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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??. Definition Structure Set up Cases

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Ambulatory anaesthesia

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  1. 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

  2. Can we go about like that?? • Definition • Structure • Set up • Cases • Anaesth technique • PACU

  3. 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 !!

  4. 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

  5. SAMBA • Recognized respected subspecialty occurred with establishment of the Society for Ambulatory Anesthesia (SAMBA) in 1984.

  6. 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

  7. Structure Fast track

  8. 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

  9. 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

  10. Unbelievable list • Otolaryngology Adenoidectomy, laryngoscopy, mastoidectomy, myringotomy, polypectomy, rhinoplasty, tonsillectomy, tympanoplasty • Pain clinic Chemical sympathectomy, epidural injection, nerve blocks

  11. 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

  12. 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 !!

  13. 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

  14. 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.

  15. 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

  16. Specific situations

  17. 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

  18. 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.

  19. Drug abuse • Body builders – OK • But alcohol – • consider nutrition , LFT and type of surgery

  20. 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

  21. Pregnancy – second trimester preferable • 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

  22. Liver and kidney disease • Acute illness • Dialysis prior • LFT results • INR • Type of surgery

  23. Thyroid • Airway • hyperthyroidism • Doubt for ambulatory surgery

  24. Other systemic illness • 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.

  25. Other systemic illness • Problems with previous anesthetics or with anesthesia in close family • Beware and analyse • Myaesthenia – avoid

  26. Personnel • Anaesth + staff + nurse anaesth • Surgeon only local small cases

  27. Monitors • 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

  28. In case of emergencies there must be fast access to a suction device, a self-expanding ventilation bag with reservoir and extra oxygen supply, a defibrillator and emergency drugs • intubation kit including devices for difficult intubations.

  29. Consent for ambulatory surgery • 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

  30. Preanaesthesia • 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

  31. Preop • 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

  32. Principles • two primary concerns for ambulatory anesthesia are • speed of wake-up • incidence of postoperative nausea and vomiting. • Wake up time and discharge fit time !!

  33. Pharmacology

  34. Problems • 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

  35. general anesthesia, regional anesthesia, and local anesthesia • In obstetrics, regional anesthesia, and local anesthesia are preferable • In others all are acceptable

  36. Local • 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

  37. Spinal • 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

  38. Epidural and caudal • Longer • Difficult • Failure

  39. Nerve blocks • 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 .

  40. Post op pain relief

  41. General 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

  42. Principles • two primary concerns for ambulatory anesthesia are • speed of wake-up • incidence of postoperative nausea and vomiting. • Wake up time and discharge fit time !!

  43. Agents • 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

  44. Pharmacologic antagonists • 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.

  45. specifically selective serotonin antagonists and acupuncture • Nitrous • Agents • Opioids(fent- NSAIDs)

  46. Airways • Supraglottic airway device especially LMA • Cough • Sorethroat • Anas requirements • But gastric sufflationand PONV

  47. 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

  48. 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

  49. 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

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