Saeid Safari, MD.

Saeid Safari, MD.

Saeid Safari, MD.

Saeid Safari, MD.

GUIDELINES FOR AMBULATORY ANESTHESIA AND SURGERY COMMITTEE OF ORIGIN: AMBULATORY SURGICAL CARE

(APPROVED BY THE ASA HOUSE OF DELEGATES ON OCTOBER 15, 2003, LAST AMENDED ON OCTOBER 22, 2008, AND

REAFFIRMED ON OCTOBER 16, 2013)

Saeid Safari, MD.

AMERICAN SOCIETY OF ANESTHESIOLOGISTS

• Endorses and supports the concept of Ambulatory Anesthesia

and Surgery.

• ASA encourages the anesthesiologist to play a leadership role as

the perioperative physician in all hospitals, ambulatory surgical

facilities and office-based settings

• To participate in facility accreditation as a means for

standardization and improving the quality of patient care.

Saeid Safari, MD.

GUIDELINES

1. ASA Standards, Guidelines and Policies should be adhered to

in all settings except where they are not applicable to outpatient

care.

2. A licensed physician should be in attendance in the facility, or in

the case of overnight care, immediately available by telephone,

at all times during patient treatment and recovery and until the

patients are medically discharged.

Saeid Safari, MD.

GUIDELINES

3. The facility must be established, constructed, equipped and

operated in accordance with applicable local, state and federal

laws and regulations.

At a minimum, all settings should have a reliable source of oxygen,

suction, resuscitation equipment and emergency drugs.

Saeid Safari, MD.

GUIDELINES

4. Staff should be adequate to meet patient and facility needs for

all procedures performed in the setting, and should consist of:

• A. Professional Staff

• 1. Physicians and other practitioners who hold a valid license or

certificate are duly qualified.

• 2. Nurses who are duly licensed and qualified.

• B. Administrative Staff

• C. Housekeeping and Maintenance Staff

Saeid Safari, MD.

GUIDELINES

5. Physicians providing medical care in the facility should assume

responsibility for credentials review, delineation of privileges,

quality assurance and peer review.

6. 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.

Saeid Safari, MD.

7. 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.

(In the event that nonphysician personnel are utilized in the process, the anesthesiologist must

verify the information and repeat and record essential key elements of the evaluation.)

Saeid Safari, MD.

7. MINIMAL PATIENT CARE SHOULD INCLUDE:C. Preoperative studies and consultations as medically indicated.

D. An anesthesia plan developed by an anesthesiologist, discussed

with and accepted by the patient and documented.

E. Administration of anesthesia by anesthesiologists, other qualified

physicians or nonphysician anesthesia personnel medically

directed by an anesthesiologist.

Non-anesthesiologist physicians who are administering or supervising the administration of the continuum of

anesthesia must be qualified by education, training, licensure, and appropriately credentialed by the facility.

Saeid Safari, MD.

7. MINIMAL PATIENT CARE SHOULD INCLUDE:F. Discharge of the patient is a physician responsibility.

G. Patients who receive other than unsupplemented local

anesthesia must be discharged with a responsible adult.

H. Written postoperative and follow-up care instructions.

I. Accurate, confidential and current medical records.

Saeid Safari, MD.

NON–OPERATING ROOM ANESTHESIA (NORA)This chapter serves as a general guide to the cadence and focus of procedure

performed outside of the OR, and highlights some of the adaptations, both cultural

and practical, that are needed to provide a safe and optimal anesthetic.

Saeid Safari, MD.

THE PURPOSES

• The first is to highlight the intrinsic, common, and unique

characteristics of NORA cases that impose unusual constraints

on anesthesiologists in the out of OR arena.

• The second is to present goals, methodologies, and pitfalls of

interventions that may be unfamiliar to anesthesiologists.

Saeid Safari, MD.

• As medical procedures become even more technically

demanding and patient conditions more complex, medical

proceduralists will find increasing benefit from the support of

anesthesiologists.

• This requires collaboration and teamwork, but teams cannot

function without mutual respect, excellent communication,

common vocabulary, shared experience, and some truly

overlapping competencies.

Saeid Safari, MD.

Statement on Anesthesia Care For Endoscopic Procedures

Saeid Safari, MD.

ANESTHESIA CARE FOR ENDOSCOPIC PROCEDURES

• It is the position of the American Society of Anesthesiologists that:

“There is no circumstance when it is considered acceptable for a

person to experience emotional or psychological duress or untreated

pain amenable to safe intervention while under a physician’s care.”

• (See ASA’s Position Statement on the Medical Necessity of Anesthesiology Services, Approved by the House

of Delegates on October 16, 2013.)

Saeid Safari, MD.

ANESTHESIA CARE FOR ENDOSCOPIC PROCEDURES

• Anesthesiology is a discipline within the practice of medicine that

involves the safeguarding and medical management of patients

who are rendered unconscious and/or insensible to pain and

emotional distress during surgical, obstetrical and other medical

procedures.

Saeid Safari, MD.

ANESTHESIA CARE FOR ENDOSCOPIC PROCEDURES

• Therapeutic endoscopic procedures are more likely to require

anesthesia.

• Conditions may exist that make anesthesia necessary for

procedures not usually requiring such care.

• Particular co-morbidities and mental or psychological

impediments to cooperation are examples of conditions dictating

anesthesia care for even minor procedures in certain patients.

Patients with a personal history of failed moderate sedation may

also require anesthesia care.

Saeid Safari, MD.

ANESTHESIA CARE FOR ENDOSCOPIC PROCEDURES

• Procedures that are prolonged or painful may warrant the use of

anesthesia.

• These include, but are not limited to, biopsies or polyp resections,

endoscopic retrograde cholangiopancreatography (ERCP), other

biliary tract procedures, dilation of intestinal structures with or

without stents, endoscopic resections, and other procedures that

potentially result in discomfort.

Saeid Safari, MD.

ANESTHESIA CARE FOR ENDOSCOPIC PROCEDURES

• The decision as to the medical necessity of anesthesiology

services for a particular patient is a medical judgment that must

consider all:

• Patient factors and preferences,

• procedure requirements,

• potential risks and benefits, requirements or preferences of the

physician performing the underlying procedure, and

• competencies of the involved practitioners.

Saeid Safari, MD.

GENERAL INFORMATION ON AMBULATORY ANESTHESIABARASH'S AMBULATORY ANESTHESIA

Saeid Safari, MD.

KEY POINTS

• Procedures appropriate for ambulatory surgery are those associated

with postoperative care that is easily managed at home and with low

rates of postoperative complications that require intensive physician

or nursing management.

• Whatever their age, ambulatory surgery is no longer restricted to

patients of ASA physical status I or II. Patients of ASA physical status

III or IV are appropriate candidates, providing their systemic

diseases are medically stable.

Saeid Safari, MD.

KEY POINTS

• In the 2006 ASA guidelines, the authors state that for patients

with OSA, if a procedure is typically performed as an outpatient

procedure and local or regional anesthesia is used, that the

procedure can also be performed as an ambulatory procedure.

Saeid Safari, MD.

KEY POINTS

• For adults, airflow obstruction has been shown to persist for up to 6

weeks after viral respiratory infections. For that reason, surgery

should be delayed if an adult presents with a URI until 6 weeks have

elapsed.

• In 1999, the ASA published practice guidelines for preoperative

fasting. The guidelines allow a patient to have a light meal up to 6

hours before an elective procedure and support a fasting period for

clear liquids of 2 hours for all patients.

Saeid Safari, MD.

KEY POINTS

• In a meta-analysis of peripheral nerve and centroneuraxial blocks

compared to general anesthesia, time until discharge from the

ambulatory surgery unit was no different for the three groups.

• Postoperative pain control is best with regional techniques.

• Nerve blocks using catheters can be placed before surgery that

can be used to provide analgesia after the operation.

Saeid Safari, MD.

KEY POINTS

• After induction doses of propofol or thiopental, impairment after

thiopental can be apparent for up to 5 hours, but only for 1 hour

after propofol.

• Although many factors affect the choice of agents for

maintenance of anesthesia, two primary concerns for ambulatory

anesthesia are speed of wake-up and incidence of postoperative

nausea and vomiting.

Saeid Safari, MD.

KEY POINTS

• It is important to distinguish between wake-up time and discharge

time.

• Patients may emerge from anesthesia with desflurane and nitrous

oxide significantly faster than after propofol or sevoflurane and

nitrous oxide, though the ability to sit up, stand, and tolerate fluids

and the time to fitness for discharge may be no different.

Saeid Safari, MD.

KEY POINTS

• Nausea, with or without vomiting, is probably the most important

factor contributing to a delay in discharge of patients and an

increase in unanticipated admissions of both children and adults

after ambulatory surgery.

• In addition to the PACU, many ambulatory surgery centers in the

United States have another area, often known as a phase II

recovery room, where patients may stay until they are able to

tolerate liquids, walk, and/or void.

Saeid Safari, MD.

TOPICS

• Place, Procedures, and Patient Selection

• Upper Respiratory Tract Infection

• Restriction of Food and Liquids Before Ambulatory Surgery

• Anxiety Reduction

• Managing the Anesthetic: Premedication

• Benzodiazepines

• Opioids and Nonsteroidal Analgesics

Saeid Safari, MD.

TOPICS

• Intraoperative Management: Choice of Anesthetic Method

• Regional Techniques

• Spinal Anesthesia

• Epidural and Caudal Anesthesia

• Nerve Blocks

• Sedation and Analgesia

• General Anesthesia

• Paralysis

• Intraoperative Management of Postoperative Pain

• Depth of Anesthesia

• Airways

Saeid Safari, MD.

TOPICS

•Management of Postanesthesia Care

•Reversal of Drug Effects

•Nausea and Vomiting

•Pain

•Preparation for Discharging the Patient

Saeid Safari, MD.

PLACE, PROCEDURES, AND PATIENT SELECTION• Ambulatory surgery occurs in a variety of settings. Some centers are within a hospital or in a

freestanding satellite facility that is either part of or independent from a hospital. The independent

facilities are often for-profit and not located in rural or inner-city areas. Some private companies

acquire or build ambulatory facilities and then work usually with local surgeons who become the

company's affiliated staff. Physicians' offices may also serve for procedures. Freestanding,

independent facilities will continue to grow in number and popularity, although some consumers

prefer care in units affiliated with hospitals.

• A major concern of freestanding ambulatory surgery growth is that the surgery centers may force

some hospitals out of business. This issue can be particularly problematic in areas in which

population density or median income is low. Hospitals usually are nonprofit and care for patients who

both can and cannot pay. Freestanding ambulatory facilities may also be nonprofit but usually do not

provide charity care.

• Some surgeons may work exclusively in a freestanding facility and not be on the staff of a hospital. A

requirement for hospital staff privileges frequently is that a physician provides coverage for the

hospital's emergency department. Some hospitals have lost emergency department coverage for an

entire surgical specialty because that surgical specialty works exclusively in a freestanding facility.

Saeid Safari, MD.

PLACE, PROCEDURES, AND PATIENT SELECTION

• Procedures appropriate for ambulatory surgery are those

associated with postoperative care that are easily managed at

home and with low rates of postoperative complications that

require intensive physician or nursing management. Establishing

a low rate of postoperative complication depends on the relative

aggressiveness of the facility, surgeon, patient, and payer.

Saeid Safari, MD.

PLACE, PROCEDURES, AND PATIENT SELECTION

• At the other extreme of life, advanced age alone is not a reason

to disallow surgery in an ambulatory setting. Age, however, does

affect the pharmacokinetics of drugs. Even short-acting drugs

such as midazolam and propofol have decreased clearance in

older individuals. In addition, as previously mentioned, increased

age may be a factor that affects the likelihood of unanticipated

admission.

Saeid Safari, MD.

PLACE, PROCEDURES, AND PATIENT SELECTION

• Most medical problems that older individuals may experience

after ambulatory procedures are not related to patient age, but to

specific organ dysfunction. For that reason, all individuals,

whether young or old, deserve a careful preoperative history and

physical examination.

Saeid Safari, MD.

PLACE, PROCEDURES, AND PATIENT SELECTION

• Whatever their age, ambulatory surgery is no longer restricted to

patients of American Society of Anesthesiologists (ASA) physical

status I or II. Patients of ASA physical status III or IV are

appropriate candidates, providing their systemic diseases are

medically stable.

Saeid Safari, MD.

PLACE, PROCEDURES, AND PATIENT SELECTION

• For patients with OSA, if a procedure is typically performed as an

outpatient procedure and local or regional anesthesia is used, the

procedure can also be performed as an ambulatory procedure.

Yet for patients who are at increased risk for perioperative

complications, the procedure should not be performed in a

freestanding ambulatory surgery facility.

Saeid Safari, MD.

PLACE, PROCEDURES, AND PATIENT SELECTION• Patients who undergo ambulatory surgery should have someone to take them

home and stay with them afterward to provide care. Before the procedure, the

patient should receive information about the procedure itself, where it will be

performed, laboratory studies that will be ordered, and dietary restrictions.

• The patient must understand that he or she will be going home on the day of

surgery. The patient, or some responsible person, must ensure all instructions are

followed. Once at home, the patient must be able to tolerate the pain from the

procedure, assuming adequate pain therapy is provided.

• The majority of patients are satisfied with early discharge, although a few prefer a

longer stay in the hospital. Patients for certain procedures such as laparoscopic

cholecystectomy or transurethral resection of the prostate should live close to the

ambulatory facility because postoperative complications may require their prompt

return.

Saeid Safari, MD.

UPPER RESPIRATORY TRACT INFECTION• For adults, airflow obstruction has been shown to persist for up to 6 weeks after

viral respiratory infections. For that reason, surgery should be delayed if an adult

presents with an upper respiratory infection (URI) until 6 weeks have elapsed. In

the case of children, whether surgery should be delayed for that length of time is

questionable.

• But children with active or recent URIs had more episodes of breath holding,

incidences of desaturation <90%, and more respiratory events compared with

children without symptoms

• Generally, if a patient with a URI has a normal appetite, does not have a fever or

an elevated respiratory rate, and does not appear toxic, it is probably safe to

proceed with the planned procedure

Saeid Safari, MD.

RESTRICTION OF FOOD AND LIQUIDS

• In 1999, the ASA published practice guidelines for preoperative

fasting. The guidelines allow a patient to have a light meal up to 6

hours before an elective procedure and support a fasting period

for clear liquids of 2 hours for all patients. Coffee and tea are

considered clear liquids.

Saeid Safari, MD.

RESTRICTION OF FOOD AND LIQUIDS

• Coffee and tea drinkers should follow fasting guidelines but

should be encouraged to drink coffee prior to their procedure

because physical signs of withdrawal (e.g., headache) can easily

occur. It is not clear if the guidelines should apply to patients with

diabetes or dyspepsia.

• There is some evidence that shorter periods of preoperative

fasting are accompanied by less postoperative nausea and

vomiting (PONV). Yet, it is unclear whether rehydration during

surgery is equivalent to a shorter fast before surgery in relation to

PONV.

Saeid Safari, MD.

PATIENT ANXIETY

• Preoperative reassurance from nonanesthesia staff and providing

booklets with information about the procedure also reduce

preoperative anxiety.

• Much of a child's anxiety before surgery concerns separation from a

parent or parents.

• Family-centered therapy consisted of providing the families of

children with a videotape, three pamphlets, and a mask practice kit

during their preoperative visit.

Saeid Safari, MD.

MANAGING THE ANESTHETIC: PREMEDICATION

Saeid Safari, MD.

BENZODIAZEPINES

• premedication is useful to control anxiety, postoperative pain,

nausea and vomiting, and to reduce the risk of aspiration during

induction of anesthesia.

• Benzodiazepines are currently the drugs most commonly used.

Midazolam is the benzodiazepine most commonly used

preoperatively. It can be used intravenously and orally.

Saeid Safari, MD.

BENZODIAZEPINES

• For children, oral midazolam in doses as small as 0.25 mg/kg

produces effective sedation and reduces anxiety.

• With this dose, most children can be effectively separated from their

parents after 10 minutes and satisfactory sedation can be maintained

for 45 minutes.

• In adults, particularly when midazolam is combined with fentanyl,

patients can remain sleepy for up to 8 hours. Although children may

be sleepier after oral midazolam, discharge times are not affected.

Saeid Safari, MD.

BENZODIAZEPINES

• At proper doses, neither midazolam nor diazepam place patients

at any additional risk for cardiovascular and respiratory

depression.

• The potential for amnesia after premedication is another concern,

especially for patients undergoing ambulatory surgery.

Anterograde amnesia certainly occurs.

Saeid Safari, MD.

BENZODIAZEPINES

• Oral diazepam, 2 to 5 mg per 70 kg body weight, is prescribed for the

night before and at 6:00 AM on the day of surgery (even if surgery is

scheduled for 1:00 PM or later).

• Midazolam, 0.01 mg/kg, is administered intravenously,

• Into the OR and propofol, 0.7 mg/kg, is injected intravenously.

• For children, oral midazolam, 0.25 mg/kg, is administered in the

preoperative holding area.

• When the child is asleep, acetaminophen, 40 mg/kg rectally, and

ketorolac, 0.5 mg/kg intravenously, are administered prior to initiation

of surgery.

Saeid Safari, MD.

OPIOIDS AND NONSTEROIDAL ANALGESICS

• Preoperative administration of opioids or nonsteroidal anti-

inflammatory drugs (NSAIDs) may be useful for controlling pain in

the early postoperative period.

• Celecoxib, up to 400 mg, is effective in reducing postoperative

pain.23 Ibuprofen or acetaminophen can be given rectally to

children around the time of induction.

Saeid Safari, MD.

OPIOIDS AND NONSTEROIDAL ANALGESICS

• If rectal acetaminophen is used in children, an initial loading dose

of 40 mg/kg is appropriate; subsequent doses of 20 mg/kg every

6 hours can be used.

• When preoperative rectal acetaminophen is combined with

ketoprofen, particularly for more painful procedures,

postoperative pain is less than when the drugs are given

individually.

Saeid Safari, MD.

INTRAOPERATIVE MANAGEMENT

Saeid Safari, MD.

REGIONAL TECHNIQUES

• Performing a block takes longer than inducing general

anesthesia, and the incidence of failure is higher.

• Unnecessary delays can be obviated by performing the block

beforehand in a preoperative holding area.

• Because a postoperative nursing intervention, usually associated

with general anesthesia, is associated with a 27- to 45-minute

delay, the increased setup time for a regional anesthetic may be

associated with a shorter time to discharge.

• Postoperative pain control is best with regional technique

Saeid Safari, MD.

SPINAL ANESTHESIA

• Children:

• Spinal anesthesia is used in some centers particularly for children

undergoing inguinal hernia repair.

• The anesthesiology team used 0.5% hyperbaric bupivacaine at a

dose of 0.2 mg/kg.

• Adult:

• Lidocaine and mepivacaine are ideal for ambulatory surgery

because of their short duration of action, although lidocaine use has

been problematic because of transient neurologic symptoms.

Saeid Safari, MD.

SPINAL ANESTHESIA

• Both ropivacaine and bupivacaine have been used for ambulatory

surgical procedures, but recovery time is relatively long.

• Spinal anesthesia should not be avoided in ambulatory surgery

patients simply because they may be more active postoperatively

than inpatients.

• Bed rest does not reduce the frequency of headache. Indeed,

early ambulation may decrease the incidence.

Saeid Safari, MD.

EPIDURAL AND CAUDAL ANESTHESIA• Epidural anesthesia takes longer to perform than spinal

anesthesia. Onset with spinal anesthesia is more rapid, although

recovery may be the same with either technique. \

• Caudal anesthesia is a form of epidural anesthesia commonly

used in children before surgery below the umbilicus as a

supplement to general anesthesia and to control postoperative

pain.

Saeid Safari, MD.

EPIDURAL AND CAUDAL ANESTHESIA• The block is usually administered while the child is anesthetized.

After injection, the depth of general anesthesia can be reduced.

• Because of better pain control after a caudal block, children can

usually ambulate earlier and be discharged sooner than without a

caudal block.

• Pain control and discharge times are no different whether the

caudal block is placed before surgery or after it is completed.

Saeid Safari, MD.

NERVE BLOCKS

• There was shown to be widespread use of axillary and

interscalene blocks for surgery in the upper extremity, and of

ankle and femoral blocks for lower extremity surgery.

• Nerve blocks improve postoperative patient satisfaction—PONV

and postoperative pain are less. Costs are also less.

Saeid Safari, MD.

NERVE BLOCKS

• Patients who go home with catheters inserted must be taught

about pump function, understand signs of local anesthesia

toxicity, and have someone else at home who can provide

assistance.

• In addition, the patients must be able to communicate with

someone by phone. The number of patients who have been sent

home with catheters is increasing but is not large. More study is

needed in order to demonstrate patient safety.

Saeid Safari, MD.

SEDATION AND ANALGESIA

• Many patients who undergo surgery with local or regional

anesthesia prefer to be sedated and to have no recollection of the

procedure.

• Sedation is important, in part, because injection with local

anesthetics can be painful and lying on a hard OR table can be

uncomfortable.

• Levels of sedation vary from light, during which a patient's

consciousness is minimally depressed, to very deep, in which

protective reflexes are partially blocked and response to physical

stimulation or verbal command may not be appropriate.

Saeid Safari, MD.

GENERAL ANESTHESIA

• The popularity of propofol as an induction agent for outpatient

surgery in part relates to its half-life: the elimination half-life of

propofol is 1 to 3 hours, shorter than that of methohexital (6 to 8

hours) or thiopental (10 to 12 hours).

• After induction doses of propofol or thiopental, psychomotor

impairment after thiopental can be apparent for up to 5 hours, but

only for 1 hour after propofol.

Saeid Safari, MD.

GENERAL ANESTHESIA

• Pain on injection can be a problem with propofol.

• Thrombophlebitis does not appear to be a problem after

intravenous administration of propofol, whereas it can be evident

after thiopental.

• Most children and some adults prefer not to have an intravenous

catheter inserted before the start of anesthesia.

• For short procedures, some patients may not require

neuromuscular-blocking drugs; others may need brief paralysis

(e.g., with succinylcholine) to facilitate tracheal intubation.

Saeid Safari, MD.

MAINTENANCE

• Two primary concerns for ambulatory anesthesia are speed of

wake-up and incidence of PONV.

Saeid Safari, MD.

WAKE-UP TIMES

• Propofol has a short half-life and, when used as a maintenance

agent, results in rapid recovery and few side effects. Desflurane and

sevoflurane, halogenated ether anesthetics with low blood-gas

partition coefficients, seem to be ideal for general anesthesia for

ambulatory surgery.

• Sevoflurane, unlike desflurane, facilitates a smooth inhalation

induction of anesthesia, the preferred technique to ensure rapid

recovery of children in ambulatory surgery centers.

•

Saeid Safari, MD.

WAKE-UP TIMES

• It is important to distinguish between wake-up time and discharge

time.

• Patients may emerge from anesthesia with desflurane and nitrous

oxide significantly faster than after propofol or sevoflurane and

nitrous oxide, although the ability to sit up, stand, and tolerate

fluids and the time to fitness for discharge may be no different.

Saeid Safari, MD.

INTRAOPERATIVE MANAGEMENT OF PONV

• Nausea, with or without vomiting, is probably the most important

factor contributing to a delay in discharge of patients and an

increase in unanticipated admissions of both children and adults

after ambulatory surgery.

Saeid Safari, MD.

HAVE A HIGHER INCIDENCE OF PONV:

• Women, especially those who are pregnant,

• Previous history of motion sickness or postanesthetic emesis,

• Surgery within 1 to 7 days of the menstrual cycle,

• Not smoking,

• Laparoscopy, lithotripsy, major breast surgery, and ear, nose, or

throat surgery.

Saeid Safari, MD.

• Selective serotonin antagonists (ondansetron, dolasetron, and

granisetron.

• Dopamine antagonists,

• Antihistamines,

• Anticholinergic drugs are useful and are generally less expensive,

but are associated with extensive side effects.

• Neurokinin (NK1) receptor antagonists may also be useful to

control PONV.

• Therapies useful in controlling PONV include acupuncture

Saeid Safari, MD.

COMBINATION THERAPY

• Avoidance of nitrous oxide;

• Avoidance of inhalation agents;

• Avoidance of muscle relaxant reversal, if clinically indicated;

• Avoidance of narcotics;

• Fluid hydration

• Administration of a 5-HT3 antagonist, an antiemetic from a

different drug class, and dexamethasone.

Saeid Safari, MD.

PARALYSIS

• Muscle paralysis for ambulatory anesthesia extends beyond the

time of paralysis for intubation, particularly when nondepolarizing

drugs are used.

• Reversal agents must be used unless there is no doubt that

muscle relaxation has been fully reversed.

Saeid Safari, MD.

INTRAOPERATIVE MANAGEMENT OF POSTOPERATIVE PAIN

• Opioids, when given intraoperatively, are useful to supplement

both intraoperative and postoperative analgesia.

• Fentanyl is pro

• To control postoperative pain, combination therapy is most

useful.bably the most popular drug.

Saeid Safari, MD.

DEPTH OF ANESTHESIA

• Use of BIS, and entropy, or auditory-evoked potential monitors

can decrease anesthesia requirement without sacrificing amnesia

during general anesthesia.

• Because less anesthesia is used, titration of anesthesia with

these monitors results in earlier emergence from anesthesia.

Saeid Safari, MD.

AIRWAYS

• The use of an LMA, or similar type of airway, provides several

advantages for allowing a patient to return to baseline status

quickly.

• Muscle relaxants required for intubation can be avoided.

• Coughing is less than with tracheal intubation.

• Anesthetic requirements are reduced.

• Hoarseness and sore throat are also reduced.

• Overall, cost savings result with the use of LMAs

Saeid Safari, MD.

MANAGEMENT OF POSTANESTHESIA CARE

Saeid Safari, MD.

PACU

• The three most common reasons for delay in patient discharge

from the PACU are:

• Drowsiness,

• Nausea And Vomiting,

• Pain.

• All three are a function of intraoperative management, but

nausea, vomiting, and pain also can be treated in the PACU.

Saeid Safari, MD.

PACU- REVERSAL OF DRUG EFFECTS

• Reversal of opioids may sometimes be necessary.

• Flumazenil, a benzodiazepine receptor antagonist,

• Flumazenil should not be used routinely as a benzodiazepine

antagonist, but may be used when sedation appears to be

excessive

Saeid Safari, MD.

PACU- NAUSEA AND VOMITING

• Nausea and vomiting are also the most common adverse effect in

patients in the PACU.

• In adults, granisetron, 40 µg/kg; metoclopramide, 0.2 mg/kg; or

hydroxyzine, 25 mg, are effective.

• Dexamethasone, 8 mg, given with other antiemetics can enhance

treatment of established PONV in the PACU.

• Midazolam and propofol, have antiemetic effects that are longer

in duration than their effects on sedation.

Saeid Safari, MD.

PACU- PAIN

• Postsurgical pain must be treated quickly and effectively.

• It is important for the practitioner to differentiate postsurgical pain

from the:

• Discomfort of hypoxemia,

• Hypercapnia,

• Full bladder.

Saeid Safari, MD.

PACU- PAIN

• When swelling and pain are problematic postoperatively, NSAIDs

can be more effective than opioids in relieving both.

• For children, we also use an elixir of acetaminophen containing

codeine (120 mg acetaminophen and 12 mg codeine, in each 5

mL of solution).

• Five milliliters is administered to children between the ages of 3

and 6, and 10 mL to children between the ages of 7 and 12.

Saeid Safari, MD.

PREPARATION FOR DISCHARGING THE PATIENT

• Patients should also be informed that they may experience pain,

headache, nausea, vomiting, or dizziness and, if succinylcholine

was used, muscle aches and pains apart from the incision for at

least 24 hours.

• A patient will be less stressed if the described symptoms are

expected in the course of a normal recovery.

• Written instructions are important. The addition of written and oral

education techniques at discharge has a significant impact on

improving compliance.

Saeid Safari, MD.

THE MODIFIED ALDRETE’SSCORING SYSTEM IS A HIGHLYACCEPTABLE CRITERIA FORDISCHARGING PATIENTS FROMTHE PACU.

Proposed fast-track criteria to determine whether

outpatients can be transferred directly from the

operating room to the step-down (phase II) unit. A

minimal score of 12 (with no score ,1 in any individual

category) would be required for a patient to be fast

tracked (i.E., Bypass the post anesthesia care unit)

after general anesthesia.

Saeid Safari, MD.

CONCLUSION

Saeid Safari, MD.

CONCLUSION

• Patient, procedure, availability and quality of aftercare, and

anesthetic technique must be individually and collectively

assessed to determine acceptability for ambulatory surgery.

• A delicate balance must be maintained between the physical

status of the patient, the proposed surgical procedure, and the

appropriate anesthetic technique, to which must be added the

expertise level of the anesthesiologist caring for a patient.

Saeid Safari, MD.

CONCLUSION

• Anesthesia for ambulatory surgery is a rapidly evolving specialty.

• Patients who were once believed to be unsuitable for ambulatory

surgery are now considered to be appropriate candidates.

• Operations once believed unsuitable for outpatients are now

routinely performed in the morning so patients can be discharged

in the afternoon or evening.

Saeid Safari, MD.

CONCLUSION

• The appropriate anesthetic management before these patients

come to the OR, during their operation, and then afterward is the

key to success.

• The availability of both shorter-acting anesthetics and longer-

acting analgesics and antiemetics enables us to care for patients

in ambulatory centers effectively.

Saeid Safari, MD.