OutPatient anesthesia

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OutPatient anesthesia
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1970

• Phoenix Surgicenter opened
• First (modern) free standing ambulatory surgery
  center
• Founded by two anesthesiologists Dr. John Ford
  and Dr. Wallace Reed

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1981

• American College of Surgeons officially endorses
  the concept of ambulatory surgery

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• 1995 66 of all surgeries performed were done on
  an
• out-patient basis 2000 80

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Factors influencing growth of ambulatory surgery

• Advances in anesthetic agents and techniques
• Advances in surgical techniques
• Third party payer push to decrease costs

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Advances in Anesthetic Agents and Techniques

• Fast onset agents
• Rapid re-distribution / metabolism
• Examples
• propofol
• Fentanyl Family

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Advances in Anesthetic Agents and Techniques

• Cleaner Agents with fewer side effects
• More agents to deal with common post-op problems
  (pain and nausea)

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Advances in Anesthetic Agents and Techniques

• Liberal use of local anesthetic at surgical site
• Infusion of local anesthetic/duramorph following
  arthroscopies
• Local nerve blocks in operative field

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Advances in surgical techniques

• Less invasive endoscopic techniques replacing
  open surgical procedures
• Proliferation of lasers leading to reduced tissue
  damage and reduced blood loss
• Increased awareness of outpatient capabilities
  (both surgeon and patient)

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Third party payer push to decrease costs

• Introduction of Diagnosis Related Groups (early
  1980s) which disallow overnight admission for
  specific procedures

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Third party payer push to decrease costs

• Changes in Medicare reimbursement in 1987
  increased the number of approved codes for
  outpatient procedures to include over 1600
  surgical codes

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Economics of Free Standing Ambulatory Surgery
Centers

• Do not have to support costly services of
  hospitals
• ER, ICU, food service, laundry
• Facility fees for specific procedures
  significantly lower than hospitals
• Buyers Guide Outpatient Procedures. Published
  by Missouri Dept. of Health, 1995

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Patient Selection is the Key for Successful
Outpatient Surgery
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Patient considerations for outpatient surgery

• ASA status
• Proposed procedure
• Significant history
• Optimized coexisting diseases
• Discharge criteria

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Patient considerations

• ASA status Vs. level of proposed surgical assault
  / required anesthetic intervention

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Patient considerations

• If ASA 3 patient acceptable for MAC hernia repair
  why not do outpatient exploratory laproscopy?
• Has coexisting disease been optimized?

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Coexisting Disease

• Encourage surgeons to obtain consult early.
• Educate surgeons about anesthetic considerations
  of coexisting diseases.
• Offer suggested questions for consult.

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Patient Considerations Significant history

• Malignant Hyperthermia
• Latex allergy
• Morbid obesity
• Difficult airway

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Common Logistical Problems

• Preoperative workup
• Preoperative medications
• NPO status
• Anxiety
• Coordination of Transportation
• Home care

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Other Logistical Problems

• Accreditation of freestanding clinic
• Medical Emergencies
• Admission following complications

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Patient Considerations Discharge Criteria

• When will patient be able to meet discharge
  criteria?
• Which discharge criteria do you use?
• Aldrete / PDSS

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Patient Considerations Discharge Criteria

• Does patient have someone to drive them home?

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Anesthetic Considerations for Ambulatory Surgery

• What level of monitoring is acceptable?
• How to minimize post-anesthetic hang-over
• What regional anesthetics are appropriate?

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Anesthetic Considerations Monitoring

• ASA basic standards
• Invasive monitors?

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What Level of Monitoring Is Acceptable?

• AANA Standards for monitoring
• Invasive monitoring
• A-line, CVP, PA Catheter, TEE, EEG

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Anesthetic Considerations Drugs

• Minimize postop sedation, pain, N/V
• Economics
• cost/case Vs time to discharge

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Sodium Pentothal Vs. Propofol

• Time to discharge
• propofol - 103 minutes
• sodium pentothal - 115 minutes
• Postop anxiety more frequent with sodium
  pentothal (Plt0.05)
• Nausea/emesis less frequent with propofol
• Acta Anesth Scand 1995 May39(4)503-7

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Sevoflurane Vs Halothane

• Emergence times Sevoflurane - 7.11 min /
  Halothane - 9.58 minutes
• Time to discharge criteria Sevo - 184 min /
  Halothane - 189 minutes (no clinical diff)J Clin
  Anesth 1995 Aug 7(5)398-402

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Isoflurane Vs Sevoflurane

• Time to open eyes Isoflurane - 4.1 min
  Sevoflurane - 2.3 minutes
• Time to fluid intake Isoflurane - 35 min
  Sevoflurane - 37 minutes
• Time to discharge Isoflurane - 242 min
  Sevoflurane - 281 minutes
• Acta Anesth Scand 995 Apr39(3)377-80

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How to minimize post-anesthesia hangover

• Nausea one of largest factors delaying time to
  discharge
• Frequency of postop nausea directly related to
  type of surgery (strabismus correction,
  laproscopy) and duration of anesthetic

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How to minimize post-anesthesia hang over
(Contd)

• Droperidol effective anti-emetic at
• 25-75 mcg/kg
• best when given prior to surgery

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Droperidol vs. Ondansetron (Post Op Nausea
Vomiting)

• Droperidol 2.5 mg Vs. Ondansetron 8 mg
• PONV absent in 88 of droperidol group, absent in
  68 of ondansetron group

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Droperidol Vs. Ondansetron

• Time to discharge
• droperidol - 229 min
• ondansetron - 171 minutes
• Anesth Analg 1995 Sep81(3)603-7

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What regional anestheticsare appropriate?

• Well defined end-point when performing block
• Quick onset
• Easily reproducible surgical anesthetic depth

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What regional anesthetics are appropriate?

• Bier block

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What regional anestheticsare appropriate?

• Bier block success rate gt98 , minimal morbidity
• J Hand Surg 1995 Oct20(5) 679-680
• Bier block success rate same when utilizing
  dorsum hands vein Vs antecubital fossa

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What regional anestheticsare appropriate?

• Subarachnoid block
• small gauge, pencil point needle
• Pediatric caudal
• 22 gauge angiocath passes easily ONLY into caudal
  space

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Less appropriateregional anesthetics

• Take more time to perform
• Less well defined end point
• Slower onset, less dependable surgical depth
• Examples epidural, brachial plexus block
  (interscalene, supraclavicular, axillary),
  fem-sciatic block

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Discharge Criteria

• Vital signs
• Ambulation / mental status
• Pain / nausea / vomiting
• Surgical bleeding
• Intake and output

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Have Machine Will Travel
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Common Problems

• Patients physical status
• Equipment / Physical constraints
• Support Personnel
• Transport of a sick patient
• Postanesthesia recovery
• Environmental hazards

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Environmental Hazards

• Unfamiliar area
• Small room
• Temperature
• Radiation
• Noise

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Common Anesthetizing Areas

• Computed Tomography (CT)
• Magnetic Resonance Imaging (MRI)
• Diagnostic x-ray
• Gastroenterology
• Emergency Room

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Common Anesthetizing Areas

• Cardiology
• Electroshock wave lithotripsy (ESWL)
• Electroconvulsive Therapy (ECT)
• Cancer Center

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Computed Tomography

• Patient either claustrophobic or trauma patient
• Room very small
• Cold temperature
• Radiation risk
• May be a stop en route to OR

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MRI

• Distant location
• Magnetic risk
• equipment and monitors must be adapted for the
  magnetic environment
• noise

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Diagnostic X-Ray

• Small room already full of equipment (watch your
  head)
• Radiation
• Contrast media
• X-Ray staff unable to help with anesthetic
  emergency
• Transport to recovery

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Gastroenterology

• Remote location
• Very sick patients
• they do their own sedation on most patients
• Awkward patient position

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Emergency Room

• Trauma patients
• need airway
• need IV access
• May need stops en route to OR
• Many chiefs (whos in charge?)
• Needle stick risk

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Cardiology

• Cardioversion
• Angioplasty
• very sick patient in remote area and you dont
  have your normal monitors or supplies

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ESWL

• Noise hazard
• May be in remote location
• MAC versus General Anesthesia
• transport to recovery

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ECT

• May be in remote area
• Brief general anesthesia is needed
• transport to recovery
• Airway management

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Cancer Center

• Chemotherapy or radiation therapy
• Sick patients
• physiologic effects of chemo
• Nausea
• Fluid needs

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Office Anesthesia
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Long Term Care Facilities
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Home Care
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Pain Management