniques
  • Spinal anesthesia is the simplest and most
    reliable regional anesthetic technique. However,
    the incidence of side effects is surprisingly
    high when used in the ambulatory setting. The
    most troublesome complications of outpatient
    spinal anesthesia are residual effects of the
    block on motor, sensory, and sympathetic nervous
    system function, which can contribute to delayed
    ambulation, dizziness, urinary retention, and
    impaired balance.In addition, post-dural puncture
    headache and backache remain problems after
    spinal anesthesia.

88
  • Epidural anesthesia is technically more difficult
    to perform, it has a slower onset of action, the
    potential for intravascular or intrathecal
    injection exists, and it is associated with a
    greater chance of an incomplete
  • sensory block than spinal anesthesia .

89
Intravenous Regional Anesthesia
  • For short superficial surgical procedures 60
    minutes) limited to a single extremity, the
    intravenous regional (Bier) block technique with
    0.5 lidocaine is a simple and reliable technique.

90
  • The addition of adjuvant (e.g., ketorolac, 15 mg,
    clonidine, 1 µg/kg, dexmeditomidine, 0.5 /µgkg)
    will improve the quality of postoperative
    analgesia.

91
Peripheral Nerve Block
92
Monitored Anesthesia Care
  • The combination of local anesthesia with
    intravenous sedative and analgesic drugs is
    extremely popular in the ambulatory setting. It
    has been suggested that up to 50 of all
    outpatient procedures could be performed with a
    MAC technique and that the cost of perioperative
    care can be reduced by up to 80 in comparison to
    general anesthesia.

93
  • Many different sedative-hypnotic drugs have been
    used during MAC (including barbiturates,
    benzodiazepines ketamine, and propofol) with a
    wide variety of delivery systems (e.g.,
    intermittent boluses, variable-rate infusion,
    target-controlled infusion, patient-controlled
    sedation). The most commonly used sedation
    techniqueis a small dose of midazolam (1 to 2 mg)
    or propofol (0.5 to I mg/kg), or both, followed
    by a propofol infusion at 25 to 100 µg/kg/min.
    Methohexital has also been used successfully
    during MAC as intermittent
  • boluses (10 to 20 mg) or as a variable-rate
    infusion (1 to 3 mg/min).

94
Cerebral Monitoring
  • Monitoring patient vital signs remains the most
    common method for determining the "depth of
    anesthesia" during surgery.
  • Recent studies have suggested that the use of
    cerebral monitoring improves early recovery after
    general anesthesia in the ambulatory setting
    because of its ability to minimize both
    "overdosing" and "underdosing with both
    intravenous (e.g., propofol) and inhaled
    anesthetic (e.g., sevoflurane and desflurane)
    drugs during the maintenance period.

95
Optimal Anesthetic Techniques
  • The optimal anesthetic technique in the
    ambulatory setting would provide for excellent
    operating conditions, rapid "fast-track" recovery
    without postoperative side effects or
    complications, and a high degree of patient
    satisfaction.

96
Fast-Tracking Concepts
  • Bypassing the PACU has been termed
    "fast-tracking" after ambulatory surgery.
  • If careful titration of short-acting drugs
    permits safe transfer of patients directly from
    the operating room suite to a less labor
    intensive recovery area, some patients can be
    discharged home within 1 hour after surgery .

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Multimodal Approaches to minimizing side Effects
  1. Minimally invasive surgical approaches (e.g.,
    laparoscopic adrenalectomy and nephrectomy
    arthroscopic knee and shoulder reconstructions).

100
  • 2-For routine antiemetic prophylaxis, the most
    cost-effective combination consists of low dose
    droperidol (0.5 to 1 mg) and dexamethasone (4 to
    8 mg).

101
  • 3-The addition of low-dose ketamine (75 to 150
    µg/kg) to a multi modal analgesic regimen
    improved postoperative analgesia and functional
    outcome after painful orthopedic surgery
    procedures.
  • Acetazolamide (5 mg/kg IV) reduces
  • referred pain after laparoscopic surgery with CO2
    insufflation.

102
  • 4- One of the keys to facilitating the recovery
    process is the routine use of local anesthetics
    as part of a multimodal regimen.
  • After arthroscopic knee surgery, instillation of
    30 mL of O.5 bupivacaine into the joint space
    reduces postoperative opiate requirements and
    permits earlier ambulation and discharge.The
    addition of morphine (1 to 2 mg), ketorolac (15
    to 30 mg), clonidine (0.1 to 0.2 mg), and/or
    triamcinolone (10 to 20 mg) to the
    intra-articular local anesthetic solution can
    further reduce pain after arthroscopic
  • surgery.

103
DISCHARGE CRITERIA
  • Discharge after General Anesthesia
  • and Monitored Anesthesia Care

104
  • The three stages of recovery after ambulatory
    surgery are the early, intermediate, and late
    recovery periods . The early and intermediate
    recovery stages occur in the ambulatory surgical
    facility, whereas late recovery refers to the
    resumption of normal daily activities and occurs
    after discharge home

105
Early recovery
  • The time interval during which patients emerge
    from anesthesia, recover control of their
    protective reflexes, and resume early motor
    activity. During this phase of recovery, patients
    are cared for in the PACU, where their vital
    signs and oxygen saturation are carefully
    monitored and
  • supplemental oxygen, analgesics, or anti emetics
    can be readily administered.

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Intermediate recovery
  • During the intermediate recovery period, patients
    are usually cared for in a reclining chair and
    progressively begin to ambulate, drink fluids,
    void, and prepare for discharge. Most ambulatory
    surgical facilities have a separate area for the
    intermediate recovery of outpatients to a
    home-ready state

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late recovery
  • The late recovery period starts 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. The
    anesthetics, analgesics, and anti emetics can
    also have an effect on the patient's recovery
    during the postdischarge period. However, the
    surgical procedure itself has the highest impact
    on the patient's full functional recovery.

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  • Factors that predict a more prolonged stay in the
    day-surgery unit include female gender, advanced
    age, longer operations, large fluid or blood loss
    and opioid use, nondepolarizing muscle
    relaxants, postoperative pain and PONY, and
    spinal anesthesia.

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  • Guidelines for safe discharge from an ambulatory
    surgical facility include stable vital signs,
    return to baseline orientation, ambulation
    without dizziness, minimal pain and PONY, and
    minimal bleeding at the surgical site.

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post anesthetic dischargescoring (PADS) system
  • (1) vital signs, including blood pressure, heart
    rate, respiratory rate, and temperature
  • (2) ambulation and mental status
  • (3) pain and PONY
  • (4) surgical bleeding
  • (5) fluid intake/output
  • Patients who achieve a score of 9 or greater and
    have an adult escort are considered fit for
    discharge (or home ready).

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.Discharge after regional Anesthesia
  • With spinal or epidural anesthesia,
  • it is generally accepted that motor and sensory
    function returns before sympathetic nerve
    function.
  • Residual blockade of the sympathetic nerve supply
    to the bladder and urethra may cause urinary
    retention.

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  • Before ambulation, these patients should have
    normal perianal (S4-5) sensation, the ability to
    plantar-reflex the foot, and proprioception of
    the big toe. Thus, discharge criteria after
    spinal and epidural anesthesia should include the
    return of normal sensation, muscle strength, and
    proprioception, as well as the return of
    sympathetic nervous function.

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Controversies Related to Discharge Criteria
  • well-hydrated outpatients can be safely
    discharged home without demonstrating an ability
    to tolerate oral fluids after surgery .

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  • The requirement to void before discharge has also
    been
  • challenged.The inability to void and urinary
    retention may be caused by pain (which inhibits
    normal bladder detrusor function) or by opioid
    analgesics, spinal or epidural anesthesia,
    administration of drugs with anticholinergic
  • effects, and prolonged blockade of the autonomic
    innervation
  • to the bladder. Patients may be discharged
    earlier if voiding is not a discharge
    requirement. Delaying discharge for voiding after
    spinal or epidural anesthesia with short-acting
    local anesthetics is unnecessary in low-risk
    patients (e.g., age lt70 years no hernia, rectal,
    or urologic surgery no history of voiding
    problems).

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  • 1. The majority of operations today are performed
    on an outpatient basis.
  • 2. Although restrictions on the types of cases
    appropriate for ambulatory surgery have been
    reduced, hospital admissions after outpatient
    procedures should not be common.
  • 3. Preoperative administration of the combination
    of midazolam and fentanyl can make patients
    sleepy up to 8 hours later. Preoperative sedation
    is not required for every patient.
  • 4. Postoperative pain is less after regional
    anesthesia, although performing a block requires
    more time than does induction of general
    anesthesia and has a higher incidence of failure .

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  • 5. Even when thiopental is used only for
    induction, psychomotor impairment can be evident
    up to 5 hours after administration compared to
    only 1 hour after propofol.
  • 6. Although some drugs have faster recovery time
    than others, actual discharge from an ambulatory
    center may depend more on administrative issues,
    such as obtaining the written discharge order
    from the surgeon or anesthesiologist.
  • 7. Nausea probably is the most important factor
    contributing to a delay in discharge and an
    increase in admission after ambulatory surgery.
    Combination therapy probably is the most
    effective way to control postoperative nausea and
    vomiting.
  • 8. Pain may be associated with nausea, and
    treatment of the pain frequently decreases nausea.

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KEY POINTS
  • 1. The continued growth in ambulatory surgery is
    related to expansion in minimally invasive
    surgical techniques and office-based procedures.
  • 2. Preexisting medical conditions are rarely, if
    ever an exclusionary criterion for ambulatory
    surgery.
  • 3. Routine laboratory testing is not recommended
    before ambulatory surgery.
  • 4. The choice of anesthetic technique has a
    significant effect on postoperative side effects
    and discharge time. The use of local anesthesia
    with sedation, so-called monitored anesthesia
    care, is associated with the fewest side effects
    and the shortest time to discharge home.
  • 5. The use of propofol for induction or
    maintenance of anesthesia (or both) is associated
    with a reduced incidence of postoperative nausea
    and vomiting

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  • 6. The use of desflurane or nitrous oxide (or
    both) in conjunction with antiemetic prophylaxis
    will facilitate the "fast-track" recovery
    process.
  • 7. The use of potent opioid analgesics (e.g.,
    fentanyl, sufentanil) in combination with local
    anesthetics will decrease the time to discharge
    home after spinal anesthesia.
  • 8. Multimodal ("balanced") analgesic and
    antiemetic regimens will allow most outpatients
    to be fasttracked after ambulatory surgery under
    general
  • anesthesia.
  • 9. Fast-tracking after ambulatory surgery is
    accomplished by taking the patient directly from
    the operating room to the day-surgery step-down
    unit
  • ("bypassing the PACU")or simply discharging the
    patient home from the PACU("PACUbypassing").
  • 1O. Outcomes after ambulatory (and office-based)
    surgery are no different than after inpatient
    (hospital-based) surgery procedures. Recent data
  • suggest that for elderly patients, the surgical
    outcome may be improved.

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