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Introduction
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
Four A s are:
1)Alertness
2)Ambulation
3)Analgesia
4)Alimentation
Contra-Indications to Ambulatory
Surgery
Preoperative assessment
Pre-operative Assessment
Age Range
Men
Women
<40
None
Pregnancy Test
40-49
E.C.G
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
Pharmacologic Preparation
Anxiolysis and Sedation
Pre medication
Benzodiazepines
Drug
Dosage Range
MIDAZOLAM
Onset(min)
Key Points
7.5-15 mg PO
15-30
5-7 mg I.M
15-30
Water soluble,nonirritating
1-2 mg I.V
1-5
DIAZEPAM
5-10 mg PO
45-90
TEMAZEPAM
15-30 mg PO
15-40
Comparable to MDZ
LORAZEPAM
1-2 mg PO
45-90
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
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
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
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
Droperidol
0.625-1.25 mg I.V
End of Surgery
Ephedrine
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
Ondansetron
Scopolamine
Management of PONV
Pharmacologic Preparation
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 .
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
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
Ketamine
0.75-1.5 Immediate
Intermediate
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
INHALATIONAL ANESTHETICS
Muscle Relaxants
Regional Anesthesia
Spinal Anesthesia
Regional Anesthesia
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
Physical activity
Able to move all extremities on command
Hemodynamic Stability
Blood Pressure <15% of the baseline MAP value
WHITES Criteria
Respiratory Stability
Able to breathe deeply
1
0
WHITES Criteria
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.
Ambulation
With Assistance
No ambulation/dizziness
Moderate
Severe
Pain
Minimal
Moderate
Severe
Surgical Bleeding
Minimal
Moderate
Severe
PADS System
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.
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
Learn from yesterday, live for today, hope for
tomorrow. The important thing is not to stop
questioning- Albert Einstein
THANK YOU !