By

Dr.MAHESH BABU B.V M.D,

Associate Professor of Anaesthesiology,

R.M.C, KAKINADA.

The first freestanding outpatient surgical facility was built and

managed by an anesthesiologist, Wallace Reed.

Ambulatory Surgery is also known as Day-Case Surgery, Same-Day Surgery etc.

SAMBA-SOCIETY FOR AMBULATORY ANESTHESIA

SAMBA represents the interests of clinicians, works to enhance patient safety and provides research and education for

practitioners of ambulatory anesthesia.

SCOR- SAMBA Clinical Outcome Registry

Introduction

I. ASA Standards, Guidelines and Policies should be adhered to in all settings except where they are not applicable to outpatient care.

II. A licensed physician should be in attendance in the facility, or in the case of overnight care, immediately available by telephone, at all times during patient treatment and recovery and until the patients are medically discharged.

III. The facility must be established, constructed, equipped and operated in accordance with applicable local laws and regulations. At a minimum, all settings should have a reliable source of oxygen, suction, resuscitation equipment and emergency drugs.

IV. Staff should be adequate to meet patient and facility needs for all procedures performed in the setting, and should consist of:

1)Professional Staff

2)Administrative Staff

3)House-keeping & Maitenance Staff.

A.S.A GUIDELINES FOR AMBULATORY ANESTHESIA AND SURGERY

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.

VII. Minimal patient care should include:

A. Preoperative instructions and preparation.

B. An appropriate pre-anesthesia evaluation and examination by an anesthesiologist, prior to anesthesia and surgery.

C. Preoperative studies and consultations as medically indicated.

Approved by the ASA House of Delegates on October 15, 2003, and last amended on

October 22, 2008)

A.S.A Guidelines

D. An anesthesia plan developed by an anesthesiologist, discussed with and accepted by the patient and documented.

E. Administration of anesthesia by anesthesiologists, other qualified physicians or non-physician anesthesia personnel medically directed by an anesthesiologist. Non-anesthesiologist physicians must be qualified by education, training, licensure, and appropriately credentialed by the facility.

F. Discharge of the patient is a physician responsibility.

G. Patients who receive other than un supplemented local anesthesia must be discharged with a responsible adult.

H. Written postoperative and follow-up care instructions.

I. Accurate, confidential and current medical records.

A.S.A Guidelines

1)Patient preference, especially children and the elderly

2)Lack of dependence on the availability of hospital beds

3)Greater flexibility in scheduling operations

4)Low morbidity and mortality

5)Lower incidence of infection

6)Lower incidence of respiratory complications

7)Higher volume of patients (greater efficiency)

8)Shorter surgical waiting lists

9)Lower overall procedural costs

10)Less preoperative testing and postoperative medication

Benefits of Ambulatory Anesthesia

Four „A‟ s are:

1)Alertness

2)Ambulation

3)Analgesia

4)Alimentation

Priorities of Out-Patient Surgery

Dental- Extraction, Fractures of Mandibular & Maxillary bones

Dermatology- Excision of skin lesions

General Surgery-Biopsy, Endoscopy,Excision of masses, Haemorrhoidectomy ,Herniorrhaphy, Lap procedures, Varicose vein surgery

Gynaecology-Cone biopsy, D&C, Hysteroscopy, Diagnostic Lap, Polypectomy ,Tubal Ligation, Vaginal Hysterectomy

Ophtholmology-Cataract Extraction, Naso lacrimal duct probing, Strabismus repair, Chalazion Excision, Tonometry

Surgeries taken under Ambulatory Anesthesia

Orthopedic surgeries: Arthroscopies, Tendon repairs, Ligament

repairs, Carpal Tunnel Release, Bunionectomy etc.

Plastic Surgery: Cleft lip repair, Liposuction, Mammoplasty, Scar Excision, Rhinoplasty etc.

Urology: Bladder surgeries, Circumcision, Cystoscopy, Vasovasostomy ,Prostate Biopsy etc.

E.N.T: Adeno -tonsillectomy, ,Mastoidectomy, Septoplasty, Foreign body removal, Tympanoplsty, Myringotomy etc.

Pain Clinic: Epidural Injections, Sympathectomy, Nerve Blocks

Modified from White PF (ed): Ambulatory Anesthesia and Surgery. London, WB Saunders, 1997

Surgeries that can be taken up under Ambulatory Anesthesia

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 (e.g., use of monoamine

oxidase inhibitors such as Pargyline and Tranylcypromine) and/or active

Cocaine abuse

4)Ex-premature infants less than 60 weeks‟ post -conceptual age requiring

General Endo-tracheal anesthesia

5)No responsible adult at home to care for the patient on the evening after

surgery.

Contra-Indications to Ambulatory Surgery

Preoperative assessment

The three primary components of a preoperative assessment – History (86%), Physical examination (6%), and Laboratory testing (8%)

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

All paperwork (consent form, History, Physical examination, and Laboratory test results) should be reviewed before the patient arrives for surgery.

Appropriate patient preparation before the day of surgery can prevent unnecessary delays, absences , last-minute cancellations, and substandard perioperative care.

Age Range Men Women

<40 None Pregnancy Test

40-49 E.C.G Hematocrit, Pregnancy Test

50-64 E.C.G Hb/Hematocrit Level& E.C.G

65-74 Hb /Hematocrit, E.C.G serum Urea &Nitrogen, Glucose

Hb /Hematocrit, E.C.G serum Urea &Nitrogen, Glucose

>75 Hb /Hematocrit, E.C.G serum Urea &Nitrogen, Glucose & CXR

Hb /Hematocrit, E.C.G serum Urea &Nitrogen, Glucose & CXR

Pre-operative Assessment Laboratory Tests For Patients Undergoing Ambulatory

Surgeries

Preoperative Preparation

Non-pharmacologic Preparation -– – high patient acceptance - preoperative visit -educational programs -videotapes

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

Pharmacologic Preparation

Anxiolysis and Sedation Barbiturates -residual sedation

Benzodiazepines - Diazepam 0.1 mg/kg PO Midazolam 0.5mg/kg PO or 1mg IV

α-Adrenergic Agonists - α2 agonists - Clonidine, Dexmeditomidine- anaesthetic & analgesic sparing effect-decrease emergence delirium of Sevoflurane-reduce emesis-facilitate glycemic control- reduce cardio-vascular complication

β-Blockers –Atenolol ,Esmolol –attenuate adrenergic responses-prevent cardiovascular events

Drug Dosage Range Onset(min) Key Points

MIDAZOLAM 7.5-15 mg PO 15-30 Large first-pass effect

5-7 mg I.M 15-30 Water soluble,non-irritating

1-2 mg I.V 1-5 Rapid onset , Excellent Amnesia

DIAZEPAM 5-10 mg PO 45-90 Long acting metabolites

TEMAZEPAM 15-30 mg PO 15-40 Comparable to MDZ

LORAZEPAM TRIAZOLAM

1-2 mg PO 0.125-0.25 mg PO

45-90 15-30

Prolonged amnesic effect Prominent Sedation

Pre medication Benzodiazepines

CLONIDINE 0.1-0.3 mg PO 45-60 min Prolonged sedative

effect

DEXMEDETOMIDINE 50-75 micrograms I.M

20-60 min Bradycardia Hypotension

50 micrograms I.V

5-30 min Reduced anesthetic & analgesic requirements

Alpha 2-Adrenergic Agonists

Pharmacologic Preparation

Pre-emptive /Preventive Analgesia

Opioid (Narcotic) Analgesics

Anesthetic sparing-minimize hemodynamic response

PONV, urinary retention -delay discharge

Nonopioid Analgesics

Surgical bleeding-gastric mucosal & renal tubal toxicity

A “fixed” dosing schedule beginning in the preoperative period and extending into the post discharge period.

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

Guideline 1: Identify Patient‟s Risk for PONV

Risk Factors for Adults

APFEL Score:

Risk Factors Points

1)Female Gender 1

2)Non-Smoker 1

3)History of PONV 1

4)Postoperative Opioids 1

Sum = 0 ... 4

SAMBA Guidelines For Management PONV

Risk Factors for Children

Risk Factors Points

1) Surgery > 30 min. 1

2) Age > 3 yrs 1

3) Strabismus Surgery 1

4) H/O POV or PONV

in Relatives 1

Sum 0- 4

SAMBA Guidelines for PONV

Guidelines 2 :

Reduce Baseline Risk Factors for PONV

1) Avoidance of G.A by using Regional Anesthesia

2) Use of Propofol for Induction & Maintenance

3) Avoidance of Volatile Anesthetics

4) Avoidance of Nitrous Oxide

5) Minimization of Intra-operative & Post-operative Opioids

6) Minimization of Neostigmine

7) Adequate hydration

SAMBA Guidelines For PONV

SAMBA Guidelines For PONV

Guideline 3 :Administer PONV Prophylaxis Using

One to Two Interventions in Adults at Moderate Risk for PONV Pharmacological Techniques Butyrophenones –Droperidol, Haloperidol

Phenothiazines –Prochlorperazine, Promethazine

Antihistamines –Dimenhydrinate, Hydroxyzine

Anticholinergics –Atropine, Glycopyrrolate, Trans Dermal Scopolamine

Serotonin Antagonists –Ondensetron , Granisetron, Palanosetron

Steroid - Dexamethasone

Neurokinin-1 Antagonists- Aprepitant (oral route)

Nonpharmacologic Techniques Acupuncture,

Acupressure and

TENS at the P-6 acupoint - with the Relief Band

Drugs Dose Timing

Dexamethasone 4 mg I.V At Induction

Dimenhydrinate 1 mg/kg I.V End of Surgery

Dolasetron 12.5 mg I.V End of Surgery; timing may not affect efficacy

Droperidol 0.625-1.25 mg I.V End of Surgery

Ephedrine 0.5 mg/kg I.M End of Surgery

Granisetron 0.35-1.5 mg I.V End of Surgery

Prochlorperazine 5-10 mg I.V End of Surgery

Promethazine 4 mg I.V End of Surgery

Ondansetron

Scopolamine Transdermal Patch Prior Evening or 4 hrs before surgery

Tropisetron 2 mg I.V End of Surgery

Antiemetics For PONV

Management of PONV

Pharmacologic Preparation

Prevention of Aspiration Pneumonitis No increased risk of aspiration in fasted outpatients

Routine prophylaxis for acid aspiration is no longer mandatory, except in cases of Pregnancy, Scleroderma, Hiatal hernia, Severe diabetics, Morbid obesity

-H2-Receptor Antagonists

-Proton Pump Inhibitors

Pharmacologic Preparation

NPO Guidelines

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

Hunger, thirst, hypoglycemia, discomfort

Preoperative administration of Glucose-containing fluids prevents postoperative insulin resistance and attenuates the catabolic responses to surgery while replacing fluid deficits .

Basic Anesthetic Techniques

General Anesthesia

Regional Anesthesia - Spinal and Epidural

Intravenous Regional Anesthesia

TIVA- combination of Propofol and Remifentanil -TCI

Peripheral Nerve Blocks

Local Infiltration Techniques

Monitored Anesthesia Care

Most outpatients undergoing superficial procedures under G.A

do not require tracheal intubation unless they are at an increased risk for aspiration.

The LMA can be easily positioned without direct visualization or neuromuscular blocking drugs, and patients can ventilate spontaneously throughout the procedure if muscle relaxants are not needed.

General Anesthesia

I.V Induction Agents for Ambulatory Anesthesia

Agent Dose (mg/kg)

Onset of Action

Recovery Profile

Side effects

Thiopental 3-6 Rapid Intermediate Drowsiness(“Hangover”)

Methohexital 1.5-3 Rapid Rapid Pain(Excitatory Activity)

Etomidate 0.15-o.3 Rapid Intermediate Pain, Myoclonus, Emesis

Ketamine 0.75-1.5 Immediate Intermediate Psycho mimetic reactions, Cardiovascular reaction

Midazolam 0.1-0.2 Slow Slow Drowsiness, Amnesia

Propofol 1.5-2.5 Rapid Rapid Pain on injection, Cardiovascular effects

Propofol is the preferred agent.

It can be combined with Remifentanil and used in TIVA.

The most popular technique is a combination of a volatile anesthetic with or without nitrous oxide.

Volatile anesthetics are associated with a more frequent incidence of vomiting than Propofol-based anesthetic techniques.

Etomidate can be used for short procedures when hemodynamic stability is required.

Fentanyl,Alfentanil,Sufentanil & Remifentanil are preferred

drugs.

Remifentanil is an ultrashort-acting opioid with a half life of 8-10 min and context-sensitive half life of 4 min.

Low-dose of Remifentanil(0.05-0.2 µg/kg/min) in combination with Sevoflurane or Desflurane can produce a significant anesthetic-sparing effect and thereby contribute to a faster emergence from anesthesia.

Bolus doses of Remifentanil (0.5-1 µg/kg) were more effective than a standard dose of Fentanyl in suppressing the acute hemodynamic response to laryngoscopy and tracheal intubation in outpatients undergoing laparoscopy procedures.

Lee MP, Kua JS, Chiu WK: The use of remifentanil to facilitate the insertion of the laryngeal mask airway. Anesth Analg 2001; 93:359-362.1990; 73:230.

OPIOIDS

Sevoflurane is widely used for inhaled induction.

When Desflurane is used for maintenance emergence would be significantly faster than with Sevoflurane .

Compared with the volatile anesthetics, Propofol anesthesia offer the advantage of a lower incidence of PONV .

INHALATIONAL ANESTHETICS

Succinyl choline is preferred when difficult airway is

anticipated.

Mivacurium allows spontaneous reversal of N.M blockade after brief surgical procedures.

An intubating dose of Mivacurium (0.15-0.20 mg/kg) has twice the duration of action of succinylcholine (20-30 min) but a significantly more rapid spontaneous recovery profile than Atracurium, Vecuronium, or Rocuronium.

Sugammadex produces a rapid and complete reversal of Rocuronium induced N.M. blockade.

Muscle Relaxants

Bier‟s Block( IVRA)

Peripheral Nerve Blocks

Spinal Anesthesia

Regional Anesthesia

I.V.R.A. & Peripheral Nerve Blocks are preferred .

They are better combined with Monitored Anesthesia Care (M.A.C).

Compared with General endotracheal and central neuraxial techniques for superficial (non-cavitary) surgical procedures, MAC-based techniques can facilitate desirable recovery in the ambulatory setting.

Regional Anesthesia

Spinal Anesthesia: The most troublesome complications of outpatient Spinal anesthesia

are related to residual effects of the block on motor, sensory, and sympathetic nervous system function.

These residual effects can contribute to delayed ambulation, dizziness, urinary retention, and impaired balance.

Use of so-called mini-dose Lignocaine (10-30 mg), Bupivacaine (3.5-7 mg), or Ropivacaine (5-10 mg) techniques combined with a potent opioid analgesic (e.g., fentanyl, 10-25 µg, or sufentanil, 5-10 µg) results in faster recovery of sensory and motor function.

Short-acting local anesthetics (e.g., Lignocaine and Procaine) are clearly preferable to Bupivacaine, Ropivacaine, and Tetracaine in achieving a rapid recovery.

Acta Anaesthesiologica Scandinavica Volume 10, Issue Supplement s23, pages 419–425 , October 1966

Regional Anesthesia

Criteria Score

Level of Consciousness

Awake & oriented 2

Arousable with minimal stimulation 1

Responsive only tactile stimulation 0

Physical activity

Able to move all extremities on command 2

Some weakness in the movement of extremities 1

Unable to move the extremities voluntarily 0

Hemodynamic Stability

Blood Pressure <15% of the baseline MAP value 2

Blood Pressure bet 15%-30% of the baseline MAP value 1

Blood Pressure >30% below the baseline MAP value 0

WHITE‟s Criteria Fast Track Discharge Eligibility Criteria

Respiratory Stability

Able to breathe deeply 2

Tachypnea with good cough 1

Dyspnea with weak cough 0

Oxygen Saturation Status

Maintains > 90% 2

Requires Oxygen Supplementation 1

Saturation <90% with supplemental Oxygen

Post-Operative Pain Assessment

None or mild discomfort 2

Moderate to severe pain controlled with I.V analgesics 1

Persistent severe pain 0

Post operative emetic symptoms

None or mild nausea with no active vomiting 2

Transient vomiting or retching 1

Persistent moderate to severe nausea and vomiting 0

Total Score 14

WHITE‟S Criteria

A score >12 with no individual score <1 required for

fast-tracking

White PF, Song D: New criteria for fast-tracking after outpatient anesthesia: A comparison with the modified Aldrete's scoring system. Anesth Analg 88:1069, 1999.

WHITE‟S Criteria

Vital Signs

Within 20% of the pre-operative value 2

20%-40% of the pre-operative value 1

40% of the pre-operative value 0

Ambulation

Steady gait /no dizziness 2

With Assistance 1

No ambulation/dizziness 0

Nausea & Vomiting

Minimal 2

Moderate 1

Severe 0

Modified Postanesthesia Discharge Scoring (PADS) System

PADS System Total Score >10; 9/>9 is required

Pain

Minimal 2

Moderate 1

Severe 0

Surgical Bleeding

Minimal 2

Moderate 1

Severe 0

From Chung F, Chan VW , Ong D: A postanesthetic discharge scoring system for home readiness after ambulatory surgery. J Clin Anesth 7:500, 1995

Before ambulation, patients receiving a central

neuraxial block should have normal perianal (S4-5) sensation, have the ability to plantarflex the foot, and have proprioception of the big toe.

Discharge criteria after spinal and epidural anesthesia should include the return of normal sensation, muscle strength, and proprioception, as well as the return of sympathetic nervous function.

BROWN‟S Discharge Criteria

With the availability of rapid, short-acting anesthetic,

analgesic, sympatholytic, and muscle relaxant drugs, as well as improved cerebral monitoring techniques, it has been possible to minimize the adverse effects of anesthesia on the recovery process.

Improvements in perioperative care has allowed surgeons to perform an increasing array of more invasive surgical procedures on outpatients with complex medical conditions on an ambulatory (day-case) basis.

1) Meticulous pre-operative Evaluation of the patient with all

the necessary investigations.

2) Proper Counselling of the patients & their relatives , explaining all about surgical complications and post-operative care.

3) Avoiding all the anaesthetic drugs with prolonged duration of action and residual effects.

4)Wherever possible, simple regional anaesthesia techniques should be practiced.

5)Discharge of the patients should be strictly guided by the anesthesiologist.

SUMMARY

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