Ambulatory anaesthesia
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Ambulatory anaesthesia. Dr. S. Parthasarathy MD., DA., DNB, MD ( Acu ), Dip. Diab.DCA, Dip. Software statistics PhD ( physio ) Mahatma Gandhi Medical college and research institute , puducherry , India . Can we go about like that??. Definition Structure Set up Cases

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Ambulatory anaesthesia

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Ambulatory anaesthesia

Dr. S. Parthasarathy

MD., DA., DNB, MD (Acu),

Dip. Diab.DCA, Dip. Software statistics

PhD (physio)

Mahatma Gandhi Medical college and research institute , puducherry , India


Can we go about like that??

  • Definition

  • Structure

  • Set up

  • Cases

  • Anaesth technique

  • PACU


Definition

  • ambulatory surgery

  • “An operation/procedure, excluding an office or outpatient operation/procedure, where the patient is discharged on the same working day”

  • Synonymous or different terms !!


Is there a distinction

  • distinction is to designate cases as outpatient when the patient is generally expected not to need any specialized care or specialized surveillance when the procedure is finished.

  • ambulatory surgery has grown from less than 10% to over 70% of all elective surgical procedures


SAMBA

  • Recognized respected subspecialty occurred with establishment of the Society for Ambulatory Anesthesia (SAMBA) in 1984.


the focus of ambulatory anesthesia is on the patient

  • 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


Structure

Fast track


Unbelievable list

  • 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


Unbelievable list

  • 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


Unbelievable list

  • Otolaryngology Adenoidectomy, laryngoscopy, mastoidectomy, myringotomy, polypectomy, rhinoplasty, tonsillectomy, tympanoplasty

  • Pain clinic Chemical sympathectomy, epidural injection, nerve blocks


Unbelievable list

  • 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


Unbelievable list

  • Orthopedic

  • Anterior cruciate repair, knee arthroscopy, shoulder reconstructions, bunionectomy, carpal tunnel release, closed reduction, hardware removal, manipulation under anesthesia and minimally invasive hip replacements

  • BUT !!


Thats the hitch !!

  • duration of surgery in the ambulatory setting was originally limited to procedures lasting less than 90 minutes

  • Previously ASA I and II but III also in some instances

  • Plan 1- 3 weeks prior


Ambulatory surgery ??

  • major postoperative surgical complications

  • major fluid shifts

  • procedures requiring prolonged immobilization and parenteralopioid analgesic therapy

  • ambulatory patient-controlled analgesic techniques (e.g., subcutaneous, intranasal, transcutaneous), is allowing more patients undergoing painful orthopedic procedures to be discharged home on the day of surgery.


Definite NO

  •    1.    Potentially life-threatening chronic illnesses (e.g., brittle diabetes, unstable angina, symptomatic asthma)

  •    2.    Morbid obesity complicated by symptomatic cardiorespiratory problems (e.g., angina, asthma)   

  • 3.    Multiple chronic centrally active drug therapies (MAOIs)  

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

  •   5.    No responsible adult at home to care for the patient on the evening after surgery

  • SONIA – pneumonic


Specific situations


Hypertension

  • newly discovered hypertension or very high values or unstable high values should be evaluated and optimized before being scheduled for ambulatory care.

  • Patients with arrhythmia, heart block, or a pacemaker, heart failure – better to avoid


Diabetes mellitus

  • Diabetic patients may be unsuitable for ambulatory care if they have some of the more serious complications of prolonged diabetes, namely cardiovascular disease, kidney failure, neuropathy,

  • and morbid obesity.


Drug abuse

  • Body builders – OK

  • But alcohol –

  • consider nutrition , LFT and type of surgery


Psychiatric patients, patients with cognitive dysfunction or disabilities

  • usually benefit from having as short and uneventful stay in the hospital environment as possible

  • More at home

  • But no to any acute illness


Pregnancy – second trimester preferable

  • surgery should be ambulatory or not will depend not on the pregnancy per se but on the patient’s general condition and co-morbidities.

  • Breastfeeding is fully compatible with any surgery or anesthetic- ambu – ok


Liver and kidney disease

  • Acute illness

  • Dialysis prior

  • LFT results

  • INR

  • Type of surgery


Thyroid

  • Airway

  • hyperthyroidism

  • Doubt for ambulatory surgery


Other systemic illness

  • Rheumatoid arthritis, Bechterew disease (ankylosingspondylitis), and other rheumatic conditions

  • These patients will usually be eligible for ambulatory care if they have no other major comorbidity.


Other systemic illness

  • Problems with previous anesthetics or with anesthesia in close family

  • Beware and analyse

  • Myaesthenia – avoid


Personnel

  • Anaesth + staff + nurse anaesth

  • Surgeon only local small cases


Monitors

  • noninvasive blood pressure monitoring, electrocardiography (ECG),

  • pulse oximetry,

  • capnography for all intubations,

  • gas monitoring (both in and out of patients) of oxygen and all inhalational gases,

  • alarms to alert to problems of gas delivery and a low oxygen content in the ventilation gas, and

  • temperature monitoring.

  • BIS


  • In case of emergencies there must be fast access to a suction device, a self-expanding ventilation bag with reservoir and extra oxygen supply, a defibrillator and emergency drugs

  • intubation kit including devices for difficult intubations.


Consent for ambulatory surgery

  • A general rule is that the patient should consent to being sent home

  • Journey time – not much decisive

  • In patients with drug, alcohol, or substance abuse or who have an unstable social situation- individual decisions


Preanaesthesia

  • Can have an OPD consultation with anaesth

  • Upto 3 months valid usually

  • Healthy patients can go for spot assessment

  • As a part of an inpatient hospital or alone


Preop

  • Fasting 6- 8 hours

  • URI 6 weeks gap

  • Premed – IV / oral midazolam ( not a must)

  • Opioids pain and intubation response –

  • Pethidine – antishivering

  • acetaminophen, 40 mg/kg rectally, and ketorolac, 0.5 mg/kg intravenously.

  • Antiemetic premed


Principles

  • two primary concerns for ambulatory anesthesia are

  • speed of wake-up

  • incidence of postoperative nausea and vomiting.

  • Wake up time and discharge fit time !!


Pharmacology


Problems

  • hypnotic, analgesic, and anti-nociceptive drugs have to be lipid soluble in order to penetrate the blood–brain barrier and reach their target cells in the central nervous system.

  • distributed extensively into all other cells and tissues- cant go out thro kidneys

  • brain and spinal cord have a large blood supply- hence more drugs – to be given


general anesthesia, regional anesthesia, and local anesthesia

  • In obstetrics, regional anesthesia, and local anesthesia are preferable

  • In others all are acceptable


Local

  • patients who received local anesthesia also spent less time in the OR,

  • had less postoperative pain, and the

  • least problems with urination.

  • Cost is less


Spinal

  • children aged 6 months to 14 years for procedures on the lower part of the body

  • 0.5% hyperbaric bupivacaine at a dose of 0.2 mg/kg.

  • Adults

  • pencil point, noncutting tips

  • ambulatory laparoscopic cholecystectomy

  • Drugs


Epidural and caudal

  • Longer

  • Difficult

  • Failure


Nerve blocks

  • Nerve blocks improve postoperative patient satisfaction—PONV and postoperative pain are less. Costs are also less

  • Paravertebral somatic nerve block can be used for breast surgery

  • Perineural catheters in the sciatic nerve through the poplitealfossa

  • Cont. femoral catheters

  • Interscalene catheters .


Post op pain relief


General Anesthesia

  • The popularity of propofol as an induction agent for outpatient surgery in large veins

  • Suxa or rocuronium advised for paralysis

  • An intubating dose of mivacurium (0.15-0.20 mg/kg) longer duration than suxa and better recovery


Principles

  • two primary concerns for ambulatory anesthesia are

  • speed of wake-up

  • incidence of postoperative nausea and vomiting.

  • Wake up time and discharge fit time !!


Agents

  • propofol, sevoflurane, and desflurane

    Because of its extremely low tissue solubility, desflurane is associated with the most rapid recovery of both cognitive and psychomotor function

  • Nitrous oxide : fast recovery , analgesia but PONV


Pharmacologic antagonists

  • antagonists frequently produce unwanted side effects (e.g., dizziness, headaches, nausea, vomiting).

  • duration of action of the antagonist is shorter than the agonist (e.g., naloxone, flumazenil), a “rebound” agonist effect may occur later in the recovery period.

  • Problem for ambulatory cases.


specifically selective serotonin antagonists and acupuncture

  • Nitrous

  • Agents

  • Opioids(fent- NSAIDs)


Airways

  • Supraglottic airway device especially LMA

  • Cough

  • Sorethroat

  • Anas requirements

  • But gastric sufflationand PONV


PACU

  • drowsiness,

  • nausea and vomiting,

  • pain.

  • All three are a function of intraoperative management, but nausea, vomiting, and pain also can be treated in the PACU.

  • Other problems anaesth and surgical


Discharge from the postanesthesiacare unit

  • Phase 1 - discontinuation of anesthetic agents until the recovery of the protective reflexes and motor function

  • phase 2 is the period during which the criteria for discharge from the ambulatory surgical unit (ASU) are obtained.

  • phase 3 lasts for several days and continues until the

    patient is back to their preoperative functional status and is able to resume their daily activities


modified Aldrete scoring system

  • Activity: Able to move voluntarily or on command

  • Respiration

  • Circulation

  • Consciousness

  • O2 saturation

  • Score of 10 – 8 or 9 is a must


Recovery and discharge

  • Scoring systems

  • White and Song scoring system for fast track

  • Experience explained

  • Adults


Is oral fluid intake necessary before discharge?

  • If forced,higher incidence of vomiting and a prolonged hospital stay in children

  • for adults, drinking did not influence the incidence of PONV or duration of hospital stay

  • Drinking oral fluids is not a requirement prior to discharge


Is voiding necessary before discharge?

  • voiding is not a requirement before discharge

  • Risks

  • USG


Is an escort needed followingambulatory surgery?

  • ASA recommendations – must

  • When can you drive following ambulatory surgery?

  • Recently, a prospective study involving ambulatory surgery demonstrated that patients have lower alertness levels and impaired driving skills preoperatively and 2 hours postoperatively. These parameters returned to normal at 24 hours.


Summary

  • Definition

  • Structure

  • Cases and NO

  • Premed and anaesthesia

    Recovery and PONV

    PACU

    Discharge controversies


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