This document discusses ambulatory and fast track anesthesia. It covers topics such as the benefits of ambulatory surgery including lower costs and greater efficiency. It describes different facility designs for ambulatory surgery and lists many common procedures that can be done on an outpatient basis. The document outlines considerations for patient selection and preoperative preparation including pharmacologic and non-pharmacologic techniques. It also discusses various anesthetic techniques for ambulatory surgery like general anesthesia, regional anesthesia, and monitored anesthesia care. Fast tracking approaches to minimize side effects like PONV are also summarized.
Ambulatory Anesthesia and Non–Operating Room Anesthesia (NORA)Saeid Safari
GUIDELINES FOR AMBULATORY ANESTHESIA AND SURGERY (American Society of Anesthesiologists)
GUIDELINES FOR AMBULATORY ANESTHESIA AND SURGERY
Non–Operating Room Anesthesia (NORA)
as the life expectancy has increased. more and more elderly patients are undergoing surgery. the burden of postoperative dysfunction has to be increased in future. There should be attempt to identify the risk factors and measures to prevent POCD.
Anaesthesia to patiens with liver disease or a liver transplantscanFOAM
A presentation by Anna Januszkiewicz at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Ambulatory Anesthesia and Non–Operating Room Anesthesia (NORA)Saeid Safari
GUIDELINES FOR AMBULATORY ANESTHESIA AND SURGERY (American Society of Anesthesiologists)
GUIDELINES FOR AMBULATORY ANESTHESIA AND SURGERY
Non–Operating Room Anesthesia (NORA)
as the life expectancy has increased. more and more elderly patients are undergoing surgery. the burden of postoperative dysfunction has to be increased in future. There should be attempt to identify the risk factors and measures to prevent POCD.
Anaesthesia to patiens with liver disease or a liver transplantscanFOAM
A presentation by Anna Januszkiewicz at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Preventive analgesia:
Broader definition of preemptive analgesia
Perioperative analgesic regimen that able to control pain-induced sensitization
Not the timing of the analgesic treatment but the duration and efficacy of an analgesic intervention are more important for an effective postoperative pain relief
Adequate preventive analgesia should include multimodal techniques and with a sufficient duration of tretment
Information about Fast Track Surgery by Dr. Dhaval Mangukiya
Details of Fast Track Surgery, ERAS, Sir David Cuthbertson, Procedure-Specific fast-track surgery results, Colorectal surgery, Esophageal Resection, Pancreatic Surgery, Liver Surgery, Cochrane Database of Systematic Reveiws, Primary outcomes, Secondary outcomes, and Results
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Robotic surgeries are becoming most popular in field of surgical departments due to its precision of hand in many cancer surgeries. Anaesthesia in these places are quite challenging due to lack place to move , a meticulous vigilance is always required for safety of patient and conduct safe Anesthesia
Telemedicine is a upcoming topic of interest, especially in pandemic times where remote places cannot be assesed telemedicine is a great oppurtunity in such circumstances.
anesthesia through telemedicine is possible.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
1. Presentor : Dr. Kumar
Moderator : Dr.Pradeep
Ambulatory and Fast tracking
Anaesthesia
2. Introduction
simple procedures on healthy outpatients
major procedures in outpatients with complex preexisting medical
conditions.
less than 10% to over 70% of all elective surgical procedures.
development of ambulatory anesthesia as a respected subspecialty
establishment of the Society for Ambulatory Anesthesia
development of postgraduate subspecialty training programs
The availability of rapid, shorter-acting anesthetic, analgesic, and
muscle relaxant drugs has clearly facilitated the recovery process after
surgery, and the development of minimally invasive surgical techniques
allowed more extensive procedures to be performed on an ambulatory
basis, irrespective of the patient's preexisting medical conditions
3.
4. Benefits of Ambulatory Surgery
Patient preference, especially children and the elderly
Lack of dependence on the availability of hospital beds
Greater flexibility in scheduling operations
Low morbidity and mortality
Lower incidence of infection
Lower incidence of respiratory complications
Higher volume of patients (greater efficiency)
Shorter surgical waiting lists
Lower overall procedural costs
Less preoperative testing and postoperative medication
5. Facility Design
Hospital integrated: Ambulatory surgical patients are managed in the
same surgery facility as inpatients. Outpatients may have separate
preoperative preparation and recovery areas.
Hospital-based: A separate ambulatory surgical facility within a hospital
handles only outpatients.
Freestanding: These surgical and diagnostic facilities may be associated
with a hospital or medical center but are housed in separate buildings that
share no space or patient care functions. Preoperative evaluation, surgical
care, and recovery occur within this autonomous unit.
Office-based: These operating and/or diagnostic suites are managed in
conjunction with physicians’ offices for the convenience of patients and
health care providers.
6. The first freestanding outpatient surgical facility was built and managed
by an anesthesiologist, Wallace Reed, to provide surgical care to patients
whose operations were deemed too demanding for a surgeon's office yet
did not require overnight hospitalization
7. Procedures Suitable for Ambulatory Surgery
Dental -Extraction, restoration, facial fractures
Dermatology -Excision of skin lesions
General -Biopsy, endoscopy, excision of masses,
hemorrhoidectomy, herniorrhaphy, laparoscopic
cholecystectomy, adrenalectomy, splenectomy, varicose vein
surgery
Gynecology -Cone biopsy, dilatation and curettage,
hysteroscopy, diagnostic laparoscopy, laparoscopic tubal
ligations, uterine polypectomy, vaginal hysterectomy
Ophthalmology -Cataract extraction, chalazion excision,
nasolacrimal duct probing, strabismus repair, tonometry
8. Procedures Suitable for Ambulatory Surgery
Orthopedic -Anterior cruciate repair, knee arthroscopy,
shoulder reconstructions, bunionectomy, carpal tunnel release,
closed reduction, hardware removal, manipulation under
anesthesia and minimally invasive hip replacements
Otolaryngology -Adenoidectomy, laryngoscopy,
mastoidectomy, myringotomy, polypectomy, rhinoplasty,
tonsillectomy, tympanoplasty
Pain clinic -Chemical sympathectomy, epidural injection, nerve
blocks
Plastic surgery -Basal cell cancer excision, cleft lip repair,
liposuction, mammoplasty (reductions and augmentations),
otoplasty, scar revision, septorhinoplasty, skin graft
Urology -Bladder surgery, circumcision, cystoscopy,
lithotripsy, orchiectomy, prostate biopsy, vasovasostomy,
laparoscopic nephrectomy and prostatectomy
9. Minimally invasive outpatient
procedures
parathyroidectomy and thyroidectomy, laparoscopically
assisted vaginal hysterectomy, removal of ectopic tubal
pregnancy, and ovarian cystectomy, as well as laparoscopic
cholecystectomy and fundoplication,
laparoscopic adrenalectomy, splenectomy, and
nephrectomy, lumbar microdiscectomy, and video-assisted
thoracic surgery
superficial procedures (mastectomy)
11. Patient Characteristics
ASA physical status I or II
ASA physical status III (and even some IV)
The risk of complications can be minimized if preexisting
medical conditions are stable, for at least 3 months before
the scheduled operation.
Even morbid obesity (BMI >40 kg/m2
) is no longer
considered an exclusionary criterion for day-case surgery.
12. Extremes of Age
“elderly elderly” patient (>100 years) should not be denied
ambulatory surgery solely on the basis of age
ex-premature infants (gestational age < 37 weeks) recovering from
minor surgical procedures under general anesthesia have an
increased risk for postoperative apnea, persists until the 60th
postconceptual week
no relationship between apnea and intraoperative use of opioid
analgesics or muscle relaxants.-IV caffeine
13. Contraindications to Outpatient
Surgery
Potentially life-threatening chronic illnesses ( brittle
diabetes, unstable angina, symptomatic asthma)
Morbid obesity complicated by symptomatic cardio-
respiratory problems ( angina, asthma)
Multiple chronic centrally active drug therapies
(monoamine oxidase inhibitors such as pargyline and
tranylcypromine) and/or active cocaine abuse
Ex-premature infants less than 60 weeks’ postconceptual
age requiring general endotracheal anesthesia
No responsible adult at home to care for the patient on
the evening after surgery
14. Preoperative assessment
The three primary components of a preoperative assessment –
history (86%), physical examination (6%), and laboratory testing
(8%)
Computerized questionnaires -telephone interview by a trained
nurse -guide preoperative laboratory testing
15.
16.
17. Preoperative assessment
All paperwork (consent form, history, physical examination,
and laboratory test results) should be reviewed before the
patient arrives for surgery
Appropriate patient preparation before the day of surgery
can prevent unnecessary delays, absences (“no shows”), last-
minute cancellations, and substandard perioperative care.
18. Preoperative Preparation
Patients should be encouraged to continue all their chronic
medications up to the time that they arrive at the surgery center.
Oral medications can be taken with a small amount of water up to
30 minutes before surgery
19. Preoperative Preparation
Non-pharmacologic Preparation -– economic-lack side
effects – high patient acceptance - preoperative visit
-educational programs -videotapes
written and verbal instructions regarding arrival time
and place, fasting instructions, and information
concerning the postoperative course, effects of
anesthetic drugs on driving and cognitive skills
immediately after surgery, and the need for a responsible
adult to care for the patient during the early post
discharge period (<24 hours).
20. Pharmacologic Preparation
Anxiolysis and Sedation
Barbiturates -residual sedation
Benzodiazepines - diazepam 0.1 mg/kg PO midazolam
0.5mg/kg PO or 1mg IV
-Adrenergic Agonists -α α2 agonist clonidine,
dexmeditomidine-anaesthetic & analgesic sparing effect-
decrease emergence delirium of sevoflurane-reduce
emesis-facilitate glycemic control- reduce cardio-vascular
complication
-Blockers -atenolol,esmolol –attenuate adrenergicβ
responses-prevent cardiovascular events
21. Pharmacologic Preparation
Pre-emptive (Preventative) Analgesia
Opioid (Narcotic) Analgesics
Anesthetic sparing-minimize hemodynamic response
PONV, urinary retention -delay discharge
Nonopioid Analgesics
Surgical bleeding-gastric mucosal & renal tubal toxicity
a “fixed” dosing schedule beginning in the preoperative
period and extending into the post discharge period.
addition of dexamethasone to a COX-2 inhibitor leads to
improvement in postoperative analgesia
22. Pharmacologic Preparation
Prevention of Nausea and Vomiting
Pharmacologic Techniques
Butyrophenones –droperidol- dexamethasone
Phenothiazines -prochlorperazine
Antihistamines –dimenhydrinate, hydroxyzine
Anticholinergics –atropine, glycopyrrolate, TDS
Serotonin Antagonists –ondensetron,palanosetron
Neurokinin-1 Antagonists- aprepitant
Nonpharmacologic Techniques
Acupuncture,
Acupressure and
TENS at the P-6 acupoint - with the Relief Band
23.
24. Pharmacologic Preparation
Prevention of Aspiration Pneumonitis
no increased risk of aspiration in fasted outpatients
routine prophylaxis for acid aspiration is no longer
recommended -pregnancy, scleroderma, hiatal hernia,
nasogastric tubes, severe diabetics, morbid obesity
H2-Receptor Antagonists
Proton Pump Inhibitors
25. Pharmacologic Preparation
NPO Guidelines
Prolonged fasting does not guarantee an empty stomach at the
time of induction
Hunger, thirst, hypoglycemia, discomfort
Preoperative administration of glucose-containing fluids
prevents postoperative insulin resistance and attenuates the
catabolic responses to surgery while replacing fluid deficits
26. Basic Anesthetic Techniques
General Anesthesia
Regional Anesthesia - Spinal and Epidural
Intravenous Regional Anesthesia
TIVA- combination of propofol and remifentanil -TCI
Peripheral Nerve Blocks
Local Infiltration Techniques
Monitored Anesthesia Care
31. Local Infiltration Techniques
simple wound infiltration (or instillation)
use of a local anesthetic at the portals and topical application
at the surgical site
instillation of 30 ml of 0.5% bupivacaine into the joint space
perioperative administration of IV lidocaine improved
patient outcomes
32. Monitored Anesthesia Care
The combination of local anesthesia and/or peripheral
nerve blocks with intravenous sedative and analgesic
drugs is commonly referred to as MAC and has become
extremely popular in the ambulatory setting
The standard of care for patients receiving MAC should
be the same as for patients undergoing general or
regional anesthesia and includes preoperative
assessment, intraoperative monitoring, and
postoperative recovery care.
33. Monitored Anesthesia Care
MAC is the term used when an anesthesiologist monitors a
patient receiving local anesthesia or administers
supplemental drugs to patients undergoing diagnostic or
therapeutic procedures
Anesthetic drugs are administered during procedures under
MAC with the goal of providing analgesia, sedation, and
anxiolysis and ensuring rapid recovery without side effects
34. Monitored Anesthesia Care
Systemic analgesics are often used to reduce the discomfort
associated with the injection of local anesthetics and
prolonged immobilization
Sedative-hypnotic drugs are used to make procedures more
tolerable for patients by reducing anxiety and providing a
degree of intraoperative amnesia
35. Monitored Anesthesia Care
sedative-hypnotic drugs have been administered during MAC
-barbiturates, benzodiazepines, ketamine, and propofol
intermittent boluses- variable-rate infusion, target-controlled
infusion, and even patient-controlled sedation.
Methohexital -intermittent boluses 10-20 mg or as a variable-
rate infusion 1-3 mg/min
The α2-agonists clonidine and dexmedetomidine
36. Cerebral Monitoring
EEG-derived indices - The bispectral index (BIS),
physical state index (PSI), spectral and response entropy,
auditory evoked potential (AEP) index, and cerebral
state index (CSI)
The BIS, PSI, and CSI values are dimensionless numbers
that vary from 0 to 100, with values less than 60
associated with “adequate” hypnosis under general
anesthesia and values greater than 75 typically observed
during emergence from anesthesia
37. FAST TRACKING
Bypassing the PACU has been termed “fast-tracking” after
ambulatory surgery.
In addition, fast-tracking can be accomplished directly from
the PACU (“PACU fast-tracking”) by creating a specialized
area within an existing PACU where recovery procedures
are organized along the lines of a step-down unit.
This approach represents a key component of the “total
care” package for ambulatory surgery.[463]
38.
39. Fast-Tracking
Multimodal Approaches to Minimize Side
Effects
PONV- droperidol 0.625-1.25 mg IV, dexamethasone 4-8 mg IV,
ondansetron 4-8 mg IV, long-acting 5-HT3 antagonist-
palonosetron 75 µg IV, and NK-1 antagonist - aprepitant, a
transdermal scopolamine patch, or an acu-stimulation
device - SeaBand, Relief Band
Non-opioid analgesics -NSAIDs, cyclooxygenase-2 [COX-
2] inhibitors, acetaminophen, 2-agonists,α
glucocorticoids, ketamine, and local anesthetics
41. Fast-Tracking
Multimodal Approaches to Minimize Side Effects
low-dose ketamine 75-150 µg/kg
Non-pharmacologic factors
conventional CO2 insufflation technique /gasless technique -
subdiaphragmatic instillation of local anesthetic - local anesthetic at
the portals and topical application at the surgical site.
instillation of 30 mL of 0.5% bupivacaine into the joint space
reduces postoperative opiate requirements and permits earlier
ambulation and discharge. The addition of adjuvants- morphine 1-
2 mg, ketorolac 15-30 mg, clonidine 0.1-0.2 mg, ketamine 10-20 mg,
triamcinolone 10-20 mg
TENS
42. Guidelines for ambulatory surgical facilities
Employment of appropriately trained and credentialed
anesthesia personnel
Availability of properly maintained anesthesia equipment
appropriate to the anesthesia care being provided
As complete documentation of the care provided as that
required at other surgical sites
Use of standard monitoring equipment according to the
ASA policies and guidelines
Provision of a PACU or recovery area that is staffed by
appropriately trained nursing personnel and provision of
specific discharge instructions
43. Availability of emergency equipment (e.g., airway
equipment, cardiac resuscitation)
Establishment of a written plan for emergency transport of
patients to a site that provides more comprehensive care
should an untoward event or complication occur that requires
more extensive monitoring or overnight admission of the
patient
Maintenance and documentation of a quality assurance
program
Establishment of a continuing education program for
physicians and other facility personnel
Safety standards that cannot be jeopardized for patient
convenience or cost savings
44. Discharge Criteria
Early recovery is the time interval during which patients
emerge from anesthesia, recover control of their
protective reflexes, and resume early motor activity –
Aldrete score – operating room
Intermediate recovery- recovery room -begin to
ambulate, drink fluids, void, and prepare for discharge
Late recovery period starts when the patient is
discharged home and continues until complete functional
recovery is achieved and the patient is able to resume
normal activities of daily living
45. Discharge Criteria
anesthetics, analgesics, and antiemetics can affect the
patient's early and intermediate recovery,
the surgical procedure has the highest impact on late
recovery
Before ambulation, patients receiving a central neuraxial
block should have normal perianal (S4 -5) sensation, have the
ability to plantarflex the foot, and have proprioception of the
big toe
46. PADS
(1) vital signs, including blood pressure, heart rate, respiratory
rate, and temperature
(2) ambulation and mental status
(3) pain and PONV
(4) surgical bleeding and
(5) fluid intake/output
47. Post-anesthesia Discharge Scoring (PADS) System
Vital Signs
2-Within 20% of the preoperative value
1 -20%-40% of the preoperative value
0-40% of the preoperative value
Ambulation
2 -Steady gait/no dizziness
1-With assistance
0-No ambulation/dizziness
Nausea and Vomiting
2-Minimal
1-Moderate
0-Severe
Pain
2-Minimal
1-Moderate
0-Severe
Surgical Bleeding
2-Minimal
1-Moderate
0-Severe