Ambulatory Anesthesia - An Overview

Introduction

Ambulatory surgery use has continued to increase due to advances in anesthesia techniques, such as regional anesthesia, and the accessibility of ultrashort-acting anesthetics with fewer side effects. Because of the rise of minimally invasive surgery and the aim of lowering overall healthcare costs, ambulatory anesthesia has grown exponentially. The fundamental concept of fast-track recovery was introduced in the early 1990s, allowing for faster recovery from anesthesia and, as a result, a rapid reinstitution of activities of daily living and earlier discharge from the hospital. There is a very low incidence of mortality and significant morbidity associated directly with ambulatory surgery. There are numerous essential advantages of ambulatory surgery when compared to inpatient surgeries, such as a lower rate of terminations of surgeries, relatively short waiting times, lower hospital bills, and a decreased incidence of nosocomial infection.

For an ambulatory surgery to be effective, both the patient and the technique to be followed for surgery must be suitable for ambulatory anesthesia. In the case of ambulatory surgeries, the patient's recovery is the most crucial consideration when deciding on the method of anesthesia. Prophylactic and active treatment should be used to reduce complications such as postoperative pain, nausea, and vomiting, which can postpone discharge and increase the chance of unexpected hospital readmission during the perioperative period.

How Is Preoperative Anesthetic Assessment Done?

Preoperative evaluation of patients for ambulatory surgery has several advantages:

• First, it can reduce the cancellation of the surgery and postponements. Canceling surgery not only wastes time and money but increases the patient's pain.

• Second, a preoperative assessment should enhance the patient's condition and allow modifications to improve their suitability for ambulatory surgery. Identifying the patient's health issues can improve their suitability for ambulatory surgery.

• Third, effective evaluations accelerate the entire process, thus saving a lot of time.

Mode of Selection of the Patient for Ambulatory Anesthesia

Unless there is a valid reason for an overnight stay, most patients are eligible for ambulatory surgery. The selection of the patient for ambulatory surgery is influenced by various factors, including surgical, social, medical, and anesthetic considerations.

What Are the Surgical Considerations for Ambulatory Anesthesia?

• Ambulatory surgery must not pose a significant risk of severe side effects (bleeding and cardiovascular instability).

• A minimally invasive procedure should be used to open the thoracic or abdominal cavities.

• Oral analgesic medications and regional or local anesthetic techniques should be used to limit postoperative pain.

• Patients are likely to return to normal functions as quickly as possible (for example, drinking through the mouth).

• Patients should be active to some degree before being discharged.

• There is no need for long-term medical assistance or supervision following surgery.

• The anticipated level of surgical trauma seems to be more crucial than the length of the procedure.

• The surgeon should be well-versed in the technique.

What Are the Social Considerations for Ambulatory Anesthesia?

• Patients must fully comprehend the process and postoperative care needs before consenting to ambulatory surgery.

• When a patient is discharged, they should be supported by a responsible person who can care for the first 24 hours.

• Patients must resist driving for at least 24 hours after being sedated or anesthetized.

• It is also critical to be within one hour of emergency medical services and to avoid pain.

• The environment of the patient’s home should be appropriate for postoperative care.

What Are the Medical Considerations for Ambulatory Anesthesia?

• Selection of the patient should be based on the patient's functional status at the time of evaluation and is not constrained by age, body mass index, or American Society of Anesthesiologists status. Obese patients may have additional medical problems, such as obstructive sleep apnea (OSA), even though a high BMI is not an absolute contraindication. In the case of obese patients, the preoperative evaluation must be detailed enough to identify patients with obesity-related diseases while excluding those with severe comorbid conditions that may be better treated in a hospital setting.

• Patients with chronic but stable illnesses choose to stay at home because it interferes with their everyday routine.

• Patients with unstable health issues, such as unstable angina or poorly controlled diabetes, are unsuitable.

What Are the Anesthetic Considerations for Ambulatory Anesthesia?

In addition, the general medical examination should also acknowledge specific areas such as anesthesia history and postoperative nausea and vomiting (PONV) complications. An airway evaluation should also be performed.

1. Anesthetic History: It is critical to look into anesthesia-related issues like Suxamethonium (Succinylcholine) apnea, malignant hyperthermia, and other side effects, as well as a family history of reactions, and collect necessary details. PONV is the most common anesthesia complication, and the risk varies significantly depending on the anesthetic approach. In preoperative assessments, the four Apfel risk factors (female gender, history of postoperative nausea and vomiting, motion sickness, non-smoking status, and usage of postoperative opioids) can be used to assess the risk of postoperative nausea and vomiting. This allows for better anesthesia planning by categorizing patients into risk groups.

2. Airway Assessment: A preoperative airway examination should be carried out to anticipate difficult airway intubation. Specific patient groups may be more susceptible to anesthesia-related side effects, including those with obstructive sleep apnea and obesity. Still, proper patient and treatment selection can inhibit airway-related complications. Supraglottic devices must be analyzed properly to identify their role in routine and emergency airway management.

What Are the Special Considerations for Ambulatory Anesthesia?

1. Elderly Populations:

• The general aging population and survival rates increase, so do the severity and number of severe complications requiring cardiovascular drugs. Moreover, age alone should not be utilized to evaluate whether ambulatory surgery is relevant.

• Preoperative evaluation is necessary to determine whether there are any exclusion criteria for ambulatory surgery. After discharge, older outpatients require more supervision and should consider social problems such as patient independence, mobility, and family-related or feelings of loneliness in this population.

• Postoperative cognitive dysfunction may be managed effectively at home, in a familiar setting, allowing for a faster discharge following ambulatory surgery.

2. Obstructive Sleep Apnea:

• The risk of perioperative complications is high in obstructive sleep apnea (OSA) patients. If OSA has not been identified, the doctor should search for signs and symptoms during assessments in high-risk groups. The STOP-BANG (snoring history, tired during the day, observed stop breathing while sleep, high blood pressure, body mass index more than 35 kilograms per square meter, age above 50, neck circumference more than 40 centimeters and gender male) questionnaire aids in the prediction of OSA risk.

• This device is a fast tool for assessing undiagnosed OSA patients and helping anesthetists prepare appropriate postoperative monitoring and care regimens.

Conclusion

Advancements in the healthcare system have contributed to a rapid rise in the utilization of ambulatory surgery. Anesthetic challenges during recovery have been lowered due to use of fast and short-acting anesthetics, analgesics, muscle relaxants, and improved brain monitoring techniques. Furthermore, advances in medical intervention have enabled surgeons to accomplish more invasive surgical procedures and complex medical procedures on an outpatient basis. Evaluating the patient's overall condition, including any past and family history, is critical when choosing ambulatory surgery. The selection of an anesthesia technique based on the patient's condition and type of surgery is a vital factor influencing recovery and discharge. Postoperative complications such as pain, nausea, and vomiting are common and can postpone the healing process and increase the likelihood of readmission. Therefore, a multimodal and prophylactic strategy should be planned to prevent postoperative complications from facilitating early discharge and returning to daily life.