1. Dr CHANDRASHEKARA.C.R
Consultant Anaesthesiologist
NOVA MEDICAL CENTERS,SAGAR HOSPITALS,
BANGALORE

2. Anaesthesia
 Day careanaesthesia/ ambulatory anaesthesia/ Office
based anaesthesia
 25 million surgeries per year -70 % ambulatory
surgeries,10% - children –IDEAL FOR DAY CARE

3. Development
 Ether- Sevoflurane, Deflurane
 Thiopentone- Propofol
 Short acting muscle relaxants
 Short acting yet potent analgesics
 Open surgery to Laparoscopic surgery
 Patient xx / Pain Abdomen

4. Surgery means – Pain
?Discharge same day

6. OUR CHALLENGES
 Challenging-
 Difficulty – convince -Surgeons, anaesthetists, Pts
 Type of surgery- quick recovery
 Assessment pain { children}
 Lack of experience{Standalone day care center}
 Pts with acute/chronic undiagnosed diseases.
 Proper planning

7. Procedure
General surgery /Urology
 Inguinal hernia repair  Circumcision
 Orchidopexy  Cystoscopy
 Umbilical hernia repair  Preputial
 thyroglossalcyst adhesionreleaserelease
 Cervical lymph node biopsy  Minor hypospadias
 Ganglion excision  Ureteric stent placement
 Laparoscopic procedures

8. Contd
Plastic surgery Orthopaedic
 Removal of spica, nails,
 Removal of nevus Achilles lengthening
 Otoplasty  Arthroscopic procedures
 Suture removal  osteochondromaexcision
 Dressing changes  Muscle biopsy
 Mammoplasty  ORIF ulna, radius
 Liposuction

9. Procedure
ENT/Dental
OBG
 D&E  Myringotomies
 D&C, Hysteroscopic  Nasal and aural foreign body
D&C removal
 Lap ovarian  Adenotonsillectomy
cystectomy  Mastoidecomy/tympanoplasty
 Diagnostic lap Restoration
 Others  Extraction

10. NOT FOR DAY CARE
 Active asthma/URTI/Difficult
Airway
 CHF/IHD/Un controlled
HTN/Cardio myopathies
 Uncontrolled DM
 Morbid obesity
 Haemorrhage/fluid shifts
 ?Procedures more than 90
minutes
 Prematures

11. Our Success
 Proper Selection of cases
 Pre-operative assessment /Stabilisation .
 Well planned anaesthetic techniques/ modified?
 Management of post-operative pain, nausea and
vomiting
 Discharge according to protocol
 Extended Day care facility

12. PAC
 Premedication-
 H2 receptor antagonists ,antacids,
analgesics,Steroids,Chest physiotherapy, Nebulisation
 To continue other medications
 Phy/Cardio/Endocrinology opinion

13. Anaesthesia
 Pre op counseling/
Premedication
 GA – LMA/ETT
 Propofol/Short acting
Relaxants
 OPIOD/Non opiod based
analgesia
 Local anaesthetics/ Nerve
blocks/ Epidurals

14. CONTD
 Laser prostatectomy- under Sedation+ peudendal
nerve block

15. Pain-Multimodal approach
 Targeting different
levels
 Optimal pain relief
with minimal side
effect
 Combination of
analgesics drugs and
techniques enhance
the analgesic level

16. Pain management
shorter discharge times, lower pain scores, and a lower incidence of nausea and
vomiting, compared with traditional opiate-based anesthetic techniques

17. Pain
 IV Fentanyl-2 mic gms/kg bolus/1mic gms infusion
 IV Paracetamol 20 mg/kg – upto 4 gms/day
 ?IV Diclofenac upto 150 mg/ day
 IV Ketorolac[0.8 mg/kg, max 60 mg- low pain score,
decreased opiods
 Extended day care- Morphine, Pethidine

18. PONV
 PONV distressing complication of ambulatory
anesthesia
 Delayed discharge and unanticipated admissions
 The role of Nitrous oxide in contributing to PONV is
unclear
 Propofol- less nausea and vomiting than other
induction drugs with its rapid recovery profile
 Neostigmine be associated with an increased
incidence of PONV

19. PONV
 Avoid opioids- Morphine, pethidine
 Ondensetron[8mg], Metachlorpropamide 10 mg
 Dexamethsone 8 mg
 Granisetron, Tropisetron, Dolasetron

20. Discharge
 Stable vital signs
 Orientated/Orally taking.
 Adequate Pain control
 No- PONV ,Voiding difficulty, dizziness
 No bleeding
 Emergency Contact no/Responsible Adult
 Compliance – studied, Educate them-Video, Talking to
other pts
 Dissatisfaction do Exist

21. Thank you

22. Post op Follow up

23. Figure 1. Most patients had recovered from anesthesia and were discharged home within 1–2
h after surgery.
Marshall S I , Chung F Anesth Analg 1999;88:508-508
©1999 by Lippincott Williams & W ilkins