OUTPATIENT SURGERY Dr Abdollahi
Another Name • Ambulatory surgery • Day-case surgery • Same-day surgery • Come and go surgery
In the early 1900s, an american anesthesiologist, Ralph Waters, opened an outpatient anesthesia clinic in Sioux City, lowa.
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.
Interestingly, there was little ,interest in ambulatory surgical care until the late 1960s,when the first hospital-based ambulatory surgery units were developed.
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.
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 60%of 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.
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.
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.
Outpatient surgery allows a person to return home on the same day that a surgical procedure is performed.
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
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
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).
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.
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 .
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.
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
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.
Contraindications in infant • premature infant with Hct <30% (apnea ) • history of RDS • History of sudden death in family
Susceptibility to Malignant Hyperthermia MH-susceptible patients can be successfully managed with non triggering anesthetics (e.g., local anesthesia) in the outpatient setting .
Contraindications to Outpatient Surgery 1. Serious, potentially life-threatening diseases that are not optimally managed (e.g., brittle diabetes, unstable angina, symptomatic asthma)
2. Morbid obesity complicated by symptomatic cardiovascular (e.g., angina) or respiratory (e.g., asthma) problems.
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.
4.Ex-premature infants less than 60 weeks' postconceptual age requiring general endotracheal anesthesia
5. Lack of a responsible adult at home to care for the patient on the evening after surgery.
Preoperative Preparation Nonpharmacologic Preparationsia
opioid Routine use of narcotic (opioid) analgesics for premedication is not recommended unless the patient is experiencing acute pain .
Butyrophenones • Phenothiazines • Gastrokinetic drugs (Metoclopramide and domperidone) • Anticholinergics • Dexamethasone, 4 to 8 mg intravenously, • Nonpharmacologic Techniques • Acupuncture and acupressure
Prevention of Aspiration Pneumonitis 1.H2 Receptor Antagonists and Proton Pump Inhibitors 2.Antiacid 3.Gastrokinetic Agents (Metoclopramide) 4. NPO Guidelines
ANESTHETIC TECHNIQUES • Quality, safety, efficiency, and the cost of drugs and equipment are all important considerations in choosing an anesthetic technique for outpatient surgery.
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.
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.
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.
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.
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]) .
Despite a higher incidence of side effects, general anesthesia remains the most widely used anesthetic technique for managing ambulatory surgery.
General Anesthesia • warming devices • Tracheal intubation causes a high incidence of postoperative airway-related complaints, including sore throat, croup, and hoarseness
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 .