Procedures

Procedures—direct laryngoscopy, fiberoptic bronchoscopy, rigid bronchoscopy, foreign body removal, laser surgery, airway stents, or airway trauma

Requires close communication between surgeon and anesthetist

If respiratory distress—surgical airway

High prevalence of cigarette smoking (COPD, airway tumors)

Options for ventilation:

• Spontaneous ventilation + local anesthesia/sedation—limited procedures that patients can tolerate
• Spontaneous ventilation + GA—for upper airway endoscopy
• Positive pressure ventilation (with small ETT) + GA—obscures surgical view but allows for standard equipment
• Jet ventilation + GA—unobstructed view but risk barotrauma

Lasers—risk of airway fire. Use minimal inspired oxygen concentration to maintain oxygenation and use specialized laser airway endotracheal tubes

TIVA useful to maintain anesthesia and/or reduce pollution

Anesthetics with adequate recovery profile

Major complications (MI, stroke, PE, respiratory failure) are rare

Minor complications (pain, PONV, sore throat, somnolence, hypotension, hypertension, and bleeding) are common

Ease of transfer in case of unplanned admission? Know your surroundings—office-based procedure, freestanding ambulatory surgery center, or hospital

Predictors of hospital admission after ambulatory surgery:

• >65 years, prior inpatient admission in last 6 months, invasiveness of surgery, surgery >2 hours, general anesthesia rather than regional anesthesia

Unanticipated admission causes:

• Medication—complications from preexisting disease
• Surgical—direct complication, pain, bleeding
• Anesthesia—aspiration, PONV, somnolence
• Social—no escort, long distance from home

Controversial patients for ambulatory surgery—elderly, morbid obesity, severe OSA, significant COPD or asthma, and infants (risk of apnea if postconceptual age <60 weeks)

ENT, urology, and generally surgery—higher rates of unanticipated admission