anesthesia for day care surgery

ANESTHESIA FOR DAY CARE SURGERY

Presented : Dr. Nitin Bhalla,P.G. Student,

Department of Anesthesiology and Critical care,

Dr. S.N. Medical College,Jodhpur.

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Introduction to Ambulatory Surgery

Ambulatory anesthesia is administered with the dual goals of rapidly and safely establishing satisfactory condition for the performance of therapeutic or diagnostic procedures while ensuring rapid, predictable recovery with minimal post operative sequelae.

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Benefits of “Day Care” or “Ambulatory” Surgery

Patient preference, esp. 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 Shorter surgical waiting lists Lower overall procedural costs Less preoperative testing and postoperative medications

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Patient selection criteria for ambulatory anaesthesia

ASA physical status ASA status I, II and medically stable ASA status III The risk of complication can be reduced if pre-existing medical

conditions are under good control for at least 3 months before operation.

Age Premature infants < 46 weeks of postconceptional age are at

increased risk and are not an ideal candidate for Ambulatory surgery. Anemia is a sinificant independent risk factor , particularly for infants

less than 43 weeks of post conceptional age. Elderly outpatients may experience a higher incidence of

perioperative CVS event and slow recovery of fine motor skills and cognitive functions.

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Patient selection criteria for ambulatory anaesthesia

Social Factors 1.The patient must be prepared to have the procedure performed as a day case,

2. live close to the hospital, and

3. Should have a responsible, able, adult carer at home with them for 24 hours

postoperatively Surgical procedure - Ideally, surgical procedures for the ambulatory

patient should be completed in a reasonable amount of time, should not require blood transfusion and should not create excessive fluid shifts.

Duration of Surgery – in the ambulatory setting should be less than 90 minutes.

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Medical contraindications for day case anesthesia

Morbid obesity• Body mass index > 35 kg/m2 or weight > 125 kg

Cardiovascular disease• Poorly controlled angina, arrhythmia or cardiac failure• Hypertension > 180/100 mm Hg• Significant valvular or congenital heart disease• Myocardial infarction or stroke within 6 months

Respiratory disease/airway• Poorly controlled asthma or chronic obstructive pulmonary disease (patients taking oralcorticosteroids, with poor exercise tolerance or with a peak expiratory flow rate < 200litres/minute are unlikely to be suitable) 1

• Severe restrictive lung disease (e.g. kyphoscoliosis)• Previous failed intubation• Significant obstructive sleep apnoea

Continued...

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Medical contraindications for day case anesthesia (contd.)

Metabolic/endocrine/haematological• Poorly controlled diabetes or insulin dependent 1

• Active liver disease• Anaemia (haemoglobin < 10 g/dl) 1

• Haemophilia/anticoagulation 1

• Cholinesterase deficiency 1

• Hypo- or hyperkalaemia (acceptable range 3–6 mmol/litre)Renal disease

• Patients requiring renal support 1

Neuromuscular disease• Myasthenia gravis• Significant multiple sclerosis• Malignant hyperpyrexia susceptibility• Poorly controlled epilepsy• Parkinson’s disease interfering with daily activity• Significant motor neuron disease

Acute substance abuse

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Operative procedures suitable for Ambulatory surgery

Specialty Type of Procedure

Dental Extraction , restoration, facial fractures

Dermatology Excision of skin lesions

General Biopsy, endoscopy, excision of masses, hemorrhoidectomy, herniorrhaphy, laproscopic procedures, varicose vein surgery

Gynecology Cone biopsy, dilatation and curettage, hysteroscopy, laparoscopy, polypectomy, tubal ligation, vaginal hysterectomy

ophthalmology Cataract extraction, chalazion excision, NLD probing, Strabismus repair, tonometry

Orthopedic AC repair, arthroscopy, bunionectomy, carpal tunnel release, closed reduction, hardware removal, manipulation under anesthesia

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

Pain clinic Chemical sympathectomy, epidural injection, nerve blocks

Plastic surgery BCC excision, cleft lip repair, liposuction, mammaplasty, otoplasty, scar revision, septorhinoplasty, skin grafting

Urology Bladder surgery, circumcision, cystoscopy, lithotripsy, orchiectomy, prostate biopsy, vasovasostomy

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Pre – Operative evaluation

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Recommended Laboratory tests for ambulatory surgery

Age Range Men Women

< 40 yrs None Pregnancy test

40-49 ECG Hematocrit , pregnancy test

50-64 ECG Hb / Hematocrit, ECG

65-74 Hb/ Hematocritt, ECG, Bl. Urea nitrogen, glucose

Hb/ Hematocritt, ECG, Bl. Urea nitrogen, glucose

>75 Hb/ Hematocritt, ECG, Bl. Urea nitrogen, glucose, X ray chest

Hb/ Hematocritt, ECG, Bl. Urea nitrogen, glucose, chest radiograph

Pre –operative evaluation includes history , examination and Laboratory testing

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Pre – Operative Preparation

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Aims of Pre – Operative Preparation

Aims – Reducing the risk inherited in Ambulatory

Surgery. Improving patient outcome. Making the surgical experience more pleasant to

the patient. Minimizing patient anxiety. Reduce potential post operative problems.

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Non Pharmacological Methods

Non – Pharmacological techniques should be aimed to allay anxiety and fear of the patient regarding the operative procedure. Patient should also be instructed (written and verbal) regarding the arrival time and place, fasting instructions and information concerning the post operative course, limitation in driving skills, and the need for a responsible adult to care for the patient during post operative period.

Benefits of Non Pharmacological methods – Economical Lacks undesirable side effects. High patient acceptance and motivation.

Non-Pharmacological methods – Patient Interview. Instructional preoperative video tapes. Music before surgery Self hypnotic relaxation techniques. Play oriented pre-operative teaching, Books, pamphlets, and video programs – specifically

in pediatric patients.

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Pharmacological methods

Anxiolysis and Sedatives

Benzodiazepines – Midazolam - drug of choice. (I.M., I.V., PO) Oral Temazepam and alprazolam

2 adrenergic agonists – Clonidine - residual post operative sedation is

concerned factor. Dexmedetomidine - Shorter duration of action and

highly selective 2 agonist.

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Pharmacological methods (contd..)

Analgesics – Opioid Analgesics –

Relive anxiety, Decreases anesthetic doses, minimize hemodynamic response, provide post operative pain relief.

Shorter acting – Fentanyl, alfentanil, Remifentanil, Sufentanil

NSAID’s – As mutiimodal analgesic technique, in combination, it facilitates early

recovery and reduces discharge time. For maximal benefit in ambulatory surgery, NSAID’s s/b administered

on “fixed” dosage shedule. More selective COX – 2 inhibitors s/b used. Oral – Rofecoxib, Celecoxib, Valdecoxib Parentral - Parecoxib

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Prevention of Nausea and Vomiting

As a mutimodal regimen , combination of anti-emitic drugs are

used to prevent PONV.

Droperidol – Low dose ( < 10mcg/kg) Metoclopramide – 20 mg iv / 0.2 mg/kg iv Dimenhydrinate and Hydoxyzine – 0.5 mg/kg. Ondansetron, granisetron, dolasetron, tropisetron Neurokinin – 1 antagonists Dexamethasone – 4 to 8 mg iv Acupuncture and acupressure.

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Prevention of Aspiration Pneumonitis H2 receptor antagonists –

Ranitidine – 150 mg p.o. ; 50 mg iv Pantoprazole – 40 mg iv

Antacids – Sodium Citrate 15-30 ml po. Prokinetic - Metoclopramide – 10-20 mg iv NPO

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Anesthesia techniques

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Anesthesia Techniques

Various techniques for Ambulatory anesthesia –

General Anesthesia

Regional Anesthesia

Monitored Anesthesia Care

Local Anesthesia

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Qualities of an ideal day care anaesthetic agent

• Fast predictable onset• Fast predictable elimination• Easily titratable depth of anaesthesia• No active metabolites• No accumulation• Stable in solution in water/volatile liquid at room temperature• No pain on injection/non-irritant on inhalation• Good side-effect profile• No PONV

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General Anesthesia

Induction of General Anesthesia –

Drug Dose (mg/Kg) Onset Recovery Side effects

Thiopental 3-6 Rapid Intermed. Drowsiness

Methohexital 1.5-3 Rapid Rapid Pain, excitatory activities

Etomidate 0.15-0.30 Rapid Intermed. Pain, emesis, myoclonus

Ketamine 0.75-1.5 Intermed. Intermed. CVS manif.,Psychomm.

Midazolam 0.1-0.2 Slow Slow Drowsiness, amnesia

Propofol 1.5-2.5 Rapid Rapid CVS depress., pain on inj.

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General Anesthesia (contd...)

Opioid Analgesics –

Fentanyl – 1-2 mcg/kg Alfentanil – 15-30 mcg/kg Sufentanil – 0.15-0.3 mcg/kg Remifentanil – 0.5-1 mcg/kg

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Sufentanil with N2O has lower incidence of nausea and P.O. pain as compared with fentanyl with N2O.

Emergence and recovery of psychomotor functions are faster with alfentanil as compared to Fentanyl. Also Afentanil is associated with lower incidence of PONV as compared to Fentanyl or Sufentanil.

Remifentnil is an ultra-short acting opioid with a half life of 8-10 minutes and a context sensitive half life of 4 minutes regardless of duration of infusion.

In elderly patients, TIVA with remifentanil and propofol is associated with more rapid recovery than a standard Fentanyl-Isoflurane technique.

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Inhaled Volatile anesthetic agents – Most commonly used for the maintance of anesthesia. Fast patient recovery and earlier discharge. Volatile anesthetic agents that can be used for ambulatory

anestheisa are – Sevoflurane, Desflurane and Isoflurane. Sevoflurane – induction of anesthesia in adults as well as in

pediatric patients. Desflurane – Emergence faster than other inhalation agents;

Rapid recovery of cognitive and psychomotor function; Better postural control than after propofol.

Associated with higher incidence of vomiting in early p.o. period Use of N2O as an adjuvant is beneficial.

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Drug Concentration (%) Onset Recovery Side effects

Halothane 0.5-1.5 Slow Slow Sedation, arrhythmias

Enflurane 0.75-1.5 Intermed. Intermed. Shivering

Isoflurane 0.5-1 Intermed. Intermed. Coughing

Desflurane 3-6 Very rapid Very rapid Coughing, tachycardia

Sevoflurane

1-2 Rapid Rapid Flammable

N2O 50-70 Very rapid Very rapid Nausea, Vomiting

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Regional Anesthesia

Modes of Regional Anesthesia –

Epidural and spinal techniques

Intravenous regional anesthesia

Peripheral Nerve Blocks

Local Infiltration techniques

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Regional Anesthesia

Advantages to patients :(a) Improved quality of recovery i. Less pain (mainly with CPNB) ii. Less PONV iii. Less unplanned hospital admission(b) Able to observe the procedure(c) Communication with surgeon during the procedure,(d) Option to receive no or light sedation.(e) Earlier mobilization.

Advantages to surgeon and Hospital :(a) Fast tracking of recovery,(b) Less requirement of post op. surgery staff,(c) Less requirement of drugs, so chance of adverse reaction is less,(d) Economical.

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Regional Anesthesia (contd..)

Disadvantages of RA in ambulatory surgery:

(a) Takes time and new separate setup to be organized,(b) Patients active co-operation is needed(c) Risk of complications : Nerve damage, TNS after Spinal

anaesthesia.(d) Variable failure rate (up to 10% with PNB)(e) Urinary retention with Spinal Anaesthesia.

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Spinal Anesthesia – Although simple and most reliable reg. anesthetic tech., is associated

with higher incidence of side effects. For Ambulatory Anesthesia , short acting local anesthetics (Lidocaine and

procaine) is preferred over the bupivacaine and tetracaine. Recommendations – Isobaric lidocaine, or combination of small dose of

hypobaric lidocaine (1% ; 20-25mg) combined with fentanyl (10-25mcg) or sufentanil.

For ambulatory surgeries lasting for > 2 hours, Intrathecal bupivacaine can be used.

Associated with – delayed ambulation, dizziness, urinary retention, and impaired balance.

Epidural Anesthesia - is technically more difficult to perform, slower onset of action, potential for intravascular / intrathecal injection, greater chances of incomplete sensory block.

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Procedure Technique Advantage Disadvantage

Hernia Repair

Field Block Good post operative pain relief

Supplementation

Spinal SpeedLittle supplementation

PDPH; urinary retention; delayed mobilization

Cataract extraction Peribulbar block Reduces confusion and discharge time

Ocular complications

Knee surgery

3-in-1 block Good analgesia Failed blocks

Spinal Speed ; little supplementation

PDPH; urinary retention; delayed mobilization

Foot surgeryPopliteal block, ankle blocks

Good analgesia Failed blocks

Hand surgery Bier’s block, brachial Analgesia Failed plexus blocks

Peripheral Nerve Blocks

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R.A. v/s G.A.

Comparison of regional and general anaesthesia

Technique Advantage Disadvantage

General Anesthesia FastNo Failures

PONVConfusion

Regional Anesthesia Prolonged analgesiaReduced PONVReduced confusion

Prolonged motor blockPDPHSlow onsetHigh Failure rate

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Monitored Anesthesia Care

MAC is the term used when an anesthesiologist monitors a patient receiving local anesthesia or administers supplemental drugs to patient undergoing diagnostic or therapeutic procedures.

ASA defines MAC – instances in which an anesthesiologist has been requested to provide specific anesthesia services to a particular patient receiving local anesthesia or, in some cases, no anesthesia al all.

Goal of MAC – providing analgesia, sedation, and anxiolysis and ensuring rapid recovery without side effects.

Vigilant monitoring is required as patient may progress from ‘Light’ level of sedation to ‘ deep’ sedation or unconciousness.

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Monitored Anesthesia Care (contd..)

Small dose of midazolam (1-2mg) or propofol (0.5-1mg/kg) or both, followed by a propofol infusion at 25-100mcg/kg/min.

Methohexital – 10-20mg bolus ; or variable rate infusion (1-3mg/min.)

Alfentanil (0.3-0.4mcg/kg/min) + propofol (25-75 mcg/kg/min.) infusion – “Avramov and White”.

Remifentanil infusion (0.05-0.15 mcg/kg/min). Ketorolac – sole or as an adjuvant to propofol. Low dose ketamine (0.25-0.5 mg/kg) with midazolam or propofol. Subanesthetic conc. Of inhaled anesthetics – (N2O -30% to 50%;

Sevoflurane 0.3% to 0.6%) 2 agonists – clonidine or Dexmedetomidine

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Concept of “Fast – Tracking”

Bypassing the PACU has been termed “Fast-Tracking” after ambulatory

surgery.

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Criteria used to determine fast-track eligibility after ambulatory anesthesia

Level of Conciousness – Awake and oriented 2 Arousable with minimal stimulation 1 Responsive only to tactile stimulation 0

Physical activity – Able to move all extremities on command 2 Some weakness in movement of extremities 1 Unable to voluntarily move the extremities 0

Hemodynamics – BP < 15% of the baseline MAP 2 BP between 15-30% of the baseline MAP 1 BP > 30% below the baseline MAP 0

Respiration – Able to breathe deeply 2 Tachypnea with good cough 1 Dyspneic with weak cough 0 contd…

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Criteria used to determine fast-track eligibility after ambulatory anesthesia (contd..)

O2 saturation status – Maintain > 90% on room air 2 Requires supplemental O2 (nasal prongs) 1 Saturatio < 90% with supplemental O2 0

Post operative pain assessment – None or mild discomfort 2 Moderte to severe pain req. IV analgesics 1 Persistent severe pain 0

Postoperative emetic symptoms – None or mild nausea with no active vomiting 2 Transient vomiting or retching 1 Persistent moderate to severe nausea and vomiting 0

Total Score – 14.

A Score of over 12 with no individual score less than 1 is required for fast- tracking.

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Assessment of Recovery Discharge Criteria

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Assessment of Recovery

Recovery includes return of normal physiological and psychomotor functions with a minimal level of morbidity associated with anaesthesia and surgery.

Recovery is a continuous process, the beginning of which overlaps with the end of the surgical procedure. Patients are not fully recovered until they have returned to their preoperative physiological and psychomotor state. The process may last for days, but it can be divided into distinct phases.

Stages of Recovery

Stage of Recovery Clinical definition 1. Early recovery : Awakening and Recovery of vital reflexes 2. Intermediate recovery : Intermediate clinical recovery, home

readiness 3. Late recovery : Full recovery, psychological recovery

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Phases / Stages of Recovery

Phase I / Early recovery – It is the time interval during which patients emerge from anesthesia, recover

control of protective reflexes, and resumes early motor activity. During this phase of recovery, patients are cared for in the PACU.

The Steward and Modified Aldrete score is commonly used to assess the fitness of patient to be transferred to the Phase II recovery area.

Phase II / Intermediate recovery – During this period , patients are usally cared for in a reclining chair and

progressively begin to ambulate, drink fluids, void, and prepare for discharge.

For second-stage recovery the Excitement Score or the Post-anaesthesia Discharge Scoring System (PADS) is used

Phase III / late recovery – This period begins when the patient is discharged home and continues until

functional recovery is achieved and the patient is able to resume normal activities of daily living.

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Steward Score

ConsciousnessAwake 2Responding to stimuli 1Not responding 0

AirwayCoughing on command or crying 2

Maintaining a good airway 1Airway needs maintenance 0

MovementMoving limbs purposefully 2Non-purposeful movement 1Not moving 0

* Six points are required for discharge.

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Modified Aldrete Scoring System

Activity: able to move, voluntarily or on commandFour extremities 2Two extremities 1No extremities 0

RespirationAble to breathe deeply and cough freely 2Dyspnoea, shallow or limited breathing 1Apnoea 0

CirculationBlood pressure within 20 mm Hg of preoperative level 2Blood pressure within 20–50 mm Hg of preoperative level 1Blood pressure ± 50 mm Hg of preoperative level 0

ConsciousnessFully awake 2Arousable on calling 1Unresponsive 0

Oxygen saturationSaturation > 92% 2Needs oxygen to maintain saturation > 90% 1Saturation < 90% with oxygen 0

* Nine or more points are required for recovery to be confirmed.

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Post-anaesthesia Discharge Scoring System for assessing home readiness

Vital signsVital signs must be stable and consistent with age and preoperative baseline

Blood pressure and pulse within 20% of baseline 2Blood pressure and pulse within 20–40% of baseline 1Blood pressure and pulse within 40% of baseline 0

Activity levelPatient must be able to ambulate at preoperative level

Steady gait, no dizziness, or meets preoperative level 2Requires assistance 1Unable to ambulate 0

Nausea and vomitingMinimal: successfully treated with oral medication 2Moderate: successfully treated with intramuscular medication 1Severe: continues after repeated treatment 0

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Post-anaesthesia Discharge Scoring System for assessing home readiness (contd.) Pain The patient should have minimal or no pain before discharge The level of pain that the patient has should be acceptable to the patient Pain should be controlled by oral analgesia The location, type and intensity of pain should be consistent with the anticipated

postoperative discomfort

Acceptable 2Unacceptable 1

Surgical bleedingPostoperative bleeding should be consistent with the expected blood loss for the procedure

Minimal: does not require dressing change 2Moderate: up to two dressing changes required 1Severe: more than three dressing changes required 0

* Nine points are required for discharge.

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Guidelines for safe discharge after day surgery

Vital signs must have been stable for at least 1 hour

The patient must be able to:Orientate themselves in person, place and timeKeep oral fluids downVoid urineDressWalk without assistance

The patient must not haveMore than minimal nausea and vomitingExcessive painBleeding

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Discharge criteria after Regional anesthesia

Besides the recovery criteria for general anesthesia, patients with regional anesthesia must fulfill additional criteria. These are –

Normal perianal sensation (S4-S5 )

Able to plantar flex the foot

Proprioception of the big toe.

Normal Blood pressure on standing and sitting.

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Causes of prolonged recovery following regional and general anaesthesia

• Pain• Nausea and vomiting• Haemorrhage• Cardiovascular or pulmonary dysfunction• Wound drains• Needing observation• Lack of escort or inadequate home conditions

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Post operative instructions

Both written and verbal instructions should be given regarding the post operative period before discharging the patient -

In general, for 24 hours after anesthesia:1.Do not drink alcohol or use nonprescription medications. 2.Do not drive a car or operate dangerous machinery. 3.Do not make important decisions.

The patient should be provided with a contact number to contact in case of any emergency.

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Application of Ambulatory anesthesia in specific

population

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Pediatric patients

Sedative premedication is generally not offered in children younger than 12 months.

Oral or rectal premedicant remains the choice in pediatric patients.

Midazolam is the most commonly used anxiolytic premedicant for pediatric patients. ( dose – 0.5 mg/kg po)

Ketamine , provides hyponsis without cardiorespiratory depression, and can be given per rectally or i.m.

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Geriatric Patients

Perioperative functional status can be difficult to quantitate because many elderly patients have reduced preoperative function related to de-conditioning, age – associated disease or cognitive impairment.

Geriatric patients tend to have decreased beta-adrenergic responsiveness and they experience an increased incidence of conduction abnormalities, bradyarrhythmias and hypertension.

Hypovolemia or overperfusion are both poorly tolerated.

The elderly have a two-third reduction in anaesthetic requirement because of fundamental neurophysiologic changes in the brain.

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Cardiovascular Disease patients

Patients with well-controlled cardiovascular disease should not be denied the opportunity to have their surgery in the ambulatory setting.

However, patients with poorly controlled angina, congestive cardiac failure, symptomatic valvular disease, uncontrolled arrhythmias or recent myocardial infarction or stroke (within 6 months) are unsuitable for elective surgery.

Hypertension is associated with an increased risk of developing perioperative cardiac events and should be treated before surgery. A reasonable upper limit for blood pressure is 180/100 mm Hg.

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Diabetic patient

Diabetes is a predictor of adverse intraoperative and postoperative events, but patients with good diabetic control and a good understanding of their disease should be allowed day surgery.

Patients with Type 2 diabetes are, in general, more suitable for day surgery than those with Type 1 diabetes.

A complication of unique concern for anaesthesiologist is the diabetic “stiff joint syndrome”.

Glycosylation of collagen decreases mobility of the cervical spine and TMJ and may increase the likelihood of difficult laryngoscopy and intubation. Stiffness of the 4th and 5th interphalangeal joints (prayer sign) assessed using palm prints is a sensitive predictor of difficult intubation.

It is recommended that patients receive insulin long with a continuous infusion of dextrose on arrival to the ambulatory unit.

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Morbid Obesity

Obesity is often associated with cardiac disease, diminished respiratory reserve and gastro-oesophageal reflux.

Body mass index greater than 35 kg/m2 is associated with perioperative anaesthetic and surgical problems, and is often used as a cut-off point for patient suitability.

Desaturation and bronchospasm are frequently noted complications.

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Patient with Asthma or COPD

Asthma, chronic obstructive pulmonary disease and smoking all predict adverse perioperative events, but patients with well-controlled disease are likely to be suitable for day surgery.

A regional anaesthetic technique can be considered for the more seriously affected.

Patients with poorly controlled disease, marked exercise limitation or a recent exacerbation of their condition should have their surgery postponed. Smokers should be encouraged to stop smoking.

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Obstructive Sleep Apnoea

Out-patient surgery for OSA patients remains controversial even in developed countries.

OSA patients are more likely to be difficult to intubate ; Several factors, including obesity, retrognathia and increased neck circumference contribute to the increased difficulty with intubation.

The severity of OSA is determined by the apnoea-hypopnoea index which is the number of apnoeas or hypopnoeas per hour of sleep. (mild 5 – 15, moderate 15 – 30, severe > 30)

Recovery room complications are also more frequent and may include hypertension, dysarrhythmias, desaturation, airway obstruction or reintubation.

well-treated OSA patients having low risk procedure performed under local anaesthesia or regional anaesthesia with little or no sedation and minimal need for narcotic-based analgesia can be discharged after surgery.

Pain should be managed with non-narcotic analgesics and opioid drugs should be avoided.

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GUIDELINES FOR AMBULATORY ANESTHESIA AND SURGERY

Committee of Origin: Ambulatory Surgical Care

(Approved by the ASA House of Delegates on October 15, 2003, and last amended on

October 22, 2008)

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I. ASA Standards, Guidelines and Policies should be adhered to in all settings except where they are not applicable to outpatient care.

II. A licensed physician should be in attendance in the facility, or in the case of overnight care, immediately available by telephone, at all times during patient treatment and recovery and until the patients are medically discharged.

III. The facility must be established, constructed, equipped and operated in accordance with applicable local, state and federal laws and regulations. At a minimum, all settings should have a reliable source of oxygen, suction, resuscitation equipment and emergency drugs. Specific reference is made to the ASA “Statement on Nonoperating Room Anesthetizing Locations.”

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IV. Staff should be adequate to meet patient and facility needs for all procedures performed in the setting, and should consist of: A. Professional Staff

1. Physicians and other practitioners who hold a valid license or certificate are duly qualified.

2. Nurses who are duly licensed and qualified. B. Administrative Staff C. Housekeeping and Maintenance Staff

V. Physicians providing medical care in the facility should assume responsibility for credentials review, delineation of privileges, quality assurance and peer review.

VI. Qualified personnel and equipment should be on hand to manage emergencies. There should be established policies and procedures to respond to emergencies and unanticipated patient transfer to an acute care facility.

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VII. Minimal patient care should include: A. Preoperative instructions and preparation. B. An appropriate pre-anesthesia evaluation and examination by an anesthesiologist, prior

to anesthesia and surgery. In the event that nonphysician personnel are utilized in the process, the anesthesiologist must verify the information and repeat and record essential key elements of the evaluation.

C. Preoperative studies and consultations as medically indicated D. An anesthesia plan developed by an anesthesiologist, discussed with and accepted by the

patient and documented. E. Administration of anesthesia by anesthesiologists, other qualified physicians or

nonphysician anesthesia personnel medically directed by an anesthesiologist. Non-anesthesiologist physicians who are administering or supervising the administration of the continuum of anesthesia must be qualified by education, training, licensure, and appropriately credentialed by the facility.

F. Discharge of the patient is a physician responsibility G. Patients who receive other than unsupplemented local anesthesia must be discharged

with a responsible adult. H. Written postoperative and follow-up care instructions I. Accurate, confidential and current medical records

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Thanks

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anesthesia for day care surgery

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