• 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