非住院病人的麻醉Outpatient Anesthesia

Benefits of Ambulatory Surgery

a) Patient preference, especially children and elderly

b) Lack of dependence on availability of hospital beds

c) Greater flexibility in scheduling operations

d) Low morbidity and mortalitye) Lower incidence of infection

f) Lower incidence of respiratory complications

g) Higher volume of patients (greater efficiency)

h) Shorter surgical waiting listsi) Lower overall procedural costsj) Less preoperative testing and

postoperative medication

Benefits of Ambulatory Surgery

Patient SelectionDuration of surgery

Less than 90 minutes

Patient characteristicsMalignant hyperthermia susceptibility

Observe for at least 4 hours postoperatively

Extremes of age Age alone should not be considered a

deterrent in the selection

Contraindications to Outpatient Surgery

a) Serious, potentially life-threatening diseases that are not optimally managed (ASAⅢ Ⅳ～ ):brittle diabetes, unstable angina, symptomatic asthma

b) Morbid obesity complicated by hemodynamic or respiratory problems

c) Drug therapy: monoamine oxidase inhibitors; acute substance abuse

Contraindications to Outpatient Surgery

e) Ex-premature infants less than 60 weeks postconceptual age

f) Lack of a responsible adult at home to care for the patient on the evening after surgery

Laboratory test recommendations for asymptomatic

healthy patients scheduled to undergo non-blood loss

peripheral procedures under general anesthesia Tests indicated

Age For men For women

≤40 none Pregnancy test

40-49 ECG HCT, pregnancy test

50-64 ECG Hb or HCT, ECG

65-74 Hb or HCT level, ECG, BUN, Glu Hb or HCT level, ECG, BUN, Glu

≥75 Hb or HCT level, ECG, BUN, Glu

Chest radiography

Hb or HCT level, ECG, BUN, Glu

Chest radiography

Preoperative Preparation

Aimed at reducing the risks inherent in ambulatory surgery, improving patient outcome, and making the surgical experience pleasant for the patient and family

Preoperative Preparation

Prepatation should minimize

patient anxiety through

pharmacologic and non-

pharmacologic means and should

reduce potential postoperative

problems by use of appropriate

premedication

Nonpharmacologic Preparation

Pharmacologic prepatation

Anixolysis and sedation

Analgesics

Prevention of nausea and vomiting

Prevention of aspiration pneumonitis

Nothing-by-mouth Guidelines

小儿术前禁食标准（h）

年龄 奶/固体 清亮液体

<6 个月 4 2

6～36个月 6 3

>36 个月 8 3

Anethetic Techniques

Quality, safety, efficiency, and the cost of drugs and equipment are important considerations in choosing an anesthetic technique for outpatient surgery

Anethetic Techniques

The ability to deliver a safe and cost-effective general anesthetic with minimal side effects and rapid recovery is critical in a busy outpatient surgery unit

General anesthesia remains the most widely used anesthetic technique for managing ambulatory surgery

Specific consideratins in General Anesthesia

Airway management

Intravenous anesthetic drugs

Inhaled anesthetic drugs

Analgesics

Muscle relaxants

Reversal of drug effects

Regional anesthesia

Monitored anesthesia

care(MAC)

Discharge Criteria

Vital signsAmbulationNausea and vomitingPainSurgical bleeding

麻醉后监测治疗室

Postanesthetic Care Unit (PACU)

主要任务收治对象 当日全麻病人术后未苏醒者 非全身麻醉后病人情况尚未稳定者 麻醉后神经功能未恢复者目的 监护和治疗病人在麻醉恢复过程中所出现的生理功能紊乱

与 ICU的区别 麻醉苏醒期的监护和治疗，短时间、一般性的麻醉恢复

PACU处理的常见问题

呼吸道梗阻通气不足低氧血症低血压高血压心律失常恶心、呕吐低温神志观察

离开恢复室的标准

呼吸循环神志椎管内麻醉平面稳定

PACU 的设置和管理

设置 足够的照明 足够的空间 足够的装备 必备的药物管理

呼吸道梗阻上呼吸道梗阻 舌后坠 上呼吸道分泌物聚积 咽或喉梗阻 喉头水肿下呼吸道梗阻 呼吸道分泌物、呕吐物、血液和脓液等阻塞下呼吸道

支气管痉挛

麻醉苏醒期终止给予麻醉药物至病人清醒的时间，可分为下面四个时相

1) 感觉和运动功能逐步恢复2) 出现自主呼吸，并能逐渐自行调控3) 呼吸道反射恢复4) 清醒

Drug name

Dose (mg/kg)

Onset of action

Recovery profile

Side effects

thiopental 3-6 rapid immediate drowsiness

etomidate 0.15-0.3 rapid immediate Pain, emisis myoclonus

ketamine 0.75-1.5 immediate immediate

Emergence reactions, cardiovascular stimulatio

midazolam 0.1-0.2 slow slow Drowsiness, amnesia

propofol 1.5-2.5 rapid rapid Pain, cardiovascular depression

Sveral intravenous anesthetics for use during ambulatory anesthesia

Compatison of inhaled anesthetics for use during ambulatory anesthesia

drug Con.(%) onset recovery Side effects halothane 0.5-1.5 slow slow sedation enflurane 0.75-1.5 intermediate intermediate shivering isoflurane 0.5-1 Intermediate Intermediate coughing

desflurane 3-6 Very rapid Very rapid Coughing, tachycardia

sevoflurane 1-2 Rapid rapid Metabolites?

Nitrous oxide

50-70 Very rapid Very rapid Nausea/emesis?

Con. =concentration

Recovery times after discontinuation of isoflurane of desflurane

50%decrease in end-tidal concentration

isoflurane desflurane

Opening eyes 9.5± 3.4 2.5± 0.8#

Following commands 10.2.5± 7.7 5.1± 2.4#

Sitting up in a chair 11.1± 7.9 6.5± 2.3

Home-ready 231± 40 207± 54

#P<0.05; mean SD

Intermidiate recovery after propofol, desflurane(± N2O), or propofol-desflurane anesthesia

Postoperative nausea after propofol, deflurane, or profofol-deflurane anesthesia

Risk Factors for Postoperative Nausea and Vomiting

Predisposing factors

Increased gastric volume

Anesthetic technique

Surgical/diagnostic procedure

Postoperative factors