ANAESTHESIA FOR DAYCARE SURGERY final.pptx

Anesthesia for day care surgery

1. ANAESTHESIA FOR DAYCARE SURGERY, MONITORED ANAESTHESIA CARE AND NON-OPERATING ROOM ANAESTHESIA DR.ARNAB PATRA DR.SOUGATA ROY DR.SOURAV DE

2. ANAESTHESIA FOR DAYCARE SURGERY INTRODUCTION It is an operation or procedure where the patient is discharged on the same working day.

3. CHOICE OF ANAESTHETIC TECHNIQUE General anaesthesia is most commonly preferred. Central neuraxial blockade are not encouraged as persistant motor block delays discharge. Local nerve and plexus blocks are good options for peripheral surgeries.

4. ANAESTHETIC GOALS Smooth onset of action Adequate intraoperative analgesia and amnesia Rapid recovery Minimal adverse effects.

5. PR0CEDURE REQUIREMENTS Minimal risk of postoperative hemorrhage Minimal risk of postoperative airway compromise Rapid return of normal fluid and food intake. Postoperative pain controllable by outpatient management techniques Postoperative care managed by common people.

6. INCLUTION CRITERIA FOR PATIENT ASA I and ASA II patients ASA III patients whose disease is well controlled preoperatively. Patient should understand the process and be able to follow discharge instructions. Patients place of residence to be within easy access to surgical facilities. Normal term infants of over 6 weeks of age

7. ADVANTAGES Reduced dependence on availability of hospital beds. Greater flexibility in scheduling surgeries Shorter surgical waiting lists Lower overall procedural costs. Lower requirements of nursing and medical supervision. Greater turnover of patients. Less incidence of hospital acquired infections. Lesser incidence of respiratory complications.

8. COMMON DAYCARE SURGERIES GENERAL SURGERY Herniorraphy Hemorrhoidectomy Herniotomy Upper and lower GI endoscopy/biopsy Laparoscopic procedure PLASTIC SURGERY Otoplasty Excision skin lesions Scar revision

9. Cont … GYNAECOLOGY D & C Hysteroscopy Vaginal hysterectomy Tubal ligation ORTHOPEDICS Implant removal Arthroscopy Closed reduction procedures. UROLOGY Cystoscopy Lithotripsy Prostate surgery

10. Cont …. OTORHINOLARYNGOLOGY Myringotomy Mastoidectomy Tympanoplasty Adenoidectomy Tonsillectomy Polypectomy OPHTHALMOLOGY Lacrimal duct probing Strabismus correction

11. EXCLUSION CRITERIA Serious life threatening diseases Morbid obesity complicated by CVS and respiratory symptoms Chronic use of centrally acting drugs Extremely premature infants (<60 weeks post conceptional age) Surgical procedures involving: Major fluid shifts Significant blood loss Significant postoperative pain Significant PONV

12. PREOPERATIVE EVALUATION Detailed history with specific focus on comorbidities. Recording of BP,Pulse , Spo2, CBG Examine cardiovascular and respiratory system Identify any airway difficulty. Preoperative counselling to diminish fear and anxiety. Written and verbal communication regarding arrival time and fasting guidelines. Investigations: complete blood count Random blood sugar, urea, creatinine Chest X ray ECG

13. CHOICE OF DRUGS INDUCTION AGENTS: Propofol, ketamine ANALGESIA: Fentanyl, remifentanil MAINTENANCE: nitrous oxide along with sevoflurane, desflurane or propofol MUSCLE RELAXANTS: succinyl choline, atracurium, cisatracurium . Regional anaesthesia Short acting drugs like lignocaine and procaine are desirable for central neuraxial blockade. Bupivacaine is used if anticipated duration of surgery is more than 2 hours. Intrathecal fentanyl is used for prolonging sensory blockade without affecting motor block.

14. MONITORED ANAESTHESIA CARE INTRODUCTION: It is an instance in which an anaesthesiologist has been called upon to provide specific anaesthesia survice to a patient undergoing a planned procedure and is in control of the patient’s nonsurgical or nonobstetrical medical care. REQUIREMENTS Performance of preanaesthetic examination and evaluation. Personal participation and medical direction of entire plan of care. Continuous physical presence of anaesthesiologist. Proximate presence of anaesthesiologist for diagnosis and management of emergencies.

15. GOALS To maintain patients safety and sense of well-being. To minimize pain and discomfort. Administration of sedatives, hypnotics, anaesthetic agents and other medications. To minimise psychological response: Anxiolysis, analgesia and amnesia. Monitor the vitals. Diagnosis and treatment of clinical problems which occur during the procedure. Provision of other medical service as needed to complete the procedure safely. To return the patient to preprocedural state.

16. Exclusion criteria ASA grade III & IV Morbid obesity Documented history of sleep apnea . Increase risk of airway obstruction: Stridor Dysmorphic facies Macroglossia Neck mass Jaw abnormalities like micrognathia Medical problems associated with alcohol/drug abuse. Pregnancy

17. Cont.. Inability to follow simple commands: Cognitive dysfunction Intoxication Psychological problems Acutely agitated Uncooperative patients. Patients of extreme age: <18 yrs and >70 yrs. History of intolerance to standard sedatives: Chronic opioid use Chronic benzodiazepine use. Spasticity or movement disorders.

18. Preoperative assessment Details history and specific focus on comorbidities. Identify difficult airway. Recording of vital signs. Preoperative counselling to diminish fear and anxiety. Routine investigation: CBC urea, creatinine, blood sugar ECG Chest X-ray

19. MONITORING Visual, tactile and auditory assessment: Response to verbal stimulation evaluated for effective titration of sedation. Rate, depth and pattern of breathing Daiphoresis,shivering,cyanosis and changes in neurological status. Auscultation: precordial stethoscope Pulse oximetry Capnography ECG BP monitoring Temperature for prolonged procedures.

20. Drugs used Benzodiazepines: Midazolam 1-2 mg IV before propofol/remifentanil infusion. Diazepam 2.5-5 mg IV Fentanyl 0.5-2 mcg/kg IV bolus 2 mins before stimulus. Remifentanyl 0.1 mcg/kg/min infusion 5 mins before stimulus, 0.05mcg/kg IV maintenance as tolerated. Propofol 250-500 mcg/kg bolus,then 25-75 mcg/kg/min infusion. Ketamine 0.25-1 mg/kg IV bolus. Dexmedetomidine 0.5-1 mcg/kg loading dose over 10 mins,then 0.2-0.7 mcg/kg/hr infusion.

21. NON OPERATING ROOM ANAESTHESIA(NORA)

22. INTRODUCTION Modern Anaesthesia is quite safe Well trained anaesthesiologist Well trained anaesthesia technique Fail-proof anaesthesia machine Monitoring aids Newer and versatile drugs.

23. Problems faced by the Anaesthesiologists Lack of adequate space Unfamiliar surroundings and equipments Central pipeline will be missing and cylinders have to be used Un-physiological postures needed for some procedures Out-patients for investigations are inadequately prepared/ investigated/ have associated medical illness. Adverse reactions to contrast media Lack of post-anaesthetic care

24. Three step approach to NORA PATIENTS PROCEDURE ENVIRONMENT

25. Patients Thorough preanaesthetic assessment and standard preanaesthetic care is required. Sound anaesthetic plan with appropriate level of monitoring and appropriate post anaesthetic care. Receive monitored anaesthesia care(MAC) or sedation Children commonly require sedation or anaesthesia for diagnostic and therapeutic procedures.

26. Patient factors requiring Sedation or Anaesthesia for Nonoperating Room Claustrophobia, anxiety and panic disorders Cerebral palsy, developmental delay and learning difficulties Seizure disorders, movement disorders and muscular contractures. Pain both related to procedure and other causes. Acute trauma with unstable cardiovascular, respiratory or neurologic functions. Raised intracranial pressure. Significant comorbidity and patient frailty( ASA status III & IV) Children specially those below 10 years.

27. Procedures CARDIOLOGY: cardiac catheterisation lab ( cath lab) Coronary angiogram Percutaneous Transluminal Coronary Angioplasty (PTCA) RADIOLOGY: CT Scan MRI Radio-therapy PSYCHIATRY Electro convulsive therapy (ECT) PLASTIC SURGERY Burn’s dressing

28. Monitoring standards ECG NIBP Spo2 FIO2 (inspired oxygen fraction) End tidal carbon-di-oxide (ETCO2) Ventilator disconnect alarm

29. Procedures in cardiology department Coronary Angiogram Per-cutaneous Trans-luminal angioplasty Done under local anaesthesia Painless procedure Only minimal sedation needed Problems Severe coronary artery disease Injury to coronary artery vessels needs emergency CABG

30. Procedure in psychiatry department Electro-convulsive therapy: Non pharmacological mode of treatment. Commonly used for depression 70-130 volts current is passed for 1 second through 2 cerebral hemispheres Shock produces muscular contraction. Cause initial parasympathetic discharge followed by sympathetic surge Causes retrograde amnesia

31. Anaesthesia for ECT Pre-anaesthetic assessment difficult in un communicative patients. MAO inhibitors and TCA drugs have drug interaction with pethidine and barbiturates No pre-medication is given Induction by thiopentone (4 mg/kg) Relaxant: Suxamethonium (1mg/kg) Patient is manually ventilated with bite block in place. ECT given Patient is ventilated till he/she recovers from the relaxant effect.

32. Plastic surgery-burn’s dressing Problems posed by a burn’s patient Pre-existing psychological trauma Problems in positioning and transfer Difficulty in vascular access Repeated anaesthetics Altered pharmacological response.

33. Anaesthetic plan for burn dressing Preoperative evaluation check airway check vascular access check volume status ROUTINE MONITORING O2 by face mask Total intravenous Anaesthesia(TIVA) Ketamine(1.5mg/kg) IV Diazepam(0.1mg/kg)IV Atropine(0.01mg/kg)IV

34. Anaesthesia in radiology department CT Scan Procedure lasts for 10 minutes. Non invesive procedure Contrast injected to do studies (acute anaphylaxis to contrast media can be disastrous) Sedation with chloral hydrate orally half an hour prior to the procedure TIVA: Propofol 1mg/kg with atropine 0.01mg/kg Tracheal intubation is a must when oral radio opaque is used Head injury patients with low GCS needs intubation and control of ventilation.

35. Anaesthesia for MRI Scan Painless procedure Children need anaesthesia services Procedure lasts for 60-75 minuites Scary feeling staying inside the tube Mandatory to intubate required patients and control ventilation using ventilator. Need for anaesthesia machine and monitors compatible with MRI environment.

36. Anaesthesia for Radiotherapy Children need sedation to stay motionless Repeated anaesthetics necessary It is a painless procedure. Procedure lasts for 10 mins. Plan: TIVA using ketamine/propofol

37. ASA guideline for non-operating room anaesthesia location Reliable O2 sources with backup. Suction apparatus Waste gas scavenging Adequate monitoring equipment Safe electrical outlets Adequate illumination, battery backup Sufficient space for anaesthesia personnel, equipment. Emergency defibrillator, drugs ect . Reliable means for two-way communication. Applicable facility Appropriate post anaesthesia management

38. Complication of NORA MINOR COMPLICATION Post operative nausea and vomiting Inadequate post operative pain control Hemodynamic instability Minor neurologic complication such as PDPH Minor respiratory complication( cardiology and radiology location) Need for opioid reversal

39. MAJOR COMPLICATIONS Unintended patient awareness Anaphylaxis Need for upgrade of care Serious hemodynamic instability Respiratory complication Need for resuscitation Central and peripheral nervous system injury Vascular access related complication Fall or burn(radiology procedure and cardiology location)

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