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Anaesthesiology
Ambulatory Anesthesia
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
16 sections · 161 slides
Overview
- Definition and scope of ambulatory anesthesia
- Roadmap of the topic
- Recurring themes of the topic
Origins and Setting
- Origins of the freestanding surgicenter
- Ford and Reed at the first surgicenter
- Growth of ambulatory anesthesia as a specialty
- Settings in which ambulatory surgery is performed
- Why ambulatory centers are financially attractive
- Health system consequences of ambulatory center growth
- Effect on hospital emergency coverage
Choosing the Procedure
- Criteria for an appropriate ambulatory procedure
- Increasing complexity of ambulatory surgery
- Determinants of an acceptable complication rate
Selecting the Patient
- Safety concerns and emergency capability in ambulatory centers
- Regulatory variation between states
- Postoperative apnea risk in infants
- Effect of monitoring requirements on referral
- Apnea after regional versus general anesthesia in infants
- Guide to determine length of stay for infants after surgery
- Advanced age in ambulatory patient selection
- Organ dysfunction versus age as the driver of problems
- ASA physical status classification in ambulatory selection
- Cataract surgery in ASA IV patients
- Individualization of selection to patient and procedure
- Causes of unplanned 30-day admission after ambulatory surgery
- Perioperative risk in obesity and obstructive sleep apnea
- Overlap of obesity and obstructive sleep apnea
- Outcomes in super morbid obesity after outpatient surgery
- Anesthetic planning for patients with obstructive sleep apnea
- Guideline position on ambulatory surgery in obstructive sleep apnea
- Requirements for the patient's escort and home care
- Distance from the facility and tolerance of pain at home
Preoperative Screening
- Methods and content of preoperative screening
- Logistical value of the screening contact
- Role of the anesthesiologist in screening
- Medication decisions on the day of surgery
- A guide to medications appropriate to take prior to surgery
- A guide to medications appropriate to take prior to surgery (continued)
Respiratory Infection Before Surgery
- Airflow obstruction after upper respiratory infection in adults
- Timing of surgery after upper respiratory infection in children
- Interpretation of the Swiss cohort on respiratory adverse events
- Risk factors for respiratory adverse events in children with URI
- Clinical decision to proceed in a child with URI
- Decision pathway for a child with upper respiratory infection
- Timing of elective surgery after COVID-19 infection
- Individualizing the decision after COVID-19
Fasting Before Surgery
- Rationale for preoperative fasting
- Key provisions of the 2017 ASA fasting guidelines
- Fasting guidelines before surgery
- Aspiration closed claims analysis
Premedication
- Sources of preoperative anxiety
- Nondrug measures to reduce preoperative anxiety
- Midazolam for preoperative anxiolysis
- Complications associated with perioperative midazolam use
- Situational guide to premedication
- A guide to premedication
- Preoperative opioid administration
- Preventive analgesia
Choice of Anesthetic
- Anesthetic options and their comparative safety
- Equal safety of the three anesthetic methods
- Anesthetic choice and postanesthesia care unit length of stay
- Pain and nausea after regional versus general anesthesia
- Limits of generalizing regional anesthesia studies
- Time cost of performing a block and its solution
Regional Techniques
- Historical and current use of regional techniques
- Needle phobia and vasovagal syncope during blocks
- Discharge with a residual block
- Spinal anesthesia in ex-premature infants
- Duration of apnea risk after spinal anesthesia in infants
- Indications for spinal anesthesia in adults
- Choice of local anesthetic for ambulatory spinal anesthesia
- Postdural puncture headache after spinal anesthesia
- Consent and follow-up for postdural puncture headache
- Epidural and caudal anesthesia in ambulatory surgery
- Benefits of peripheral nerve blocks
- Continuous interscalene block after rotator cuff repair
- Block room organization and operating room turnover
- Sedation and analgesia during local or regional anesthesia
- Characteristics of deep sedation
General Anesthesia
- Propofol for induction in ambulatory anesthesia
- Duration of psychomotor impairment after induction agents
- Pain on injection of propofol
- Lidocaine pretreatment technique for propofol injection pain
- Inhalational induction with sevoflurane
- Neuromuscular blockade for short ambulatory procedures
- Intubation without neuromuscular blockade
- Cautions with succinylcholine
- Determinants of maintenance agent choice
- Definition of recovery in an ambulatory center
- Properties of propofol, desflurane and sevoflurane for maintenance
- Total intravenous versus inhalation maintenance
- Wake-up time versus discharge time
Nausea and Vomiting
- Impact of postoperative nausea and vomiting on discharge
- Strategies to reduce postoperative nausea and vomiting risk
- Techniques to decrease postoperative nausea and vomiting risk
- Nitrous oxide and duration of exposure
- Patient and procedural risk factors for PONV
- Pharmacologic treatment of PONV
- Adjunctive therapies for PONV
- Postdischarge nausea and vomiting
- Pain and nausea after discharge
- Targeted prevention of postdischarge nausea and vomiting
Paralysis and Reversal
- Mismatch between relaxant duration and case length
- Sugammadex: mechanism and scope
- Limitations of sugammadex on pulmonary complications
- Quantitative neuromuscular monitoring
- Neuromuscular blocking agent dose and respiratory complications
- Advantages of supraglottic airways in ambulatory anesthesia
- Failure of the laryngeal mask airway
Postanesthesia Care
- Common causes of delayed discharge from the PACU
- Priority of PACU management
- Evidence gap in treating established PONV
- Nonopioid options for nausea in the PACU
- Rescue antiemetic after failed ondansetron prophylaxis
- Intraoperative opioids for postoperative analgesia
- Role of nonsteroidal analgesics around surgery
- Assessment and route of analgesia in the PACU
- Comparison of opioids for ambulatory postoperative pain
- Oral analgesia after discharge
- Nonsteroidal analgesics versus opioids after ambulatory surgery
- Bleeding risk with nonsteroidal analgesics
- Intravenous acetaminophen in ambulatory analgesia
- Dosing limits for acetaminophen
Preparation for Discharge
- Phase II recovery
- Questionable discharge criteria
- Limits of scoring systems and psychomotor tests
- Restrictions on activity after discharge
- Content of discharge instructions
- Written instructions and language barriers
- Definition of a responsible person and follow-up
- Options for patients without adequate home support
- Hospital hotels and home health care nursing
- Need for prospective evaluation of new care models
Synthesis
- Combined assessment of patient, procedure, aftercare and technique
- Balance between physical status, procedure and technique
- Evolution of the specialty
- Key points of ambulatory anesthesia
- Key points on recovery and discharge
- Anesthetic care spans the whole ambulatory episode
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition