AMBULATORY ANESTHESIA

The international Association for Ambulatory Surgery was formed in

1995

→Surgery performed on an outpatient basis

→Maybe hospital based or performed in an office or surgicenter

Ambulatory surgical procedures

PLACES

● Within the hospital

● Freestanding satellite facility affiliated with or independent from a hospital.

● Physician’s office

Maximum duration of surgery

4 HOURS

PROCEDURES

● Maximum duration of surgery (4hrs)

● Does not pose a significant safety risk

● Do not require an overnight stay

● Associated with post-operative care manageable at home ● Low rates of postoperative complications

● Blood transfusions requiring procedures are not contraindicated.

Age infants should be monitored .

12hrs post op.

Appropriate candidate for some ambulatory surgical procedures if their systemic diseases are medically stable

ASA Physical Status III or IV

A normal healthy patient

ASA I

A patient with mild systemic disease

ASA II

A patient with severe systemic disease

ASA III

A patient with severe systemic disease that is a constant threat to life

ASA IV

A morbund patient who is not expected to survive without the operation

ASA V

A declared brain-dea d patient whose organs are being remove for donor purpose

ASA VI

Mild disease only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnant, obesity (30

ASA II

Substantive functional limitations. one or more moderate to severe diseases. Examples include (but not limited to): poorly controlled DM/HTN, COPD, morbid obesity (BMI≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction or ejection fraction, ESDR undergoing regularly scheduled dialysis, premature infant PCA<60 weeks, history (>3 months) of MI, CVA, TIA, or CAD/stents.

ASA III

Examples include (but not limited to): recent (<3 months) MI

ASA IV

Examples include (but not limited to): ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology of multiple organ/system dysfunction

ASA V

→Higher incidence of obstructive sleep apnea (OSA)

Obese patients

Obese patients

→Can be done in the ambulatory center if done under local anesthesia or regional anesthesia

High risk of hypoxemia post operatively

OBSTRUCTIVE SLEEP APNEA

● Each outpatient facility should develop its own method of preoperative screening

1. Visit the facility

2. Phone call

3. Complete medical history, medications, medical problems, family history.

● Adult →Following viral URI’s, surgery should be delayed because airway flow obstruction persists up to

6 weeks

● Children→Survey showed that URI associated with an increased risk of perioperative respiratory adverse events only when

symptoms were present or had occurred within the 2 weeks before the procedure

● Independent risk factors for adverse respiratory events:

→Use of ETT

→Presence of copious secretions

→Hx of prematurity

→Nasal congestion

→Hx of reactive airway disease

→Hx of paternal smoking

→Surgery involving the airway

Clear fluids

2

Breast milk

4

Formula milk

6

Nonhuman milk

6

Light meal

6

Meals that include fried or fatty food or meat

8

● Medications that should be taken on the day of surgery:

● Medications that should be avoided on the day of surgery:

● Nonessential medications that can be continued on the day of surgery

drug most used to reduce anxiety and induce sedation

Midazolam

Dose of Midazolam

0.25 mg/kg - 0.5 mg/kg

- Can be administered preoperatively to sedate the patient, control HPN during tracheal intubation and decrease pain before surgery

● Opioids and NSAIDs

can be given post op shivering

Meperidine (also clonidine, tramadol, ketamine)

- Use most commonly for ex-premature infants undergoing hernia repair

SPINAL ANESTHESIA

General Anesthesia as back up for

SPINAL ANESTHESIA

only predictor of spinal anesthesia failure

Bloody tap on 1st attempt

Anesthesia Suitable for pelvic, lower abdominal, lower extremities etc.

SPINAL ANESTHESIA

Medication for Spinal anesthesia

Lidocaine and Bupivacaine

may cause transient neurologic symptoms

Lidocaine

: longer duration of action (usually 2-3 hours has a predictable effect)

Bupivacaine:

● Treatment of post-epidural headache

- bedrest - analgesia - oral hydration - IV caffeine - epidural blood patch

● Longer to perform

● Slower onset

● Advantageous when duration or surgery is unclear

● Decrease risk of post dural puncture headache

EPIDURAL AND CAUDAL ANESTHESIA

- form of epidural anesthesia in children having infraumbilical operation as a supplement to GA

- Difficult in obese children or those more than 10kg.

CAUDAL ANESTHESIA

Total elbow arthroplasty

● Infraclavicular block

Foot surgery

Sciatic nerve block:

Breast surgery

● Paravertebral Block

THRA

● Femoral Nerve Block

Shoulder surgery

● Interscalene Block

Hand and Forearm surgery

● Axillary Block:

● Levels of sedation

(Ramsay Sedation Scale)

Consciousness is minimally depressed

Light

(asleep patients that when touched is they can respond, or easily aroused)

● Moderate/ Conscious Sedation

Protective reflexes are partially blocked and response to physical stimulation or verbal command may not be appropriate

Deep

Maintenance drugs for general anesthesia

Propofol and Sevoflurane

T ½ of propofol

1-3 hours

Sweet smelling inhalational agent, can be given in pediatrics before IV access

Sevoflurane

Brief paralysis to facilitate tracheal intubation

Succinylcholine

Nondepolarizing drugs can also be used for neuromuscular blocking (Longer DOA: 45mins)

Rocuronium

Neuromuscular blocking Drugs

Succinylcholine and Rocuronium

● Higher Incidence for PONV

-After Nitrous oxide use

- Women

- Previous Hx of PONV/ Motion sickness

- Surgical procedures (Laparoscopy, Lithotripsy, Operations on EENT)

- Monozygotic twins

● Factors to Decrease Risk of PONV

● Reasons for delays of discharge

- Drowsiness

- Nausea and Vomiting

- Pain

- A Benzodiazepine receptor antagonist

Flumazenil

- Use to reverse the effects of sedation after endoscopy

Flumazenil

Flumazenil

- Reversal of opioids may also be necessary

Naloxone

● Post-surgical pain should be differentiated from the discomfort of

hypoxemia, hypercapnia, and full bladder.

● Post op pain must be treated effectively. Medications should be given in small intravenous doses, with short acting opioids like

fentanyl

Pain management

. PREPARATION FOR DISCHARGING THE PATIENT

• PACU

• Phase II Recovery

• Home

PHASE II RECOVERY

● Day surgery unit

● Patients remain until they are able to tolerate liquid, walk, and/or void

● Direct transfer when patients awakened in the OR

● Test higher level of function

- Ability to use one's hands

- Drive a car (Do not recommend to a patient sedated to drive within 24 hours

- Remain alert long enough to drive

● Before discharge

- Dressings should be checked

- Include responsible person for discharge instructions

- Inform patients the side effects of all drugs used

- Discuss where the patient can return in case of a problem