10 chandrashekara anaesthesia-in-ambulatory-surgery_ncas_2011

Dr CHANDRASHEKARA.C.R

Consultant Anaesthesiologist

NOVA MEDICAL CENTERS,SAGAR HOSPITALS, BANGALORE

Anaesthesia Day careanaesthesia/ ambulatory anaesthesia/ Office

based anaesthesia

25 million surgeries per year -70 % ambulatory

surgeries,10% - children –IDEAL FOR DAY CARE

Development Ether- Sevoflurane, Deflurane

Thiopentone- Propofol

Short acting muscle relaxants

Short acting yet potent analgesics

Open surgery to Laparoscopic surgery

Patient xx / Pain Abdomen

Surgery means – Pain ?Discharge same day

OUR CHALLENGES Challenging-

Difficulty – convince -Surgeons, anaesthetists, Pts

Type of surgery- quick recovery

Assessment pain { children}

Lack of experience{Standalone day care center}

Pts with acute/chronic undiagnosed diseases.

Proper planning

Procedure General surgery /Urology

Inguinal hernia repair

Orchidopexy

Umbilical hernia repair

thyroglossalcyst

Cervical lymph node biopsy

Ganglion excision

Laparoscopic procedures

Circumcision

Cystoscopy

Preputial adhesionreleaserelease

Minor hypospadias

Ureteric stent placement

Contd Plastic surgery Orthopaedic

Removal of nevus

Otoplasty

Suture removal

Dressing changes

Mammoplasty

Liposuction

Removal of spica, nails, Achilles lengthening

Arthroscopic procedures

osteochondromaexcision

Muscle biopsy

ORIF ulna, radius

Procedure

OBG ENT/Dental

D&E

D&C, Hysteroscopic D&C

Lap ovarian cystectomy

Diagnostic lap

Others

Myringotomies

Nasal and aural foreign body removal

Adenotonsillectomy

Mastoidecomy/tympanoplasty Restoration

Extraction

NOT FOR DAY CARE

Active asthma/URTI/Difficult Airway

CHF/IHD/Un controlled HTN/Cardio myopathies

Uncontrolled DM

Morbid obesity

Haemorrhage/fluid shifts

?Procedures more than 90 minutes

Prematures

Our Success Proper Selection of cases

Pre-operative assessment /Stabilisation .

Well planned anaesthetic techniques/ modified?

Management of post-operative pain, nausea and vomiting

Discharge according to protocol

Extended Day care facility

PAC Premedication-

H2 receptor antagonists ,antacids, analgesics,Steroids,Chest physiotherapy, Nebulisation

To continue other medications

Phy/Cardio/Endocrinology opinion

Anaesthesia

Pre op counseling/ Premedication

GA – LMA/ETT

Propofol/Short acting Relaxants

OPIOD/Non opiod based analgesia

Local anaesthetics/ Nerve blocks/ Epidurals

CONTD Laser prostatectomy- under Sedation+ peudendal

nerve block

Pain-Multimodal approach Targeting different

levels

Optimal pain relief with minimal side effect

Combination of

analgesics drugs and

techniques enhance

the analgesic level

Pain management

shorter discharge times, lower pain scores, and a lower incidence of nausea and vomiting, compared with traditional opiate-based anesthetic techniques

Pain IV Fentanyl-2 mic gms/kg bolus/1mic gms infusion

IV Paracetamol 20 mg/kg – upto 4 gms/day

?IV Diclofenac upto 150 mg/ day

IV Ketorolac[0.8 mg/kg, max 60 mg- low pain score, decreased opiods

Extended day care- Morphine, Pethidine

PONV PONV distressing complication of ambulatory

anesthesia

Delayed discharge and unanticipated admissions

The role of Nitrous oxide in contributing to PONV is unclear

Propofol- less nausea and vomiting than other induction drugs with its rapid recovery profile

Neostigmine be associated with an increased incidence of PONV

PONV Avoid opioids- Morphine, pethidine

Ondensetron[8mg], Metachlorpropamide 10 mg

Dexamethsone 8 mg

Granisetron, Tropisetron, Dolasetron

Discharge Stable vital signs

Orientated/Orally taking.

Adequate Pain control

No- PONV ,Voiding difficulty, dizziness

No bleeding

Emergency Contact no/Responsible Adult

Compliance – studied, Educate them-Video, Talking to other pts

Dissatisfaction do Exist

Thank you

Post op Follow up

Figure 1. Most patients had recovered from anesthesia and were discharged home within 1–2

h after surgery.

Marshall S I , Chung F Anesth Analg 1999;88:508-508

©1999 by Lippincott Williams & Wilkins