AMBULATORY ANESTHESIA

Introduction
Current estimates are that 40 to 60 percents of all surgical procedures could be performed in outpatient surgery centers Several factor that contributed to the renewed interest in ambulatory surgery; - Hospital costs are decreased 25 to 75 percents , but specialized postoperative care may be more costly - Separation from patients familiar home environment are decreased - Decreased risk of hospital-acquired infection for pediatric and immunocompromized cancer and transplant patients - Incidence of respiratory complication(e.g., pulmonary embolus and pneumonia) may also be decreased The availability of both shorter-acting anesthetics and longer acting analgesics and antiemetics enables us to care for patients effectively Ambulatory surgery occurs in a variety of setting. Some center are within a hospital or in a freestanding satellite facility that is either part or independent of a hospital

Procedures for Ambulatory Surgery

An appropriate procedures for ambulatory surgery are those associated with; - Postoperative care that easily managed at home - With low rates of postoperative complication , depends on the relative aggressiveness of the facility, surgeon, patient, and payer Preterm infants( < 50 week of post-conceptual age) associated with increased risk for the development of postoperative respiratory complication(apnea) Anemia(Ht < 30%) is also associated with an increased incidence of apnea in preterm infant < 60 week of post-conceptual age Recovery of fine motor skills and cognitive function after general anesthesia(or local anesthesia with sedation) commonly slower in older patients

Procedures for Ambulatory Surgery

Advance age is not a reason to disallow in an ambulatory procedures, because most of postoperative medical problem are not caused by age, but by specific organ dysfunction. For that reason, all individual, whether young or old, deserve a careful preoperative assessment

Preoperative Assessment
Patients selection; - ASA physical I or II - ASA physical III or IV are also acceptable candidates, providing their systemic disease are medically stable Preoperative visit by an anesthesiologist is very important to minimized cancelation and decreases the patient s anxiety An alternative approach for preoperative screening is utilize a preanesthetic questionnaire to obtain information about patient s medical problems, previous operation, drug history, and family history and to provide general review system The process also provide the staff with an opportunity to remind the patient of arrival time, suitable attire, and dietary restriction(e.g., nothing to eat or drink after midnight, no jewelry or makeup)

Preoperative Assessment
The laboratory testing required depends on the patient s age, state of health, and drug hystory
 CBC/Hct and ECG starting at age 50 yrs  SMA-6(Sequential Multiple Analysis-6 serum test) and CXR(chest radiography) for >70 yrs  CBC/Hct is essential for <50 yrs females  SMA-6 and ECG are recommended for patients chronically receiving cardiovascular drugs

Premedication
Controlling Anxiety
Psychologycal; Preoperative visit by an anesthesiologist. Was more effective in decreasing anxiety than administration of a barbiturates(Egbert et al). Both parents and children need to be involve in preoperative discussion so that the anxiety of parents are not transmitted to the child If necessary; Midazolam 0.04-0.08 mg/kg IV 0.5 mg/kg orally for children Propofol 1.5-2.5 mg/kg for adult

Controlling the Risk of Aspiration

Droperidol 5-15 g/kg IV for children 7.5-15 g/kg IV for adult H2 receptor antagonists Ranitidine 50-200 mg,the night before surgery Cimetidine 150-300 mg, 1-1,5 hr before surgery Omeprazole 80 mg, the night before surgery Metoclorpramide 0.15-0.3 mg/kg, most effective when given at the end of anesthesia or as an adjunct to other antiemetics Sodium Citrat(non-particulating antacid) 30 ml, just before the procedure

Opioids
Small dose of the potent opioid analgesics - Fentanyl 1-3 g/kg - Sulfentanyl 0.1- 0.3 g/kg - Oral transmucosal fentanyl(lollipop) Not routine, unless the patients experiencing acute or chronic pain

Controlling Postoperative Nausea Preoperatively

Nausea, with or without vomiting, is probably the most important factor contributing to a delay in discharge of patients Risk factor that contributing postoperative nausea and vomiting; - Patient s body habitus and medical condition - Type of surgery performed(e.g., laparoscopy, orchiopexy, strabismus surgery, therapeutic abortion) - Assisted ventilation with a face mask - Anesthetic and analgesic medications( fentanyl, etomidate, isoflurane, and nitrous oxide)

Controlling Postoperative Nausea Preoperatively

Droperidol lower dose(0.25-0.5 mg) 50-75 g/kg for children Promethazine 0.5-1.0 mg/kg Serotonin Antagonists Ondansetron 4-8 mg 75 g/kg for children

Outpatient Anesthetic Techniques: General Anesthesia

Induction
- Propofol; Induction agent of choice for ambulatory anesthesia, because of their short elimination half-life(1-3hr) Reduce incidence of postoperative emesis - Thiopental - Sevoflurane - Halotan drug of choice for inhalation induction in pediatric patients - Rectal etomidate(6 mg/kg) or ketamine(50 mg/kg) for children - Ketamin; 2-6 mg/kg IM, for uncooperative child

 Maintanace
- Volatile anesthetics are generally considered to be superior than intravenous anesthetic, because they are more controllable Sevoflurane and Desflurane Halogenated ether anesthetic with low blood-gas partition coefficients, seem to be ideal for general anesthesia Nitrous Oxide Combined with the other anesthetic drugs - Propofol Has a short half life, result in rapid recovery - Opioid(rapid and shorter-acting narcotics) When given intraoperatively, are useful for both intraoperative and postoperative analgesia Fentanyl, sufentanyl, alfentanyl

 Airway management;
- Face mask, laryngeal mask airway, oro-tracheal tube - Drugs facilitating tracheal intubation; Depolarizing muscle relaxants Succinylcholin Most rapid onset of muscle paralisys Muscle pains lasting up to 4 days after surgery Non-depolarizing muscle relaxants Rapacuronium, Rocuronium, Mivacuronium

Outpatient Anesthetic Techniques: Regional Anesthesia

Spinal Anesthesia
Spinal anesthesia are suitable for urologic, herniorrhapy, and lower extremity surgery Common side effects of general anesthesia are avoided(e.g., nausea, vomiting, dizziness, and lethargy) Lidocaine, mepivacaine, and 2-chloroprocaine are ideal because of their short duration of action Needle size and shape are important to reduce the incidence of postdural puncture headache(PDPH) High incidence in patients younger than 60 yrs Smaller gauge needles(e.g., 26 gauge) and pencil-point needles(Sprotte and Whitacre needles) Can produce urinary retention

Epidural and Caudal Anesthesia

Advocated for outpatients lower extremity procedure, herniorraphy, and extracorporeal shock-wave lithotripsy Onset of epidural anesthesia is more slower than spinal anesthesia, and recovery may be same with either technique Problem of postdural puncture headache is usually avoided Caudal anesthesia is a useful technique for anorectal surgery, dilatation and curetage

Peripheral Nerve Blocks

Intravenous regional anesthesia Simple and reliable technique for superficial surgical limited to a single extremity Brachial plexus block For upper extremity surgery 3 in 1 block(femoral, obturator, and lateral femoral cutaneous nerves using a perivascular technique) for knee arthroscopy Ankle block For surgery on the foot

Outpatient Anesthetic Technique: Local Anesthesia

Simplest and safest Significantly shorter recovery times Monitoring patient s vital sign Injection of local anesthetics is often associated with severe discomfort Intravenous sedative and analgesic drugs( i.e., so-called conscious sedation technique)

Management of Postanesthesia Care

The most common reason for delay in patients discharge from the PACU(Postanesthesia Care Unit) are intracable nausea and vomiting, drowsiness, airway problem(e.g., stridor, bronchospasme), inability to void, dizziness, delayed emergence, and pain Nausea, vomiting, and pain also can be treated in the PACU Nausea and vomiting Metochlorpramide 20 mg Hydroxyzine 25 mg Droperidol 0.625-1.25 mg

Management of Postanesthesia Care

Pain - Morphine 1-3 mg/70kg,or Fentanyl 10-25 g/70 kg small IV doses - Ketorolac 60 mg/kg IM or IV - Elixir of acetaminophen containing codein( 120 mg acetaminophen, 12 mg codein, in each 5 ml of solution) for chidren - Acetaminophen 60 mg/year of age,( orally or rectally) for mild pain in older infants and young children - Fentanyl 2 g/kg IV, for more severe pain - Mepheridin 0.5 mg/kg, and Codein 1-1.5 mg/kgBB if an IV route has not been establish

Preparation for Discharge the Patient

Accurate assessment about recovery of cognitive and psychomotor function is important to determining the appropriate time for discharge after ambulatory anesthesia Patients who are awakened in the OR and are evaluated as 9 or 10 according to the modified Aldrete scoring system, may be transferred directly to Phase II recovery room, where patients may stay until they are able to tolerate liquids, walk, and/or able to void

POSTANESTHETIC DISCHARGE SCORING SYSTEM

Vital sign 2 = within 20% of preoperative value 1 = 20-40% of preoperative value 0 = 40% of preoperative value Ambulation and mental status 2 = oriented 3 and has a steady gait 1 = oriented 3 or has a steady gait 0 = neither Pain or nausea 3 = minimal 2 = moderate 1 = severe Surgical bleeding 3 = minimal 2 = moderate 1 = severe Intake and output 3 = has had po fluids and has voided 2 = has had po fluids or has voided 1 = neither

Total score 10 9 ; fit for discharge

References
1. Barash PG, Cullen BF, Stoelting RK: Clinical Anesthesia, 4th ed. Philadelphia, Lippincott Williams & Wilkins, 2001 2. Miller RD: Anesthesia, 3th ed. California, Churchill Livingstone, 1990