10 chandrashekara anaesthesia-in-ambulatory-surgery_ncas_2011
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Dr CHANDRASHEKARA.C.R
Consultant Anaesthesiologist
NOVA MEDICAL CENTERS,SAGAR HOSPITALS, BANGALORE
Anaesthesia Day careanaesthesia/ ambulatory anaesthesia/ Office
based anaesthesia
25 million surgeries per year -70 % ambulatory
surgeries,10% - children –IDEAL FOR DAY CARE
Development Ether- Sevoflurane, Deflurane
Thiopentone- Propofol
Short acting muscle relaxants
Short acting yet potent analgesics
Open surgery to Laparoscopic surgery
Patient xx / Pain Abdomen
Surgery means – Pain ?Discharge same day
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
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
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
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
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
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
PAC Premedication-
H2 receptor antagonists ,antacids, analgesics,Steroids,Chest physiotherapy, Nebulisation
To continue other medications
Phy/Cardio/Endocrinology opinion
Anaesthesia
Pre op counseling/ Premedication
GA – LMA/ETT
Propofol/Short acting Relaxants
OPIOD/Non opiod based analgesia
Local anaesthetics/ Nerve blocks/ Epidurals
CONTD Laser prostatectomy- under Sedation+ peudendal
nerve block
Pain-Multimodal approach Targeting different
levels
Optimal pain relief with minimal side effect
Combination of
analgesics drugs and
techniques enhance
the analgesic level
Pain management
shorter discharge times, lower pain scores, and a lower incidence of nausea and vomiting, compared with traditional opiate-based anesthetic techniques
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
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
PONV Avoid opioids- Morphine, pethidine
Ondensetron[8mg], Metachlorpropamide 10 mg
Dexamethsone 8 mg
Granisetron, Tropisetron, Dolasetron
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
Thank you
Post op Follow up
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