Presentor : Dr. Kumar Moderator : Dr.Pradeep

Ambulatory and Fast tracking Anaesthesia

Introduction

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 The availability of rapid, shorter-acting anesthetic,

analgesic, and muscle relaxant drugs has clearly facilitated the recovery process after surgery, and the development of minimally invasive surgical techniques allowed more extensive procedures to be performed on an ambulatory basis, irrespective of the patient's preexisting medical conditions

Benefits of Ambulatory SurgeryPatient preference, especially children and

the elderlyLack of dependence on the availability of

hospital bedsGreater flexibility in scheduling operationsLow morbidity and mortalityLower incidence of infectionLower incidence of respiratory

complicationsHigher volume of patients (greater

efficiency)Shorter surgical waiting listsLower overall procedural costsLess preoperative testing and

postoperative medication

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.

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

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

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 proceduresparathyroidectomy 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 lasting less than 90 minutes

lasting 3 to 4 hours

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.

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

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

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

Preoperative assessmentAll 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

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 PreparationNon-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 PreparationAnxiolysis and Sedation

Barbiturates -residual sedationBenzodiazepines - 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

Pharmacologic PreparationPre-emptive (Preventative) Analgesia

Opioid (Narcotic) Analgesics Anesthetic sparing-minimize

hemodynamic responsePONV, urinary retention -delay discharge

Nonopioid Analgesics Surgical bleeding-gastric mucosal & renal

tubal toxicitya “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 PreparationPrevention of Nausea and Vomiting

Pharmacologic Techniques Butyrophenones –droperidol- dexamethasonePhenothiazines -prochlorperazineAntihistamines –dimenhydrinate, hydroxyzineAnticholinergics –atropine, glycopyrrolate, TDSSerotonin Antagonists –ondensetron,palanosetronNeurokinin-1 Antagonists- aprepitant

Nonpharmacologic Techniques Acupuncture, Acupressure and TENS at the P-6 acupoint - with the Relief Band

Pharmacologic PreparationPrevention of Aspiration

Pneumonitisno 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 PreparationNPO Guidelines

Prolonged fasting does not guarantee an empty stomach at the time of induction

Hunger, thirst, hypoglycemia, discomfortPreoperative administration of glucose-

containing fluids prevents postoperative insulin resistance and attenuates the catabolic responses to surgery while replacing fluid deficits

Basic Anesthetic Techniques General Anesthesia Regional Anesthesia - Spinal and Epidural Intravenous Regional Anesthesia TIVA- combination of propofol and remifentanil

-TCIPeripheral Nerve Blocks Local Infiltration Techniques Monitored Anesthesia Care

General Anesthesia

Airway managementInduction- 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 AnesthesiaMini-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 (preservative)

CSE

Intravenous Regional Anesthesiashort 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 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(patient controlled analgesia)

Ultrasound guidance

Local Infiltration Techniquessimple 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 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 CareMAC 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 CareSystemic 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 Caresedative-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

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

FAST TRACKINGBypassing the PACU has been termed “fast-

tracking” after ambulatory surgery.In addition, fast-tracking can be

accomplished directly from the PACU (“PACU fast-tracking”) by creating a specialized area within an existing PACU where recovery procedures are organized along the lines of a step-down unit.

This approach represents a key component of the “total care” package for ambulatory surgery.[463]

Fast-Tracking Multimodal Approaches to Minimize Side Effects PONV- droperidol 0.625-1.25 mg IV, dexamethasone

4-8 mg IV, ondansetron 4-8 mg IV, long-acting 5-HT3 antagonist- palonosetron 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

continuous local anesthetic infusions,nonparenteral opioid analgesic delivery

systemsambulatory patient-controlled analgesic

techniques ( subcutaneous, intranasal, transcutaneous)

Fast-Tracking Multimodal 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

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

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

Discharge Criteriaanesthetics, 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 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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