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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

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
Can we go about like that??

  • Definition

  • Structure

  • Set up

  • Cases

  • Anaesth technique

  • PACU


Definition
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
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
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
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
Structure

Fast track


Unbelievable list
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 list1
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 list2
Unbelievable list

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

  • Pain clinic Chemical sympathectomy, epidural injection, nerve blocks


Unbelievable list3
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 list4
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
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
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
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



Hypertension
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
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
Drug abuse

  • Body builders – OK

  • But alcohol –

  • consider nutrition , LFT and type of surgery


Psychiatric patients patients with cognitive dysfunction or disabilities
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
Pregnancy – second trimester preferable disabilities

  • 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
Liver and kidney disease disabilities

  • Acute illness

  • Dialysis prior

  • LFT results

  • INR

  • Type of surgery


Thyroid
Thyroid disabilities

  • Airway

  • hyperthyroidism

  • Doubt for ambulatory surgery


Other systemic illness
Other systemic illness disabilities

  • 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 illness1
Other systemic illness disabilities

  • Problems with previous anesthetics or with anesthesia in close family

  • Beware and analyse

  • Myaesthenia – avoid


Personnel
Personnel disabilities

  • Anaesth + staff + nurse anaesth

  • Surgeon only local small cases


Monitors
Monitors disabilities

  • 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



Consent for ambulatory surgery
Consent for ambulatory surgery suction device, a self-expanding ventilation bag with reservoir and extra oxygen supply, a defibrillator and emergency drugs

  • 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
Preanaesthesia suction device, a self-expanding ventilation bag with reservoir and extra oxygen supply, a defibrillator and emergency drugs

  • 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
Preop suction device, a self-expanding ventilation bag with reservoir and extra oxygen supply, a defibrillator and emergency drugs

  • 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
Principles suction device, a self-expanding ventilation bag with reservoir and extra oxygen supply, a defibrillator and emergency drugs

  • 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
Pharmacology suction device, a self-expanding ventilation bag with reservoir and extra oxygen supply, a defibrillator and emergency drugs


Problems
Problems suction device, a self-expanding ventilation bag with reservoir and extra oxygen supply, a defibrillator and emergency drugs

  • 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
general anesthesia, regional anesthesia, and local anesthesia

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

  • In others all are acceptable


Local
Local anesthesia

  • 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
Spinal anesthesia

  • 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
Epidural and caudal anesthesia

  • Longer

  • Difficult

  • Failure


Nerve blocks
Nerve blocks anesthesia

  • 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 .



General anesthesia
General Anesthesia 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


Principles1
Principles anesthesia

  • 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
Agents anesthesia

  • 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
Pharmacologic antagonists anesthesia

  • 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.



Airways
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 postanesthesia care unit
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
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
Recovery and discharge

  • Scoring systems

  • White and Song scoring system for fast track

  • Experience explained

  • Adults


Is oral fluid intake necessary before discharge
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
Is voiding necessary before discharge?

  • voiding is not a requirement before discharge

  • Risks

  • USG


Is an escort needed following ambulatory surgery
Is an escort needed following ambulatory 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
Summary

  • Definition

  • Structure

  • Cases and NO

  • Premed and anaesthesia

    Recovery and PONV

    PACU

    Discharge controversies


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