Ambulatory anaesthesia

1. Presentor : Dr. Kumar
Moderator : Dr.Pradeep
Ambulatory and Fast tracking
Anaesthesia

2. Introduction
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
The availability of rapid, shorter-acting anesthetic, analgesic, and
muscle relaxant drugs has clearly facilitated the recovery process after
surgery, and the development of minimally invasive surgical techniques
allowed more extensive procedures to be performed on an ambulatory
basis, irrespective of the patient's preexisting medical conditions

4. 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

5. 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.

6. 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

7. 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

8. 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

9. 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)

10. Duration of Surgery
lasting less than 90 minutes
lasting 3 to 4 hours

11. 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.

12. 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
no relationship between apnea and intraoperative use of opioid
analgesics or muscle relaxants.-IV caffeine

13. 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

14. 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

17. 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.

18. 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

19. 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).

20. 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 -α α2 agonist clonidine,
dexmeditomidine-anaesthetic & analgesic sparing effect-
decrease emergence delirium of sevoflurane-reduce
emesis-facilitate glycemic control- reduce cardio-vascular
complication
 -Blockers -atenolol,esmolol –attenuate adrenergicβ
responses-prevent cardiovascular events

21. 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

22. 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

24. 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

25. 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

26. 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

27. 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

28. 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 (preservative)
CSE

29. Intravenous Regional Anesthesia
short superficial surgical procedures (<60 minutes)
Ropivacaine vs. lignocaine
Adjuvants – ketorolac 15 mg, clonidine 1 µg/kg,
dexmedetomidine 0.5 µg/kg, gabapentin 1.2 mg,
dexamethasone 8 mg.

30. 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(patient controlled
analgesia)
Ultrasound guidance

31. 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

32. 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.

33. 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

34. 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

35. 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 α2-agonists clonidine and dexmedetomidine

36. 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

37. FAST TRACKING
Bypassing the PACU has been termed “fast-tracking” after
ambulatory surgery.
In addition, fast-tracking can be accomplished directly from
the PACU (“PACU fast-tracking”) by creating a specialized
area within an existing PACU where recovery procedures
are organized along the lines of a step-down unit.
 This approach represents a key component of the “total
care” package for ambulatory surgery.[463]

39. 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, 2-agonists,α
glucocorticoids, ketamine, and local anesthetics

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

41. 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

42. 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

43.  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

44. 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

45. 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

46. 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

47. 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
 0-Severe

48. THANK YOU