Outpatient Anesthesia transparencies

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					Outpatient Anesthesia (Ch46 M&M)
- 70% of all procedures in the US done on an outpatient basis - Driving force: o Economic savings (No admission the night before or after surgery) o Patient convenience, Less risk of nosocomial infections - Benefits from outpatient surgery trend: o New minimally invasive & endoscopic approaches to surgery o Increased interest on development of ultra-short-acting anesthetic agents

Site considerations: - Office-based - Free-standing surgery center - Hospital setting - Regardless of location, anesthesiologist should have drugs and equipment to provide a safe anesthetic

Surgical case selection : - Resources of facility - Estimated duration of surgery - Level of postoperative care required - Some free-standing surgery centers won’t do T&As (3% bleeding rate), > 2-3 hr surgical time, or cases complicated by infection (isolation rooms not available)

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Elvin Cruz, MD, MS Oct 2004

Patient selection : - Previously only ASA 1-2 - Many centers now allow medically stable ASA 3, and even ASA 4 for limited surgery - Sicker pts need a case-by-case evaluation for outpatient surgery - Need to consider extent of the disease & the nature of surgical procedure - Patient must be able to cooperate with written pre/post-op instructions - Responsible adult available to accompany patient home - Possibility of overnight hospital admission must be understood and accepted by patient - Age is not a contraindication for outpatient surgery except: o Premies <60 weeks postconception (50 in some places) o Infants with h/o bronchopulmonary dysplasia or apneic episodes with sxs within last 6 months o Siblings of infants who died of SIDS

Pre-op evaluation: - Same level of pre-operative care - Logistical problems lead to excessive laboratory testing and consults by some surgeons - Judicious use of short acting pre-medications

Anesthetic techniques: - GA: Same intraoperative monitoring standards as inpatient surgery patients o Propofol, STP, Etomidate, Methohexital, INH agents OK o Ketamine might give prolonged emergence o LMA vs ETT o INH agent (DES, SEVO, N2O) vs TIVA o Short acting narcotics (Remi, Alfenta, Sufenta) o Short-Intermediate acting NMB (Suxx, Mivacurium, Atra, Cisatra, Roc, Vec)
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- Regional: o Advantages  Decreased postop pain  Less CNS function alteration  Less emesis, drowsiness o Disadvantages  Time required to perform blocks  SAB/LEA: Ortho hypoTN, Prolonged motor block, Urinary retention, PDPH - MAC: o Combine sedation with field block/infiltration o Minor plastics, Breast bxs, Ophtho procedures

Postop Considerations: - Risk factors for complications: o Females (surprise!) o No previous GA o ETT o Abdominal surgery o Surgical time > 20 minutes - Risk factors for PONV: o Patient factors: Young, Female, H/o PONV, H/o motion sickness, Delayed gastric emptying (Obese?) o Anesthetic: Opiates, GA, INH/Neostigmine/Ketamine, hypoTN o Surgery: Strabismus, Ear, Laparoscopic, Orchiopexy, GYN, Tonsils - Postoperative pain: o Opiates, Ketorolac, PO NSAID pre-op?

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Elvin Cruz, MD, MS Oct 2004

- Other complications o Prolonged somnolence o HA o Urinary retention o Sore throat o Postintubation croup

Discharge criteria: - Discharge from outpatient surgery only if minimum level of “Home readiness” achieved - Accompanied by responsible adult who will stay with pt overnight - Written postop instructions on how to obtain emergency help & to perform routine follow-up care - Authority to d/c home is responsibility of physician; can be delegated to nurse if preapproved criteria rigorously applied - Complete psychomotor recovery often not achieved until 24-72 hrs postop - Outpatient center must use a follow-up system (phone calls, questionnaire, etc)

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Elvin Cruz, MD, MS Oct 2004

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