Dr. S. Parthasarathy
MD., DA., DNB, MD (Acu),
Dip. Diab.DCA, Dip. Software statistics
PhD (physio)
Mahatma Gandhi Medical college and
research institute , puducherry , India
Can we go about like that??
 Definition
 Structure
 Set up
 Cases
 Anaesth technique
 PACU
Definition
 ambulatory surgery
 “An operation/procedure, excluding an office or
outpatient operation/procedure, where the patient is
discharged on the same working day”
 Synonymous or different terms !!
Is there a distinction
 distinction is to designate cases as outpatient when the
patient is generally expected not to need any
specialized care or specialized surveillance when the
procedure is finished.
 ambulatory surgery has grown from less than 10%
to over 70% of all elective surgical procedures
SAMBA
 Recognized respected subspecialty occurred with
establishment of the Society for Ambulatory
Anesthesia (SAMBA) in 1984.
the focus of ambulatory anesthesia is on the
patient
 Patient preference, especially children and the
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elderly
Lack of dependence on the availability of hospital
beds
Greater flexibility in scheduling operations
• Low morbidity and mortality
• Lower incidence of infection
• Lower incidence of respiratory complications
• Higher volume of patients (greater efficiency)
• Shorter surgical waiting lists
• Lower overall procedural costs
• Less preoperative testing and postoperative
medication
Structure
Unbelievable list
 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
Unbelievable list
 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
Unbelievable list
 Otolaryngology Adenoidectomy, laryngoscopy,
mastoidectomy, myringotomy, polypectomy,
rhinoplasty, tonsillectomy, tympanoplasty
 Pain clinic Chemical sympathectomy, epidural
injection, nerve blocks
Unbelievable list
 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
Unbelievable list
 Orthopedic
 Anterior cruciate repair, knee arthroscopy,
shoulder reconstructions, bunionectomy, carpal
tunnel release, closed reduction, hardware
removal, manipulation under anesthesia and
minimally invasive hip replacements
 BUT !!
Thats the hitch !!
 duration of surgery in the ambulatory setting was
originally limited to procedures lasting less than 90
minutes
 Previously ASA I and II but III also in some instances
 Plan 1- 3 weeks prior
Ambulatory surgery ??
 major postoperative surgical complications
 major fluid shifts
 procedures requiring prolonged immobilization
and parenteral opioid analgesic therapy
 ambulatory patient-controlled analgesic techniques
(e.g., subcutaneous, intranasal, transcutaneous), is
allowing more patients undergoing painful orthopedic
procedures to be discharged home on the day of
surgery.
Definite NO
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1. Potentially life-threatening chronic illnesses
(e.g., brittle diabetes, unstable angina, symptomatic
asthma)
2. Morbid obesity complicated by symptomatic
cardiorespiratory problems (e.g., angina, asthma)
3. Multiple chronic centrally active drug therapies
(MAOIs)
4. Ex-premature infants less than 60 weeks’
postconceptual age requiring general endotracheal
anesthesia
5. No responsible adult at home to care for the
patient on the evening after surgery
SONIA – pneumonic
Specific situations
Hypertension
 newly discovered hypertension or very high values or
unstable high values should be evaluated and
optimized before being scheduled for ambulatory care.
 Patients with arrhythmia, heart block, or a pacemaker,
heart failure – better to avoid
Diabetes mellitus
 Diabetic patients may be unsuitable for ambulatory
care if they have some of the more serious
complications
of
prolonged
diabetes,
namely
cardiovascular disease, kidney failure, neuropathy,
 and morbid obesity.
Drug abuse
 Body builders – OK
 But alcohol –
 consider nutrition , LFT and type of surgery
Psychiatric patients, patients with cognitive
dysfunction or disabilities
 usually benefit from having as short and uneventful
stay in the hospital environment as possible
 More at home
 But no to any acute illness
Pregnancy – second trimester
preferable
 surgery should be ambulatory or not will
depend not on the pregnancy per se but on
the patient’s general condition and comorbidities.
 Breastfeeding is fully compatible with any surgery or
anesthetic- ambu – ok
Liver and kidney disease
 Acute illness
 Dialysis prior
 LFT results
 INR
 Type of surgery
Thyroid
 Airway
 hyperthyroidism
 Doubt for ambulatory surgery
Other systemic illness
 Rheumatoid arthritis, Bechterew disease (ankylosing
spondylitis), and other rheumatic conditions
 These patients will usually be eligible for ambulatory
care if they have no other major comorbidity.
Other systemic illness
 Problems with previous anesthetics or with
anesthesia in close family
 Beware and analyse
 Myaesthenia – avoid
Personnel
 Anaesth + staff + nurse anaesth
 Surgeon only local small cases
Monitors
 noninvasive blood pressure monitoring,
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electrocardiography (ECG),
pulse oximetry,
capnography for all intubations,
gas monitoring (both in and out of patients) of oxygen
and all inhalational gases,
alarms to alert to problems of gas delivery and a low
oxygen content in the ventilation gas, and
temperature monitoring.
BIS
 In case of emergencies there must be fast access to a
suction device, a self-expanding ventilation bag with
reservoir and extra oxygen supply, a defibrillator and
emergency drugs
 intubation kit including devices for difficult
intubations.
Consent for ambulatory surgery
 A general rule is that the patient should consent
to being sent home
 Journey time – not much decisive
 In patients with drug, alcohol, or substance abuse
or who have an unstable social situationindividual decisions
Preanaesthesia
 Can have an OPD consultation with anaesth
 Upto 3 months valid usually
 Healthy patients can go for spot assessment
 As a part of an inpatient hospital or alone
Preop
 Fasting 6- 8 hours
 URI 6 weeks gap
 Premed – IV / oral midazolam ( not a must)
 Opioids pain and intubation response –
 Pethidine – antishivering
 acetaminophen, 40 mg/kg rectally, and ketorolac, 0.5
mg/kg intravenously.
 Antiemetic premed
Principles
 two primary concerns for ambulatory anesthesia are
 speed of wake-up
 incidence of postoperative nausea and vomiting.
 Wake up time and discharge fit time !!
Pharmacology
Problems
 hypnotic, analgesic, and anti-nociceptive drugs
have to be lipid soluble in order to penetrate the
blood–brain barrier and reach their target cells in
the central nervous system.
 distributed extensively into all other cells and tissues-
cant go out thro kidneys
 brain and spinal cord have a large blood supply- hence
more drugs – to be given
general anesthesia, regional anesthesia, and
local anesthesia
 In obstetrics, regional anesthesia, and local
anesthesia are preferable
 In others all are acceptable
Local
 patients who received local anesthesia also spent less
time in the OR,
 had less postoperative pain, and the
 least problems with urination.
 Cost is less
Spinal
 children aged 6 months to 14 years for procedures on
the lower part of the body
 0.5% hyperbaric bupivacaine at a dose of 0.2 mg/kg.
 Adults
 pencil point, noncutting tips
 ambulatory laparoscopic cholecystectomy
 Drugs
Epidural and caudal
 Longer
 Difficult
 Failure
Nerve blocks
 Nerve blocks improve postoperative patient satisfaction—
PONV and postoperative pain are less. Costs are also less
 Paravertebral somatic nerve block can be used for breast
surgery
 Perineural catheters in the sciatic nerve through the
popliteal fossa
 Cont. femoral catheters
 Interscalene catheters .
Post op pain relief
General Anesthesia
 The popularity of propofol as an induction agent for
outpatient surgery in large veins
 Suxa or rocuronium advised for paralysis
 An intubating dose of mivacurium (0.150.20 mg/kg) longer duration than suxa and better
recovery
Principles
 two primary concerns for ambulatory anesthesia are
 speed of wake-up
 incidence of postoperative nausea and vomiting.
 Wake up time and discharge fit time !!
Agents
 propofol, sevoflurane, and desflurane
Because of its extremely low tissue solubility,
desflurane is associated with the most rapid
recovery of both cognitive and psychomotor
function
 Nitrous oxide : fast recovery , analgesia but PONV
Pharmacologic antagonists
 antagonists frequently produce unwanted side
effects (e.g., dizziness, headaches, nausea,
vomiting).
 duration of action of the antagonist is shorter
than the agonist (e.g., naloxone, flumazenil), a
“rebound” agonist effect may occur later in the
recovery period.
 Problem for ambulatory cases.
specifically selective serotonin antagonists and
acupuncture
 Nitrous
 Agents
 Opioids(fent- NSAIDs)
Airways
 Supraglottic airway device especially LMA
 Cough
 Sorethroat
 Anas requirements
 But gastric sufflation and PONV
PACU
 drowsiness,
 nausea and vomiting,
 pain.
 All three are a function of intraoperative
management, but nausea, vomiting, and pain also can
be treated in the PACU.
 Other problems anaesth and surgical
Discharge from the postanesthesia
care unit
 Phase 1 - discontinuation of anesthetic agents until the
recovery of the protective reflexes and motor function
 phase 2 is the period during which the criteria for
discharge from the ambulatory surgical unit
(ASU) are obtained.
 phase 3 lasts for several days and continues until the
patient is back to their preoperative functional status
and is able to resume their daily activities
modified Aldrete scoring system
 Activity: Able to move voluntarily or on command
 Respiration
 Circulation
 Consciousness
 O2 saturation
 Score of 10 – 8 or 9 is a must
Recovery and discharge
 Scoring systems
 White and Song scoring system for fast track
 Experience explained
 Adults
Is oral fluid intake necessary before
discharge?
 If forced,higher incidence of vomiting and a prolonged
hospital stay in children
 for adults, drinking did not infl uence the incidence of
PONV or duration of hospital stay
 Drinking oral fluids is not a requirement prior to
discharge
Is voiding necessary before discharge?
 voiding is not a requirement before discharge
 Risks
 USG
Is an escort needed following
ambulatory surgery?
 ASA recommendations – must
 When can you drive following ambulatory surgery?
 Recently, a prospective study involving ambulatory
surgery demonstrated that patients have lower
alertness levels and impaired driving skills
preoperatively and 2 hours postoperatively. These
parameters returned to normal at 24 hours.
Summary
 Definition
 Structure
 Cases and NO
 Premed and anaesthesia
Recovery and PONV
PACU
Discharge controversies