ambulatory surgery and anesthesia .pptx

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1. DAY CASE SURGERY

2. Course outlines Introduction to day case anesthesia Basic consideration for day case surgery Preoperative evaluation for day case surgery Optimization of day case surgery Basic anesthetic techniques & anesthesia management for day case surgery Discharging of day-case surgery Post-operative complications of day case surgery

3. Objectives At the end of this module, students will be able to:- Know the candidates Optimize patients undergoing ambulatory surgery Provide day-care anesthesia and procedural sedation techniques for different procedures When they should be discharged

4. Introduction Outpatient/ambulatory anesthesia is: The subspecialty of anesthetist/anesthesiology that deals with the preoperative, intraoperative , and postoperative anesthetic care of patients undergoing elective, same-day surgical procedures . D elivery of anesthetic care to patients who will return home the same day they undergo a surgical procedure. Ambulatory anesthesia for ambulatory surgery may seem to be a recent phenomenon, although it has been around for over 100 years

5. Cont … Patients undergoing ambulatory surgery:- Rarely require admission to a hospital But are fit enough to be discharged from the surgical facility less than 24 hours after the procedure

6. Cont … Non–operating room anesthesia (NORA) Referred to as out of the operating room anesthesia Includes both inpatients and ambulatory surgery patients who undergo anesthesia in settings outside of a traditional operating room . E.g. patients ranging from individuals in need of anesthesia for MRI procedures to critically ill septic patients undergoing endoscopic procedure

7. Cont … NORA requires the anesthesia provider to work in remote locations in a hospital E ase of access to the patient and anesthesia equipment may be limited Support staff at these locations may be unfamiliar with the requirements for safe anesthetic delivery.

8. Other names Day case surgery Come and go surgery Ambulatory surgery Outpatient surgery Day case anesthesia

9. What makes D.C.S special from inpatient surgery? It allows the patient to return home on the same day that surgical procedure is performed Suitable if it took<90min to complete Do not produce severe pain post-operatively Do not cause severe hemorrhage

10. Office based anesthesia Office-based anesthesia refers to the delivery of anesthesia in a practitioner’s office that has a procedural suite incorporated into its design . Office-based anesthesia is frequently administered to patients undergoing cosmetic surgery or dental procedures .

11. Contraindications for D.C.S Emergency procedures Medically unstable ASA III Poor cardiac risk such as cardiac failure, significant arrhythmia Severe aortic and mitral stenosis Severe OSA Long duration and extensive procedures

12. Cont … Need for blood transfusion Need for postoperative ventilation Anticipated sever postoperative pain requiring intravenous analgesics

13. Facility, design and safety W ell designed to ensure efficient delivery of surgical services at the lowest possible cost. There are 4 basic designs ambulatory surgical units . Hospital integrated Hospital based Free standing Office based

14. Hospital integrated Is part of regular operation theatre and patients are managed in the same surgical facility as inpatients . Outpatients may have separate preoperative preparation and recovery areas.

15. Hospital based Within a hospital building or complex. But is separate from the main operation theatre and functionally independent.

16. Free standing Which is a completely independent or autonomous set up with its own perioperative diagnostic and therapeutic facilities .

17. Office based It has operating or diagnostic suites It is the diagnostic or therapeutic procedures E.g . MRI , Dental procedure Endoscopies and Pain clinic procedures

18. Location R ecommended that all outpatient services should be organized in one dedicated area. Waiting room Preoperative evaluation area Pre-anesthetic room Operating suites and recovery areas should be in close proximity so that surgeons and anesthetists are able to visit the patient and family before and after the operation without losing time in transit.

19. Fulfilments before starting Anesthesia drugs and airway equipment should be prepared M onitoring and resuscitation equipment Staff should be familiar with the surgical procedures conducted in the center. Tie up with a hospital and facilities for transfer of patients in case of emergency is recommended. The policy and protocol should be written and easily accessible

20. Candidates for ambulatory & office based anesthesia Each patient must be considered in the context of: Their comorbidities The type of surgery to be performed The expected response to anesthesia

21. Cont … Ambulatory procedures should be of a complexity and duration such that one could reasonably assume that the patient will not require post procedure hospital admission. ASA physical status and a thorough medical history are crucial in the initial screening of patients selected for ambulatory or office-based procedures.

22. Cont … The initial screen can often be accomplished by telephone and can identify those patients who will benefit from being seen and examined prior to the day of surgery and also those patients who are inappropriate for ambulatory surgery . ASA 4 and 5 patients would not generally be candidates for ambulatory surgery.

23. Cont … ASA 3 patients with DM,HTN & stable CAD should not be precluded from an ambulatory procedure provided that their diseases are well controlled. S urgeon and anesthetist must identify patients for whom an ambulatory or office-based setting is likely to provide BENEFITS ( eg , convenience, reduced costs and charges) that OUTWEIGH RISKS ( eg , the lack of immediate availability of all hospital services, such as a cardiac catheterization laboratory, emergency cardiovascular stents, assistance with airway rescue , rapid consultation).

24. Factors considered in selecting patients for D.C.S Systemic illnesses and their current management Airway management problems OSA Morbid obesity Previous adverse anesthesia outcomes Allergies P atient’s social network ( e.g , availability of someone to be responsive to the patient for 24 h).

25. Patient with difficult airway Should probably not be candidates for office-based procedures However , they may be appropriately cared for in a well-equipped and fully staffed ambulatory surgery center . Important considerations for such patients include: Availability of difficult airway equipment, like ILMA and video laryngoscope Availability of additional experienced anesthesia providers S omeone capable of performing emergency tracheotomy/ cricothyroidotomy

26. Cont … If there are concerns regarding the ability to manage the airway in an ambulatory surgery setting , the patient will be better served in a hospital setting. Similarly, patients with unstable comorbid conditions , such as decompensated congestive heart failure or uncontrolled hypertension, may benefit from having their procedure performed in a hospital rather than a freestanding facility. The hospital-based ambulatory surgery center provides such patients with both the availability of a hospital’s resources and the convenience of being an ambulatory patient. Should their condition warrant additional care, hospital admission is possible; however, such flexibility comes with the increased costs associated with hospital care.

27. Cont … Procedures suitable for ambulatory surgery should have a minimal risk of P erioperative hemorrhage Airway compromise No particular requirement for specialized postoperative care

28. Specific patient conditions & ambulatory surgery Obesity & Obstructive Sleep Apnea Obesity is associated with many concomitant disease states, such as: HTN DM Hyperlipidemia OSA Metabolic syndrome

29. Cont … The physiological derangements that accompany these conditions include changes In oxygen demand Carbon dioxide production Alveolar ventilation Cardiac output

30. Cont … There is no precise “cutoff” BMI for patients who may or may not undergo ambulatory surgery. However , Joshi and colleagues suggest that patients with a BMI less than 40 kg/m2 tolerate ambulatory surgery adequately, assuming control of co morbidities . Patients with a BMI >50kg/m2 are thought to be at greater risk in the ambulatory surgical care environment.

31. Cont … Pts with obesity and OSA are at increased risk of postoperative respiratory complications, such as prolonged airway obstruction and apnea, particularly if they will receive opioids postoperatively. Scores for predicting the probability of these complications can aid in the preoperative assessment and referral to a hospital setting Although a sleep study is the standard way to diagnose sleep apnea, many patients with OSA have never been identified as having OSA

32. Cont … Preoperative initiation of CPAP may reduce the incidence of postoperative cardiac complications ( ASA guidelines ). Avoidance of respiratory depressants  Use of opioid-sparing multimodal analgesia  Neuraxial techniques is likewise suggested when appropriate The ASA , SAMBA, and American College of Chest Physicians published practice guidelines for the perioperative management of patients with OSA .

33. Cont … ASA recommendations include Return of room air oxygen saturation to baseline level prior to discharge Observation of respiratory function when unstimulated, such as when sleeping Consideration of CPAP or noninvasive positive-pressure ventilation (NIPPV) if frequent airway obstruction or hypoxemia develops postoperatively A possible prolonged period of postoperative observation to ensure that patients with OSA are not at increased risk from postoperative respiratory depression compared with non-OSA patients undergoing similar procedures

34. Cont … The literature is insufficient to offer guidance regarding an appropriate time to discharge patients with OSA from the surgical facility. SAMBA has issued its own consensus statement regarding the management of OSA perioperatively , the use of the STOP-Bang criteria for preoperative OSA screening. T he consensus statement also provides a decision tree to assist in determining which known and presumed OSA patients are candidates for ambulatory surgery. The Society of Anesthesia and Sleep Medicine has also issued guidelines to assist in the screening for OSA.

35. Cont … S = Snoring. Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? T = Tiredness. Do you often feel tired, fatigued, or sleepy during daytime? O = Observed apnea. Has anyone observed you stop breathing during your sleep? P = Pressure. Do you have or are you being treated for high blood pressure? B = BMI >35 kg/m2 A = Age >50 years N = Neck circumference >40 cm G = Male gender

36. Procedures Procedures appropriate for ambulatory surgery are :- Those associated with postoperative care that is easily managed at home Have low rates of postoperative complications Do not require intensive physician or nursing management

37. Procedures suitable for ambulatory surgery Dental- Extraction, restoration , certain facial fractures Dermatology- Excision of skin lesions General- Biopsy, endoscopy, excision of masses,hemorrhoiedectomy , herniorrhaphy and laparoscopic procedures Pain clinic - nerve blocks, epidural injection. Gynecology- dilatation and curettage, biopsy,hysteroscopy , and laparoscopic procedures Ophthalmology- cataract extraction, strabismus repair, and tonometry

38. Cont … Urology- circumcision, cystoscopy,lithotripsy , prostate biopsy, and certain laparoscopic procedures Radiology –Magnetic Resonance Imaging (MRI ), Computerized Tomography (CT) Plastic surgery- cleft lip repair,mammoplasty , scar revision and skin graft

39. Cont … Orthopedic- closed reduction, manipulation under anesthesia, carpel tunnel release, knee arthroscopy , shoulder reconstructions and minimally invasive hip replacements . ENT- Adenoidectomy, mastoidectomy , polypectomy , rhinoplasty , tonsillectomy, and tympanoplasty .

40. What are the primary objective of the preoperative assessment? Optimization of preexisting medical conditions such as:- HTN Obesity Asthma GERD

41. Cont … Following viral upper respiratory infections (URIs) in adults, airflow obstruction persists for up to 6 weeks. The COVID-19 pandemic presented additional questions and challenges for safety of anesthesia following infection. T he most recent multidisciplinary guidelines published in the United Kingdom recommend avoiding surgery within 7 weeks of infection , unless there is significant clinical risk of delaying surgery

42. Cont … Risk stratification: Should be identified in order to devise strategies to prevent postoperative complications . Patients with specific anesthetic concerns like 1) Difficult airway 2) Active cardiac disease 3) Those at increased risk for perioperative complications

43. Components of preop assessment History History of sleep disturbances, snoring and day time sleepiness indicate the possibility of OSA Similarly , symptoms like stridor, hoarseness, reduction in effort tolerance etc should lead to further detailed evaluation.

44. Cont … Physical examination S hould focus on identifying changes in various organ systems particularly respiratory and cardiovascular system due to any coexisting illness.

45. Cont … Laboratory investigation and imaging If indicated Routine preoperative lab. testing of patients before ambulatory surgery is unjustified and results in wastage of resources.

46. Cont … ASA I with age <40 years with normal airway and those not on any drug therapy may not require any investigation ASA II with age >40 years, smoker and alcoholic patients may require investigation appropriate to the surgical procedures.

47. Preoperative HGN Patients with an unexplained Hgb less than 10g/dl should be considered for further evaluation before elective out-patient surgery A low Hgb level may be associated with diseases that could influence per operative mortality and morbidity

48. Preoperative preparation of patients To educate patients and careers regarding day surgery pathways To import information regarding planned procedures and postoperative care to help patients make informed decisions; important information should be provided in writing To identify medical risk factors, promote health and optimize the patient’s condition

49. Fasting Standard fasting guidelines should be followed , avoiding excessive fasting. Adequate hydration (e.g., allowing oral intake of clear fluids up to 2 to 3 hrs is associated with a decreased incidence of postop side effects , including pain, dizziness, drowsiness, thirst and nausea. Both under hydration & over hydration should be avoided

50. Cont … Food/Drink & Time to Fast Prior to Surgery (h) Clear liquids (e.g., water, fruit juices without pulp,carbonated beverages, clear tea, and black coffee) /2/ Breast milk /4/ Infant formula /6/ Nonhuman milk /6/ Light meal (toast and clear liquids) /6/ Meals that include fried or fatty foods or meat /8/

51. premedication Long acting sedatives like diazepam and lorazepam may be avoided. Midazolam , with its short duration of action and good recovery profile can be used for anxiolysis and for smooth separation from parents in case of pediatric patients . Preoperative reassurance from nonanesthesia staff, use of booklets or audiovisual instruction with information about the procedure, or a preoperative visit by the anesthesiologist Large retrospective analysis show an association between perioperative midazolam use and postoperative falls, delirium, and pulmonary complications.Therefore , midazolam should not be used reflexively.

52. Basic anesthetic techniques for D.C.S

53. Introduction The anesthetic techniques used for procedures in the day case surgery will range from: Monitored anesthetic care(MAC ) Local Regional General anesthesia

54. Factors determines selection of anesthesia techniques for day case surgery The choice of anesthetic technique depends on many factors such as: Patient's condition, The procedure involved The anesthetist’s/anesthesiologist's preference

55. Cont … Specific procedure requirements will also at times determine whether the patient must be awake or not. Frequently , it is the choice of the radiologist, physician, or the standard protocol of their institution that determines the anesthetic technique. However , the anesthesiologist must always ensure that it is the best and safest technique for each patient.

56. Basic techniques of anesthesia for day case anesthesia MAC and sedation The combination of LA, and /or peripheral nerve blocks with IV sedative and analgesic drugs is commonly referred to as MAC. Advantages of MAC Lack of significant effects on hemodynamic Avoidance of multiple drugs Avoidance of airway instrumentation and rapid recovery compared to GA Disadvantages Potential for respiratory depression depending on level of sedation, risk of airway obstruction oxygen desaturation and even aspiration

57. Standard cares during MAC Standard preoperative assessment, intra-operative monitoring and postoperative recovery care Vigilant monitoring is required .why ? Patients may rapidly progress from a light level of sedation to deep sedation and thus may be at risk for airway obstruction, oxygen saturation and even aspiration. Example from experience … diazepime + propofol+pethidine

58. Precautions Preparation for GA for mgt of failed sedation Complications secondary to sedation or procedure should be taken in account Use minimal or moderate levels, airway is well protected Avoid multiple drugs for specific objectives B e familiar effects each drug on RS, CVS and PONV .

59. Cont … C ommon and popular drugs used for sedation are Fentanyl Midazolam and Dexmedetmedine Propofol Clonidine

60. Regional anesthesia (RA) Advantages of RA over GA Reduce bleeding No risk of aspiration Reduce post-operative risk of DVT No risk of transmission of infection from upper airway to lower airway Reduce cost Satisfaction Early recognition of the complication Less PONV Early feeding

61. Common RA techniques Neuraxial nerve block Peripheral nerve block IVRA Which RA techniques are more preferred? Lower incidence of side effects, Improved recovery profile and Cost effectiveness.

62. Commonly used LAA for RA Lignocaine is no more a choice of LAA for central neuraxial blocks or for peripheral nerve blocks Bupivacaine , in concentrations from 0.25 to 0.5% is most commonly used, levobupivacaine and ropivacaine are also acceptable

63. Cont … Adjuvant like dexmeditomidine , Clonidine and fentanyl can be added to LAA for RA. Why we add additives to LAA? Use of ultrasound(USG)has become popular for nerve blocks . Advantages are reduced volume injection, rapid onset of action and reduced risk of nerve injury

64. General anesthesia Advantages Safe and protected airway and Control over the patient's physiology including ventilation Providing suitable conditions for surgery like muscle relaxation. Any plan for GA should consider risk of PONV and its mgt

65. Cont … IAA for day case surgery S evoflurane and desflurane are popular for ambulatory anesthesia , with or without N2O, because of easy titratability and rapid recovery, more so with desflurane . However the incidence of PONV is more with VAA, which is further increased by the N2O

66. Cont … Airway equipment for day case surgery Decided based on the surgical needs. ETT can be performed with succinylcholine or propofol with remifentanyl combination. LMA should always be considered as alternate to intubation.

67. Preferred anesthesia drugs for day case surgery Midazolam ( 0.1- 0.15 mg/kg ), is ideal for both adults and children . In children it facilitates smooth ,separation from parents in less than 30 minutes. Anticholinergics such as atropine (.01 - .02 mg / kg) or glycopyrrolate (.005 - .01 mg / kg) have been used. Induction Agents: Propofol (25-50 mcg/kg/min) is the most commonly used drug for induction of anesthesia, maintence of sedation and treatment of nausea and vomiting. Thiopentone , Etomidate and Ketamine have been used, but not mostly replaced by Propofol . Etomidate (0.2 – 0.3 mg/kg) is preferred when hemodynamic stability is important

68. Analgesics Fentanyl (1 – 2mcg/kg) and Remifentanyl Alfentanyl ( 15-30 mcg/kg ) Dexmedetomedine ( 1- 2 mcg/ kg bolus loading over 10 -20 minutes followed by 0.25- 0.5 mg/kg/h for maintenance ) near ideal drug for sedation

69. Muscle relaxants Mivacurium (0.15- 0.20 mg/kg ) , atracurium ( O.4 – O.5 mg/kg) or rocuronium ( O.6 mg/kg ) are used for muscle relaxation. Succinylcholine, (1 mg/kg ) though associated with postoperative myalgia, has been safely used for to facilitate intubation. Reversal Agents: Neostigmine (.04 -.07mg / kg) + glycopyrrolate combination is used for reversal. sugammadex can be used. Neostigmine is associated with higher incidence of PONV than sugammadex

70. Monitoring during anesthesia Standards of monitoring ( PO,NIBP, ECG and in all patients and Capinograph in intubated patients. Additional monitors include neuromuscular blockade monitor , temperature and depth of anesthesia monitor (particularly for patients with history of awareness).

71. Postoperative Management PONV and pain are common problems in the P/O period which may delay the discharge and also affect the quality of ambulatory anesthetic care. Choosing an anesthetic plan with drugs like propofol which have inherent antiemetic properties plays an important role in preventing PONV.

72. Risk factors for PONV Patient related factors Age ,gender, history of motion sickness, pre-existing diseases Anesthesia related factors Premedication , Opiod analgisics , Induction and maintenance anesthetics Inadequate hydration Surgery related factors Length of surgery, Operative procedure

73. Cont … 5HT 3 receptor antagonists, ( ondensetron 4- 8 mg IV,palanosetron 0.075mg IV and granisetron0.35- 1.5 mgIV phenothiazines , (Prochlorperazine 5- 10 mg IM/IV), Anticholinergics , such as transdermal scopolamine Corticosteroids ( dexamethasone 4- 5mg IV)

74. Post-operative pain mgt Pain mgt is critical for improving the quality of anesthetic care and to reduce morbidity in the postoperative period Pain management consists of identifying factors which are associated with higher risk of severe PO pain such as age, gender , duration and type of surgery

75. Cont … Planning for MMA is the most effective way of managing pain MMA involves use of different groups of analgesic drugs by more than one route and use of more than one technique of anesthesia.

76. Cont … E.g. example is use of RA and opioid analgesic for intraoperative pain management followed by wound infiltration , use of NSAID ) and paracetamol Although opioid analgesics play an important role in the management of pain, the adjunctive use of nonopioid analgesics will probably assume a greater role in the future

77. Discharge criteria The three stages of recovery after ambulatory surgery are the early, intermediate, and late recovery phases. The early and intermediate recovery stages occur in the ambulatory or office based surgical facility, whereas late recovery refers to the resumption of normal daily activities and occurs after the patient has been discharged home.

78. Early recovery Is the time interval during which patients emerge from anesthesia , recover control of their protective reflexes, and resume early motor activity. The patients are cared in the PACU and day surgery unit, their vital signs and PSO2 are carefully monitored and supplemental oxygen, analgesics, or anti-emetics are administered as necessary.

79. Cont … The modified Aldrete or white score is commonly used to assess the readiness of patients to be transferred to the day surgery recovery area. It assesses the activity, respiration, circulation,consciousness and oxygen saturation, each given a score of 2, 1 and 0 total maximum score being 10. Patient should be discharged to step down unit only after the score is more than or equal to 9

80. Intermediate recovery period patients progressively begin to ambulate, drink fluids,void and prepare for discharge. The choice of anesthetic technique, as well as the appropriate use of postoperative analgesic, and antiemetic drugs, all have an impact on the duration of the intermediate recovery period.

81. Late recovery period starts Patient is discharged to home Complete functional recovery is achieved and The patient is able to resume normal activities of daily living

82. Cont … Guidelines for safe discharge from an ambulatory surgical facility include Stable vital signs, Return to baseline orientation Ambulation without dizziness Minimal pain and PONV Minimal bleeding at the surgical site

83. Cont … A revised post anesthesia discharge scoring system (PADS ) is available for discharge from the hospital or ambulatory unit to home. Unlike the modified Aldrete's scoring system, PADS includes activity, nausea and vomiting, pain and surgical bleeding, in addition to vital signs as parameters with a total score of 10. Patient is discharged only after achieving a score of 9 or more

84. Postanesthesia discharge scoring system ( PADSS ) Vital signs 2 within 20% of preoperative value 1 20% - 40% of preoperative value 0 40% of preoperative value Activity, mental status 2 Oriented and steady gait 1 Oriented or steady gait 0 Neither Surgical bleeding 2 Minimal 1 Moderate 0 Severe Intake and output 2 PO fluids and voided 1 PO fluids or voided 0 Neither Pain, nausea, vomiting 2 Minimal 1 Moderate 0 Severe

85. References Morgan and Mikhail's Clinical Anesthesiology,7th Edition Miller 9th edition Anesthesia Books 2017 Barash Clinical Anesthesia, 8th Edition Simon Bricker, the anesthesia science viva book 3rd edition(2017) Guidelines for day-case surgery 2019: Guidelines from the Association of Anesthetists and the British Association of Day Surgery - Pub Med (nih.gov)