Transcript Advances in Ambulatory Anaesthesia

Advances in Ambulatory
Anaesthesia
Dr.R.Muthukumaran M.D.,D.A.,
Thanjavur
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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
Benefits of Ambulatory Surgery
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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
Facility Design
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Hospital integrated: Ambulatory surgical patients are managed in
the same surgery facility as inpatients. Outpatients may have separate
preoperative preparation and recovery areas.
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Hospital-based: A separate ambulatory surgical facility within a
hospital handles only outpatients.
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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.
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Office-based: These operating and/or diagnostic suites are
managed in conjunction with physicians’ offices for the convenience
of patients and health care providers.
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
Procedures Suitable for Ambulatory Surgery
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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
Procedures Suitable for Ambulatory Surgery
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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
Minimally invasive outpatient procedures
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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)
Duration of Surgery
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lasting less than 90 minutes
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lasting 3 to 4 hours
Patient Characteristics
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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.
Susceptibility to Malignant Hyperthermia
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Admission solely on the basis of MH susceptibility
is no longer considered appropriate
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Non-triggering anesthetics ( local anesthesia)
Extremes of Age
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“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
Contraindications to Outpatient Surgery
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Potentially life-threatening chronic illnesses ( brittle
diabetes, unstable angina, symptomatic asthma)
Morbid obesity complicated by symptomatic cardiorespiratory 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
Preoperative assessment
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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
Preoperative assessment
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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.
Preoperative Preparation
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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
Preoperative Preparation
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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).
Pharmacologic Preparation
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Anxiolysis and Sedation
Barbiturates -residual sedation
 Benzodiazepines - diazepam 0.1 mg/kg PO midazolam
0.5mg/kg PO or 1mg IV
 α-Adrenergic Agonists - α2 agonist clonidine,
dexmeditomidine-anaesthetic & analgesic sparing effectdecrease emergence delirium of sevoflurane-reduce emesisfacilitate glycemic control- reduce cardio-vascular
complication
 β-Blockers -atenolol,esmolol –attenuate adrenergic
responses-prevent cardiovascular events
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Pharmacologic Preparation
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Pre-emptive (Preventative) Analgesia
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Opioid (Narcotic) Analgesics
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Anesthetic sparing-minimize hemodynamic response
PONV, urinary retention -delay discharge
Nonopioid Analgesics
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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
Pharmacologic Preparation
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Prevention of Nausea and Vomiting
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Pharmacologic Techniques
Butyrophenones –droperidol- dexamethasone
 Phenothiazines -prochlorperazine
 Antihistamines –dimenhydrinate, hydroxyzine
 Anticholinergics –atropine, glycopyrrolate, TDS
 Serotonin Antagonists –ondensetron,palanosetron
 Neurokinin-1 Antagonists- aprepitant
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Nonpharmacologic Techniques
Acupuncture,
 Acupressure and
 TENS at the P-6 acupoint - with the Relief Band
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Pharmacologic Preparation
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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
Pharmacologic Preparation
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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
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Basic Anesthetic Techniques
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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
General Anesthesia
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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
Regional Anesthesia
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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
CSE
Intravenous Regional Anesthesia
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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.
Peripheral Nerve Blocks
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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
Ultrasound guidance
Local Infiltration Techniques
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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
Monitored Anesthesia Care
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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.
Monitored Anesthesia Care
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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
Monitored Anesthesia Care
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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
Monitored Anesthesia Care
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sedative-hypnotic drugs have been administered
during MAC -barbiturates, benzodiazepines,
ketamine, and propofol
intermittent boluses- variable-rate infusion,
target-controlled infusion, and even patientcontrolled sedation.
Methohexital -intermittent boluses 10-20 mg or as a
variable-rate infusion 1-3 mg/min
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The α2-agonists clonidine and dexmedetomidine
Cerebral Monitoring
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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
Fast-Tracking
Multimodal Approaches to Minimize Side Effects
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PONV-
droperidol 0.625-1.25 mg IV, dexamethasone 4-8 mg IV,
ondansetron 4-8 mg IV, long-acting 5-HT3 antagonistpalonosetron 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, α2-agonists,
glucocorticoids, ketamine, and local anesthetics
Newer analgesic therapies
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continuous local anesthetic infusions,
nonparenteral opioid analgesic delivery systems
ambulatory patient-controlled analgesic
techniques ( subcutaneous, intranasal, transcutaneous)
Fast-Tracking
Multimodal Approaches to Minimize Side Effects
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low-dose ketamine 75-150 µg/kg
Non-pharmacologic factors
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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 adjuvantsmorphine 1-2 mg, ketorolac 15-30 mg, clonidine 0.1-0.2 mg,
ketamine 10-20 mg, triamcinolone 10-20 mg
TENS
Guidelines for ambulatory surgical facilities
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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
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
Discharge Criteria
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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
Discharge Criteria
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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
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
Post-anesthesia Discharge Scoring (PADS) System
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Vital Signs
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Ambulation
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2-Minimal
1-Moderate
0-Severe
Pain
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2 -Steady gait/no dizziness
1-With assistance
0-No ambulation/dizziness
Nausea and Vomiting
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2-Within 20% of the preoperative value
1 -20%-40% of the preoperative value
0-40% of the preoperative value
2-Minimal
1-Moderate
0-Severe
Surgical Bleeding
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2-Minimal
1-Moderate
0-Severe
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