By

Dr.MAHESH BABU B.V M.D,

Associate Professor of Anaesthesiology,
R.M.C, KAKINADA.

Introduction

The first freestanding outpatient surgical facility was built and

managed by an anesthesiologist, Wallace Reed.

Ambulatory Surgery is also known as Day-Case Surgery, SameDay 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

A.S.A GUIDELINES FOR AMBULATORY

ANESTHESIA AND SURGERY

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
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.

Benefits of Ambulatory Anesthesia

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

Priorities of Out-Patient Surgery

Four A s are:
1)Alertness
2)Ambulation

3)Analgesia
4)Alimentation

Surgeries taken under Ambulatory

Anesthesia

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 that can be taken up 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

Contra-Indications to Ambulatory
Surgery

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.

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.

Pre-operative Assessment

Laboratory Tests For Patients Undergoing Ambulatory

Surgeries

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,

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

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
-Adrenergic Agonists - 2 agonists - Clonidine, Dexmeditomidineanaesthetic & analgesic sparing effect-decrease emergence delirium
of Sevoflurane-reduce emesis-facilitate glycemic control- reduce
cardio-vascular complication
-Blockers Atenolol ,Esmolol attenuate adrenergic responsesprevent cardiovascular events

Pre medication
Benzodiazepines
Drug

Dosage Range

MIDAZOLAM

Onset(min)

Key Points

7.5-15 mg PO

15-30

Large first-pass effect

5-7 mg I.M

15-30

Water soluble,nonirritating

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

1-2 mg PO

45-90

Prolonged amnesic effect

Alpha 2-Adrenergic Agonists

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

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 .

SAMBA Guidelines For Management

PONV

Guideline 1: Identify Patients 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 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

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

Antiemetics For PONV

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

Transdermal Patch

Prior Evening or 4 hrs

before surgery

Ondansetron
Scopolamine

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

General Anesthesia

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.

I.V Induction Agents for Ambulatory

Anesthesia
Agent

Dose
(mg/kg
)

Onset of
Action

Thiopental

3-6

Methohexital

1.5-3

Etomidate

Recovery
Profile

Side effects

Rapid

Intermediate

Drowsiness(Hangover)

Rapid

Rapid

Pain(Excitatory Activity)

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,


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.

OPIOIDS

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 g/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 g/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.

INHALATIONAL ANESTHETICS

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 .

Muscle Relaxants

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.

Regional Anesthesia

Biers 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 g, or sufentanil, 5-10 g)
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 419425
, October 1966

WHITEs Criteria
Fast Track Discharge Eligibility Criteria
Criteria
Level of Consciousness

Score

Awake & oriented

Arousable with minimal stimulation

Responsive only tactile stimulation

Physical activity
Able to move all extremities on command

Some weakness in the movement of extremities

Unable to move the extremities voluntarily

Hemodynamic Stability
Blood Pressure <15% of the baseline MAP value

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

Blood Pressure >30% below the baseline MAP value

WHITES Criteria
Respiratory Stability
Able to breathe deeply

Tachypnea with good cough

Dyspnea with weak cough

1
0

Oxygen Saturation Status

Maintains > 90%

Requires Oxygen Supplementation

Saturation <90% with supplemental Oxygen

Post-Operative Pain Assessment
None or mild discomfort

Moderate to severe pain controlled with I.V analgesics

Persistent severe pain

Post operative emetic symptoms

WHITES 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.

Modified Postanesthesia Discharge

Scoring (PADS) System
Vital Signs
Within 20% of the pre-operative value

20%-40% of the pre-operative value

40% of the pre-operative value

Ambulation

Steady gait /no dizziness

With Assistance

No ambulation/dizziness

Nausea & Vomiting

Minimal

Moderate

Severe

Pain
Minimal

Moderate

Severe

Surgical Bleeding
Minimal

Moderate

Severe

PADS System

Total Score >10; 9/>9 is required

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.

BROWNS 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 (daycase) basis.

SUMMARY

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.


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tomorrow. The important thing is not to stop
questioning- Albert Einstein

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