Anesthesia for Ambulatory Surgery

Introduction:

Ambulatory surgery gives the patient the freedom to walk around after the procedure. Ambulatory surgeries are in increasing demand due to the short-acting anesthetic agents and minimally invasive surgical procedures employed. Anesthesiologists should consider the appropriate selection of patients and surgical and anesthetic methods for successful and safe ambulatory anesthesia, which will have a positive impact on postoperative recovery as well. Postoperative complications like pain, nausea, and vomiting can be minimized by using efficient anesthetic and surgical techniques.

What Is an Ambulatory Surgical Procedure?

Ambulatory surgery is a minimally invasive, planned surgical procedure where the patient can move out of the hospital the same day and need not be admitted for postoperative recovery after surgery. It is also called day surgery, day-case surgery, and same-day surgery. The word ‘ambulate’ refers to “move.”

Which Are the Common Ambulatory Surgical Procedures?

1. Lens and cataract procedures.

2. Excision of semilunar cartilage of the knee.

3. Tonsillectomy (surgical removal of tonsils).

4. Decompression peripheral nerve.

5. Inguinal and femoral hernia repair.

6. Incision or fusion of the joint, destruction of joint lesion.

7. Operating room procedures of skin and breast.

8. Muscle, tendon, and soft tissue operating room procedures.

9. Repair of diaphragmatic, incisional, and umbilical hernia.

10. Cholecystectomy.

What Are the Advantages of Ambulatory Surgical Procedures?

Ambulatory surgical procedures are more advantageous to conventional, in-patient surgeries in the following aspects.

• Convenience: The recovery phase will be easier and more convenient at home compared to the stay in the hospital.

• Lower Cost: Ambulatory surgeries render cost-effective treatment as there are no room charges or related hospital charges. Some insurance companies will cover certain surgical procedures only on an outpatient basis, which can be claimed easily by the patients.

• Reduced Stress: Outpatient surgery seems to be less stressful than in-patient surgery. This is especially true for children who are afraid of being away from home.

• Predictable Schedule: Compared to conventional surgeries with longer procedures, ambulatory procedures offer a more planned and predictable schedule as they are routine procedures and are less complex.

When to Opt for an Ambulatory Surgical Procedure?

Ambulatory surgery can be opted for in most cases until and unless there is a specific reason for an overnight stay. Postoperative results can be improvised by a detailed preoperative assessment and optimization according to medical comorbidities. Patients for ambulatory surgery are selected based on the following aspects,

1. Surgical Considerations:

• Ambulatory surgery is not carried out in cases carrying the risk of major complications like hemorrhage or cardiovascular instability.

• The surgeon should have sufficient experience with the procedure and a low complication rate record.

• When opening the abdominal or thoracic cavities, minimally invasive surgical techniques should be used.

• Long-term professional care or observation after surgery is not required.

2. Medical Considerations:

• Patients with unstable medical conditions, such as unstable angina or poorly controlled diabetes, are not appropriate for ambulatory surgery.

• Although having a high BMI ( body mass index) is not an absolute contraindication, obese patients may have other medical problems, such as obstructive sleep apnea (OSA). Preoperative assessment in obese patients should be carried out in detail, and cases carrying obesity-related complications should be excluded as they are managed better than in-patient cases.

3. Anesthetic Considerations:

• Anesthetic History: It is important to investigate anesthesia-related problems, such as Suxamethonium (succinylcholine) apnea, malignant hyperthermia, and other related complications. They are not necessarily absolute contraindications, but additional preparation may be necessary if they are present. There is a possibility of malignant hypersensitivity (less than one percent) even after the administration of a trigger-free anesthetic, and postoperative temperature monitoring for at least four hours is recommended.

• Airway Assessment: To predict difficult airway intubation, a preoperative airway examination should be done. Certain patient groups, such as those with OSA and obesity, may be at higher risk for anesthesia-related complications, but appropriate patient and treatment selection can prevent airway-related complications.

4. Special Considerations:

• Elderly Populations: Many medical complications increase with age and require cardiovascular drugs. Preoperative assessment should be done to exclude any risk factors associated with ambulatory procedures.

• Patients With OSA: The risk factors should be considered when opting for ambulatory surgery for such patients and, even if opted for surgery, should be carefully managed by taking appropriate measures.

What Are the Anesthetic Considerations Taken during Ambulatory Surgical Procedures?

1. Preoperative Management:

• Anesthetic agents with rapid onset of action, fast recovery time, and no problems concerning intraoperative consciousness control and pain relief, with no other side effects, are chosen.

• The choice of anesthetic method depends on the type of surgery and the patient's status.

• Anesthesia for ambulatory surgery includes general and regional anesthesia, local anesthesia, monitored anesthesia care (MAC), or a combination of these methods.

2. Anesthetic Techniques:

a. General Anesthesia: It is the most common choice because it is safe, economical, easy to recover from, and familiar to most anesthesiologists.

The use of new anesthetics, such as Propofol, Sevoflurane, and Desflurane, allows for easier titration and early awakening, with reduced postoperative risks.

• Inhalational agents carry a 20 to 50 percent risk of (PONV) postoperative nausea and vomiting, which can be minimized by adequate use of prophylactic drugs.

• Intravenous agents like Propofol show a rapid recovery rate from anesthesia with fewer adverse effects due to faster metabolism.

• Remifentanil is also useful during ambulatory surgery because of its rapid onset and short duration of action, which leads to rapid awakening and recovery from anesthesia.

b. Regional Anesthesia:

• The major types of regional anesthesia include peripheral nerve blockade (with or without a continuous peripheral nerve catheter) and neuraxial blockade.

• Regional anesthesia can avoid the side effects often caused by general anesthesia, such as nausea, vomiting, dizziness, residual muscle relaxation, and aspiration pneumonia, and analgesic effects can start from the early postoperative period.

• However, regional anesthesia requires more time to take effect, and in cases in which the anesthesia is unsuccessful or incomplete, general anesthesia is used.

c. Monitored Anesthesia Care:

• MAC is a method in which patients are anesthetized by intravenous injection of analgesic and sedative drugs. Rather than being used alone, MAC is often used in conjunction with local infiltration anesthesia and peripheral nerve block.

• MAC can increase patient satisfaction and shorten recovery times compared with general anesthesia or neuraxial block.

• Recently, Propofol, low-dose Ketamine, and Dexmedetomidine have been used increasingly for their decreased incidence of respiratory depression. caused by sedative-analgesic use.

3. Postoperative Anesthetic Management:

• For successful ambulatory surgery, postoperative pain, nausea, vomiting, dizziness, and intestinal and bladder obstruction, which delays patient discharge and increases the likelihood of readmission, must be minimized.

• Excessive use of opioids to control postoperative pain may cause PONV, and pain itself is a risk factor for PONV.

• Therefore, opioids should be used judicially.

4. Postoperative Pain Management:

• Postoperative pain management is an integral aspect of successful ambulatory anesthesia.

• The infiltration of local anesthetics or nerve block at the surgical site after the operation may reduce the dose of anesthetics and analgesics required thereafter, reducing the anxiety and postoperative recovery time.

• Multimodal or balanced analgesia therapy, or the use of more than one pain relief method, can increase analgesic effects while simultaneously reducing the side effects associated with certain medications.

• NSAIDs (Non-steroidal anti-inflammatory drugs), Acetaminophen, Ketamine, Alpha-2 agonists, and Gabapentin have been used increasingly in multimodal analgesia therapies for postoperative pain control.

• Multimodal analgesia therapy minimizes postoperative pain, reduces organ damage resulting from the use of narcotic analgesics, and facilitates early recovery from anesthesia.

Conclusion:

Recent advances have created an increased demand for ambulatory surgery. The use of fast- and short-acting anesthetics, analgesics, and muscle relaxants has reduced anesthetic complications during recovery. The choice of anesthesia technique according to the patient's condition and type of surgery is an important factor affecting recovery and discharge. A multimodal and prophylactic approach to prevent postoperative complications should be planned to ensure early discharge and return to daily life.