OUTPATIENT SURGERY

2. OUTPATIENT SURGERY Dr Masood Entezari Asl

3. OUTPATIENT SURGERY • outpatient (ambulatory, day-case, same-day, come-and-go) surgery and anesthesia continue to evolve in scope and complexity throughout the world. • Multimodal regimens for the management of postoperative pain, nausea, and vomiting promote more timely discharge, a better quality of recovery, and greater patient satisfaction.

4. OUTPATIENT SURGERY • The elements of care that provide for safe and uncomplicated anesthesia in the outpatient venue are no less important when the patient is to be discharged after an overnight hospital stay. • Sites for outpatient surgery include main operating room complex or separate operating rooms within a hospital, a separate facility physically attached to a hospital or on hospital grounds, or a hospital-independent facility (freestanding "surgicenter.")

5. OUTPATIENT SURGERY • Such procedures commonly involve children and include : • radiation therapy • interventional radiologic procedures • neuroradiologic interventions • compute tomography(CT)/magnetic resonance imaging(MRI) • endoscopy • examination under anesthesia • auditory evoked potentials • electroretinography • bone marrow biopsy • intrathecal drug therapy

6. ADVANTAGES OF OUTPATIENT SURGERY • Decreased medical costs • Increased availability of beds for patients who require hospitalization • Protection of immunocompromised patients from hospital-acquired infections • Avoidance of disruption of the family unit by hospitalization.

7. Cost savings may extend beyond actual medical expenses in as much as patients can often return to daily activity or work sooner. • An alternative to the same-day surgical concept is a planned overnight admission to the hospital after surgery.

8. OFFICE-BASED ANESTHESIA • Patient preference, convenience, and privacy, along with theoretically reduced expenses, are the public's push behind this trend. • Surgeons enjoy convenience and control over a lower overhead. • reduce their costs. • Today, virtually every medical and surgical discipline has its office-based procedures. • The escalating scope and complexity of office-based procedures make provision of monitored anesthesia care (MAC), regional anesthesia, or general anesthesia an increasingly common requirement.

9. Patient Safety Considerations • The publicdeserves and expects a single safety and quality standard of anesthetic and surgical care regardless of venue • When outpatient surgery is performed in a freestanding facility or the physician's office, a transfer and admission agreement with a nearby affiliated hospital must be in place should unexpected hospitalization be required in the immediate perioperative period. • The need to deliver a safe anesthetic with minimal undesirable side effects and rapid recovery is critically important for office-based surgery. Short-acting, fast emergence (SAFE) anesthetics such as propofol, remifentanil,desflurane, and sevoflurane facilitate timely achievement of discharge criteria. • Regional anesthesia with longer-acting local anesthetics can provide excellent analgesia during surgery and effective postoperative pain relief for complex surgical procedures.

10. FACILITIES • operating rooms, anesthetic equipment, and recovery facilities used for outpatient surgery not differ in quality from those used for inpatient surgery. • Policies and procedures should be consistent • staffshould possess equivalent skillsand be equally competent. • staff must be capable of permitting patients to remain for several hours after surgery if needed. • Having a medical director, often an anesthesiologist, who is responsible for the medical care delivered in the facility. • Administrative responsibility may be the medical director's or be under the purview of an individualwith administrative expertise.

11. PATIENT SELECTION • Selection of individuals for outpatient surgery was determined by : • 1- the characteristics of the patient • 2- the type of operation • other elements : - the psychosocial aspects of the patient - human and physical resources for preoperative and postoperative care - proximity to emergency care - resources of the facility - the skill set of both the surgeon and the anesthesiologist

12. Characteristics of the Patient • Many patients are in good general health • Having systemic diseases (non-insulin dependent diabetes mellitus, essential hypertension, seizure disorder, asthma) that are controlled • As outpatient surgery continues to expand in scope, more patients will have severe conditions • The development and application of less invasive surgical techniques and better anesthetic regimens have promoted the performance of more complex procedures in those more infirm.

13. Characteristics of the Patient • The venue the night after surgery will have proximity to emergency care • Patient or caretaker competence and proximity to emergency care may permit discharge

14. PEDIATRIC PATIENTS • Age is not a factor in the selection of patients • Many operations and diagnostic/therapeutic procedures in children are amenable to being performed on an outpatient basis

15. Postoperative Apnea • The age at which premature or full-term infants can safely undergo surgery and return home remains controversial • the subsequent incidence of apnea after inguinal herniorrhaphy was not less than 5% until post conceptual age was 48 weeks and gestational age was 35 weeks. • Any infant with apnea in the PACU or anemia, regardless of age, should be admitted to the hospital

16. ELDERLY PATIENTS • More important than advanced age is the medical control of diseases often associated with aging, as well as provision for social and physical support of the elderly patient both before and after surgery and anesthesia.

17. TYPES OF PROCEDURES • Procedural factors may predict prolonged PACU stay or unplanned admission to the hospital • Such factors include intraoperative blood loss and duration of the procedure. • Patient or caregiver (parent/guardian) sophistication and competence may facilitate discharge in one case and prevent it in another. • Postoperative complications that might require intensive physician or nursing management should be very rare. • Pain should be Manageable • Postoperative nausea and vomiting (PONV) should be minimal to absent. • Operations that require major intervention into the cranium and thorax remain unacceptable for outpatient surgery • Infected patients and emergency surgery are "disruptive“ and not usually welcome in an outpatient facility.

18. PREOPERATIVE PREPARATION ANDINSTRUCTIONS TO THE PATIENT • Coexisting medical conditions must be evaluated to determine whether the patient's health is acceptable, in need of further evaluation, or in need of intervention. • Preoperative teaching • Psychosocial issues can be even more important than medical issues • Examples : - third-party authorization for the procedure - transportation to and from the facility - local lodgings before and after surgery - access to a telephone - the ability to understand and followinstructions - the availability of translation services - proximity to emergency care - the competence of the patient's supportive network

19. Timing of Preoperative Evaluation • Sick patients or those with psychosocial issues are best identified early in the process (daysbefore) • Some systems rely on the surgeon to identify such patients • Others ask that at least the patient's history be made available beforehand so that the anesthesiologist can make a determination.

20. Historical Information • Historical information is often obtained through an oral, written, or electronic questionnaire • The questionnaire can be self-administeredor administered by trained staff, a registered nurse, a nurse practitioner, a nurse anesthetist or an anesthesiologist • Security of confidential information is one of the major concerns. • Medical conditions may require active intervention and management or just awareness. • Examples commonly include poorly controlled systemic hypertension, diabetes, anticoagulation, and chronic pain

21. Medications • Most medications should be continued • Adjustment for Insulin, oral hyperglycemic agents, diuretics, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and some psychiatric medications • Taking an oral drug with a sip of water • Patients who require food along with their medication present an issue that must be dealt with on an individual basis. • Preoperative interventions now common to inpatient care: - perioperative βblockade for ischemia - medications or compression devices for thrombosis - aggressive glucose control

22. Orientation to the Facility • Providing information through a tour, video, or web-based material. • If parents are allowed to be present for induction of anesthesia, they should be educated so that they have realistic expectations of the experience.

23. Laboratory Data Required Preoperatively • depend on : the patient's age, medical history, physical examination, current drug therapy. • Routine laboratory tests in the absence of positive findings on the history or physical examination are not usually warranted.

24. Patient Instructions • Instructions should be provided in writingor at least by telephone in the relevant language • It is best to contact the patient or caretaker • Arriving 1 to 2 hours before the expected time of surgery • Patient with a higher cancellation rate (children and the mentally challenged) may also be asked to arrive earlier.

26. FASTING • Clear fluids (water, black coffee , clear tea, pulp-free juice, carbonated beverage) in reasonable volumes up to 2 hours before induction of anesthesia. • Breast milk up to 4 hours before induction • Infant formula up to 6 hours • light meal (dry toast, milk) up to 6 hours before induction • Consideration for conditions (gastroparesis) that slow the transport of food through the gastrointestinal tract • In practice, misunderstanding or failure to follow fasting instructions is a very common reason for cancellation or postponement of surgery

27. ARRIVAL ON THE DAY OF SURGEYR • Compliance with preoperative instructions is verified particularly with respect to the ingestion of solid food and clear liquids • Preoperative database including the patient's health history and physical examination, indicated laboratory or study results, and surgical consent must be rechecked for completeness

28. Check-in Procedure • State requirements for timeliness of the history and physical examination vary : - within 7 days of the procedure. - At the time of surgery - within 24 hours of surgery • A check-in procedure confirms : - the identification of the patient - the nature of the procedure - the surgical site • Patients change into a gown if indicated, NPO times are confirmed, vital signs are obtained, and if indicated, an intravenous catheter is inserted.

29. ROLE OF THE ANESTHESIOLOGIST • reviewing the patient's medical record, laboratory data, and surgical consent and verifying the site of surgery • Vital signs are noted and current medications and medication allergies reviewed • pediatric patients must be thoroughly evaluated for the recent onset of an upper respiratory tract infection

30. PEDIATRIC PATIENTS AND RHINORRHEA • Benign rhinorrhea is usually an allergic rhinitis that does not contraindicate elective surgery • An ill appearance and a body temperature higher than 38°C are suggestive of an infectious rather than a noninfectious process

31. Preoperative Medication • preoperative medication for ameliorating anxiety and addressing preoperative discomfort • Additional medication acutely to treat systemic hypertension, institute β-blockade , treat bronchoconstriction, prevent infection (prophylactic antibiotics), control blood glucose concentrations, and provide corticosteroid coverage. • Drugs administered for preoperative medication should neither delay recovery from anesthesia nor produce excessive amnesia. • Fentanyl (1.0 чg/kg IV) and midazolam (0.04 mg/kg IV) administered before induction of anesthesia tend to decrease anesthetic requirements and airway irritability and do not delay recovery.

32. PEDIATRIC PATIENTS • The need for pharmacologic premedication may be less if the parents are calm and can participate in the induction of general anesthesia or physical transfer of the child to the nurse or anesthesiologist • Preoperative administration of midazolam (0.5 to 1.0 mg/kg orally or rectally) is effective in promoting separation from the parents within 20 to 30 minutes and is not associated with delayed recovery

33. MENTALLY CHALLENGED PATIENT • Uncooperative, mentally challenged adults pose unique issues because they cannot be physically manipulated as easily as children • Some will cooperate and accept insertion of an intravenous catheter • Others may cooperate with inhalation induction of anesthesia • Regimens include midazolam, up to 20 mg orally, ketamine, 2 to 3 mg/kg intramuscularly, or a combination of midazolam (0.3 mg/kg) and ketamine (2 mg/kg) intramuscularly

34. GOALS • Preoperative medication intended to decrease preoperative anxiety in adults is most often provided by the administration of small doses of midazolam (1 to 2 mg IV) • Sedation can be produced by the oral administration of a benzodiazepine such as diazepam • Unmedicated patients may walk to the operating room, whereas others may be transported by gurney or wheelchair.

35. Prophylaxis against Postoperative Nausea and Vomiting • A prophylactic antiemetic (serotonin antagonists, corticosteroid) may be useful for patients who : (1) have a history of PONV (2) are subject to motion sickness (3) are undergoing operationsassociatedwitha high incidence of PONV. • The routine use of prophylactic antiemetics remains controversial because a large percentage of patients do not experience nausea and vomiting • As with inpatients, outpatients considered to be at risk for pulmonary aspiration may receive preoperative pharmacologic therapy intended to speed gastric emptying, increase gastric fluid pH, or decrease gastric fluid volume. Any antacid administered orally should be clear, not particulate.

36. Use of Anticholinergics • an antisialagogue effect may be useful before procedures involving the oropharynx, where excessive secretions could interfere with the production of topical anesthesia.

37. TECHNIQUES OF ANESTHESIA • All techniques of anesthesia (general anesthesia, regional anesthesia, local anesthesia with or without sedation, and MAC) and most drugs available to inpatients are also appropriate for outpatients. • Prompt and nearly complete recovery with minimal side effects (residual sedation, PONV; orthostatic hypotension, pain) is ideal • Expense may be a factor in the choice of anesthetics • The cost of sedation is usually less than the cost of a general anesthetic. • The incidence of PONV tends to be less after local anesthesia and MAC than after general anesthesia • Awakening is usually more rapid after local anesthesia and MAC than after general anesthesia • The safety of modern ambulatory anesthesia is impressive, and the complications that occur in these patients are generally easily managed and self-limited

38. General Anesthesia • General anesthesia is frequently selected for outpatient surgery. • Its onset is fast and it can be controlled easily • Administration of so-called SAFE drugs for general anesthesia • Propofol has become the induction drug of choice for patients undergoing outpatient surgery despite the availability of alternative drugs (thiopental, etomidate). • Psychomotor recovery is more rapid after induction of anesthesia with propofol • have less nausea and vomiting • patients may experience euphoria on emergence from propofol anesthesia, especially when combined with the ultrashort-acting opioid remifentanil • Etomidate is associated with rapid awakening, but the increased incidence of myoclonic movements and PONV detracts from its use for outpatients.

39. INDUCTION OF ANESTHESIA IN PEDIATRIC PATIENTS • Facilitating cooperation for inhalation induction of anesthesia by : - Introduction to the facemask - choice of "flavored medicine“ - parental presence - involvement of the child in a game or story - premedication • With skill, a small-gauge intravenous catheter can be placed with minimal discomfort • When inhalation induction of anesthesia is planned, the most frequently selected drug is Sevoflurane • Sevoflurane does not cause airway irritation • Poor solubility in blood permits more rapid achievement of an anesthetizing concentration than is possible with halothane • Postoperative delirium in children may result from the rapid offset of drugs such as sevoflurane.

40. AIRWAY ADJUVANTS • Facemasks and oral airways may be used during anesthesia for brief and superficial surgical procedures • The laryngeal mask airway (LMA) and other supraglottic airway devices have completely changedairway management for such patients • In comparison with tracheal intubation, use of an LMA does not require neuromuscular blocking drugs nor their antagonism • An LMA tends to be less irritating, and placement is associated with a smaller hemodynamic response and a smaller rise in intraocular pressure • The original LMA Classic does not protect the airway from aspiration, and the use of positive-pressure ventilation may be questionable • The LMA ProSeal attempts to address both issues.

41. TRACHEAL INTUBATION • Some patients and procedures require tracheal intubation • A disadvantage of succinylcholine in outpatients is the occasional occurrence of myalgia. • Spontaneous recovery from the effects of mivacurium is prompt • Atracurium, cisatracurium, vecuronium, and rocuronium are somewhat longer-acting alternatives • Some believe that any nondepolarizing neuromuscular blockade should be antagonized • Othersfeel comfortable if the blockade has fully resolved spontaneously as reflected by neuromuscular blockade monitoring or clinical criteria.

42. MAINTENANCE OF ANESTHESIA • Maintenance of anesthesia is often achieved with the combination of nitrous oxide and a volatile anesthetic (desflurane or sevoflurane) • Nitrous oxide may be avoided based on the concern that this gas promotes PONV • An alternative to volatile anesthetics for maintenance of anesthesia is the continuous intravenous infusion of propofol, usually with an adjunct such as fentanyl, remifentanil, or ketamine. • Total intravenous anesthesia (TIVA) techniques avoid all inhaled anesthetics and may include a neuromuscular blocking drug • Inhaled and intravenous anesthetics are not mutually exclusive, and many use them in combination.

43. ANALGESIA • Analgesia is best provided by the use of a local anesthetic administered by : - infiltration - nerve block - plexus block - intra-articular - intracavitary - topical • Opioids such as fentanyl and meperidine have traditionally been used to provide perioperative analgesia • Such drugs are associated with side effects, including respiratory depression, drowsiness, PONV, pruritus, and urinary retention-each of which can delay discharge and produce dissatisfaction • Analgesic modalities include NSAIDs, acetaminophen, ketamine, and a2 agonists such as clonidine and dexmedetomidine • Severe postoperative pain in adults may require acute treatment by the intravenous administration of an opioid such as fentanyl, meperidine, or hydromorphone. • Severe, protracted pain remains a common reason for unanticipated hospital admission after planned outpatient surgery

44. POSTOPERATIVE NAUSEA AND VOMITING • Treatment of severe postoperative vomiting may include the rescue administration of ondansetron, dexamethasone, promethazine, or dimenhydrinate • For motion-related PONV some find intramuscular hydroxyzine or ephedrine (or both) efficacious • Protracted PONV is a common reason for prolonged time in the PACUor unanticipated hospital admission after planned outpatient surgery.

45. Regional Anesthesia • Regional anesthetic techniques in outpatient surgery: - peripheral nerve blocks (femoral, median, sciatic nerve) - combination of peripheral nerve blocks (ankle, hand block) - brachial or lumbar plexus blocks - neuraxial blocks (spinal and epidural) • Performing a regional anesthetic may take longer than inducing general anesthesia, and the possibility of failure exists.

46. TECHNIQUE • Regional anesthesia may be used in combination with intravenous sedation or general anesthesia • Except in children, the administration of a neuraxial block is not recommended when the patient is unconscious • An unconscious patient cannot report pain or severe paresthesia • Adjuncts to improve the success and reduce the complications associated with regional anesthesia include the use of an electrical stimulator with an insulated needle and ultrasound guidance to localize the nerve. • Recovery from the effects of a regional anesthetic (sensory, motor, and sympathetic nervous system blockade) can take longer and delay ambulation when compared with recovery from a general anesthetic

47. SPINAL ANESTHESIA • Spinal anesthesia does not need to be avoided in outpatients • The use of very thin (>=25-gauge), rounded- or pencil-point needles reduces the incidence of post-dural puncture headache (PDPH) • The headaches are usually mild and self limited • Many believe that early ambulation does not increase the incidence of PDPH • Epidural anesthesia may become a suitable alternative to spinal anesthesia • Prolonged spinal block can delay discharge and lead to patient frustration and urinary retention in susceptible males. • Epinephrine should not be added to the local anesthetic solution • lidocaine has been used for spinal anesthesia in the outpatient setting because of its short duration of action • Concern about painful transient radicular symptoms after spinal anesthesia with lidocainehas reduced its popularity substantially • Procaine, mepivacaine, bupivacaine, ropivacaine, and levobupivacaine may provide alternatives to lidocaine • Concomitant administration of intrathecal fentanyl can also be useful

48. POSTOPERATIVE ANALGESIA • Postoperative use of patient-controlled analgesia or epidural local anesthetic/opioidinfusions has not proved practical for analgesia after outpatient surgery • Indwelling peripheral nerve and plexus catheters that allow continuous instillation of low doses of local anesthetic solution may be used for postoperative analgesiaafter more complex procedures involving the extremities • Such techniques give the patient a reusable or disposable reservoir and pump to use at home • Patient and caretaker education about its proper use and potential complications is mandatory

49. Sedation and Analgesia • Anesthesia for many outpatient surgical procedures, invasive medical procedures, and diagnostic tests can be accomplished simply and effectively by the use of intravenous sedative-hypnotics and analgesics • MAC entails the administration of these drugs and monitoring of the patient's vital signs by an anesthesiologist • The combination of a regional anesthetic or local infiltration anesthesia with the intravenous injection of drugs to produce sedation or analgesia (or both) is particularly well suited for outpatient surgery. • Drugs commonly administered to adults to produce sedation and amnesia include midazolam or propofol • Continuous low-dose intravenous infusion of propofol (25 to 100 чg/kg/min) is particularly useful for producing sedation more painful procedures or when a peripheral nerve block requires supplementation, an opioid such as fentanyl (25 to 50 чg IV) or an infusion of remifentanil (0.075 to 0.15 чg/kg/min) or ketamine (5 to 20 чg/kg/min) may be useful

50. DISCHARGE FROM THE OUTPATIENTFACILITY • Discharge from the outpatient PACU is based on specific criteria and documentation that the residual effects of anesthesia have dissipated • More important is the use of criterion-based milestones to determine the propriety of discharge • Hospital-based outpatient facilities may admit postoperative outpatients to a PACU more suited for inpatient care (first stage or phase I) • When defined criteria are met, patients then transfer to a less intensive and acute care area where they may still recover on a gurney or flattened recliner (second stage or phase II) • Patients who meet these criteria in the operating room or very soon after leaving the operating room may be admitted directly to this phase II area (Table 36-2)