• Complex ambulatory procedures

• Advances in surgical procedures

• Fine tuning of anesthetic techniques
• Adequate anesthesia, minimizing
adverse effects, afford timely
discharge
• Physician office, Ambulatory
centers, or in a hospital
• Cost low
• Turn round time is minimum
• Common misconception: only ASA PS
I & II
• ASA PS (III & IV ) cared for
successfully
• Comorbidities stable and optimized
• Surgeries associated with low risk post
op complications, minimal post op
care.
• Shorter duration of surgery
• Infants and premature 12 hour post op
monitoring
• Extremes of age alone not
contraindicated.
• Responsible adult escort home and
take for first 24 hours
• Pre op screening absolute must
• Complete medical history including
surgeries, difficulties with
anesthesia in the past current
medications and allergy
• Pre op fasting guidelines
• Post op plan for transportation by
an adult
• Adult with URI no elective surgery
delayed by 6 weeks following URI
• Children appear well, afebrile,
breathing and eating normally
• Pre operative visit by
anesthesiologist
• Pre op education, instructions and
medications
• Children: Parental presence,
distraction techniques and
medications
• Adults: Tablet Lorazepam 1-2 mg
orally previous day at bed time.
• Children: Midazolam 0.25 to 0.5 mg
orally 1 hour before surgery PO.
• Premedication: careful selection of
agents and dose
• Benzodiazepines: Midazolam
anxiolytic and amnesic
• Opioids : Pre procedural sedation,
decrease sympathetic response
• NSAIDS : Ketorolac, Ibuprofen,
acetaminophen: modulate pain,
opioid sparing effect.
• General anesthesia
• Regional anesthesia
• Neuraxial anesthesia
• Monitored anesthesia care
• Local anesthesia
• Type of surgery dictates the
techniques
• Neuraxial block
• Peripheral nerve block (PNB)
• Intravenous regional block (Bier’s
block)
• Local anesthetic infiltration
• Field block
• Advantages: less sedation required,
duration can be prolonged by
catheter insertion
• Appropriate choice in lower
extremity and infra umbilical
surgeries
• Short acting drugs: rapid recovery
of motor and sensory functions
• Shortens duration to discharge
• PDPH uncommon due to use of
lower gauge needles.
• Epidural catheter : drugs can
injected and given continuously by
infusion

• Caudal anesthesia : children lower

abdominal surgery in conjunction
with general anesthesia
• Provides excellent post operative
analgesia
• Reduced pain, nausea and vomiting
• Increased patient satisfaction
• Orthopedic surgery post op
analgesia assured by continuous
infusion of local anesthetic using
catheter placed near the nerve using
ultrasound
• IV sedation adjunct to local
anesthetic provides analgesia,
reduces discomfort of positioning
on the OR table and also provides
amnesia
• Appropriate anesthetic: rapid
awakening, shorter recovery and
timely discharge
• Induction agent : Propofol
• Muscle relaxant: vecuronium/
Rocuronium
• Maintenance of anesthesia: volatile
anesthetic sevoflurane / Desflurane
• Nitrous oxide : good analgesic and
reduces requirement of volatile
anesthetic, increase incidence of
PONV
• Multimodal approach: concomitant
use of analgesic agents with
different mechanism of action
• Opioid sparing effect
• Fewer deleterious side effects
• Ketorolac or Ibuprofen and /or
acetaminophen
• Same standard of Pre operative
evaluation, Preparations,
intraoperative monitoring and
postoperative care.
• Policies and procedures must be in
place to ensure minimum standard
of care
• Follow up of patients and outcome
will allow to continuously increase
patient safety and satisfaction