Ambulatory AnaesthesiaAmbulatory Anaesthesia

Dr .Sachin Anand Dr .Sachin Anand ,,

Mod By:Dr Meera KharbandaMod By:Dr Meera Kharbanda

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.

Safety in Day Case Safety in Day Case AnaesthesiaAnaesthesia

Safety in day cases is optimised by:Safety in day cases is optimised by:

• • Patient selection.Patient selection.

• • Procedure selectionProcedure selection

• • Anaesthetic choice. (GA Vs. LA etc.)Anaesthetic choice. (GA Vs. LA etc.)

• • Discharge planning.Discharge planning.

These are the anaesthetic issues most These are the anaesthetic issues most specific to day case anaesthesia.specific to day case anaesthesia.

Clear evidence and policy exist.Clear evidence and policy exist.

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

Recommendations for the Perioperative Recommendations for the Perioperative Care of Patients SelectedCare of Patients Selected

for Day Care Surgeryfor Day Care Surgery

1. Procedures suitable for day care surgery must entail:1. Procedures suitable for day care surgery must entail: 1.1 A minimal risk of post operative haemorrhage.1.1 A minimal risk of post operative haemorrhage. 1.2 A minimal risk of post operative airway 1.2 A minimal risk of post operative airway

compromise.compromise. 1.3 Post operative pain controlled by out patient 1.3 Post operative pain controlled by out patient

management techniques.management techniques. 1.4 No special post operative nursing requirements 1.4 No special post operative nursing requirements

that cannot be met by the hospital in the home or that cannot be met by the hospital in the home or district nursing facilities.district nursing facilities.

1.5 A rapid return to normal fluid and food intake.1.5 A rapid return to normal fluid and food intake. 1.6 Early commencement of procedures for which a 1.6 Early commencement of procedures for which a

long recovery period is likely.long recovery period is likely.

2. Patient requirements for day care surgery 2. Patient requirements for day care surgery include:include:

2.1 Willingness, understanding, an ability 2.1 Willingness, understanding, an ability to follow discharge instruction.to follow discharge instruction.

2.2 Place of residence within one hour 2.2 Place of residence within one hour from medical attention.from medical attention.

2.3 ASA I or II. Medically stable ASA III or 2.3 ASA I or II. Medically stable ASA III or IV may be accepted following consultation IV may be accepted following consultation with the anaesthetist.with the anaesthetist.

2.4 Normal term infants > six weeks of age 2.4 Normal term infants > six weeks of age or ex-premature infants of > 60 weeks or ex-premature infants of > 60 weeks post-conceptual age.post-conceptual age.

3. Social requirements for day care surgery include:3. Social requirements for day care surgery include: 3.1 A responsible person to transport the patient 3.1 A responsible person to transport the patient

in a suitable vehicle.in a suitable vehicle. 3.2 A responsible person staying at least 3.2 A responsible person staying at least

overnight.“Mentally able.”overnight.“Mentally able.” 3.3 Patient /responsible person understands 3.3 Patient /responsible person understands

instructions and intends to comply… particularly instructions and intends to comply… particularly with regard to public safety.with regard to public safety.

3.4 Remain within one hour of medical attention 3.4 Remain within one hour of medical attention until the morning following.until the morning following.

3.5 Ready access to a telephone.3.5 Ready access to a telephone. 3.6 Advice as to when to resume activities such as 3.6 Advice as to when to resume activities such as

driving and decision making.driving and decision making.

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 < gestational age <

37 weeks37 weeks) recovering from minor ) recovering from minor surgical procedures under general surgical procedures under general anesthesia have an increased risk anesthesia have an increased risk for postoperative apnea, persists for postoperative apnea, persists until the 60th postconceptual week until the 60th postconceptual week

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

Controversial exclusion Controversial exclusion criteria.criteria.

 Morbid obesity Morbid obesity â Significant sleep apnoeaâ Significant sleep apnoea â Fragile diabetesâ Fragile diabetes â COPDâ COPD â Severe asthmaâ Severe asthma â Significant epilepsyâ Significant epilepsy â Patients prone to malignant â Patients prone to malignant

hyperpyrexiahyperpyrexia â Alcohol abuseâ Alcohol abuse

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 benzodiazepines, ketamine, and propofol 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 4-8 mg4-8 mg IVIV, ondansetron , ondansetron 4-8 mg4-8 mg IVIV, long-acting 5-, long-acting 5-HT3 antagonist- palonosetron HT3 antagonist- palonosetron 75 µg75 µg IVIV, and , and NKNK--1 antagonist - aprepitant, a transdermal 1 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 conventional CO2 insufflation technique /gasless technique - subdiaphragmatic /gasless technique - subdiaphragmatic instillation of local anesthetic - local anesthetic instillation of local anesthetic - local anesthetic at the portals and topical application at the at the portals and topical application at the surgical site. surgical site.

TENSTENS

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

Score based recoveryScore based recovery Patient is moved through the unit and Patient is moved through the unit and

discharged when they achieve a set of discharged when they achieve a set of criteria using a scoring systemcriteria using a scoring system

Time based recoveryTime based recovery Patient is moved through the unit and Patient is moved through the unit and

discharged when they achieve a set of discharged when they achieve a set of criteria and required time length of stay criteria and required time length of stay in the unit.in the unit.

Fast trackingFast tracking Clinical pathway that involves Clinical pathway that involves

transferring the patient from the transferring the patient from the operating room to the day surgery ward operating room to the day surgery ward (2(2ndnd Stage recovery) and bypassing Stage recovery) and bypassing PACU (1PACU (1stst stage) stage)

Discharge Scoring Discharge Scoring systemssystems

Aldrete scoring systemAldrete scoring system White et al scoring systemWhite et al scoring system PADSSPADSS Modified PADSSModified PADSS

Aldrete Scoring systemAldrete Scoring system

Requires a patient to reach the Requires a patient to reach the criteria of 9 or 10/10 before the cancriteria of 9 or 10/10 before the can Move from 1Move from 1stst stage to 2 stage to 2ndnd stage stage By pass 1By pass 1stst stage (by achieving the score stage (by achieving the score

in the operating room)in the operating room)

Aldrete Scoring systemAldrete Scoring system

Does not addressDoes not address PainPain NauseaNausea VomitingVomiting

Aldrete Scoring Aldrete Scoring systemsystem

Discharge Criteria Score

Activity: Able to move voluntarily or on commandFour extremities 2

Two extremities 1

Zero extremities 0

RespirationAble to deep breathe and cough freely 2

Dyspnoea, shallow or limited breathing 1

Apneic 0

CirculationBP +/- 20mm of pre anaesthetic level 2

BP +/- 20-50 mm of pre anaesthetic level 1

BP +/- 50mm of pre anaesthetic level 0

Discharge Criteria Score

ConsciousnessFully awake 2

Arousable on calling 1

Not responding 0

O2 SaturationAble to maintain O2 saturation >92% room air 2

Needs O2 inhalation to maintain O2 saturation >90% 1

O2 saturation <90% with O2 supplementation 0

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

Post anaesthesia discharge score (PADS) was noted after Post anaesthesia discharge score (PADS) was noted after surgery and patients are discharged only when they surgery and patients are discharged only when they achieved total score of =9achieved total score of =9

Discharge of the patient from the day Discharge of the patient from the day care unit:care unit:

1. Stable vital signs1. Stable vital signs 2. Orientated.2. Orientated. 3. Pain control3. Pain control 4. PONV, dizziness4. PONV, dizziness 5. Minimal bleeding5. Minimal bleeding 6. Hydration adequate, likelihood of oral intake.6. Hydration adequate, likelihood of oral intake. 7. Patients at significant risk of urinary retention 7. Patients at significant risk of urinary retention

must have passed urine.must have passed urine. 8. Responsible adult8. Responsible adult 9. Written and verbal instructions.9. Written and verbal instructions. 10. Suitable analgesia provided.10. Suitable analgesia provided. 11. A telephone inquiry (following day) whenever 11. A telephone inquiry (following day) whenever

possible.possible.

Discharge Criteria: Discharge Criteria: “Input & Output”“Input & Output”

Areas of controversy exist:Areas of controversy exist: 1. “Input”: oral intake prior to discharge.1. “Input”: oral intake prior to discharge. 2. “Output”: Requirement for urinary output.2. “Output”: Requirement for urinary output. ie: no definite direction/guidelines in ie: no definite direction/guidelines in

literature.literature. Discharge sooner if requirements relaxed:Discharge sooner if requirements relaxed: • • Associated cost saving.Associated cost saving. • • Increased readmission/complication risk.Increased readmission/complication risk.

““Input”:Input”:

Discharge contraindicated while actively Discharge contraindicated while actively vomiting.vomiting.

In children:In children:

• • Vomiting increased by 50% if forced oral Vomiting increased by 50% if forced oral intake.intake.

Vomiting more likely after discharge.Vomiting more likely after discharge.

• • (Therefore oral intake not predictive of later (Therefore oral intake not predictive of later vomiting.)vomiting.)

Is voiding necessary?Is voiding necessary?

Risk factors for post operative Risk factors for post operative urinary retention areurinary retention are Anorectal surgeryAnorectal surgery Old ageOld age Male sexMale sex Spinal anaesthesiaSpinal anaesthesia Hernia surgeryHernia surgery

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