AMBULATORY SURGERY JOZELITO NUMA ITE REVIEW 

INTRODUCTION • Subspecialty of anesthesia that deals with preoperative, intraoperative and postoperative anesthestic care of patient undergoing elective, same day procedures • Noncomplex surgery on healthy individual • Different type of Facility Design • ASA guidelines of Ambulatory Anesthesia and Surgery • Varities of cases ranging from claustrophobic patient in need of anesthesia for a MRI to a patient receiving ERCP in GI suite. • Monitors, patient selection and Discharge requirement 

TYPES OF FACILITY DESIGN • Office base anesthesia • Hospital integrated • Hospital Based • Freestanding 

REQUIREMENT OF AMBULATORY SURGICAL FACILITY • Employment of appropriate trained and credential Anesthesia personnel • Availability of maintained, tested and inspected anesthesia equipment • Sufficient Back up power to ensure patient protection during emergency • Written protocol for cardiopulmonary emergencies and fire • Facility provide medication, equipment and written protocol regarding malignant hyperthermia • Written policies regarding timely and safe transfer of patient to the hospital for extended or emergency services • Anesthesiologist will follow Standard monitoring equipment according to ASA policies and guidelines • PACU and recovery area staffed by appropriate trained nursing personnel with specific discharge instructions • Discharge of patient is the responsibility of the physcians 

QUESTION • The office manager of ASC wants to establish guidelines for appropriate patient criteria. Which patient is a poor candidate for surgery for free standing –Ambulatory Center? • A. 45 year old Hx of MI one month ago with no intervention and scheduled for hernia surgery 1 month from now. • B. 27 yo M with Hx of Malignant Hyperthermia scheduled for eye surgery • C. Three month old, Ex preemie born at 40 weeks, scheduled for a circumcision • D. 35 yo F Hx of OSA compliant with CPaP at night and stable CAD scheduled for knee surgery in 1 month 

PATIENT CHARACTERISTICS • ASA I,II,III • The risk of complication can be reduced, if preexisting medical conditions are stable for at least 3months prior to procedure • Morbidly obese no longer considered exclusionary criteria • Extreme age is no longer exclusionary criteria 

CONTRAINDICATION OF AMBULATORY SURGERY • Potential life threatening chronic disease • Extreme BMI complicated by symptomatic cardiopulmonary disease • Acute substance abuse • Ex premature infant less than 60 weeks post conceptual age requiring general anesthesia • No responsible adult at home to care of the patient the evening of the surgery 

TYPES OF ANESTHESIA • MAC • TIVA with Propofol/Remifentanil • Regional Anesthesia and local anesthetics techniques • General Anesthesia 

MONITORING 

DISCHARGE CRITERIA • Scoring system have been developed to facilitate timely and safe ambulatory surgery discharge • Aldrete scoring system which includes activity, respiration, circulation, consciousness, and oxygen saturation • Criteria 1. Alert and oriented to time and place 2. Stable vitals 3. Pain controlled by oral analgesics or peripheral nerve block 4. Control nausea and emesis 5. Able to walk without dizziness 6. No unexpected bleeding from surgery 7. Has discharge instruction and prescription from surgeon anesthesiologist 

REFERENCE • Morgan and Makail • Up to date Ambulatory surgery • Pass Machine anesthesia. Topic: Ambulatory surgery I,II,III