ANESTHESIOLOGY

AMBULATORY ANESTHESIA
Vivienne O. Lusaya, MD, FPSA, DPBA
First Loop | 1 August 2020

Note. Green – Facilitator’s notes and comments • Preoperative screening

TABLE OF CONTENTS
I. Distribution of Anesthesia Services by Facility Setting o Preoperative history and physical examination (documented
II. Ambulatory Anesthesia within 30 days)
III. Patient Section
IV. Procedure Selection ▪ Current medications, drug or latex allergies, psychological
A. Surgical Techniques
B. Anesthetic Drugs and Techniques history, family history
V. Requirements for Ambulatory Anesthesia ▪ Airway concerns
VI. Causes of Injury
VII. Factors that Cause Morbidity and Mortality in Ambulatory Anesthesia o Optimally managed medical condition
VIII. Anesthetic Management
IX. Anesthetic Agents
▪ Asthma, diabetes mellitus, hypertension
A. Sedation or General Anesthesia o Availability of laboratory test results
B. Prevention of Anesthesia
X. Anesthetic Techniques o Availability of medically indicated specialist consultations
XI. Intraoperative Anesthetic Management • NPO status (instructions on how many hours should be clear to them)
A. Techniques
XII. Postoperative/Post-anesthesia Management • Presence of an escort and post-procedure plans (if no adult to
A. Postoperative Nausea and Vomiting (PONV)
B. Postoperative Pain Management (Multimodal Approach) accompany them home, procedure will be postponed)
XIII. Discharge • Other considerations:
A. PACU Discharge Criteria Scoring Systems
B. Preparations for Discharging the Patient o Age: Extremes of age
XIV. Summary
▪ Very young – There is risk of postoperative apnea
▪ Advanced age – Decreased clearance of drugs (prolonged
DISTRIBUTION OF ANESTHESIA SERVICES BY FACILITY effect of anesthesia) and likelihood of unanticipated admission
SETTING o ASA III or IV
• Over a 20-year period, there is an increase in anesthesia services ▪ Systemic diseases are medically stable (allowed if with
done in an ambulatory center or office-based facility clearance)
▪ Should have anesthesia and specialists’ consultation
▪ Procedure performed under local anesthetic without sedation
(MAC)
o Obese with obstructive sleep apnea (OSA)
▪ If the procedure to be done is typically performed as an
outpatient procedure
▪ Local or regional anesthesia is used
• Poor candidates
o Extreme or morbid obesity
o Known severe OSA syndrome
o Potentially difficult airway
o High aspiration risk
o Possible anaphylaxis risk
o Possible MH risk
o Previous adverse outcomes after anesthesia
o Severe or exacerbated COPD
o Seizure disorder
o Recent MI
o Recent stroke
o Abnormal bleeding tendency
o Abnormal clotting tendency (DVT)
AMBULATORY ANESTHESIA o Poorly controlled diabetes mellitus
• Patient arrives to the surgical venue on the day of the procedure, is o Poorly controlled hypertension
anesthetized, and is discharged home later that same day o Inability to cooperate
• Venue: o History of substance abuse
o Hospital-based
o Surgicenter (ambulatory surgical center, free-standing facility) PROCEDURE SELECTION
o Office – “office-based anesthesia” • Duration
• Advantages o Limited to 6 hours (operations done earlier in the day) and
o Cost containment completed by 3:00 PM
o Patient • Complexity
▪ Convenience o Does not pose a significant safety risk
▪ Improved privacy and personal attention o Does not require an overnight stay
▪ Decreased exposure to nosocomial infection o Associated with postoperative care that is easily managed at
o Surgeon home
▪ Convenience and ease of scheduling o Have low rates of postoperative complications (e.g., PONV, pain,
▪ Consistency in nursing personnel and bleeding)
▪ Efficiency o Does not require intensive physician or nursing management
• Disadvantages • Other considerations:
o Safety concerns o Type of anesthesia that will be required
▪ Facility’s resources (specialists, personnel, equipment) o Expected blood loss needing blood transfusion
• Crisis management of cardiac arrest, unanticipated o Major fluid shifts (third space loss)
difficult airway, anaphylaxis, local anesthetic systemic o Likelihood of need for postoperative opioid
toxicity, MH o Capabilities of the facility
▪ Anesthetic technique used (oversedation) o Adequacy of post-discharge observation at the patient’s home
▪ Regulation (reporting, quality improvement, peer review) (relatives at home that can monitor the patient when he is sent
home)
PATIENT SELECTION
• ASA I or II – Ideal patient
o ASA I – Healthy
o ASA II – Well-controlled mild systemic diseases

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A. Surgical Techniques A. Sedation or General Anesthesia

• Oral surgery (e.g., release of tongue tie on a pediatric patient) • Short-acting agents to produce either sedation or general anesthesia
• ENT procedures (e.g., foreign body removal) o IV drugs: Midazolam, propofol, ketamine, dexmedetomidine
• Endoscopic procedures (e.g., endoscopy, gastroscopy, o Inhalational agents: Sevoflurane, desflurane
duodenoscopy, colonoscopy)
• Orthopedic procedures (e.g., knee arthroscopy) B. Prevention of PONV
• Use anesthetic and analgesic drugs that do not cause PONV
1. Office-Based Procedures o Propofol (total intravenous anesthesia, TIVA)
• GI endoscopy o Dexmedetomidine – α-2 agonist
• Liposuction o Central neuraxial block (subarachnoid/spinal and epidural blocks)
• Aesthetic facial and breast surgery o Peripheral nerve block
• Oral, dental, and maxillofacial surgery • Use antiemetic drugs targeting different receptors (multimodal)
• Gynecologic and genitourinary surgery (e.g., fractional D&C, cervical o 5-HT inhibitor: Ondansetron
polypectomy, cystoscopy, insertion of double J stent) o Dexamethasone – A steroid with central antiemetic mechanism
• Ophthalmologic and otolaryngologic procedures (e.g., phaecoemulsi- • Use opioid-sparing analgesic
fication, cataract surgery) o Paracetamol, NSAIDs
• Orthopedic surgery o Try to avoid using opioids
• Ensuring adequate hydration to avoid hypotension and decreased
B. Anesthetic Drugs and Techniques blood flow to the midbrain emetic centers
• No different from the ones done in an in-patient
ANESTHETIC TECHNIQUES
• General anesthesia per intravenous route
• Choice of technique depends on the following:
• Inhalational anesthesia via mask (GA mask, GA-LMA, GETA)
o Surgical procedure
• Regional anesthesia: Spinal/subarachonid, epidural blocks
o Medical profile of the patient
• Kiddie caudal block – Epidural block in pediatric patients o Preferences of the surgeon, patient, and anesthesiologist
• Peripheral nerve block (ultrasound guided) • Techniques suitable for ambulatory surgical procedures include:
• Local infiltration o Sedation at minimal, moderate, or deep levels
o General anesthesia
REQUIREMENTS FOR AMBULATORY ANESTHESIA o Regional anesthesia
• Standard of anesthetic care should be no less than of a hospital
• Safe anesthetizing environment INTRAOPERATIVE ANESTHETIC MANAGEMENT
o Anesthesia and emergency equipment including airway A. Techniques
equipment, MH cart, and suction machines 1. General Anesthesia
o Monitoring in conformance with ASA standards: ECG, BP, SpO2,
• The drugs selected for GA determine how long the patient will stay in
EtCO2, TO
the post-anesthesia care unit (PACU) after surgery
o ‘E’ drugs and defibrillators (ACLS)
• Induction
o Controlled substance handling and storage
o Propofol
o Medical director (facility management)
▪ Ultra-short-acting hypnotic agent
o Contingency plan for hospital admission if needed
▪ Half-life is 1-3 hours
o Fire prevention and preparedness
▪ After an induction dose, psychomotor impairment is apparent
o Accreditation
for only 1 hour
• Anesthesiologist – Trained, board-certified
• Maintenance
• Surgeons – Trained, board-certified, credentialed for the procedure
o Propofol
• Personnel (nurses, aids, etc.) ▪ Maintenance for TIVA
▪ Has short half-life
CAUSES OF INJURY ▪ Rapid recovery with few side effects
• Inadequate resuscitation equipment o Sevoflurane
• Inadequate monitoring ▪ Halogenated ether anesthetic with low blood-gas partition
• Inadequate preoperative and postoperative evaluation coefficients
• Human error (slow recognition of an event, slow response to an event,
lack of experience) 2. Regional Anesthesia
• Drug overdosage • Spinal or epidural blocks
• Suitable for pelvic, lower abdominal, and lower extremity surgery
FACTORS THAT CAUSE MORBIDITY AND MORTALITY IN • Use of low-dose spinal anesthesia to avoid delay in patient’s ability to
AMBULATORY ANESTHESIA walk and be discharged
• Systemic toxicity of local anesthetic • Nausea is much less frequent
• Prolonged surgery with occult blood loss • Use smaller gauge needles to lower the incidence of post-dural
• Hypovolemia puncture headache (PDPH)
• Pulmonary embolism
• Hypoxemia 3. Peripheral Nerve Blocks
• Oversedation • Reduce PONV and postoperative pain
• Use of reversal drugs with short half-lives
4. IV Sedation
ANESTHETIC MANAGEMENT • Minimal Sedation
• Goals o Patient responds normally to verbal commands
o Safety o Cognitive and motor function may be impaired
o Rapid recovery from the effects of anesthetic agents o Ventilatory and cardiovascular functions maintained normally
o Minimal side effects • Moderate/Conscious Sedation
o Rapid discharge from the office/clinic, surgical center or hospital o Patient responds purposefully to verbal commands alone or with
light tactile stimulation
ANESTHETIC AGENTS o Patient presents a patent airway and spontaneous ventilation
• Goals o Cardiovascular function is maintained
o Short duration to facilitate rapid discharge after the procedure • Deep Sedation
(ideally 1 hour or less) o Patient cannot be easily aroused but can respond purposefully to
o Absence of PONV repeated or painful stimulation
o Cost-effectiveness o Cardiovascular function is usually maintained

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o Ventilatory function may be impaired, requiring assistance in

maintaining a patent airway, and spontaneous ventilation may be
inadequate
o Benzodiazepine (midazolam, to sedate the patient) + Opioid
(fentanyl, Nubain) or Dexmedetomidine
o Low dose propofol to seduce the patient

POSTOPERATIVE / POST-ANESTHESIA MANAGEMENT

A. Postoperative Nausea and Vomiting (PONV)
• Nausea with or without vomiting is probably the most important factor
contributing to a delay in discharge of patients and increase in
unanticipated admissions

Risk Factors for PONV

• Female gender
• With previous history of PONV
• Motion sickness
• Procedures such as laparoscopy, lithotripsy, major breast surgery,
ENT surgery

Treatment of PONV
• Antiemetic drugs targeting different receptors (multimodal)
o 5-HT inhibitor: Ondansetron
o Dopamine antagonists
o Dexamethasone – A steroid with central antiemetic mechanism
which can improve efficacy of both serotonin and dopamine
antagonists

B. Postoperative Pain Management (Multimodal Approach)

• Non-opioid analgesics are preferred
o Examples: Paracetamols, NSAIDs, COXIBs
o Wound infiltration with local anesthetic agent
o Peripheral nerve block
• Opioids have unwanted side effects that are undesirable in the
outpatient setting
o Nausea and vomiting
o Itching
o Constipation
Respiratory depression
o Altered mental status

DISCHARGE
• The 3 most common reasons for delay in patient discharge from
PACU:
o Drowsiness (delayed emergence from anesthesia)
o Nausea and vomiting
o Pain
• Other reasons:
o Respiratory events
o Urinary retention
o Hypothermia
• In the PACU:
o Patient should be able to sit in a chair
o Ambulate to dress postoperatively
o Free of pain and PONV SUMMARY
o All vital signs should be within 10% of baseline • The number of surgical procedures performed in an ambulatory setting
has expanded rapidly
A. PACU Discharge Criteria Scoring Systems • Advantages: Patient and surgeon convenience, cost containment, and
• Used to guide anesthesiologists whether to discharge the patients decreased nosocomial infection rates
• Two most used PACU discharge criteria systems: • Disadvantages: Safety concerns
o Modified Aldrete Scoring System • Patient-specific and procedure-specific criteria determine suitability for
▪ Parameters: Respiration, O2 saturation, consciousness, outpatient procedures
circulation, activity • Minimal, moderate, or deep sedation, general anesthesia or regional
o Post Anesthetic Discharge Scoring System anesthesia are each suitable anesthetic technique
▪ Parameters: VS, activity, nausea and vomiting, pain, surgical • Use short-acting agents for sedation or general anesthesia to facilitate
bleeding rapid discharge after the procedure
• Score of 9 or more = Patient is fit to be sent home • To prevent or treat PONV—use a multimodal approach, use
alternative anesthetic techniques, use non-opioid analgesics, and
adequate hydration
B. Preparations for Discharging the Patient • To manage postoperative pain—use multimodal approach and
• Should be advised against driving for at least 24 hours after a techniques
procedure • Standard discharge criteria should be used to supplement the
• Should not operate power tools assessment of the responsible anesthesiologist for release home
• Should not be involved in major business decisions for up to 24 hours
• Written instructions as well as oral education techniques at discharge
should be done to improve compliance

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