Advances in Ambulatory Advances in Ambulatory AnaesthesiaAnaesthesia

Dr.R.Muthukumaran Dr.R.Muthukumaran M.D.,D.A.,M.D.,D.A.,

ThanjavurThanjavur

simple procedures on healthy simple procedures on healthy outpatients outpatients

major procedures in outpatients with major procedures in outpatients with complex preexisting medical conditions. complex preexisting medical conditions.

less than 10% to over 70% of all less than 10% to over 70% of all elective surgical procedures. elective surgical procedures.

development of ambulatory anesthesia development of ambulatory anesthesia as a respected subspecialty as a respected subspecialty

establishment of the Society for establishment of the Society for Ambulatory Anesthesia Ambulatory Anesthesia

development of postgraduate development of postgraduate subspecialty training programs subspecialty training programs

Benefits of Ambulatory Benefits of Ambulatory SurgerySurgery

Patient preference, especially children Patient preference, especially children and the elderlyand the elderly

Lack of dependence on the availability of Lack of dependence on the availability of hospital bedshospital beds

Greater flexibility in scheduling operationsGreater flexibility in scheduling operations Low morbidity and mortalityLow morbidity and mortality Lower incidence of infectionLower incidence of infection Lower incidence of respiratory Lower incidence of respiratory

complicationscomplications Higher volume of patients (greater Higher volume of patients (greater

efficiency)efficiency) Shorter surgical waiting listsShorter surgical waiting lists Lower overall procedural costsLower overall procedural costs Less preoperative testing and Less preoperative testing and

postoperative medicationpostoperative medication

Facility DesignFacility Design Hospital integrated:Hospital integrated: Ambulatory surgical patients Ambulatory surgical patients

are managed in the same surgery facility as inpatients. are managed in the same surgery facility as inpatients. Outpatients may have separate preoperative Outpatients may have separate preoperative preparation and recovery areas.preparation and recovery areas.

Hospital-based:Hospital-based: A separate ambulatory surgical A separate ambulatory surgical facility within a hospital handles only outpatients.facility within a hospital handles only outpatients.

Freestanding:Freestanding: These surgical and diagnostic facilities These surgical and diagnostic facilities may be associated with a hospital or medical center but may be associated with a hospital or medical center but are housed in separate buildings that share no space or are housed in separate buildings that share no space or patient care functions. Preoperative evaluation, patient care functions. Preoperative evaluation, surgical care, and recovery occur within this surgical care, and recovery occur within this autonomous unit.autonomous unit.

Office-based:Office-based: These operating and/or diagnostic These operating and/or diagnostic suites are managed in conjunction with physicians’ suites are managed in conjunction with physicians’ offices for the convenience of patients and health care offices for the convenience of patients and health care providers.providers.

The first freestanding outpatient surgical The first freestanding outpatient surgical facility was built and managed by an facility was built and managed by an anesthesiologist, Wallace Reedanesthesiologist, Wallace Reed, to , to

provide surgical care to patients whose provide surgical care to patients whose operations were deemed too demanding operations were deemed too demanding for a surgeon's office yet did not require for a surgeon's office yet did not require

overnight hospitalization overnight hospitalization

Procedures Suitable for Procedures Suitable for Ambulatory SurgeryAmbulatory Surgery

DentalDental -Extraction, restoration, facial -Extraction, restoration, facial fractures fractures

DermatologyDermatology -Excision of skin lesions -Excision of skin lesions GeneralGeneral -Biopsy, endoscopy, excision of -Biopsy, endoscopy, excision of

masses, hemorrhoidectomy, herniorrhaphy, masses, hemorrhoidectomy, herniorrhaphy, laparoscopic cholecystectomy, adrenalectomy, laparoscopic cholecystectomy, adrenalectomy, splenectomy, varicose vein surgery splenectomy, varicose vein surgery

GynecologyGynecology -Cone biopsy, dilatation and -Cone biopsy, dilatation and curettage, hysteroscopy, diagnostic curettage, hysteroscopy, diagnostic laparoscopy, laparoscopic tubal ligations, laparoscopy, laparoscopic tubal ligations, uterine polypectomy, vaginal hysterectomy uterine polypectomy, vaginal hysterectomy

OphthalmologyOphthalmology -Cataract extraction, chalazion -Cataract extraction, chalazion excision, nasolacrimal duct probing, excision, nasolacrimal duct probing, strabismus repair, tonometry strabismus repair, tonometry

Procedures Suitable for Procedures Suitable for Ambulatory SurgeryAmbulatory Surgery

OrthopedicOrthopedic -Anterior cruciate repair, knee -Anterior cruciate repair, knee arthroscopy, shoulder reconstructions, arthroscopy, shoulder reconstructions, bunionectomy, carpal tunnel release, closed bunionectomy, carpal tunnel release, closed reduction, hardware removal, manipulation under reduction, hardware removal, manipulation under anesthesia and minimally invasive hip anesthesia and minimally invasive hip replacements replacements

Otolaryngology -Adenoidectomy, laryngoscopy, Otolaryngology -Adenoidectomy, laryngoscopy, mastoidectomy, myringotomy, polypectomy, mastoidectomy, myringotomy, polypectomy, rhinoplasty, tonsillectomy, tympanoplasty rhinoplasty, tonsillectomy, tympanoplasty

Pain clinicPain clinic -Chemical sympathectomy, epidural -Chemical sympathectomy, epidural injection, nerve blocks injection, nerve blocks

Plastic surgeryPlastic surgery -Basal cell cancer excision, cleft lip -Basal cell cancer excision, cleft lip repair, liposuction, mammoplasty (reductions and repair, liposuction, mammoplasty (reductions and augmentations), otoplasty, scar revision, augmentations), otoplasty, scar revision, septorhinoplasty, skin graft septorhinoplasty, skin graft

UrologyUrology -Bladder surgery, circumcision, -Bladder surgery, circumcision, cystoscopy, lithotripsy, orchiectomy, prostate cystoscopy, lithotripsy, orchiectomy, prostate biopsy, vasovasostomy, laparoscopic nephrectomy biopsy, vasovasostomy, laparoscopic nephrectomy and prostatectomyand prostatectomy

Minimally invasive outpatient Minimally invasive outpatient proceduresprocedures

parathyroidectomy and thyroidectomy, parathyroidectomy and thyroidectomy, laparoscopically assisted vaginal laparoscopically assisted vaginal hysterectomy, removal of ectopic tubal hysterectomy, removal of ectopic tubal pregnancy, and ovarian cystectomy, as pregnancy, and ovarian cystectomy, as well as laparoscopic cholecystectomy well as laparoscopic cholecystectomy and fundoplication, and fundoplication,

laparoscopic adrenalectomy, laparoscopic adrenalectomy, splenectomy, and nephrectomy, lumbar splenectomy, and nephrectomy, lumbar microdiscectomy, and video-assisted microdiscectomy, and video-assisted thoracic surgery thoracic surgery

superficial procedures (mastectomy) superficial procedures (mastectomy)

Duration of SurgeryDuration of Surgery

lasting less than 90 minutes lasting less than 90 minutes

lasting 3 to 4 hours lasting 3 to 4 hours

Patient CharacteristicsPatient Characteristics

ASA physical status I or II ASA physical status I or II ASA physical status III (and even some ASA physical status III (and even some

IV) IV) The risk of complications can be The risk of complications can be

minimized if preexisting medical minimized if preexisting medical conditions are stable, for at least 3 conditions are stable, for at least 3 months before the scheduled operation. months before the scheduled operation.

Even morbid obesity (Even morbid obesity (BMI >40 kg/mBMI >40 kg/m22) is no ) is no longer considered an exclusionary longer considered an exclusionary criterion for day-case surgery. criterion for day-case surgery.

Susceptibility to Malignant Susceptibility to Malignant

HyperthermiaHyperthermia Admission solely on the basis of MH Admission solely on the basis of MH

susceptibility is no longer considered susceptibility is no longer considered appropriate appropriate

Non-triggering anesthetics ( local Non-triggering anesthetics ( local anesthesia) anesthesia)

Extremes of AgeExtremes of Age ““elderly elderly” patient elderly elderly” patient (>100 years(>100 years) )

should not be denied ambulatory should not be denied ambulatory surgery solely on the basis of age surgery solely on the basis of age

ex-premature infants (ex-premature infants (gestational age < 37 gestational age < 37

weeksweeks) recovering from minor surgical ) recovering from minor surgical procedures under general anesthesia procedures under general anesthesia have an increased risk for have an increased risk for postoperative apnea, persists until the postoperative apnea, persists until the 60th postconceptual week 60th postconceptual week

no relationship between apnea and no relationship between apnea and intraoperative use of opioid analgesics intraoperative use of opioid analgesics or muscle relaxants.-or muscle relaxants.-IV IV caffeine caffeine

Contraindications to Outpatient Contraindications to Outpatient

SurgerySurgery Potentially life-threatening chronic illnesses Potentially life-threatening chronic illnesses

( ( brittle diabetes, unstable angina, symptomatic brittle diabetes, unstable angina, symptomatic asthmaasthma))

Morbid obesity complicated by symptomatic Morbid obesity complicated by symptomatic cardio-respiratory problems ( cardio-respiratory problems ( angina, asthmaangina, asthma))

Multiple chronic centrally active drug Multiple chronic centrally active drug therapies (therapies (monoamine oxidase inhibitors such as monoamine oxidase inhibitors such as pargyline and tranylcyprominepargyline and tranylcypromine) and/or active ) and/or active cocaine abusecocaine abuse

Ex-premature infants less than 60 weeks’ Ex-premature infants less than 60 weeks’ postconceptual age requiring general postconceptual age requiring general endotracheal anesthesiaendotracheal anesthesia

No responsible adult at home to care for the No responsible adult at home to care for the patient on the evening after surgerypatient on the evening after surgery

Preoperative assessment Preoperative assessment

The three primary components of a The three primary components of a preoperative assessment – history preoperative assessment – history (86%),(86%), physical examination physical examination (6%),(6%), and and laboratory testing laboratory testing (8%)(8%)

Computerized questionnaires -Computerized questionnaires -telephone interview by a trained telephone interview by a trained nurse -guide preoperative laboratory nurse -guide preoperative laboratory testingtesting

Preoperative assessmentPreoperative assessment

All paperwork (consent form, history, All paperwork (consent form, history, physical examination, and laboratory physical examination, and laboratory test results) should be reviewed before test results) should be reviewed before the patient arrives for surgery the patient arrives for surgery

Appropriate patient preparation before Appropriate patient preparation before the day of surgery can prevent the day of surgery can prevent unnecessary delays, absences (“no unnecessary delays, absences (“no shows”), last-minute cancellations, and shows”), last-minute cancellations, and substandard perioperative care. substandard perioperative care.

Preoperative PreparationPreoperative Preparation

Patients should be encouraged to Patients should be encouraged to continue all their chronic medications continue all their chronic medications up to the time that they arrive at the up to the time that they arrive at the surgery center. surgery center.

Oral medications can be taken with a Oral medications can be taken with a small amount of water up to 30 small amount of water up to 30 minutes before surgery minutes before surgery

Preoperative PreparationPreoperative Preparation

Non-pharmacologic PreparationNon-pharmacologic Preparation -– economic- -– economic-lack side effects – high patient acceptance - lack side effects – high patient acceptance - preoperative visit -educational programs -preoperative visit -educational programs -videotapes videotapes

written and verbal instructions regarding written and verbal instructions regarding arrival time and place, fasting instructions, and arrival time and place, fasting instructions, and information concerning the postoperative information concerning the postoperative course, effects of anesthetic drugs on driving course, effects of anesthetic drugs on driving and cognitive skills immediately after surgery, and cognitive skills immediately after surgery, and the need for a responsible adult to care for and the need for a responsible adult to care for the patient during the early post discharge the patient during the early post discharge period period (<24 hours).(<24 hours).

Pharmacologic PreparationPharmacologic Preparation Anxiolysis and SedationAnxiolysis and Sedation

Barbiturates -residual sedationBarbiturates -residual sedation Benzodiazepines - diazepam 0.1 mg/kg Benzodiazepines - diazepam 0.1 mg/kg POPO

midazolam 0.5mg/kg midazolam 0.5mg/kg POPO or 1mg IV or 1mg IV α-Adrenergic Agonists - αα-Adrenergic Agonists - α22 agonist clonidine, agonist clonidine,

dexmeditomidine-anaesthetic & analgesic dexmeditomidine-anaesthetic & analgesic sparing effect-decrease emergence delirium sparing effect-decrease emergence delirium of sevoflurane-reduce emesis-facilitate of sevoflurane-reduce emesis-facilitate glycemic control- reduce cardio-vascular glycemic control- reduce cardio-vascular complicationcomplication

β-Blockers -atenolol,esmolol –attenuate β-Blockers -atenolol,esmolol –attenuate adrenergic responses-prevent cardiovascular adrenergic responses-prevent cardiovascular eventsevents

Pharmacologic Pharmacologic PreparationPreparation

Pre-emptive (Preventative) AnalgesiaPre-emptive (Preventative) Analgesia Opioid (Narcotic) Analgesics Opioid (Narcotic) Analgesics

Anesthetic sparing-minimize hemodynamic responseAnesthetic sparing-minimize hemodynamic response PONV, urinary retention -delay dischargePONV, urinary retention -delay discharge

Nonopioid Analgesics Nonopioid Analgesics Surgical bleeding-gastric mucosal & renal tubal Surgical bleeding-gastric mucosal & renal tubal

toxicitytoxicity a “fixed” dosing schedule beginning in the a “fixed” dosing schedule beginning in the

preoperative period and extending into the post preoperative period and extending into the post discharge period. discharge period.

addition of dexamethasone to a COX-2 inhibitor leads addition of dexamethasone to a COX-2 inhibitor leads to improvement in postoperative analgesia to improvement in postoperative analgesia

Pharmacologic PreparationPharmacologic Preparation Prevention of Nausea and VomitingPrevention of Nausea and Vomiting

Pharmacologic TechniquesPharmacologic Techniques Butyrophenones –droperidol- dexamethasoneButyrophenones –droperidol- dexamethasone Phenothiazines -prochlorperazinePhenothiazines -prochlorperazine Antihistamines –dimenhydrinate, hydroxyzineAntihistamines –dimenhydrinate, hydroxyzine Anticholinergics –atropine, glycopyrrolate, Anticholinergics –atropine, glycopyrrolate,

TDSTDS Serotonin Antagonists –Serotonin Antagonists –

ondensetron,palanosetronondensetron,palanosetron Neurokinin-1 Antagonists- aprepitant Neurokinin-1 Antagonists- aprepitant

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

BandBand

Pharmacologic PreparationPharmacologic Preparation

Prevention of Aspiration PneumonitisPrevention of Aspiration Pneumonitis no increased risk of aspiration in fasted no increased risk of aspiration in fasted

outpatients outpatients routine prophylaxis for acid aspiration is routine prophylaxis for acid aspiration is

no longer recommended -pregnancy, no longer recommended -pregnancy, scleroderma, hiatal hernia, nasogastric scleroderma, hiatal hernia, nasogastric tubes, severe diabetics, morbid obesity tubes, severe diabetics, morbid obesity

H2-Receptor Antagonists H2-Receptor Antagonists Proton Pump Inhibitors Proton Pump Inhibitors

Pharmacologic Pharmacologic PreparationPreparation

NPO GuidelinesNPO Guidelines Prolonged fasting does not guarantee an Prolonged fasting does not guarantee an

empty stomach at the time of induction empty stomach at the time of induction Hunger, thirst, hypoglycemia, discomfortHunger, thirst, hypoglycemia, discomfort Preoperative administration of glucose-Preoperative administration of glucose-

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

Basic Anesthetic Basic Anesthetic TechniquesTechniques

General Anesthesia General Anesthesia Regional Anesthesia - Spinal and Regional Anesthesia - Spinal and

Epidural Epidural Intravenous Regional Anesthesia Intravenous Regional Anesthesia TIVA- combination of propofol and TIVA- combination of propofol and

remifentanil -TCIremifentanil -TCI Peripheral Nerve Blocks Peripheral Nerve Blocks Local Infiltration Techniques Local Infiltration Techniques Monitored Anesthesia Care Monitored Anesthesia Care

General AnesthesiaGeneral Anesthesia

Airway managementAirway management Induction- barbiturates, benzodiazepines, Induction- barbiturates, benzodiazepines,

ketamine, propofol ketamine, propofol Inhaled anaesthetics- sevoflurane, desflurane Inhaled anaesthetics- sevoflurane, desflurane Opiod analgesics – fentanyl Opiod analgesics – fentanyl 1-2 µg/kg1-2 µg/kg , alfentanil , alfentanil

15-30 µg/kg15-30 µg/kg , sufentanil , sufentanil 0.15-0.3 µg/kg0.15-0.3 µg/kg , remifentanil , remifentanil 0.5-1 µg/kg.0.5-1 µg/kg.

Muscle relaxants- succinylcholine, mivacurium, Muscle relaxants- succinylcholine, mivacurium, Antagonists- nalaxone, succinylcholine, Antagonists- nalaxone, succinylcholine,

flumazenil, neostigmine, atipamezole, caffeine flumazenil, neostigmine, atipamezole, caffeine IV, modafinil, sugammadex IV, modafinil, sugammadex

                                                                                          

                                                                                          

Regional AnesthesiaRegional Anesthesia

Mini-dose spinal- lignocaine Mini-dose spinal- lignocaine 10-30 mg10-30 mg , , bupivacaine bupivacaine 3.5-7 mg3.5-7 mg , ropivacaine , ropivacaine 5-5-

10 mg10 mg , fentanyl , fentanyl 10-25 µg10-25 µg , sufentanil , sufentanil 5-5-10 µg 10 µg

Epidural- 3% 2-chloroprocaine- back Epidural- 3% 2-chloroprocaine- back pain from muscle spasm - pain from muscle spasm - EDTAEDTA

CSECSE

Intravenous Regional Intravenous Regional AnesthesiaAnesthesia

short superficial surgical procedures short superficial surgical procedures (<60 minutes) (<60 minutes)

Ropivacaine vs. lignocaine Ropivacaine vs. lignocaine Adjuvants – ketorolac Adjuvants – ketorolac 15 mg15 mg, clonidine , clonidine

1 µg/kg1 µg/kg, dexmedetomidine , dexmedetomidine 0.5 µg/kg0.5 µg/kg, , gabapentin gabapentin 1.2 mg1.2 mg, dexamethasone , dexamethasone 8 mg8 mg. .

Peripheral Nerve BlocksPeripheral Nerve Blocks

Brachial plexus -axillary, subclavicular, Brachial plexus -axillary, subclavicular, or interscalene blockor interscalene block

“ “Three-in-one block” - femoral, Three-in-one block” - femoral, obturator, and lateral femoral obturator, and lateral femoral cutaneous nerves cutaneous nerves

Deep and superficial cervical plexus Deep and superficial cervical plexus blocks blocks

Continuous perineural techniques -PCAContinuous perineural techniques -PCA Ultrasound guidanceUltrasound guidance

Local Infiltration Local Infiltration TechniquesTechniques

simple wound infiltration (or simple wound infiltration (or instillation)instillation)

use of a local anesthetic at the portals use of a local anesthetic at the portals and topical application at the surgical and topical application at the surgical site site

instillation of instillation of 30 ml of 0.5%30 ml of 0.5% bupivacaine bupivacaine into the joint space into the joint space

perioperative administration of perioperative administration of IVIV lidocaine improved patient outcomes lidocaine improved patient outcomes

Monitored Anesthesia CareMonitored Anesthesia Care

The combination of local anesthesia and/or The combination of local anesthesia and/or peripheral nerve blocks with intravenous peripheral nerve blocks with intravenous sedative and analgesic drugs is commonly sedative and analgesic drugs is commonly referred to as MAC and has become referred to as MAC and has become extremely popular in the ambulatory setting extremely popular in the ambulatory setting

The standard of care for patients receiving The standard of care for patients receiving MAC should be the same as for patients MAC should be the same as for patients undergoing general or regional anesthesia undergoing general or regional anesthesia and includes and includes preoperative assessment, preoperative assessment, intraoperative monitoring,intraoperative monitoring, and and postoperative postoperative recovery carerecovery care. .

Monitored Anesthesia CareMonitored Anesthesia Care

MAC is the term used when an MAC is the term used when an anesthesiologist monitors a patient anesthesiologist monitors a patient receiving local anesthesia or administers receiving local anesthesia or administers supplemental drugs to patients undergoing supplemental drugs to patients undergoing diagnostic or therapeutic procedures diagnostic or therapeutic procedures

Anesthetic drugs are administered during Anesthetic drugs are administered during procedures under MAC with the goal of procedures under MAC with the goal of providing analgesia, sedation, and providing analgesia, sedation, and anxiolysis and ensuring rapid recovery anxiolysis and ensuring rapid recovery without side effects without side effects

Monitored Anesthesia CareMonitored Anesthesia Care

Systemic analgesics are often used to Systemic analgesics are often used to reduce the discomfort associated reduce the discomfort associated with the injection of local anesthetics with the injection of local anesthetics and prolonged immobilization and prolonged immobilization

Sedative-hypnotic drugs are used to Sedative-hypnotic drugs are used to make procedures more tolerable for make procedures more tolerable for patients by reducing anxiety and patients by reducing anxiety and providing a degree of intraoperative providing a degree of intraoperative amnesia amnesia

Monitored Anesthesia CareMonitored Anesthesia Care

sedative-hypnotic drugs have been sedative-hypnotic drugs have been administered during MAC -barbiturates, administered during MAC -barbiturates, benzodiazepines, ketamine, and propofol benzodiazepines, ketamine, and propofol

intermittent boluses- variable-rate intermittent boluses- variable-rate infusion, target-controlled infusion, and infusion, target-controlled infusion, and even patient-controlled sedation. even patient-controlled sedation.

Methohexital -Methohexital -intermittent boluses 10-20 mg or intermittent boluses 10-20 mg or as a variable-rate infusion 1-3 mg/min as a variable-rate infusion 1-3 mg/min

The αThe α22-agonists clonidine and -agonists clonidine and dexmedetomidine dexmedetomidine

Cerebral MonitoringCerebral Monitoring

EEG-derived indices - The bispectral index EEG-derived indices - The bispectral index ((BISBIS), physical state index (), physical state index (PSIPSI), spectral and ), spectral and response entropy, auditory evoked potential response entropy, auditory evoked potential ((AEPAEP) index, and cerebral state index () index, and cerebral state index (CSICSI) )

The BIS, PSI, and CSI values are The BIS, PSI, and CSI values are dimensionless numbers that vary from 0 to dimensionless numbers that vary from 0 to 100, with values less than 60 associated with 100, with values less than 60 associated with “adequate” hypnosis under general “adequate” hypnosis under general anesthesia and values greater than 75 anesthesia and values greater than 75 typically observed during emergence from typically observed during emergence from anesthesia anesthesia

Fast-TrackingFast-Tracking Multimodal Approaches to Minimize Multimodal Approaches to Minimize

Side EffectsSide Effects

PONVPONV- droperidol - droperidol 0.625-1.25 mg0.625-1.25 mg IVIV, dexamethasone , dexamethasone 4-4-

8 mg8 mg IVIV, ondansetron , ondansetron 4-8 mg4-8 mg IVIV, long-acting 5-HT3 , long-acting 5-HT3 antagonist- palonosetron antagonist- palonosetron 75 µg75 µg IVIV, and , and NKNK-1 -1 antagonist - aprepitant, a transdermal antagonist - aprepitant, a transdermal scopolamine patch, or an acu-stimulation scopolamine patch, or an acu-stimulation device - SeaBand, Relief Band device - SeaBand, Relief Band

Non-opioid analgesics -Non-opioid analgesics -NSAIDNSAIDs, s, cyclooxygenase-2 [cyclooxygenase-2 [COX-2COX-2] inhibitors, ] inhibitors, acetaminophen, α2-agonists, glucocorticoids, acetaminophen, α2-agonists, glucocorticoids, ketamine, and local anesthetics ketamine, and local anesthetics

Newer analgesic therapiesNewer analgesic therapies

continuous local anesthetic infusions,continuous local anesthetic infusions, nonparenteral opioid analgesic nonparenteral opioid analgesic

delivery systemsdelivery systems ambulatory patient-controlled ambulatory patient-controlled

analgesic techniques analgesic techniques ( subcutaneous, ( subcutaneous,

intranasal, transcutaneousintranasal, transcutaneous))

Fast-TrackingFast-Tracking Multimodal Approaches to Minimize Multimodal Approaches to Minimize

Side EffectsSide Effects low-dose ketamine low-dose ketamine 75-150 µg/kg75-150 µg/kg Non-pharmacologic factors Non-pharmacologic factors

conventional CO2 insufflation technique /gasless conventional CO2 insufflation technique /gasless technique - subdiaphragmatic instillation of local technique - subdiaphragmatic instillation of local anesthetic - local anesthetic at the portals and anesthetic - local anesthetic at the portals and topical application at the surgical site. topical application at the surgical site.

instillation of 30 mL of 0.5% bupivacaine into instillation of 30 mL of 0.5% bupivacaine into the joint space reduces postoperative opiate the joint space reduces postoperative opiate requirements and permits earlier ambulation and requirements and permits earlier ambulation and discharge. The addition of adjuvants- morphine discharge. The addition of adjuvants- morphine 1-1-

2 mg2 mg, ketorolac , ketorolac 15-30 mg, 15-30 mg, clonidine clonidine 0.1-0.2 mg0.1-0.2 mg, , ketamine ketamine 10-20 mg10-20 mg, triamcinolone , triamcinolone 10-20 mg 10-20 mg

TENSTENS

Guidelines for ambulatory surgical Guidelines for ambulatory surgical

facilitiesfacilities Employment of appropriately trained and credentialed Employment of appropriately trained and credentialed

anesthesia personnelanesthesia personnel Availability of properly maintained anesthesia equipment Availability of properly maintained anesthesia equipment

appropriate to the anesthesia care being providedappropriate to the anesthesia care being provided As complete documentation of the care provided as that As complete documentation of the care provided as that

required at other surgical sitesrequired at other surgical sites Use of standard monitoring equipment according to the ASA Use of standard monitoring equipment according to the ASA

policies and guidelinespolicies and guidelines Provision of a PACU or recovery area that is staffed by Provision of a PACU or recovery area that is staffed by

appropriately trained nursing personnel and provision of specific appropriately trained nursing personnel and provision of specific discharge instructionsdischarge instructions

Availability of emergency equipment (e.g., airway equipment, Availability of emergency equipment (e.g., airway equipment, cardiac resuscitation)cardiac resuscitation)

Establishment of a written plan for emergency transport of Establishment of a written plan for emergency transport of patients to a site that provides more comprehensive care should patients to a site that provides more comprehensive care should an untoward event or complication occur that requires more an untoward event or complication occur that requires more extensive monitoring or overnight admission of the patientextensive monitoring or overnight admission of the patient

Maintenance and documentation of a quality assurance programMaintenance and documentation of a quality assurance program Establishment of a continuing education program for physicians Establishment of a continuing education program for physicians

and other facility personneland other facility personnel Safety standards that cannot be jeopardized for patient Safety standards that cannot be jeopardized for patient

convenience or cost savingsconvenience or cost savings

Discharge CriteriaDischarge Criteria Early recovery is the time interval during which Early recovery is the time interval during which

patients emerge from anesthesia, recover patients emerge from anesthesia, recover control of their protective reflexes, and resume control of their protective reflexes, and resume early motor activity –Aldrete score – operating early motor activity –Aldrete score – operating roomroom

Intermediate recovery- recovery room -begin to Intermediate recovery- recovery room -begin to ambulate, drink fluids, void, and prepare for ambulate, drink fluids, void, and prepare for discharge discharge

Late recovery period starts when the patient is Late recovery period starts when the patient is discharged home and continues until complete discharged home and continues until complete functional recovery is achieved and the patient functional recovery is achieved and the patient is able to resume normal activities of daily is able to resume normal activities of daily living living

Discharge CriteriaDischarge Criteria

anesthetics, analgesics, and anesthetics, analgesics, and antiemetics can affect the patient's antiemetics can affect the patient's early and intermediate recovery,early and intermediate recovery,

the surgical procedure has the the surgical procedure has the highest impact on late recovery highest impact on late recovery

Before ambulation, patients receiving Before ambulation, patients receiving a central neuraxial block should have a central neuraxial block should have normal perianal (normal perianal (S4 -5S4 -5) sensation, have ) sensation, have the ability to plantarflex the foot, and the ability to plantarflex the foot, and have proprioception of the big toe have proprioception of the big toe

PADSPADS

(1) vital signs, including blood (1) vital signs, including blood pressure, heart rate, respiratory pressure, heart rate, respiratory rate, and temperature rate, and temperature

(2) ambulation and mental status(2) ambulation and mental status(3) pain and (3) pain and PONVPONV

(4) surgical bleeding and (4) surgical bleeding and

(5) fluid intake/output (5) fluid intake/output

Post-anesthesia Discharge Scoring (PADS) Post-anesthesia Discharge Scoring (PADS)

SystemSystem Vital SignsVital Signs  

2-Within 20% of the preoperative value2-Within 20% of the preoperative value 1 -20%-40% of the preoperative value1 -20%-40% of the preoperative value 0-40% of the preoperative value0-40% of the preoperative value

AmbulationAmbulation   2 -Steady gait/no dizziness 2 -Steady gait/no dizziness 1-With assistance1-With assistance 0-No ambulation/dizziness0-No ambulation/dizziness

Nausea and VomitingNausea and Vomiting 2-Minimal2-Minimal 1-Moderate1-Moderate 0-Severe0-Severe

PainPain 2-Minimal2-Minimal 1-Moderate1-Moderate 0-Severe 0-Severe

Surgical BleedingSurgical Bleeding   2-Minimal2-Minimal 1-Moderate1-Moderate 0-Severe0-Severe

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