Advances in Ambulatory Anaesthesia

1. Advances in Ambulatory Anaesthesia Dr.R.Muthukumaran M.D.,D.A., Thanjavur

2. 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

3. 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

4. Facility Design • Hospital integrated:Ambulatory surgical patients are managed in the same surgery facility as inpatients. Outpatients may have separate preoperative preparation and recovery areas. • Hospital-based:A separate ambulatory surgical facility within a hospital handles only outpatients. • 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. • Office-based:These operating and/or diagnostic suites are managed in conjunction with physicians’ offices for the convenience of patients and health care providers.

5. 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

6. Procedures Suitable for Ambulatory Surgery • 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

7. Procedures Suitable for Ambulatory Surgery • 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

8. Minimally invasive outpatient procedures • 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)

9. Duration of Surgery • lasting less than 90 minutes • lasting 3 to 4 hours

10. Patient Characteristics • 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.

11. Susceptibility to Malignant Hyperthermia • Admission solely on the basis of MH susceptibility is no longer considered appropriate • Non-triggering anesthetics ( local anesthesia)

12. Extremes of Age • “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

13. Contraindications to Outpatient Surgery • Potentially life-threatening chronic illnesses ( brittle diabetes, unstable angina, symptomatic asthma) • Morbid obesity complicated by symptomatic cardio-respiratory 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

14. Preoperative assessment • 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

18. Preoperative assessment • 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.

19. Preoperative Preparation • 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

20. Preoperative Preparation • 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).

21. Pharmacologic Preparation • 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 effect-decrease emergence delirium of sevoflurane-reduce emesis-facilitate glycemic control- reduce cardio-vascular complication • β-Blockers -atenolol,esmolol –attenuate adrenergic responses-prevent cardiovascular events

22. Pharmacologic Preparation • Pre-emptive (Preventative) Analgesia • Opioid (Narcotic) Analgesics • Anesthetic sparing-minimize hemodynamic response • PONV, urinary retention -delay discharge • Nonopioid Analgesics • 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

23. Pharmacologic Preparation • Prevention of Nausea and Vomiting • Pharmacologic Techniques • Butyrophenones –droperidol- dexamethasone • Phenothiazines -prochlorperazine • Antihistamines –dimenhydrinate, hydroxyzine • Anticholinergics –atropine, glycopyrrolate, TDS • Serotonin Antagonists –ondensetron,palanosetron • Neurokinin-1 Antagonists- aprepitant • Nonpharmacologic Techniques • Acupuncture, • Acupressure and • TENS at the P-6 acupoint - with the Relief Band

24. Pharmacologic Preparation • 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

25. Pharmacologic Preparation • 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

26. Basic Anesthetic Techniques • 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

27. General Anesthesia • 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

29. Regional Anesthesia • 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

30. Intravenous Regional Anesthesia • 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.

31. Peripheral Nerve Blocks • 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

32. Local Infiltration Techniques • 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

33. Monitored Anesthesia Care • 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.

34. Monitored Anesthesia Care • 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

35. Monitored Anesthesia Care • 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

36. Monitored Anesthesia Care • sedative-hypnotic drugs have been administered during MAC -barbiturates, benzodiazepines, ketamine, and propofol • intermittent boluses- variable-rate infusion, target-controlled infusion, and even patient-controlled sedation. • Methohexital -intermittent boluses 10-20 mg or as a variable-rate infusion 1-3 mg/min • The α2-agonists clonidine and dexmedetomidine

37. Cerebral Monitoring • 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

38. Fast-TrackingMultimodal Approaches to Minimize Side Effects • PONV- droperidol 0.625-1.25 mgIV, dexamethasone 4-8 mgIV, ondansetron 4-8 mgIV, long-acting 5-HT3 antagonist- palonosetron 75 µgIV, 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

39. Newer analgesic therapies • continuous local anesthetic infusions, • nonparenteral opioid analgesic delivery systems • ambulatory patient-controlled analgesic techniques ( subcutaneous, intranasal, transcutaneous)

40. Fast-TrackingMultimodal Approaches to Minimize Side Effects • low-dose ketamine 75-150 µg/kg • Non-pharmacologic factors • 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 adjuvants- morphine 1-2 mg, ketorolac 15-30 mg, clonidine 0.1-0.2 mg, ketamine 10-20 mg, triamcinolone 10-20 mg • TENS

41. Guidelines for ambulatory surgical facilities • 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

42. Discharge Criteria • 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

43. Discharge Criteria • 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

44. 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

45. Post-anesthesia Discharge Scoring (PADS) System • Vital Signs • 2-Within 20% of the preoperative value • 1 -20%-40% of the preoperative value • 0-40% of the preoperative value • Ambulation • 2 -Steady gait/no dizziness • 1-With assistance • 0-No ambulation/dizziness • Nausea and Vomiting • 2-Minimal • 1-Moderate • 0-Severe • Pain • 2-Minimal • 1-Moderate • 0-Severe • Surgical Bleeding • 2-Minimal • 1-Moderate • 0-Severe

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