10 chandrashekara anaesthesia-in-ambulatory-surgery_ncas_2011

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10 chandrashekara anaesthesia-in-ambulatory-surgery_ncas_2011

  1. 1. Dr CHANDRASHEKARA.C.R Consultant AnaesthesiologistNOVA MEDICAL CENTERS,SAGAR HOSPITALS, BANGALORE
  2. 2. Anaesthesia Day careanaesthesia/ ambulatory anaesthesia/ Office based anaesthesia 25 million surgeries per year -70 % ambulatory surgeries,10% - children –IDEAL FOR DAY CARE
  3. 3. Development Ether- Sevoflurane, Deflurane Thiopentone- Propofol Short acting muscle relaxants Short acting yet potent analgesics Open surgery to Laparoscopic surgery Patient xx / Pain Abdomen
  4. 4. Surgery means – Pain?Discharge same day
  5. 5. 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
  6. 6. ProcedureGeneral surgery /Urology Inguinal hernia repair  Circumcision Orchidopexy  Cystoscopy Umbilical hernia repair  Preputial thyroglossalcyst adhesionreleaserelease Cervical lymph node biopsy  Minor hypospadias Ganglion excision  Ureteric stent placement Laparoscopic procedures
  7. 7. ContdPlastic surgery Orthopaedic  Removal of spica, nails, Removal of nevus Achilles lengthening Otoplasty  Arthroscopic procedures Suture removal  osteochondromaexcision Dressing changes  Muscle biopsy Mammoplasty  ORIF ulna, radius Liposuction
  8. 8. Procedure ENT/DentalOBG D&E  Myringotomies D&C, Hysteroscopic  Nasal and aural foreign body D&C removal Lap ovarian  Adenotonsillectomy cystectomy  Mastoidecomy/tympanoplasty Diagnostic lap Restoration Others  Extraction
  9. 9. 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
  10. 10. 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
  11. 11. PAC Premedication- H2 receptor antagonists ,antacids, analgesics,Steroids,Chest physiotherapy, Nebulisation To continue other medications Phy/Cardio/Endocrinology opinion
  12. 12. Anaesthesia Pre op counseling/ Premedication GA – LMA/ETT Propofol/Short acting Relaxants OPIOD/Non opiod based analgesia Local anaesthetics/ Nerve blocks/ Epidurals
  13. 13. CONTD Laser prostatectomy- under Sedation+ peudendal nerve block
  14. 14. Pain-Multimodal approach Targeting different levels Optimal pain relief with minimal side effect Combination of analgesics drugs and techniques enhance the analgesic level
  15. 15. Pain management shorter discharge times, lower pain scores, and a lower incidence of nausea andvomiting, compared with traditional opiate-based anesthetic techniques
  16. 16. 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
  17. 17. 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
  18. 18. PONV Avoid opioids- Morphine, pethidine Ondensetron[8mg], Metachlorpropamide 10 mg Dexamethsone 8 mg Granisetron, Tropisetron, Dolasetron
  19. 19. 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
  20. 20. Thank you
  21. 21. Post op Follow up
  22. 22. 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 & W ilkins

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