Anesthesia for day care surgery

1. ANAESTHESIA FOR DAYCARE SURGERY,
MONITORED ANAESTHESIA CARE AND
NON-OPERATING ROOM ANAESTHESIA
DR.ARNAB PATRA
DR.SOUGATA ROY
DR.SOURAV DE

2. ANAESTHESIA FOR DAYCARE SURGERY
 INTRODUCTION
It is an operation or procedure where the patient is discharged on the same
working day.

3. CHOICE OF ANAESTHETIC TECHNIQUE
 General anaesthesia is most commonly preferred.
 Central neuraxial blockade are not encouraged as persistant motor block
delays discharge.
 Local nerve and plexus blocks are good options for peripheral surgeries.

4. ANAESTHETIC GOALS
 Smooth onset of action
 Adequate intraoperative analgesia and amnesia
 Rapid recovery
 Minimal adverse effects.

5. PR0CEDURE REQUIREMENTS
 Minimal risk of postoperative hemorrhage
 Minimal risk of postoperative airway compromise
 Rapid return of normal fluid and food intake.
 Postoperative pain controllable by outpatient management techniques
 Postoperative care managed by common people.

6. INCLUTION CRITERIA FOR PATIENT
 ASA I and ASA II patients
 ASA III patients whose disease is well controlled preoperatively.
 Patient should understand the process and be able to follow discharge
instructions.
 Patients place of residence to be within easy access to surgical facilities.
 Normal term infants of over 6 weeks of age

7. ADVANTAGES
 Reduced dependence on availability of hospital beds.
 Greater flexibility in scheduling surgeries
 Shorter surgical waiting lists
 Lower overall procedural costs.
 Lower requirements of nursing and medical supervision.
 Greater turnover of patients.
 Less incidence of hospital acquired infections.
 Lesser incidence of respiratory complications.

8. COMMON DAYCARE SURGERIES
 GENERAL SURGERY
 Herniorraphy
 Hemorrhoidectomy
 Herniotomy
 Upper and lower GI endoscopy/biopsy
 Laparoscopic procedure
 PLASTIC SURGERY
 Otoplasty
 Excision skin lesions
 Scar revision

9. Cont…
 GYNAECOLOGY
 D & C
 Hysteroscopy
 Vaginal hysterectomy
 Tubal ligation
 ORTHOPEDICS
 Implant removal
 Arthroscopy
 Closed reduction procedures.
 UROLOGY
 Cystoscopy
 Lithotripsy
 Prostate surgery

10. Cont….
 OTORHINOLARYNGOLOGY
 Myringotomy
 Mastoidectomy
 Tympanoplasty
 Adenoidectomy
 Tonsillectomy
 Polypectomy
 OPHTHALMOLOGY
 Lacrimal duct probing
 Strabismus correction

11. EXCLUSION CRITERIA
 Serious life threatening diseases
 Morbid obesity complicated by CVS and respiratory symptoms
 Chronic use of centrally acting drugs
 Extremely premature infants (<60 weeks post conceptional age)
 Surgical procedures involving: Major fluid shifts
Significant blood loss
Significant postoperative pain
Significant PONV

12. PREOPERATIVE EVALUATION
 Detailed history with specific focus on comorbidities.
 Recording of BP,Pulse, Spo2, CBG
 Examine cardiovascular and respiratory system
 Identify any airway difficulty.
 Preoperative counselling to diminish fear and anxiety.
 Written and verbal communication regarding arrival time and fasting
guidelines.
 Investigations: complete blood count
Random blood sugar, urea, creatinine
Chest X ray
ECG

13. CHOICE OF DRUGS
 INDUCTION AGENTS: Propofol, ketamine
 ANALGESIA: Fentanyl, remifentanil
 MAINTENANCE: nitrous oxide along with sevoflurane, desflurane or
propofol
 MUSCLE RELAXANTS: succinyl choline, atracurium, cisatracurium.
 Regional anaesthesia
• Short acting drugs like lignocaine and procaine are desirable for central
neuraxial blockade.
• Bupivacaine is used if anticipated duration of surgery is more than 2 hours.
• Intrathecal fentanyl is used for prolonging sensory blockade without affecting
motor block.

14. MONITORED ANAESTHESIA CARE
 INTRODUCTION:
It is an instance in which an anaesthesiologist has been called upon to provide
specific anaesthesia survice to a patient undergoing a planned procedure and is
in control of the patient’s nonsurgical or nonobstetrical medical care.
 REQUIREMENTS
• Performance of preanaesthetic examination and evaluation.
• Personal participation and medical direction of entire plan of care.
• Continuous physical presence of anaesthesiologist.
• Proximate presence of anaesthesiologist for diagnosis and management of
emergencies.

15. GOALS
 To maintain patients safety and sense of well-being.
 To minimize pain and discomfort.
 Administration of sedatives, hypnotics, anaesthetic agents and other
medications.
 To minimise psychological response: Anxiolysis, analgesia and amnesia.
 Monitor the vitals.
 Diagnosis and treatment of clinical problems which occur during the
procedure.
 Provision of other medical service as needed to complete the procedure
safely.
 To return the patient to preprocedural state.

16. Exclusion criteria
 ASA grade III & IV
 Morbid obesity
 Documented history of sleep apnea.
 Increase risk of airway obstruction: Stridor
Dysmorphic facies
Macroglossia
Neck mass
Jaw abnormalities like micrognathia
 Medical problems associated with alcohol/drug abuse.
 Pregnancy

17. Cont..
 Inability to follow simple commands: Cognitive dysfunction
Intoxication
Psychological problems
Acutely agitated
Uncooperative patients.
 Patients of extreme age: <18 yrs and >70 yrs.
 History of intolerance to standard sedatives: Chronic opioid use
Chronic benzodiazepine use.
 Spasticity or movement disorders.

18. Preoperative assessment
 Details history and specific focus on comorbidities.
 Identify difficult airway.
 Recording of vital signs.
 Preoperative counselling to diminish fear and anxiety.
 Routine investigation: CBC
urea, creatinine, blood sugar
ECG
Chest X-ray

19. MONITORING
 Visual, tactile and auditory assessment:
• Response to verbal stimulation evaluated for effective titration of sedation.
• Rate, depth and pattern of breathing
• Daiphoresis,shivering,cyanosis and changes in neurological status.
 Auscultation: precordial stethoscope
 Pulse oximetry
 Capnography
 ECG
 BP monitoring
 Temperature for prolonged procedures.

20. Drugs used
 Benzodiazepines: Midazolam 1-2 mg IV before propofol/remifentanil infusion.
 Diazepam 2.5-5 mg IV
 Fentanyl 0.5-2 mcg/kg IV bolus 2 mins before stimulus.
 Remifentanyl 0.1 mcg/kg/min infusion 5 mins before stimulus, 0.05mcg/kg IV
maintenance as tolerated.
 Propofol 250-500 mcg/kg bolus,then 25-75 mcg/kg/min infusion.
 Ketamine 0.25-1 mg/kg IV bolus.
 Dexmedetomidine 0.5-1 mcg/kg loading dose over 10 mins,then 0.2-0.7
mcg/kg/hr infusion.

21. NON OPERATING ROOM
ANAESTHESIA(NORA)

22. INTRODUCTION
 Modern Anaesthesia is quite safe
• Well trained anaesthesiologist
• Well trained anaesthesia technique
• Fail-proof anaesthesia machine
• Monitoring aids
• Newer and versatile drugs.

23. Problems faced by the
Anaesthesiologists
• Lack of adequate space
• Unfamiliar surroundings and equipments
• Central pipeline will be missing and cylinders have to be used
• Un-physiological postures needed for some procedures
• Out-patients for investigations are inadequately prepared/ investigated/ have
associated medical illness.
• Adverse reactions to contrast media
• Lack of post-anaesthetic care

24. Three step approach to NORA
 PATIENTS
PROCEDURE ENVIRONMENT

25. Patients
 Thorough preanaesthetic assessment and standard preanaesthetic care is
required.
 Sound anaesthetic plan with appropriate level of monitoring and appropriate post
anaesthetic care.
 Receive monitored anaesthesia care(MAC) or sedation
 Children commonly require sedation or anaesthesia for diagnostic and
therapeutic procedures.

26. Patient factors requiring Sedation or
Anaesthesia for Nonoperating Room
 Claustrophobia, anxiety and panic disorders
 Cerebral palsy, developmental delay and learning difficulties
 Seizure disorders, movement disorders and muscular contractures.
 Pain both related to procedure and other causes.
 Acute trauma with unstable cardiovascular, respiratory or neurologic
functions.
 Raised intracranial pressure.
 Significant comorbidity and patient frailty( ASA status III & IV)
 Children specially those below 10 years.

27. Procedures
 CARDIOLOGY: cardiac catheterisation lab (cath lab)
• Coronary angiogram
• Percutaneous Transluminal Coronary Angioplasty (PTCA)
 RADIOLOGY:
• CT Scan
• MRI
• Radio-therapy
 PSYCHIATRY
• Electro convulsive therapy (ECT)
 PLASTIC SURGERY
• Burn’s dressing

28. Monitoring standards
 ECG
 NIBP
 Spo2
 FIO2 (inspired oxygen fraction)
 End tidal carbon-di-oxide (ETCO2)
 Ventilator disconnect alarm

29. Procedures in cardiology department
 Coronary Angiogram
 Per-cutaneous Trans-luminal angioplasty
1. Done under local anaesthesia
2. Painless procedure
3. Only minimal sedation needed
 Problems
1. Severe coronary artery disease
2. Injury to coronary artery vessels needs emergency CABG

30. Procedure in psychiatry department
 Electro-convulsive therapy:
• Non pharmacological mode of treatment.
• Commonly used for depression
• 70-130 volts current is passed for 1 second through 2 cerebral hemispheres
• Shock produces muscular contraction.
• Cause initial parasympathetic discharge followed by sympathetic surge
• Causes retrograde amnesia

31. Anaesthesia for ECT
 Pre-anaesthetic assessment difficult in un communicative patients.
 MAO inhibitors and TCA drugs have drug interaction with pethidine and
barbiturates
 No pre-medication is given
 Induction by thiopentone (4 mg/kg)
 Relaxant: Suxamethonium (1mg/kg)
 Patient is manually ventilated with bite block in place.
 ECT given
 Patient is ventilated till he/she recovers from the relaxant effect.

32. Plastic surgery-burn’s dressing
 Problems posed by a burn’s patient
• Pre-existing psychological trauma
• Problems in positioning and transfer
• Difficulty in vascular access
• Repeated anaesthetics
• Altered pharmacological response.

33. Anaesthetic plan for burn dressing
 Preoperative evaluation
• check airway
• check vascular access
• check volume status
 ROUTINE MONITORING
 O2 by face mask
 Total intravenous Anaesthesia(TIVA)
• Ketamine(1.5mg/kg) IV
• Diazepam(0.1mg/kg)IV
• Atropine(0.01mg/kg)IV

34. Anaesthesia in radiology department
CT Scan
 Procedure lasts for 10 minutes.
 Non invesive procedure
 Contrast injected to do studies (acute anaphylaxis to contrast media can be
disastrous)
 Sedation with chloral hydrate orally half an hour prior to the procedure
 TIVA: Propofol 1mg/kg with atropine 0.01mg/kg
 Tracheal intubation is a must when oral radio opaque is used
 Head injury patients with low GCS needs intubation and control of
ventilation.

35. Anaesthesia for MRI Scan
 Painless procedure
 Children need anaesthesia services
 Procedure lasts for 60-75 minuites
 Scary feeling staying inside the tube
 Mandatory to intubate required patients and control ventilation using ventilator.
 Need for anaesthesia machine and monitors compatible with MRI environment.

36. Anaesthesia for Radiotherapy
 Children need sedation to stay motionless
 Repeated anaesthetics necessary
 It is a painless procedure.
 Procedure lasts for 10 mins.
 Plan: TIVA using ketamine/propofol

37. ASA guideline for non-operating room
anaesthesia location
 Reliable O2 sources with backup.
 Suction apparatus
 Waste gas scavenging
 Adequate monitoring equipment
 Safe electrical outlets
 Adequate illumination, battery
backup
 Sufficient space for anaesthesia
personnel, equipment.
 Emergency defibrillator, drugs ect.
 Reliable means for two-way
communication.
 Applicable facility
 Appropriate post anaesthesia
management

38. Complication of NORA
 MINOR COMPLICATION
• Post operative nausea and vomiting
• Inadequate post operative pain control
• Hemodynamic instability
• Minor neurologic complication such as PDPH
• Minor respiratory complication( cardiology and radiology location)
• Need for opioid reversal

39. MAJOR COMPLICATIONS
 Unintended patient awareness
 Anaphylaxis
 Need for upgrade of care
 Serious hemodynamic instability
 Respiratory complication
 Need for resuscitation
 Central and peripheral nervous system injury
 Vascular access related complication
 Fall or burn(radiology procedure and cardiology location)

40. THANK YOU