Ambulatory Anesthesia Presentasi

8/3/2019 Ambulatory Anesthesia Presentasi

1/23

AMBULATORY ANESTHESIA


2/23

Introduction

Current estimates are that 40 to 60 percents of all surgical procedures could beperformed in outpatient surgery centers

Several factor that contributed to the renewed interest in ambulatory surgery;

- Hospital costs are decreased 25 to 75 percents , but specialized

postoperative care may be more costly

- Separation from patients familiar home environment are decreased- Decreased risk of hospital-acquired infection for pediatric and

immunocompromized cancer and transplant patients

- Incidence of respiratory complication(e.g., pulmonary embolus and

pneumonia) may also be decreased

The availability of both shorter-acting anesthetics and longer acting analgesicsand antiemetics enables us to care for patients effectively

Ambulatory surgery occurs in a variety of setting. Some center are within ahospital or in a freestanding satellite facility that is either part or independent of ahospital


3/23

Procedures for Ambulatory Surgery

An appropriate procedures for ambulatory surgery are those associated

with;

- Postoperative care that easily managed at home

- With low rates of postoperative complication , depends on the

relative aggressiveness of the facility, surgeon, patient, and

payer

Preterm infants( < 50 week of post-conceptual age) associated with

increased risk for the development of postoperative respiratory

complication(apnea)

Anemia(Ht < 30%) is also associated with an increased incidence of apnea

in preterm infant < 60 week of post-conceptual age

Recovery of fine motor skills and cognitive function after general

anesthesia(or local anesthesia with sedation) commonly slower in older

patients


4/23

Procedures for Ambulatory Surgery

Advance age is not a reason to disallow in an ambulatory

procedures, because most of postoperative medical problem

are not caused by age, but by specific organ dysfunction. For

that reason, all individual, whether young or old, deserve a

careful preoperative assessment


5/23

Preoperative Assessment

Patients selection;

- ASA physical I or II

- ASA physical III or IV are also acceptable candidates,

providing their systemic disease are medically stable

Preoperative visit by an anesthesiologist is very important tominimized cancelation and decreases the patients anxiety

An alternative approach for preoperative screening is utilize apreanesthetic questionnaire to obtain information about patientsmedical problems, previous operation, drug history, and familyhistory and to provide general review system

The process also provide the staff with an opportunity to remindthe patient of arrival time, suitable attire, and dietaryrestriction(e.g., nothing to eat or drink after midnight, no jewelry ormakeup)


6/23

Preoperative Assessment

The laboratory testing required depends on the patients age,

state of health, and drug hystory

CBC/Hct and ECG starting at age 50 yrs

SMA-6(Sequential Multiple Analysis-6 serum test) and CXR(chest

radiography) for >70 yrs

CBC/Hct is essential for


7/23

Premedication

Controlling Anxiety Psychologycal;

Preoperative visit by an anesthesiologist. Was more effective

in decreasing anxiety than administration of abarbiturates(Egbert et al). Both parents and children need tobe involve in preoperative discussion so that the anxiety ofparents are not transmitted to the child

If necessary;

Midazolam 0.04-0.08 mg/kg IV0.5 mg/kg orally for children

Propofol 1.5-2.5 mg/kg for adult


8/23

Controlling the Risk of Aspiration

Droperidol 5-15 g/kg IV for children

7.5-15 g/kg IV for adult

H2 receptor antagonistsRanitidine 50-200 mg,the night before surgery

Cimetidine 150-300 mg, 1-1,5 hr before surgery

Omeprazole 80 mg, the night before surgery

Metoclorpramide 0.15-0.3 mg/kg, most effective when givenat the end of anesthesia or as an adjunct to other antiemetics

Sodium Citrat(non-particulating antacid) 30 ml, just before theprocedure


9/23

Opioids

Small dose of the potent opioid analgesics

- Fentanyl 1-3 g/kg

- Sulfentanyl 0.1- 0.3 g/kg

- Oral transmucosal fentanyl(lollipop)

Not routine, unless the patients experiencing acute or chronic

pain


10/23

Controlling Postoperative Nausea Preoperatively

Nausea, with or without vomiting, is probably the most important

factor contributing to a delay in discharge of patients

Risk factor that contributing postoperative nausea and vomiting;- Patients body habitus and medical condition

- Type of surgery performed(e.g., laparoscopy, orchiopexy,

strabismus surgery, therapeutic abortion)

- Assisted ventilation with a face mask- Anesthetic and analgesic medications( fentanyl, etomidate,

isoflurane, and nitrous oxide)


11/23

Controlling Postoperative Nausea Preoperatively

Droperidollower dose(0.25-0.5 mg)

50-75 g/kg for children

Promethazine 0.5-1.0 mg/kg

Serotonin Antagonists

Ondansetron 4-8 mg

75 g/kg for children


12/23

Outpatient Anesthetic Techniques:

General Anesthesia

Induction- Propofol;

Induction agent of choice for ambulatory anesthesia,

because of their short elimination half-life(1-3hr)

Reduce incidence of postoperative emesis

- Thiopental

- Sevoflurane

- Halotan

drug of choice for inhalation induction in pediatric patients

- Rectal etomidate(6 mg/kg) or ketamine(50 mg/kg) for children

- Ketamin; 2-6 mg/kg IM, for uncooperative child


13/23

Maintanace- Volatile anesthetics are generally considered to be superior than

intravenous anesthetic, because they are more controllable

Sevoflurane and Desflurane

Halogenated ether anesthetic with low blood-gas partition

coefficients, seem to be ideal for general anesthesia

Nitrous Oxide

Combined with the other anesthetic drugs

- Propofol

Has a short half life, result in rapid recovery

- Opioid(rapid and shorter-acting narcotics)

When given intraoperatively, are useful for both

intraoperative and postoperative analgesia

Fentanyl, sufentanyl, alfentanyl


14/23

Airway management;

- Face mask, laryngeal mask airway, oro-tracheal tube

- Drugs facilitating tracheal intubation;Depolarizing muscle relaxants Succinylcholin

Most rapid onset of muscle paralisys

Muscle pains lasting up to 4 days after surgery

Non-depolarizing muscle relaxants Rapacuronium,Rocuronium, Mivacuronium


15/23

Outpatient Anesthetic Techniques:

Regional Anesthesia

Spinal Anesthesia Spinal anesthesia are suitable for

urologic, herniorrhapy, and lower extremity surgery

Common side effects of general anesthesia are

avoided(e.g., nausea, vomiting, dizziness, and lethargy) Lidocaine, mepivacaine, and 2-chloroprocaine are ideal because of their

short duration of action

Needle size and shape are important to reduce the incidence of postduralpuncture headache(PDPH)

High incidence in patients younger than 60 yrs

Smaller gauge needles(e.g., 26 gauge) and pencil-pointneedles(Sprotte and Whitacre needles)

Can produce urinary retention


16/23

Epidural and Caudal Anesthesia

Advocated for outpatients lower extremity procedure,

herniorraphy, and extracorporeal shock-wave lithotripsy

Onset of epidural anesthesia is more slower than spinalanesthesia, and recovery may be same with either technique

Problem of postdural puncture headache is usually avoided

Caudal anesthesia is a useful technique for anorectal surgery,

dilatation and curetage


17/23

Peripheral Nerve Blocks

Intravenous regional anesthesia

Simple and reliable technique for superficial surgical limited to

a single extremity Brachial plexus block

For upper extremity surgery

3 in 1 block(femoral, obturator, and lateral femoralcutaneous nerves using a perivascular technique) for knee

arthroscopy

Ankle block

For surgery on the foot


18/23

Outpatient Anesthetic Technique:

Local Anesthesia

Simplest and safest

Significantly shorter recovery times

Monitoring patients vital sign

Injection of local anesthetics is often associated with severediscomfort

Intravenous sedative and analgesic drugs( i.e., so-called

conscious sedation technique)


19/23

Management ofPostanesthesia Care

The most common reason for delay in patients discharge from

the PACU(Postanesthesia Care Unit) are intracable nausea and

vomiting, drowsiness, airway problem(e.g., stridor,

bronchospasme), inability to void, dizziness, delayed

emergence, and pain

Nausea, vomiting, and pain also can be treated in the PACU

Nausea and vomiting

Metochlorpramide 20 mg

Hydroxyzine 25 mg

Droperidol 0.625-1.25 mg


20/23

Management ofPostanesthesia Care

Pain

- Morphine 1-3 mg/70kg,or

Fentanyl 10-25 g/70 kg small IV doses

- Ketorolac 60 mg/kg IM or IV

- Elixir of acetaminophen containing codein( 120 mg

acetaminophen, 12 mg codein, in each 5 ml of solution) for

chidren

- Acetaminophen 60 mg/year of age,( orally or rectally) for

mild pain in older infants and young children- Fentanyl 2 g/kg IV, for more severe pain

- Mepheridin 0.5 mg/kg, and Codein 1-1.5 mg/kgBB if an IV

route has not been establish


21/23

Preparation for Discharge the Patient

Accurate assessment about recovery of cognitive and

psychomotor function is important to determining the

appropriate time for discharge after ambulatory anesthesia

Patients who are awakened in the OR and are evaluated as 9or 10 according to the modified Aldrete scoring system, may

be transferred directly to Phase II recovery room, where

patients may stay until they are able to tolerate liquids, walk,

and/or able to void


22/23

POSTANESTHETIC DISCHARGE SCORING SYSTEM

Vital sign

2 = within 20% of preoperative value

1 = 20-40% of preoperative value

0 = 40% of preoperative value

Ambulation and mental status

2 = oriented 3 and has a steady gait

1 = oriented 3 or has a steady gait

0 = neitherPain or nausea Total score 10

3 = minimal 9 ; fit for discharge

2 = moderate

1 = severe

Surgical bleeding

3 = minimal

2 = moderate

1 = severe

Intake and output

3 = has had po fluids and has voided

2 = has had po fluids or has voided

1 = neither


23/23

References

1. Barash PG, Cullen BF, Stoelting RK: Clinical Anesthesia, 4th ed.

Philadelphia, Lippincott Williams & Wilkins, 2001

2. Miller RD: Anesthesia, 3th ed. California, Churchill

Livingstone, 1990

Documents

Ambulatory Anesthesia Presentasi