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Dr CHANDRASHEKARA.C.R
Consultant Anaesthesiologist
NOVA MEDICAL CENTERS,SAGAR HOSPITALS, BANGALORE
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Anaesthesia Day careanaesthesia/ ambulatory anaesthesia/ Office
based anaesthesia
25 million surgeries per year -70 % ambulatory
surgeries,10% - children –IDEAL FOR DAY CARE
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Development Ether- Sevoflurane, Deflurane
Thiopentone- Propofol
Short acting muscle relaxants
Short acting yet potent analgesics
Open surgery to Laparoscopic surgery
Patient xx / Pain Abdomen
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Surgery means – Pain ?Discharge same day
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OUR CHALLENGES Challenging-
Difficulty – convince -Surgeons, anaesthetists, Pts
Type of surgery- quick recovery
Assessment pain { children}
Lack of experience{Standalone day care center}
Pts with acute/chronic undiagnosed diseases.
Proper planning
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Procedure General surgery /Urology
Inguinal hernia repair
Orchidopexy
Umbilical hernia repair
thyroglossalcyst
Cervical lymph node biopsy
Ganglion excision
Laparoscopic procedures
Circumcision
Cystoscopy
Preputial adhesionreleaserelease
Minor hypospadias
Ureteric stent placement
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Contd Plastic surgery Orthopaedic
Removal of nevus
Otoplasty
Suture removal
Dressing changes
Mammoplasty
Liposuction
Removal of spica, nails, Achilles lengthening
Arthroscopic procedures
osteochondromaexcision
Muscle biopsy
ORIF ulna, radius
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Procedure
OBG ENT/Dental
D&E
D&C, Hysteroscopic D&C
Lap ovarian cystectomy
Diagnostic lap
Others
Myringotomies
Nasal and aural foreign body removal
Adenotonsillectomy
Mastoidecomy/tympanoplasty Restoration
Extraction
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NOT FOR DAY CARE
Active asthma/URTI/Difficult Airway
CHF/IHD/Un controlled HTN/Cardio myopathies
Uncontrolled DM
Morbid obesity
Haemorrhage/fluid shifts
?Procedures more than 90 minutes
Prematures
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Our Success Proper Selection of cases
Pre-operative assessment /Stabilisation .
Well planned anaesthetic techniques/ modified?
Management of post-operative pain, nausea and vomiting
Discharge according to protocol
Extended Day care facility
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PAC Premedication-
H2 receptor antagonists ,antacids, analgesics,Steroids,Chest physiotherapy, Nebulisation
To continue other medications
Phy/Cardio/Endocrinology opinion
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Anaesthesia
Pre op counseling/ Premedication
GA – LMA/ETT
Propofol/Short acting Relaxants
OPIOD/Non opiod based analgesia
Local anaesthetics/ Nerve blocks/ Epidurals
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CONTD Laser prostatectomy- under Sedation+ peudendal
nerve block
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Pain-Multimodal approach Targeting different
levels
Optimal pain relief with minimal side effect
Combination of
analgesics drugs and
techniques enhance
the analgesic level
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Pain management
shorter discharge times, lower pain scores, and a lower incidence of nausea and vomiting, compared with traditional opiate-based anesthetic techniques
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Pain IV Fentanyl-2 mic gms/kg bolus/1mic gms infusion
IV Paracetamol 20 mg/kg – upto 4 gms/day
?IV Diclofenac upto 150 mg/ day
IV Ketorolac[0.8 mg/kg, max 60 mg- low pain score, decreased opiods
Extended day care- Morphine, Pethidine
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PONV PONV distressing complication of ambulatory
anesthesia
Delayed discharge and unanticipated admissions
The role of Nitrous oxide in contributing to PONV is unclear
Propofol- less nausea and vomiting than other induction drugs with its rapid recovery profile
Neostigmine be associated with an increased incidence of PONV
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PONV Avoid opioids- Morphine, pethidine
Ondensetron[8mg], Metachlorpropamide 10 mg
Dexamethsone 8 mg
Granisetron, Tropisetron, Dolasetron
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Discharge Stable vital signs
Orientated/Orally taking.
Adequate Pain control
No- PONV ,Voiding difficulty, dizziness
No bleeding
Emergency Contact no/Responsible Adult
Compliance – studied, Educate them-Video, Talking to other pts
Dissatisfaction do Exist
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Thank you
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Post op Follow up
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Figure 1. Most patients had recovered from anesthesia and were discharged home within 1–2
h after surgery.
Marshall S I , Chung F Anesth Analg 1999;88:508-508
©1999 by Lippincott Williams & Wilkins
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