Office based Anesthesia Ambulatory Anesthesia NORA (Non operating Room Anesthesia)

1. Saeid Safari,MD.

2. Saeid Safari,MD.
The Institute for Safety in Office Based Surgery

3. Saeid Safari,MD.
“WILD WILD WEST OF HEALTHCARE”
• Lack of uniform regulation of office based practice
• Increasing number and variety of cases
• Increasing complexity of cases and patients
• Sedation by anesthesia and non-anesthesia personnel
• Widely publicized fatalities and malpractice claims

4. Saeid Safari,MD.
IMPROVING QUALITY AND SAFETY IN OFFICE BASED
SURGERY AND ANESTHESIA

5. Saeid Safari,MD.
THE INSTITUTE FOR SAFETY IN
OFFICE BASED SURGERY
• Non profit organization established 2009
• Purpose:
• promote patient safety in office-based surgery
• design tools for advanced detection and prevention of adverse
events
• Encourage collaboration across all subspecialties
• improve physician and patient education
• generate evidence based standard of care for safer office based
practice

6. Saeid Safari,MD.
THE COMEDIAN
JOAN RIVERS
, WHO WENT INTO CARDIAC ARREST DURING
WHAT WAS SUPPOSED TO BE A ROUTINE
ENDOSCOPY ON AUG. 28, 2014. SHE DIED
SEVERAL DAYS LATER.
THE NEW YORK TIMES

7. Saeid Safari,MD.
ERRORS IN THE CASE
• The Centers for Medicare and Medicaid Services subsequently
investigated the Yorkville Endoscopy clinic and found that the
clinic made numerous errors including:
• Taking cell phone photos,
• Failing to keep proper medication records,
• Failing to receive informed consent for every procedure,
• Failing to record Joan’s weight prior to administering anesthesia

8. “
”
Saeid Safari,MD.
WORK TOWARDS ENSURING
HIGHER SAFETY STANDARDS
IN OUTPATIENT SURGICAL
CLINICS.
IN A STATEMENT, MELISSA RIVERS VOWED TO :

10. Saeid Safari,MD.

11. Saeid Safari,MD.
ASA CLOSED CLAIMS ANALYSIS:
MAC CASES
• Respiratory depression most common mechanism (21%)
• 46% deemed preventable by:
• Better Monitoring eg. Capnography
• Improved Vigilance
• Audible Alarms

12. Saeid Safari,MD.

13. Saeid Safari,MD.

14. Saeid Safari,MD.

15. Saeid Safari,MD.

16. Saeid Safari,MD.

17. Saeid Safari,MD.

18. Saeid Safari,MD.

19. Saeid Safari,MD.

20. Saeid Safari,MD.
GOALS:
TO BECOME KNOWLEDGEABLE
• Appropriate selection of patients for ambulatory surgery.
• Anesthetic management of a wide variety of ambulatory general surgery cases.
• Pharmacology of anesthetic agents and their appropriate use in ambulatory
surgery.
• Prevention and management of common causes of unanticipated admission in
ambulatory surgery.

21. Saeid Safari,MD.
OBJECTIVES:
UPON COMPLETION OF AMBULATORY ANESTHESIA FELLOWSHIP TRAINING, THE FELLOW WILL:
• Demonstrate the ability to screen patients appropriately for
ambulatory surgery with sedation / analgesia, general and regional
anesthesia.
• Demonstrate the ability to discuss the advantages and
disadvantages of various anesthetic techniques with surgeon and
patient.
• Demonstrate knowledge of pharmacology of anesthetic agents and
their appropriate use in ambulatory surgery.
• Demonstrate knowledge of the common causes of unanticipated
admission in ambulatory surgery and of the appropriate methods for
prevention and management of these adverse events.

22. Saeid Safari,MD.

23. Saeid Safari,MD.

24. 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)

25. 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.

26. 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.

27. 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.

28. 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

29. 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.

30. 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.)

31. 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.

32. 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.

33. 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.

34. 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.

35. 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.

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

37. 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.)

38. 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.

39. 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.

40. 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.

41. 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.

42. Saeid Safari,MD.
GENERAL INFORMATION ON
AMBULATORY ANESTHESIA
BARASH AND MILLER AMBULATORY ANESTHESIA

43. 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.

44. 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.

45. 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.
•

46. 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.

47. 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.

48. 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.
• 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.

49. 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

50. 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

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

52. Saeid Safari,MD.
PATIENT SELECTION CRITERIA

53. Saeid Safari,MD.
PATIENT SELECTION CRITERIA
• Selection of Procedures
• Duration of Surgery
• Patient Characteristics
• Susceptibility to Malignant Hyperthermia
• Extremes of Age
• Contraindications to Outpatient Surgery

54. Saeid Safari,MD.
SELECTION OF PROCEDURES
• Minimal postoperative physiologic disturbances and an
uncomplicated recovery.
• The primary predictors of prolonged stay or unanticipated
admission after day-case surgery are related to the type of
surgical procedure and associated complications (e.g., blood
loss, incisional pain, postoperative nausea and vomiting [PONV])

55. Saeid Safari,MD.
THE CONTINUUM OF SEDATION AND GENERAL
ANESTHESIA.

56. Saeid Safari,MD.
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
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

57. Saeid Safari,MD.
MORE IDEALLY SUITED TO A 23-HOUR
STAY:
• Major postoperative surgical complications
• Major fluid shifts Autologous blood transfusions
• Lengthy procedures associated with excessive fluid shifts,
• Requiring prolonged immobilization and
• parenteral opioid analgesic therapy

58. Saeid Safari,MD.
THE MODIFIED ALDRETE RECOVERY SCORE

59. Saeid Safari,MD.
EXAMPLE OF A PAIN MANAGEMENT PROTOCOL FOR AMBULATORY SURGERY PATIENTS.
NSAID, NONSTEROIDAL ANTIINFLAMMATORY DRUG.

60. Saeid Safari,MD.
DURATION OF SURGERY
• Was originally limited to procedures lasting less than 90 minutes
• Now, Surgical procedures lasting 3 to 4 hours are performed on
an ambulatory basis.

61. Saeid Safari,MD.
PATIENT CHARACTERISTICS
• Originally, the majority of patients were classified as ASA physical
status I or II.
• Patients with preexisting medical conditions do not have an
increased incidence of perioperative complications or unexpected
admissions
• The risk can be minimized if preexisting medical conditions are
stable for at least 3 months before the scheduled operation.

62. Saeid Safari,MD.
Flowchart illustrating the basic process for selecting
patients for ambulatory surgery.

63. Saeid Safari,MD.
PATIENT CHARACTERISTICS
The ASA should not be considered in isolation
Because these factors can also influence decisions making:
1. Surgical procedure,
2. Anesthetic technique,
3. A Multitude of medical and social factors

64. Saeid Safari,MD.
SO…
• Even morbid obesity (body mass index >40 kg/m2) is no longer
considered an exclusionary criterion for day-case surgery.
• The presence of obstructive sleep apnea syndrome was not
associated with an increased risk of unanticipated admission to
the hospital.

65. Saeid Safari,MD.

66. Saeid Safari,MD.
SUSCEPTIBILITY TO MALIGNANT
HYPERTHERMIA
• Managed with nontriggering anesthetics (e.g., local anesthesia).
• Admission solely on the basis of MH susceptibility is no longer
considered appropriate, and it should be based on clinical criteria
• If the anesthesia and surgery were uneventful, MH-susceptible
patients can be safely discharged home on the day of surgery.

67. Saeid Safari,MD.
EXTREMES OF AGE
• Even the “elderly” patient (>100 years) should not be denied
ambulatory surgery solely on the basis of age.
• Most studies suggest that the risk is greatest in premature infants
younger than 46 weeks’ postconceptual age.
• The risk of apnea may persist until the 60th postconceptual week
and when anemia (hematocrit < 30%) exists.

68. Saeid Safari,MD.
CONTRAINDICATIONS:
1. Potentially life-threatening chronic illnesses (e.g., brittle diabetes, unstable
angina, symptomatic asthma)
2. Morbid obesity complicated by symptomatic cardiorespiratory problems
(e.g., angina, asthma)
3. Multiple chronic centrally active drug therapies (e.g., use of monoamine
oxidase inhibitors such as pargyline and tranylcypromine) and/or active
cocaine abuse
4. Ex-premature infants less than 60 weeks’ postconceptual age requiring
general endotracheal anesthesia
5. No responsible adult at home to care for the patient on the evening after
surgery

69. Saeid Safari,MD.
PREOPERATIVE ASSESSMENT

70. Saeid Safari,MD.
PREOPERATIVE ASSESSMENT
• Preoperative Evaluation
• Preoperative Preparation:
1. Nonpharmacologic Preparation
2. Pharmacologic Preparation

71. Saeid Safari,MD.
PREOPERATIVE EVALUATION
• For outpatients undergoing superficial surgical procedures no
laboratory tests appear to be indicated in males, and only a
hemoglobin (or hematocrit) test is indicated for adult females of
child-bearing age.
• Obviously, patients with chronic diseases (e.g., hypertension,
diabetes) require additional laboratory studies (e.g., electrolytes,
glucose).

72. Saeid Safari,MD.
PREOPERATIVE EVALUATION
• Patients with an unexplained hemoglobin concentration of less
than 10 g/dL should be considered for further evaluation
• Eliminating routine preoperative testing (even in elderly
outpatients) will allow cost savings without compromising the
safety or the quality of patient care.

73. Saeid Safari,MD.
PREOPERATIVE EVALUATION
• Preoperative assessment 1 to 2 weeks before surgery was found
to reduce preoperative anxiety.
• Appropriate patient preparation before the day of surgery can
prevent:
1. Unnecessary delays,
2. Absences (“no shows”),
3. Last-minute cancellations,
4. Substandard perioperative care.

74. Saeid Safari,MD.
THE PREPARATION PROCESS IS
AIMED AT :
1. Reducing the risks inherent in ambulatory surgery,
2. Improving patient outcome,
3. Making the surgical experience more pleasant for the patient and their
family.
• Patients should be encouraged to continue all their chronic
medications up to the time that they arrive at the surgery center.

75. Saeid Safari,MD.
NONPHARMACOLOGIC
PREPARATION
• High levels of stress preoperatively are associated with slower
recovery and greater analgesic and antiemetic requirements after
surgery, but it can be effectively reduced by careful preoperative
preparation
• Well-informed patients tend to recover faster and experience less
pain and fewer postoperative complications.

76. Saeid Safari,MD.
PREOPERATIVE PSYCHOLOGICAL PREPARATION REDUCES STRESS
BEFORE AND UP TO 1 WEEK AFTER SURGERY

77. Saeid Safari,MD.
NONPHARMACOLOGIC
PREPARATION
• Anesthetist's preoperative visit
• Preoperative educational programs
• Timing of the preoperative interview
• Instructional preoperative videotapes
• Self-hypnotic relaxation techniques
• Play-oriented preoperative teaching, books, pamphlets, and video
Pediatric
patients

78. Saeid Safari,MD.
PHARMACOLOGIC PREPARATION
• Prospective studies have not found recovery to be prolonged
after the use of appropriate doses of sedative premedication in
the outpatient setting (e.g., midazolam, 1-2 mg intravenously [IV]
• Midazolam premedication not only decreases preoperative
anxiety but may also be associated with a reduction in
postoperative pain.

79. Saeid Safari,MD.
Pharmacologic Preparation:
1.Anxiolysis and Sedation
2.Preemptive (Preventative) Analgesia
3.Prevention of Nausea and Vomiting
4.Prevention of Aspiration Pneumonitis

80. Saeid Safari,MD.
ANXIOLYSIS AND SEDATION:
• The most widely used premedicants have been barbiturates and
benzodiazepines.
• Methohexital and ketamine have been used for rectal
premedication in children.
• Melatonin produces sedation and anxiolysis comparable to oral
midazolam when administered for premedication

81. Saeid Safari,MD.
ANXIOLYSIS AND SEDATION:
• Benzodiazepines,
• α-Adrenergic Agonists
• β-Blockers

82. Dosage Range Onset (min) Key Points
B e n z o d i a z e p i n e s
Midazolam
7.5-15 mg PO 15-30 Large first-pass effect
5-7 mg IM 15-30 Water soluble, nonirritating
1-2 mg IV 1-53 Rapid onset, excellent amnesia
Diazepam 5-10 mg PO 45-90 Long-acting metabolites
Temazepam 15-30 mg PO 15-40 Comparable anxiolysis to midazolam
Triazolam 0.125-0.25 mg PO 15-30 Prominent sedation
Lorazepam 1-2 mg PO 45-90 Prolonged amnestic effect
α 2 - A d r e n e r g i c A g o n i s t s
Clonidine 0.1-0.3 mg PO 45-60 Prolonged sedative effect
Dexmedetomidine
50-70 µg IM 20-60 Bradycardia and hypotension
50 µg IV 5-30 Reduced anesthetic/analgesic requirements

83. Saeid Safari,MD.
ANXIOLYSIS AND SEDATION:
• Temazepam and alprazolam also are effective oral premedicants
for outpatient surgery.
• Lorazepam, because of its long duration of amnesia, is not
recommended in the ambulatory setting.
• After admission to the day surgery center, intravenous midazolam
(1-3 mg IV) is the most useful drug.

84. Saeid Safari,MD.
ANXIOLYSIS AND SEDATION:
• Oral clonidine, the prototypical α2-agonist, has been successfully
used for ambulatory premedication and may reduce
intraoperative blood loss, as well as the anesthetic and analgesic
requirements.
• Dexmedetomidine is a more highly selective α2-agonist that has a
shorter duration of action than clonidine.

85. Saeid Safari,MD.
THE ROLE OF Β-ADRENERGIC
BLOCKERS
• Appears to be increasing in ambulatory surgery because of their
ability to control acute autonomic responses during surgery while
minimizing the need for opioid analgesics.

86. Saeid Safari,MD.
PREEMPTIVE (PREVENTATIVE)
ANALGESIA:
• Opioid (Narcotic) Analgesics,
• Nonopioid Analgesics

87. Saeid Safari,MD.
PREEMPTIVE (PREVENTATIVE)
ANALGESIA:
• Perioperative multimodal analgesia is helpful in facilitating a
faster emergence from anesthesia and an earlier discharge.
• Use of opioid analgesics for premedication is not recommended
unless the patient is experiencing acute pain
• Opioid premedication can increase the incidence of PONV and
urinary retention, which can contribute to a delayed discharge
after ambulatory surgery

88. Saeid Safari,MD.
PREEMPTIVE (PREVENTATIVE)
ANALGESIA:
• NSAIDs can facilitate early recovery, decrease side effects, and
reduce discharge times,
When administered as part of a balanced
(“multimodal”) analgesic technique in
combination with local anesthetics and
acetaminophen.

89. Saeid Safari,MD.
PREEMPTIVE (PREVENTATIVE)
ANALGESIA:
• Ketorolac, a parenterally active NSAID, was more effective than
acetaminophen with codeine in preventing pain after outpatient
procedures in children.
• Celecoxib (400 mg)
• Addition of dexamethasone to a COX-2 inhibitor
• Gabapentin

90. Saeid Safari,MD.
PREVENTION OF NAUSEA AND
VOMITING

91. Patient-Related Factors
Age
Gender
Preexisting diseases (e.g.,
diabetes)
History of motion sickness or
postoperative nausea and vomiting
Smoking history
Level of anxiety
Intercurrent illness (e.g., viral
infection, pancreatic disease)
Anesthesia-Related Factors
Premedication
Opioid analgesics
Induction and maintenance
anesthetics
Reversal (antagonist) drugs
Gastric distention
Inadequate hydration
Residual sympathectomy
Surgery-Related Factors
Operative procedure
Length of surgery
Blood in the gastrointestinal tract
Forcing oral intake
Opioid analgesics
Premature ambulation (postural
hypotension)
Pain

92. Saeid Safari,MD.
PREVENTION OF NAUSEA AND
VOMITING
1. Pharmacologic Techniques:
• Butyrophenones, (e.g. Droperidol )
• Phenothiazines, (Prochlorperazine)
• Anticholinergics, (transdermal scopolamine)
• Antihistamines, (Dimenhydrinate and hydroxyzine)
• Serotonin Antagonists, (Ondansetron, granisetron, dolasetron,
and palonsetron )
• Neurokinin-1 Antagonists

93. Saeid Safari,MD.
PREVENTION OF NAUSEA AND
VOMITING
• Nonpharmacologic Techniques:
1. Acupuncture,
2. acupressure, and
3. transcutaneous electrical nerve stimulation
at the P-6 acupoint

94. Saeid Safari,MD.
PREVENTION OF ASPIRATION
PNEUMONITIS
• H2-Receptor Antagonists
• Proton Pump Inhibitors,
• NPO Guidelines,

95. Saeid Safari,MD.
PREVENTION OF ASPIRATION
PNEUMONITIS
• Premedication with the rapid-acting proton pump inhibitor
pantoprazole (40 mg IV) was less effective than use of ranitidine
(50 mg IV) in reducing gastric volume and increasing pH.
• Prolonged fasting does not guarantee an empty stomach at the
time of induction.

96. Saeid Safari,MD.
NPO GUIDELINES
• Recent studies have confirmed the importance of ensuring adequate
hydration.
• Importantly, adequate hydration is associated with a decreased
incidence of postoperative side effects, including:
1.Pain,
2.Dizziness,
3.Drowsiness,
4.Thirst,
5.Nausea

97. Saeid Safari,MD.
Preoperative hydration of 20-mL/kg versus 2-mL/kg decreases in
postoperative morbidity in outpatients.

98. 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.

99. Saeid Safari,MD.
CONCLUSION

100. 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.

101. 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.

102. 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.

103. Saeid Safari,MD.