Anesthesia For Day Care Surgery
Anesthesia For Day Care Surgery
Anesthesia For Day Care Surgery
SURGERY
Presented : Dr. Nitin Bhalla,
P.G. Student,
Department of Anesthesiology and Critical
care,
Dr. S.N. Medical College,
Jodhpur.
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Introduction to Ambulatory Surgery
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Benefits of “Day Care” or “Ambulatory”
Surgery
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Patient selection criteria for ambulatory
anaesthesia
Age
Premature infants < 46 weeks of postconceptional age are at increased
risk and are not an ideal candidate for Ambulatory surgery.
Anemia is a sinificant independent risk factor , particularly for infants less
than 43 weeks of post conceptional age.
Elderly outpatients may experience a higher incidence of perioperative
CVS event and slow recovery of fine motor skills and cognitive functions.
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Patient selection criteria for ambulatory
anaesthesia
Social Factors
1.The patient must be prepared to have the procedure performed as a day case,
2. live close to the hospital, and
3. Should have a responsible, able, adult carer at home with them for 24 hours
postoperatively
Surgical procedure - Ideally, surgical procedures for the ambulatory
patient should be completed in a reasonable amount of time, should not
require blood transfusion and should not create excessive fluid shifts.
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Medical contraindications for day case
anesthesia
Morbid obesity
• Body mass index > 35 kg/m2 or weight > 125 kg
Cardiovascular disease
• Poorly controlled angina, arrhythmia or cardiac failure
• Hypertension > 180/100 mm Hg
• Significant valvular or congenital heart disease
• Myocardial infarction or stroke within 6 months
Respiratory disease/airway
• Poorly controlled asthma or chronic obstructive pulmonary disease (patients taking oral
corticosteroids, with poor exercise tolerance or with a peak expiratory flow rate < 200
litres/minute are unlikely to be suitable) 1
• Severe restrictive lung disease (e.g. kyphoscoliosis)
• Previous failed intubation
• Significant obstructive sleep apnoea
Continued...
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Medical contraindications for day case
anesthesia (contd.)
Metabolic/endocrine/haematological
• Poorly controlled diabetes or insulin dependent 1
• Active liver disease
• Anaemia (haemoglobin < 10 g/dl) 1
• Haemophilia/anticoagulation 1
• Cholinesterase deficiency 1
• Hypo- or hyperkalaemia (acceptable range 3–6 mmol/litre)
Renal disease
• Patients requiring renal support 1
Neuromuscular disease
• Myasthenia gravis
• Significant multiple sclerosis
• Malignant hyperpyrexia susceptibility
• Poorly controlled epilepsy
• Parkinson’s disease interfering with daily activity
• Significant motor neuron disease
Acute substance abuse
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Operative procedures suitable for
Ambulatory surgery
Specialty Type of Procedure
Dental Extraction , restoration, facial fractures
Dermatology Excision of skin lesions
General Biopsy, endoscopy, excision of masses, hemorrhoidectomy, herniorrhaphy,
laproscopic procedures, varicose vein surgery
Gynecology Cone biopsy, dilatation and curettage, hysteroscopy, laparoscopy,
polypectomy, tubal ligation, vaginal hysterectomy
ophthalmology Cataract extraction, chalazion excision, NLD probing, Strabismus repair,
tonometry
Orthopedic AC repair, arthroscopy, bunionectomy, carpal tunnel release, closed
reduction, hardware removal, manipulation under anesthesia
Otolaryngology Adenoidectomy, laryngoscopy, mastoidectomy, myringotomy, polypectomy,
rhinoplasty, tonsillectomy, tympanoplasty
Pain clinic Chemical sympathectomy, epidural injection, nerve blocks
Plastic surgery BCC excision, cleft lip repair, liposuction, mammaplasty, otoplasty, scar
revision, septorhinoplasty, skin grafting
Urology Bladder surgery, circumcision, cystoscopy, lithotripsy, orchiectomy, prostate
biopsy, vasovasostomy
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Pre – Operative evaluation
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Recommended Laboratory tests for
ambulatory surgery
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Aims of Pre – Operative Preparation
Aims –
Reducing the risk inherited in Ambulatory
Surgery.
Improving patient outcome.
the patient.
Minimizing patient anxiety.
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Non Pharmacological Methods
Non – Pharmacological techniques should be aimed to allay anxiety and fear of the patient regarding
the operative procedure. Patient should also be instructed (written and verbal) regarding the arrival
time and place, fasting instructions and information concerning the post operative course, limitation
in driving skills, and the need for a responsible adult to care for the patient during post operative
period.
Economical
Lacks undesirable side effects.
High patient acceptance and motivation.
Non-Pharmacological methods –
Patient Interview.
Instructional preoperative video tapes.
Music before surgery
Self hypnotic relaxation techniques.
Play oriented pre-operative teaching, Books, pamphlets, and video programs – specifically in
pediatric patients.
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Pharmacological methods
Benzodiazepines –
Midazolam - drug of choice. (I.M., I.V., PO)
Oral Temazepam and alprazolam
α 2 adrenergic agonists –
Clonidine - residual post operative sedation is
concerned factor.
Dexmedetomidine - Shorter duration of action and
highly selective α 2 agonist.
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Pharmacological methods (contd..)
Analgesics –
Opioid Analgesics –
Relive anxiety, Decreases anesthetic doses, minimize hemodynamic
response, provide post operative pain relief.
Shorter acting – Fentanyl, alfentanil, Remifentanil, Sufentanil
NSAID’s –
As mutiimodal analgesic technique, in combination, it facilitates early
recovery and reduces discharge time.
For maximal benefit in ambulatory surgery, NSAID’s s/b administered
on “fixed” dosage shedule.
More selective COX – 2 inhibitors s/b used.
Oral – Rofecoxib, Celecoxib, Valdecoxib
Parentral - Parecoxib
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Pharmacological methods (contd..)
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Pharmacological methods (contd..)
Pantoprazole – 40 mg iv
NPO
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Anesthesia techniques
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Anesthesia Techniques
General Anesthesia
Regional Anesthesia
Local Anesthesia
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Qualities of an ideal day care
anaesthetic agent
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General Anesthesia
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General Anesthesia (contd...)
Opioid Analgesics –
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General Anesthesia (contd...)
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General Anesthesia (contd...)
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General Anesthesia (contd...)
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Regional Anesthesia
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Regional Anesthesia
Advantages to patients :
(a) Improved quality of recovery
i. Less pain (mainly with CPNB)
ii. Less PONV
iii. Less unplanned hospital admission
(b) Able to observe the procedure
(c) Communication with surgeon during the procedure,
(d) Option to receive no or light sedation.
(e) Earlier mobilization.
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Regional Anesthesia (contd..)
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Regional Anesthesia (contd..)
Spinal Anesthesia –
Although simple and most reliable reg. anesthetic tech., is associated
with higher incidence of side effects.
For Ambulatory Anesthesia , short acting local anesthetics (Lidocaine and
procaine) is preferred over the bupivacaine and tetracaine.
Recommendations – Isobaric lidocaine, or combination of small dose of
hypobaric lidocaine (1% ; 20-25mg) combined with fentanyl (10-25mcg)
or sufentanil.
For ambulatory surgeries lasting for > 2 hours, Intrathecal bupivacaine
can be used.
Associated with – delayed ambulation, dizziness, urinary retention, and
impaired balance.
Epidural Anesthesia - is technically more difficult to perform, slower onset of
action, potential for intravascular / intrathecal injection, greater chances of
incomplete sensory block.
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Regional Anesthesia (contd..)
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Monitored Anesthesia Care
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Monitored Anesthesia Care (contd..)
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Concept of “Fast – Tracking”
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Criteria used to determine fast-track
eligibility after ambulatory anesthesia
Level of Conciousness –
Awake and oriented 2
Arousable with minimal stimulation 1
Responsive only to tactile stimulation 0
Physical activity –
Able to move all extremities on command 2
Some weakness in movement of extremities 1
Unable to voluntarily move the extremities 0
Hemodynamics –
BP < 15% of the baseline MAP 2
BP between 15-30% of the baseline MAP 1
BP > 30% below the baseline MAP 0
Respiration –
Able to breathe deeply 2
Tachypnea with good cough 1
Dyspneic with weak cough 0 contd…
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Criteria used to determine fast-track
eligibility after ambulatory anesthesia
(contd..)
O2 saturation status –
Maintain > 90% on room air 2
Requires supplemental O2 (nasal prongs) 1
Saturatio < 90% with supplemental O2 0
Post operative pain assessment –
None or mild discomfort 2
Moderte to severe pain req. IV analgesics 1
Persistent severe pain 0
Postoperative emetic symptoms –
None or mild nausea with no active vomiting 2
Transient vomiting or retching 1
Persistent moderate to severe nausea and vomiting 0
A Score of over 12 with no individual score less than 1 is required for fast- tracking.
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Assessment of Recovery
Discharge Criteria
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Assessment of Recovery
Stages of Recovery
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Phases / Stages of Recovery
Consciousness
Awake 2
Responding to stimuli 1
Not responding 0
Airway
Coughing on command or crying 2
Maintaining a good airway 1
Airway needs maintenance 0
Movement
Moving limbs purposefully 2
Non-purposeful movement 1
Not moving 0
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Modified Aldrete Scoring System
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Post-anaesthesia Discharge Scoring
System for assessing home readiness
Vital signs
Vital signs must be stable and consistent with age and preoperative baseline
Activity level
Patient must be able to ambulate at preoperative level
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Post-anaesthesia Discharge Scoring
System for assessing home readiness
(contd.)
Pain
The patient should have minimal or no pain before discharge
The level of pain that the patient has should be acceptable to the patient
Pain should be controlled by oral analgesia
The location, type and intensity of pain should be consistent with the anticipated
postoperative discomfort
Acceptable 2
Unacceptable 1
Surgical bleeding
Postoperative bleeding should be consistent with the expected blood loss for the procedure
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Guidelines for safe discharge after day
surgery
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Discharge criteria after Regional
anesthesia
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Causes of prolonged recovery following
regional and general anaesthesia
• Pain
• Nausea and vomiting
• Haemorrhage
• Cardiovascular or pulmonary dysfunction
• Wound drains
• Needing observation
• Lack of escort or inadequate home conditions
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Post operative instructions
Both written and verbal instructions should be given regarding the post
operative period before discharging the patient -
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Application of Ambulatory
anesthesia in specific
population
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Pediatric patients
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Geriatric Patients
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Cardiovascular Disease patients
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Diabetic patient
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Morbid Obesity
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Patient with Asthma or COPD
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Obstructive Sleep Apnoea
Out-patient surgery for OSA patients remains controversial even in developed countries.
OSA patients are more likely to be difficult to intubate ; Several factors, including obesity,
retrognathia and increased neck circumference contribute to the increased difficulty with
intubation.
The severity of OSA is determined by the apnoea-hypopnoea index which is the number of
apnoeas or hypopnoeas per hour of sleep. (mild 5 – 15, moderate 15 – 30, severe > 30)
Recovery room complications are also more frequent and may include hypertension,
dysarrhythmias, desaturation, airway obstruction or reintubation.
well-treated OSA patients having low risk procedure performed under local anaesthesia or
regional anaesthesia with little or no sedation and minimal need for narcotic-based analgesia
can be discharged after surgery.
Pain should be managed with non-narcotic analgesics and opioid drugs should be avoided.
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GUIDELINES FOR AMBULATORY ANESTHESIA
AND SURGERY
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GUIDELINES FOR AMBULATORY
ANESTHESIA AND SURGERY
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GUIDELINES FOR AMBULATORY
ANESTHESIA AND SURGERY
IV. Staff should be adequate to meet patient and facility needs for all
procedures performed in the setting, and should consist of:
A. Professional Staff
1. Physicians and other practitioners who hold a valid license or
certificate are duly qualified.
2. Nurses who are duly licensed and qualified.
B. Administrative Staff
C. Housekeeping and Maintenance Staff
V. Physicians providing medical care in the facility should assume responsibility
for credentials review, delineation of privileges, quality assurance and peer
review.
VI. Qualified personnel and equipment should be on hand to manage
emergencies. There should be established policies and procedures to respond
to emergencies and unanticipated patient transfer to an acute care facility.
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GUIDELINES FOR AMBULATORY
ANESTHESIA AND SURGERY
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Thanks
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