GUIDELINES FOR AMBULATORY ANESTHESIA AND SURGERY (American Society of Anesthesiologists) GUIDELINES FOR AMBULATORY ANESTHESIA AND SURGERY Non–Operating Room Anesthesia (NORA)

1. Saeid Safari,MD.

2. Saeid Safari,MD.

3. Saeid Safari,MD.

4. Saeid Safari,MD.
GUIDELINES FOR AMBULATORY
ANESTHESIA AND SURGERY
COMMITTEE OF ORIGIN: AMBULATORY SURGICAL CARE
(APPROVED BY THE ASA HOUSE OF DELEGATES ON OCTOBER 15, 2003, LAST AMENDED ON OCTOBER 22, 2008, AND
REAFFIRMED ON OCTOBER 16, 2013)

5. Saeid Safari,MD.
AMERICAN SOCIETY OF ANESTHESIOLOGISTS
• Endorses and supports the concept of Ambulatory Anesthesia
and Surgery.
• ASA encourages the anesthesiologist to play a leadership role as
the perioperative physician in all hospitals, ambulatory surgical
facilities and office-based settings
• To participate in facility accreditation as a means for
standardization and improving the quality of patient care.

6. Saeid Safari,MD.
GUIDELINES
1. ASA Standards, Guidelines and Policies should be adhered to
in all settings except where they are not applicable to outpatient
care.
2. A licensed physician should be in attendance in the facility, or in
the case of overnight care, immediately available by telephone,
at all times during patient treatment and recovery and until the
patients are medically discharged.

7. Saeid Safari,MD.
GUIDELINES
3. The facility must be established, constructed, equipped and
operated in accordance with applicable local, state and federal
laws and regulations.
At a minimum, all settings should have a reliable source of oxygen,
suction, resuscitation equipment and emergency drugs.

8. Saeid Safari,MD.
GUIDELINES
4. Staff should be adequate to meet patient and facility needs for
all procedures performed in the setting, and should consist of:
• A. Professional Staff
• 1. Physicians and other practitioners who hold a valid license or
certificate are duly qualified.
• 2. Nurses who are duly licensed and qualified.
• B. Administrative Staff
• C. Housekeeping and Maintenance Staff

9. Saeid Safari,MD.
GUIDELINES
5. Physicians providing medical care in the facility should assume
responsibility for credentials review, delineation of privileges,
quality assurance and peer review.
6. Qualified personnel and equipment should be on hand to
manage emergencies. There should be established policies
and procedures to respond to emergencies and unanticipated
patient transfer to an acute care facility.

10. Saeid Safari,MD.
7. MINIMAL PATIENT CARE SHOULD
INCLUDE:
A. Preoperative instructions and preparation.
B. An appropriate pre-anesthesia evaluation and examination by
an anesthesiologist, prior to anesthesia and surgery.
(In the event that nonphysician personnel are utilized in the process, the anesthesiologist must
verify the information and repeat and record essential key elements of the evaluation.)

11. Saeid Safari,MD.
7. MINIMAL PATIENT CARE SHOULD
INCLUDE:
C. Preoperative studies and consultations as medically indicated.
D. An anesthesia plan developed by an anesthesiologist, discussed
with and accepted by the patient and documented.
E. Administration of anesthesia by anesthesiologists, other qualified
physicians or nonphysician anesthesia personnel medically
directed by an anesthesiologist.
Non-anesthesiologist physicians who are administering or supervising the administration of the continuum of
anesthesia must be qualified by education, training, licensure, and appropriately credentialed by the facility.

12. Saeid Safari,MD.
7. MINIMAL PATIENT CARE SHOULD
INCLUDE:
F. Discharge of the patient is a physician responsibility.
G. Patients who receive other than unsupplemented local
anesthesia must be discharged with a responsible adult.
H.Written postoperative and follow-up care instructions.
I. Accurate, confidential and current medical records.

13. Saeid Safari,MD.
NON–OPERATING ROOM
ANESTHESIA (NORA)This chapter serves as a general guide to the cadence and focus of procedure
performed outside of the OR, and highlights some of the adaptations, both cultural
and practical, that are needed to provide a safe and optimal anesthetic.

14. Saeid Safari,MD.
THE PURPOSES
• The first is to highlight the intrinsic, common, and unique
characteristics of NORA cases that impose unusual constraints
on anesthesiologists in the out of OR arena.
• The second is to present goals, methodologies, and pitfalls of
interventions that may be unfamiliar to anesthesiologists.

15. Saeid Safari,MD.
• As medical procedures become even more technically
demanding and patient conditions more complex, medical
proceduralists will find increasing benefit from the support of
anesthesiologists.
• This requires collaboration and teamwork, but teams cannot
function without mutual respect, excellent communication,
common vocabulary, shared experience, and some truly
overlapping competencies.

16. Saeid Safari,MD.
Statement on Anesthesia Care
For Endoscopic Procedures

17. Saeid Safari,MD.
ANESTHESIA CARE FOR
ENDOSCOPIC PROCEDURES
• It is the position of the American Society of Anesthesiologists that:
“There is no circumstance when it is considered acceptable for a
person to experience emotional or psychological duress or untreated
pain amenable to safe intervention while under a physician’s care.”
• (See ASA’s Position Statement on the Medical Necessity of Anesthesiology Services, Approved by the House
of Delegates on October 16, 2013.)

18. Saeid Safari,MD.
ANESTHESIA CARE FOR
ENDOSCOPIC PROCEDURES
• Anesthesiology is a discipline within the practice of medicine that
involves the safeguarding and medical management of patients
who are rendered unconscious and/or insensible to pain and
emotional distress during surgical, obstetrical and other medical
procedures.

19. Saeid Safari,MD.
ANESTHESIA CARE FOR
ENDOSCOPIC PROCEDURES
• Therapeutic endoscopic procedures are more likely to require
anesthesia.
• Conditions may exist that make anesthesia necessary for
procedures not usually requiring such care.
• Particular co-morbidities and mental or psychological
impediments to cooperation are examples of conditions dictating
anesthesia care for even minor procedures in certain patients.
Patients with a personal history of failed moderate sedation may
also require anesthesia care.

20. Saeid Safari,MD.
ANESTHESIA CARE FOR
ENDOSCOPIC PROCEDURES
• Procedures that are prolonged or painful may warrant the use of
anesthesia.
• These include, but are not limited to, biopsies or polyp resections,
endoscopic retrograde cholangiopancreatography (ERCP), other
biliary tract procedures, dilation of intestinal structures with or
without stents, endoscopic resections, and other procedures that
potentially result in discomfort.

21. Saeid Safari,MD.
ANESTHESIA CARE FOR
ENDOSCOPIC PROCEDURES
• The decision as to the medical necessity of anesthesiology
services for a particular patient is a medical judgment that must
consider all:
• Patient factors and preferences,
• procedure requirements,
• potential risks and benefits, requirements or preferences of the
physician performing the underlying procedure, and
• competencies of the involved practitioners.

22. Saeid Safari,MD.
GENERAL INFORMATION ON
AMBULATORY ANESTHESIA
BARASH'S AMBULATORY ANESTHESIA

23. Saeid Safari,MD.
KEY POINTS
• Procedures appropriate for ambulatory surgery are those associated
with postoperative care that is easily managed at home and with low
rates of postoperative complications that require intensive physician
or nursing management.
• Whatever their age, ambulatory surgery is no longer restricted to
patients of ASA physical status I or II. Patients of ASA physical status
III or IV are appropriate candidates, providing their systemic
diseases are medically stable.

24. Saeid Safari,MD.
KEY POINTS
• In the 2006 ASA guidelines, the authors state that for patients
with OSA, if a procedure is typically performed as an outpatient
procedure and local or regional anesthesia is used, that the
procedure can also be performed as an ambulatory procedure.

25. Saeid Safari,MD.
KEY POINTS
• For adults, airflow obstruction has been shown to persist for up to 6
weeks after viral respiratory infections. For that reason, surgery
should be delayed if an adult presents with a URI until 6 weeks have
elapsed.
• In 1999, the ASA published practice guidelines for preoperative
fasting. The guidelines allow a patient to have a light meal up to 6
hours before an elective procedure and support a fasting period for
clear liquids of 2 hours for all patients.

26. Saeid Safari,MD.
KEY POINTS
• In a meta-analysis of peripheral nerve and centroneuraxial blocks
compared to general anesthesia, time until discharge from the
ambulatory surgery unit was no different for the three groups.
• Postoperative pain control is best with regional techniques.
• Nerve blocks using catheters can be placed before surgery that
can be used to provide analgesia after the operation.

27. Saeid Safari,MD.
KEY POINTS
• After induction doses of propofol or thiopental, impairment after
thiopental can be apparent for up to 5 hours, but only for 1 hour
after propofol.
• Although many factors affect the choice of agents for
maintenance of anesthesia, two primary concerns for ambulatory
anesthesia are speed of wake-up and incidence of postoperative
nausea and vomiting.

28. Saeid Safari,MD.
KEY POINTS
• It is important to distinguish between wake-up time and discharge
time.
• Patients may emerge from anesthesia with desflurane and nitrous
oxide significantly faster than after propofol or sevoflurane and
nitrous oxide, though the ability to sit up, stand, and tolerate fluids
and the time to fitness for discharge may be no different.

29. Saeid Safari,MD.
KEY POINTS
• Nausea, with or without vomiting, is probably the most important
factor contributing to a delay in discharge of patients and an
increase in unanticipated admissions of both children and adults
after ambulatory surgery.
• In addition to the PACU, many ambulatory surgery centers in the
United States have another area, often known as a phase II
recovery room, where patients may stay until they are able to
tolerate liquids, walk, and/or void.

30. Saeid Safari,MD.
TOPICS
• Place, Procedures, and Patient Selection
• Upper Respiratory Tract Infection
• Restriction of Food and Liquids Before Ambulatory Surgery
• Anxiety Reduction
• Managing the Anesthetic: Premedication
• Benzodiazepines
• Opioids and Nonsteroidal Analgesics

31. Saeid Safari,MD.
TOPICS
• Intraoperative Management: Choice of Anesthetic Method
• Regional Techniques
• Spinal Anesthesia
• Epidural and Caudal Anesthesia
• Nerve Blocks
• Sedation and Analgesia
• General Anesthesia
• Paralysis
• Intraoperative Management of Postoperative Pain
• Depth of Anesthesia
• Airways

32. Saeid Safari,MD.
TOPICS
•Management of Postanesthesia Care
•Reversal of Drug Effects
•Nausea and Vomiting
•Pain
•Preparation for Discharging the Patient

33. Saeid Safari,MD.
PLACE, PROCEDURES, AND PATIENT
SELECTION
• Ambulatory surgery occurs in a variety of settings. Some centers are within a hospital or in a
freestanding satellite facility that is either part of or independent from a hospital. The independent
facilities are often for-profit and not located in rural or inner-city areas. Some private companies
acquire or build ambulatory facilities and then work usually with local surgeons who become the
company's affiliated staff. Physicians' offices may also serve for procedures. Freestanding,
independent facilities will continue to grow in number and popularity, although some consumers
prefer care in units affiliated with hospitals.
• A major concern of freestanding ambulatory surgery growth is that the surgery centers may force
some hospitals out of business. This issue can be particularly problematic in areas in which
population density or median income is low. Hospitals usually are nonprofit and care for patients who
both can and cannot pay. Freestanding ambulatory facilities may also be nonprofit but usually do not
provide charity care.
• Some surgeons may work exclusively in a freestanding facility and not be on the staff of a hospital. A
requirement for hospital staff privileges frequently is that a physician provides coverage for the
hospital's emergency department. Some hospitals have lost emergency department coverage for an
entire surgical specialty because that surgical specialty works exclusively in a freestanding facility.

34. Saeid Safari,MD.
PLACE, PROCEDURES, AND PATIENT
SELECTION
• Procedures appropriate for ambulatory surgery are those
associated with postoperative care that are easily managed at
home and with low rates of postoperative complications that
require intensive physician or nursing management. Establishing
a low rate of postoperative complication depends on the relative
aggressiveness of the facility, surgeon, patient, and payer.

35. Saeid Safari,MD.
PLACE, PROCEDURES, AND PATIENT
SELECTION
• At the other extreme of life, advanced age alone is not a reason
to disallow surgery in an ambulatory setting. Age, however, does
affect the pharmacokinetics of drugs. Even short-acting drugs
such as midazolam and propofol have decreased clearance in
older individuals. In addition, as previously mentioned, increased
age may be a factor that affects the likelihood of unanticipated
admission.

36. Saeid Safari,MD.
PLACE, PROCEDURES, AND PATIENT
SELECTION
• Most medical problems that older individuals may experience
after ambulatory procedures are not related to patient age, but to
specific organ dysfunction. For that reason, all individuals,
whether young or old, deserve a careful preoperative history and
physical examination.

37. Saeid Safari,MD.
PLACE, PROCEDURES, AND PATIENT
SELECTION
• Whatever their age, ambulatory surgery is no longer restricted to
patients of American Society of Anesthesiologists (ASA) physical
status I or II. Patients of ASA physical status III or IV are
appropriate candidates, providing their systemic diseases are
medically stable.

38. Saeid Safari,MD.
PLACE, PROCEDURES, AND PATIENT
SELECTION
• For patients with OSA, if a procedure is typically performed as an
outpatient procedure and local or regional anesthesia is used, the
procedure can also be performed as an ambulatory procedure.
Yet for patients who are at increased risk for perioperative
complications, the procedure should not be performed in a
freestanding ambulatory surgery facility.

39. Saeid Safari,MD.
PLACE, PROCEDURES, AND PATIENT
SELECTION
• Patients who undergo ambulatory surgery should have someone to take them
home and stay with them afterward to provide care. Before the procedure, the
patient should receive information about the procedure itself, where it will be
performed, laboratory studies that will be ordered, and dietary restrictions.
• The patient must understand that he or she will be going home on the day of
surgery. The patient, or some responsible person, must ensure all instructions are
followed. Once at home, the patient must be able to tolerate the pain from the
procedure, assuming adequate pain therapy is provided.
• The majority of patients are satisfied with early discharge, although a few prefer a
longer stay in the hospital. Patients for certain procedures such as laparoscopic
cholecystectomy or transurethral resection of the prostate should live close to the
ambulatory facility because postoperative complications may require their prompt
return.

40. Saeid Safari,MD.
UPPER RESPIRATORY TRACT
INFECTION
• For adults, airflow obstruction has been shown to persist for up to 6 weeks after
viral respiratory infections. For that reason, surgery should be delayed if an adult
presents with an upper respiratory infection (URI) until 6 weeks have elapsed. In
the case of children, whether surgery should be delayed for that length of time is
questionable.
• But children with active or recent URIs had more episodes of breath holding,
incidences of desaturation <90%, and more respiratory events compared with
children without symptoms
• Generally, if a patient with a URI has a normal appetite, does not have a fever or
an elevated respiratory rate, and does not appear toxic, it is probably safe to
proceed with the planned procedure

41. Saeid Safari,MD.
RESTRICTION OF FOOD AND LIQUIDS
• In 1999, the ASA published practice guidelines for preoperative
fasting. The guidelines allow a patient to have a light meal up to 6
hours before an elective procedure and support a fasting period
for clear liquids of 2 hours for all patients. Coffee and tea are
considered clear liquids.

42. Saeid Safari,MD.
RESTRICTION OF FOOD AND LIQUIDS
• Coffee and tea drinkers should follow fasting guidelines but
should be encouraged to drink coffee prior to their procedure
because physical signs of withdrawal (e.g., headache) can easily
occur. It is not clear if the guidelines should apply to patients with
diabetes or dyspepsia.
• There is some evidence that shorter periods of preoperative
fasting are accompanied by less postoperative nausea and
vomiting (PONV). Yet, it is unclear whether rehydration during
surgery is equivalent to a shorter fast before surgery in relation to
PONV.

43. Saeid Safari,MD.
PATIENT ANXIETY
• Preoperative reassurance from nonanesthesia staff and providing
booklets with information about the procedure also reduce
preoperative anxiety.
• Much of a child's anxiety before surgery concerns separation from a
parent or parents.
• Family-centered therapy consisted of providing the families of
children with a videotape, three pamphlets, and a mask practice kit
during their preoperative visit.

44. Saeid Safari,MD.
MANAGING THE ANESTHETIC:
PREMEDICATION

45. Saeid Safari,MD.
BENZODIAZEPINES
• premedication is useful to control anxiety, postoperative pain,
nausea and vomiting, and to reduce the risk of aspiration during
induction of anesthesia.
• Benzodiazepines are currently the drugs most commonly used.
Midazolam is the benzodiazepine most commonly used
preoperatively. It can be used intravenously and orally.

46. Saeid Safari,MD.
BENZODIAZEPINES
• For children, oral midazolam in doses as small as 0.25 mg/kg
produces effective sedation and reduces anxiety.
• With this dose, most children can be effectively separated from their
parents after 10 minutes and satisfactory sedation can be maintained
for 45 minutes.
• In adults, particularly when midazolam is combined with fentanyl,
patients can remain sleepy for up to 8 hours. Although children may
be sleepier after oral midazolam, discharge times are not affected.

47. Saeid Safari,MD.
BENZODIAZEPINES
• At proper doses, neither midazolam nor diazepam place patients
at any additional risk for cardiovascular and respiratory
depression.
• The potential for amnesia after premedication is another concern,
especially for patients undergoing ambulatory surgery.
Anterograde amnesia certainly occurs.

48. Saeid Safari,MD.
BENZODIAZEPINES
• Oral diazepam, 2 to 5 mg per 70 kg body weight, is prescribed for the
night before and at 6:00 AM on the day of surgery (even if surgery is
scheduled for 1:00 PM or later).
• Midazolam, 0.01 mg/kg, is administered intravenously,
• Into the OR and propofol, 0.7 mg/kg, is injected intravenously.
• For children, oral midazolam, 0.25 mg/kg, is administered in the
preoperative holding area.
• When the child is asleep, acetaminophen, 40 mg/kg rectally, and
ketorolac, 0.5 mg/kg intravenously, are administered prior to initiation
of surgery.

49. Saeid Safari,MD.
OPIOIDS AND NONSTEROIDAL
ANALGESICS
• Preoperative administration of opioids or nonsteroidal anti-
inflammatory drugs (NSAIDs) may be useful for controlling pain in
the early postoperative period.
• Celecoxib, up to 400 mg, is effective in reducing postoperative
pain.23 Ibuprofen or acetaminophen can be given rectally to
children around the time of induction.

50. Saeid Safari,MD.
OPIOIDS AND NONSTEROIDAL
ANALGESICS
• If rectal acetaminophen is used in children, an initial loading dose
of 40 mg/kg is appropriate; subsequent doses of 20 mg/kg every
6 hours can be used.
• When preoperative rectal acetaminophen is combined with
ketoprofen, particularly for more painful procedures,
postoperative pain is less than when the drugs are given
individually.

51. Saeid Safari,MD.
INTRAOPERATIVE
MANAGEMENT

52. Saeid Safari,MD.
REGIONAL TECHNIQUES
• Performing a block takes longer than inducing general
anesthesia, and the incidence of failure is higher.
• Unnecessary delays can be obviated by performing the block
beforehand in a preoperative holding area.
• Because a postoperative nursing intervention, usually associated
with general anesthesia, is associated with a 27- to 45-minute
delay, the increased setup time for a regional anesthetic may be
associated with a shorter time to discharge.
• Postoperative pain control is best with regional technique

53. Saeid Safari,MD.
SPINAL ANESTHESIA
• Children:
• Spinal anesthesia is used in some centers particularly for children
undergoing inguinal hernia repair.
• The anesthesiology team used 0.5% hyperbaric bupivacaine at a
dose of 0.2 mg/kg.
• Adult:
• Lidocaine and mepivacaine are ideal for ambulatory surgery
because of their short duration of action, although lidocaine use has
been problematic because of transient neurologic symptoms.

54. Saeid Safari,MD.
SPINAL ANESTHESIA
• Both ropivacaine and bupivacaine have been used for ambulatory
surgical procedures, but recovery time is relatively long.
• Spinal anesthesia should not be avoided in ambulatory surgery
patients simply because they may be more active postoperatively
than inpatients.
• Bed rest does not reduce the frequency of headache. Indeed,
early ambulation may decrease the incidence.

55. Saeid Safari,MD.
EPIDURAL AND CAUDAL
ANESTHESIA
• Epidural anesthesia takes longer to perform than spinal
anesthesia. Onset with spinal anesthesia is more rapid, although
recovery may be the same with either technique.
• Caudal anesthesia is a form of epidural anesthesia commonly
used in children before surgery below the umbilicus as a
supplement to general anesthesia and to control postoperative
pain.

56. Saeid Safari,MD.
EPIDURAL AND CAUDAL
ANESTHESIA
• The block is usually administered while the child is anesthetized.
After injection, the depth of general anesthesia can be reduced.
• Because of better pain control after a caudal block, children can
usually ambulate earlier and be discharged sooner than without a
caudal block.
• Pain control and discharge times are no different whether the
caudal block is placed before surgery or after it is completed.

57. Saeid Safari,MD.
NERVE BLOCKS
• There was shown to be widespread use of axillary and
interscalene blocks for surgery in the upper extremity, and of
ankle and femoral blocks for lower extremity surgery.
• Nerve blocks improve postoperative patient satisfaction—PONV
and postoperative pain are less. Costs are also less.

58. Saeid Safari,MD.
NERVE BLOCKS
• Patients who go home with catheters inserted must be taught
about pump function, understand signs of local anesthesia
toxicity, and have someone else at home who can provide
assistance.
• In addition, the patients must be able to communicate with
someone by phone. The number of patients who have been sent
home with catheters is increasing but is not large. More study is
needed in order to demonstrate patient safety.

59. Saeid Safari,MD.
SEDATION AND ANALGESIA
• Many patients who undergo surgery with local or regional
anesthesia prefer to be sedated and to have no recollection of the
procedure.
• Sedation is important, in part, because injection with local
anesthetics can be painful and lying on a hard OR table can be
uncomfortable.
• Levels of sedation vary from light, during which a patient's
consciousness is minimally depressed, to very deep, in which
protective reflexes are partially blocked and response to physical
stimulation or verbal command may not be appropriate.

60. Saeid Safari,MD.
GENERAL ANESTHESIA
• The popularity of propofol as an induction agent for outpatient
surgery in part relates to its half-life: the elimination half-life of
propofol is 1 to 3 hours, shorter than that of methohexital (6 to 8
hours) or thiopental (10 to 12 hours).
• After induction doses of propofol or thiopental, psychomotor
impairment after thiopental can be apparent for up to 5 hours, but
only for 1 hour after propofol.

61. Saeid Safari,MD.
GENERAL ANESTHESIA
• Pain on injection can be a problem with propofol.
• Thrombophlebitis does not appear to be a problem after
intravenous administration of propofol, whereas it can be evident
after thiopental.
• Most children and some adults prefer not to have an intravenous
catheter inserted before the start of anesthesia.
• For short procedures, some patients may not require
neuromuscular-blocking drugs; others may need brief paralysis
(e.g., with succinylcholine) to facilitate tracheal intubation.

62. Saeid Safari,MD.
MAINTENANCE
• Two primary concerns for ambulatory anesthesia are speed of
wake-up and incidence of PONV.

63. Saeid Safari,MD.
WAKE-UP TIMES
• Propofol has a short half-life and, when used as a maintenance
agent, results in rapid recovery and few side effects. Desflurane and
sevoflurane, halogenated ether anesthetics with low blood-gas
partition coefficients, seem to be ideal for general anesthesia for
ambulatory surgery.
• Sevoflurane, unlike desflurane, facilitates a smooth inhalation
induction of anesthesia, the preferred technique to ensure rapid
recovery of children in ambulatory surgery centers.
•

64. Saeid Safari,MD.
WAKE-UP TIMES
• It is important to distinguish between wake-up time and discharge
time.
• Patients may emerge from anesthesia with desflurane and nitrous
oxide significantly faster than after propofol or sevoflurane and
nitrous oxide, although the ability to sit up, stand, and tolerate
fluids and the time to fitness for discharge may be no different.

65. Saeid Safari,MD.
INTRAOPERATIVE MANAGEMENT OF
PONV
• Nausea, with or without vomiting, is probably the most important
factor contributing to a delay in discharge of patients and an
increase in unanticipated admissions of both children and adults
after ambulatory surgery.

66. Saeid Safari,MD.
HAVE A HIGHER INCIDENCE OF
PONV:
• Women, especially those who are pregnant,
• Previous history of motion sickness or postanesthetic emesis,
• Surgery within 1 to 7 days of the menstrual cycle,
• Not smoking,
• Laparoscopy, lithotripsy, major breast surgery, and ear, nose, or
throat surgery.

67. Saeid Safari,MD.
• Selective serotonin antagonists (ondansetron, dolasetron, and
granisetron.
• Dopamine antagonists,
• Antihistamines,
• Anticholinergic drugs are useful and are generally less expensive,
but are associated with extensive side effects.
• Neurokinin (NK1) receptor antagonists may also be useful to
control PONV.
• Therapies useful in controlling PONV include acupuncture

68. Saeid Safari,MD.
COMBINATION THERAPY
• Avoidance of nitrous oxide;
• Avoidance of inhalation agents;
• Avoidance of muscle relaxant reversal, if clinically indicated;
• Avoidance of narcotics;
• Fluid hydration
• Administration of a 5-HT3 antagonist, an antiemetic from a
different drug class, and dexamethasone.

69. Saeid Safari,MD.
PARALYSIS
• Muscle paralysis for ambulatory anesthesia extends beyond the
time of paralysis for intubation, particularly when nondepolarizing
drugs are used.
• Reversal agents must be used unless there is no doubt that
muscle relaxation has been fully reversed.

70. Saeid Safari,MD.
INTRAOPERATIVE MANAGEMENT OF
POSTOPERATIVE PAIN
• Opioids, when given intraoperatively, are useful to supplement
both intraoperative and postoperative analgesia.
• Fentanyl is pro
• To control postoperative pain, combination therapy is most
useful.bably the most popular drug.

71. Saeid Safari,MD.
DEPTH OF ANESTHESIA
• Use of BIS, and entropy, or auditory-evoked potential monitors
can decrease anesthesia requirement without sacrificing amnesia
during general anesthesia.
• Because less anesthesia is used, titration of anesthesia with
these monitors results in earlier emergence from anesthesia.

72. Saeid Safari,MD.
AIRWAYS
• The use of an LMA, or similar type of airway, provides several
advantages for allowing a patient to return to baseline status
quickly.
• Muscle relaxants required for intubation can be avoided.
• Coughing is less than with tracheal intubation.
• Anesthetic requirements are reduced.
• Hoarseness and sore throat are also reduced.
• Overall, cost savings result with the use of LMAs

73. Saeid Safari,MD.
MANAGEMENT OF
POSTANESTHESIA CARE

74. Saeid Safari,MD.
PACU
• The three most common reasons for delay in patient discharge
from the PACU are:
• Drowsiness,
• Nausea And Vomiting,
• Pain.
• All three are a function of intraoperative management, but
nausea, vomiting, and pain also can be treated in the PACU.

75. Saeid Safari,MD.
PACU- REVERSAL OF DRUG EFFECTS
• Reversal of opioids may sometimes be necessary.
• Flumazenil, a benzodiazepine receptor antagonist,
• Flumazenil should not be used routinely as a benzodiazepine
antagonist, but may be used when sedation appears to be
excessive

76. Saeid Safari,MD.
PACU- NAUSEA AND VOMITING
• Nausea and vomiting are also the most common adverse effect in
patients in the PACU.
• In adults, granisetron, 40 µg/kg; metoclopramide, 0.2 mg/kg; or
hydroxyzine, 25 mg, are effective.
• Dexamethasone, 8 mg, given with other antiemetics can enhance
treatment of established PONV in the PACU.
• Midazolam and propofol, have antiemetic effects that are longer
in duration than their effects on sedation.

77. Saeid Safari,MD.
PACU- PAIN
• Postsurgical pain must be treated quickly and effectively.
• It is important for the practitioner to differentiate postsurgical pain
from the:
• Discomfort of hypoxemia,
• Hypercapnia,
• Full bladder.

78. Saeid Safari,MD.
PACU- PAIN
• When swelling and pain are problematic postoperatively, NSAIDs
can be more effective than opioids in relieving both.
• For children, we also use an elixir of acetaminophen containing
codeine (120 mg acetaminophen and 12 mg codeine, in each 5
mL of solution).
• Five milliliters is administered to children between the ages of 3
and 6, and 10 mL to children between the ages of 7 and 12.

79. Saeid Safari,MD.
PREPARATION FOR DISCHARGING
THE PATIENT
• Patients should also be informed that they may experience pain,
headache, nausea, vomiting, or dizziness and, if succinylcholine
was used, muscle aches and pains apart from the incision for at
least 24 hours.
• A patient will be less stressed if the described symptoms are
expected in the course of a normal recovery.
• Written instructions are important. The addition of written and oral
education techniques at discharge has a significant impact on
improving compliance.

80. Saeid Safari,MD.
THE MODIFIED ALDRETE’S
SCORING SYSTEM IS A HIGHLY
ACCEPTABLE CRITERIA FOR
DISCHARGING PATIENTS FROM
THE PACU.
Proposed fast-track criteria to determine whether
outpatients can be transferred directly from the
operating room to the step-down (phase II) unit. A
minimal score of 12 (with no score ,1 in any individual
category) would be required for a patient to be fast
tracked (i.E., Bypass the post anesthesia care unit)
after general anesthesia.

81. Saeid Safari,MD.
CONCLUSION

82. Saeid Safari,MD.
CONCLUSION
• Patient, procedure, availability and quality of aftercare, and
anesthetic technique must be individually and collectively
assessed to determine acceptability for ambulatory surgery.
• A delicate balance must be maintained between the physical
status of the patient, the proposed surgical procedure, and the
appropriate anesthetic technique, to which must be added the
expertise level of the anesthesiologist caring for a patient.

83. Saeid Safari,MD.
CONCLUSION
• Anesthesia for ambulatory surgery is a rapidly evolving specialty.
• Patients who were once believed to be unsuitable for ambulatory
surgery are now considered to be appropriate candidates.
• Operations once believed unsuitable for outpatients are now
routinely performed in the morning so patients can be discharged
in the afternoon or evening.

84. Saeid Safari,MD.
CONCLUSION
• The appropriate anesthetic management before these patients
come to the OR, during their operation, and then afterward is the
key to success.
• The availability of both shorter-acting anesthetics and longer-
acting analgesics and antiemetics enables us to care for patients
in ambulatory centers effectively.

85. Saeid Safari,MD.