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Chapter 57. Ambulatory Anesthesia

Jennifer Wu, MD, MBA

  • Patients come from home on the day of surgery and are discharged home shortly after surgery
  • Ambulatory surgery centers are often separate from hospitals, and so do not have the resources to:
    • Admit patients postoperatively
    • Mechanically ventilate postoperatively
    • Transfuse blood
    • Insert invasive monitors (arterial line, central line)
  • Procedure selection is important to avoid:
    • Lengthy procedures
    • Large fluid shifts and/or blood loss
    • Postoperative pain management requiring IV agents
    • Prolonged mechanical ventilation
  • If a patient needs to be stabilized or admitted from a surgery center, he or she must be transferred to an admitting hospital by ambulance

  • Patients may have their initial preanesthesia evaluation on the day of surgery, or in the week prior at an anesthesia clinic or by telephone
  • Anesthetic information may be administered by handout, telephone, or video
  • Patient selection:
    • ASA 1 and 2 patients
    • ASA 3 patients who are optimized
  • Identify risk factors for unanticipated admission and consider canceling/performing in hospital:
    • Respiratory issues:
      • Requires home oxygen; Sleep apnea, especially if home CPAP
      • History of difficult airway
      • History of prolonged ventilation
    • Severe postoperative nausea and vomiting
    • History of chronic pain or substance abuse
    • Psychiatric disorders
    • Postoperative delirium
  • Consider regional anesthesia to reduce postoperative opioid use

  • Use short-acting agents with strong safety profile:
    • Propofol:
      • Rapid induction and recovery
      • Decreases incidence of PONV
    • Avoid etomidate, which is associated with PONV
    • Succinylcholine is short-acting but can cause myalgia
  • Consider LMA to eliminate the need for muscle relaxation and reversal
  • Consider monitored anesthesia care and regional anesthesia

  • Use short-acting agents
  • Consider TIVA to reduce postoperative nausea and vomiting
  • Administer prophylactic antiemetics (see Chapter 69):
    • Dexamethasone 8 mg IV after induction
    • Ondansetron 4 mg IV 30 minutes before end of surgery
    • Droperidol 0.625 mg IV for high-risk patients; black box warning mandates EKG monitoring postoperatively

  • Seek to eliminate time in the PACU by aggressively avoiding nausea, using nonopioid methods to treat pain
  • Patients may or may not need to void postoperatively, depending on the type of surgery and institutional guidelines
  • Aldrete-based criteria for discharge home (see chapter 69)
  • Patients must be provided with instructions for routine care and possible emergencies
  • Patients must have a reliable adult escort home

  • The most common anesthetic cause of postoperative unanticipated admission is nausea and vomiting. The second most common cause is pain
  • A well-organized system for administering regional anesthesia does not delay surgery and results in better postoperative pain control and faster discharge home
  • An ambulatory surgery center should have standard anesthesia equipment, suction, oxygen, emergency resuscitative equipment, treatment for MH (if general anesthesia is performed), and treatment for local anesthetic toxicity (if regional anesthesia is performed)

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1. Kakinuma A, Nagatani H, Otake H, Mizuno J, Nakata Y. The effects of short interactive animation video information on preanesthetic anxiety, knowledge, and interview time: a randomized controlled trial. Anesth Analg. 2011 Jun;112(6):1314–1318.   [PubMed: 21346166]
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2. Hadzic A, Williams BA, Karaca PE, et al. ...

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