ambulatory anesthesia presentasi
TRANSCRIPT
-
8/3/2019 Ambulatory Anesthesia Presentasi
1/23
AMBULATORY ANESTHESIA
-
8/3/2019 Ambulatory Anesthesia Presentasi
2/23
Introduction
Current estimates are that 40 to 60 percents of all surgical procedures could beperformed in outpatient surgery centers
Several factor that contributed to the renewed interest in ambulatory surgery;
- Hospital costs are decreased 25 to 75 percents , but specialized
postoperative care may be more costly
- Separation from patients familiar home environment are decreased- Decreased risk of hospital-acquired infection for pediatric and
immunocompromized cancer and transplant patients
- Incidence of respiratory complication(e.g., pulmonary embolus and
pneumonia) may also be decreased
The availability of both shorter-acting anesthetics and longer acting analgesicsand antiemetics enables us to care for patients effectively
Ambulatory surgery occurs in a variety of setting. Some center are within ahospital or in a freestanding satellite facility that is either part or independent of ahospital
-
8/3/2019 Ambulatory Anesthesia Presentasi
3/23
Procedures for Ambulatory Surgery
An appropriate procedures for ambulatory surgery are those associated
with;
- Postoperative care that easily managed at home
- With low rates of postoperative complication , depends on the
relative aggressiveness of the facility, surgeon, patient, and
payer
Preterm infants( < 50 week of post-conceptual age) associated with
increased risk for the development of postoperative respiratory
complication(apnea)
Anemia(Ht < 30%) is also associated with an increased incidence of apnea
in preterm infant < 60 week of post-conceptual age
Recovery of fine motor skills and cognitive function after general
anesthesia(or local anesthesia with sedation) commonly slower in older
patients
-
8/3/2019 Ambulatory Anesthesia Presentasi
4/23
Procedures for Ambulatory Surgery
Advance age is not a reason to disallow in an ambulatory
procedures, because most of postoperative medical problem
are not caused by age, but by specific organ dysfunction. For
that reason, all individual, whether young or old, deserve a
careful preoperative assessment
-
8/3/2019 Ambulatory Anesthesia Presentasi
5/23
Preoperative Assessment
Patients selection;
- ASA physical I or II
- ASA physical III or IV are also acceptable candidates,
providing their systemic disease are medically stable
Preoperative visit by an anesthesiologist is very important tominimized cancelation and decreases the patients anxiety
An alternative approach for preoperative screening is utilize apreanesthetic questionnaire to obtain information about patientsmedical problems, previous operation, drug history, and familyhistory and to provide general review system
The process also provide the staff with an opportunity to remindthe patient of arrival time, suitable attire, and dietaryrestriction(e.g., nothing to eat or drink after midnight, no jewelry ormakeup)
-
8/3/2019 Ambulatory Anesthesia Presentasi
6/23
Preoperative Assessment
The laboratory testing required depends on the patients age,
state of health, and drug hystory
CBC/Hct and ECG starting at age 50 yrs
SMA-6(Sequential Multiple Analysis-6 serum test) and CXR(chest
radiography) for >70 yrs
CBC/Hct is essential for
-
8/3/2019 Ambulatory Anesthesia Presentasi
7/23
Premedication
Controlling Anxiety Psychologycal;
Preoperative visit by an anesthesiologist. Was more effective
in decreasing anxiety than administration of abarbiturates(Egbert et al). Both parents and children need tobe involve in preoperative discussion so that the anxiety ofparents are not transmitted to the child
If necessary;
Midazolam 0.04-0.08 mg/kg IV0.5 mg/kg orally for children
Propofol 1.5-2.5 mg/kg for adult
-
8/3/2019 Ambulatory Anesthesia Presentasi
8/23
Controlling the Risk of Aspiration
Droperidol 5-15 g/kg IV for children
7.5-15 g/kg IV for adult
H2 receptor antagonistsRanitidine 50-200 mg,the night before surgery
Cimetidine 150-300 mg, 1-1,5 hr before surgery
Omeprazole 80 mg, the night before surgery
Metoclorpramide 0.15-0.3 mg/kg, most effective when givenat the end of anesthesia or as an adjunct to other antiemetics
Sodium Citrat(non-particulating antacid) 30 ml, just before theprocedure
-
8/3/2019 Ambulatory Anesthesia Presentasi
9/23
Opioids
Small dose of the potent opioid analgesics
- Fentanyl 1-3 g/kg
- Sulfentanyl 0.1- 0.3 g/kg
- Oral transmucosal fentanyl(lollipop)
Not routine, unless the patients experiencing acute or chronic
pain
-
8/3/2019 Ambulatory Anesthesia Presentasi
10/23
Controlling Postoperative Nausea Preoperatively
Nausea, with or without vomiting, is probably the most important
factor contributing to a delay in discharge of patients
Risk factor that contributing postoperative nausea and vomiting;- Patients body habitus and medical condition
- Type of surgery performed(e.g., laparoscopy, orchiopexy,
strabismus surgery, therapeutic abortion)
- Assisted ventilation with a face mask- Anesthetic and analgesic medications( fentanyl, etomidate,
isoflurane, and nitrous oxide)
-
8/3/2019 Ambulatory Anesthesia Presentasi
11/23
Controlling Postoperative Nausea Preoperatively
Droperidollower dose(0.25-0.5 mg)
50-75 g/kg for children
Promethazine 0.5-1.0 mg/kg
Serotonin Antagonists
Ondansetron 4-8 mg
75 g/kg for children
-
8/3/2019 Ambulatory Anesthesia Presentasi
12/23
Outpatient Anesthetic Techniques:
General Anesthesia
Induction- Propofol;
Induction agent of choice for ambulatory anesthesia,
because of their short elimination half-life(1-3hr)
Reduce incidence of postoperative emesis
- Thiopental
- Sevoflurane
- Halotan
drug of choice for inhalation induction in pediatric patients
- Rectal etomidate(6 mg/kg) or ketamine(50 mg/kg) for children
- Ketamin; 2-6 mg/kg IM, for uncooperative child
-
8/3/2019 Ambulatory Anesthesia Presentasi
13/23
Maintanace- Volatile anesthetics are generally considered to be superior than
intravenous anesthetic, because they are more controllable
Sevoflurane and Desflurane
Halogenated ether anesthetic with low blood-gas partition
coefficients, seem to be ideal for general anesthesia
Nitrous Oxide
Combined with the other anesthetic drugs
- Propofol
Has a short half life, result in rapid recovery
- Opioid(rapid and shorter-acting narcotics)
When given intraoperatively, are useful for both
intraoperative and postoperative analgesia
Fentanyl, sufentanyl, alfentanyl
-
8/3/2019 Ambulatory Anesthesia Presentasi
14/23
Airway management;
- Face mask, laryngeal mask airway, oro-tracheal tube
- Drugs facilitating tracheal intubation;Depolarizing muscle relaxants Succinylcholin
Most rapid onset of muscle paralisys
Muscle pains lasting up to 4 days after surgery
Non-depolarizing muscle relaxants Rapacuronium,Rocuronium, Mivacuronium
-
8/3/2019 Ambulatory Anesthesia Presentasi
15/23
Outpatient Anesthetic Techniques:
Regional Anesthesia
Spinal Anesthesia Spinal anesthesia are suitable for
urologic, herniorrhapy, and lower extremity surgery
Common side effects of general anesthesia are
avoided(e.g., nausea, vomiting, dizziness, and lethargy) Lidocaine, mepivacaine, and 2-chloroprocaine are ideal because of their
short duration of action
Needle size and shape are important to reduce the incidence of postduralpuncture headache(PDPH)
High incidence in patients younger than 60 yrs
Smaller gauge needles(e.g., 26 gauge) and pencil-pointneedles(Sprotte and Whitacre needles)
Can produce urinary retention
-
8/3/2019 Ambulatory Anesthesia Presentasi
16/23
Epidural and Caudal Anesthesia
Advocated for outpatients lower extremity procedure,
herniorraphy, and extracorporeal shock-wave lithotripsy
Onset of epidural anesthesia is more slower than spinalanesthesia, and recovery may be same with either technique
Problem of postdural puncture headache is usually avoided
Caudal anesthesia is a useful technique for anorectal surgery,
dilatation and curetage
-
8/3/2019 Ambulatory Anesthesia Presentasi
17/23
Peripheral Nerve Blocks
Intravenous regional anesthesia
Simple and reliable technique for superficial surgical limited to
a single extremity Brachial plexus block
For upper extremity surgery
3 in 1 block(femoral, obturator, and lateral femoralcutaneous nerves using a perivascular technique) for knee
arthroscopy
Ankle block
For surgery on the foot
-
8/3/2019 Ambulatory Anesthesia Presentasi
18/23
Outpatient Anesthetic Technique:
Local Anesthesia
Simplest and safest
Significantly shorter recovery times
Monitoring patients vital sign
Injection of local anesthetics is often associated with severediscomfort
Intravenous sedative and analgesic drugs( i.e., so-called
conscious sedation technique)
-
8/3/2019 Ambulatory Anesthesia Presentasi
19/23
Management ofPostanesthesia Care
The most common reason for delay in patients discharge from
the PACU(Postanesthesia Care Unit) are intracable nausea and
vomiting, drowsiness, airway problem(e.g., stridor,
bronchospasme), inability to void, dizziness, delayed
emergence, and pain
Nausea, vomiting, and pain also can be treated in the PACU
Nausea and vomiting
Metochlorpramide 20 mg
Hydroxyzine 25 mg
Droperidol 0.625-1.25 mg
-
8/3/2019 Ambulatory Anesthesia Presentasi
20/23
Management ofPostanesthesia Care
Pain
- Morphine 1-3 mg/70kg,or
Fentanyl 10-25 g/70 kg small IV doses
- Ketorolac 60 mg/kg IM or IV
- Elixir of acetaminophen containing codein( 120 mg
acetaminophen, 12 mg codein, in each 5 ml of solution) for
chidren
- Acetaminophen 60 mg/year of age,( orally or rectally) for
mild pain in older infants and young children- Fentanyl 2 g/kg IV, for more severe pain
- Mepheridin 0.5 mg/kg, and Codein 1-1.5 mg/kgBB if an IV
route has not been establish
-
8/3/2019 Ambulatory Anesthesia Presentasi
21/23
Preparation for Discharge the Patient
Accurate assessment about recovery of cognitive and
psychomotor function is important to determining the
appropriate time for discharge after ambulatory anesthesia
Patients who are awakened in the OR and are evaluated as 9or 10 according to the modified Aldrete scoring system, may
be transferred directly to Phase II recovery room, where
patients may stay until they are able to tolerate liquids, walk,
and/or able to void
-
8/3/2019 Ambulatory Anesthesia Presentasi
22/23
POSTANESTHETIC DISCHARGE SCORING SYSTEM
Vital sign
2 = within 20% of preoperative value
1 = 20-40% of preoperative value
0 = 40% of preoperative value
Ambulation and mental status
2 = oriented 3 and has a steady gait
1 = oriented 3 or has a steady gait
0 = neitherPain or nausea Total score 10
3 = minimal 9 ; fit for discharge
2 = moderate
1 = severe
Surgical bleeding
3 = minimal
2 = moderate
1 = severe
Intake and output
3 = has had po fluids and has voided
2 = has had po fluids or has voided
1 = neither
-
8/3/2019 Ambulatory Anesthesia Presentasi
23/23
References
1. Barash PG, Cullen BF, Stoelting RK: Clinical Anesthesia, 4th ed.
Philadelphia, Lippincott Williams & Wilkins, 2001
2. Miller RD: Anesthesia, 3th ed. California, Churchill
Livingstone, 1990