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Ambulatory Surgery

  • Most peripheral procedures can be performed on an ambulatory basis
  • Regional anesthesia, peripheral, or neuraxial:
    • Peripheral nerve blocks, single-injection or continuous, allow:
      • Performing surgery with block + MAC and bypassing PACU stage I
      • Postoperative pain control
    • Spinal: low-dose bupivacaine, chloroprocaine; no need for voiding prior to discharge
  • PONV prevention: main cause of unplanned admission with pain

Positioning Issues

  • Supine:
    • Lumbar pain by hyperextension
    • Risk of ulnar nerve compression at the elbow
    • Shoulders not abducted more than 90°
  • Fracture table (hip fracture, anterior hip replacement, hip arthroscopy):
    • Perineal pressure
    • Upper extremity of operative side positioned over the chest:
      • Padding
      • Ensure IV patency
  • Lateral decubitus (hip replacement, shoulder surgery, elbow surgery):
    • Keep neck neutral
    • Ensure that dependent eye is free (highest risk of injury)
    • “Axillary roll” to release pressure on shoulder: placed low enough that a hand fits between axilla and roll
    • Nondependent arm on board: pad well to prevent nerve compression
  • Prone (spine):
    • Head positioner (various devices) with eyes free of pressure and neck neutral; avoid lateral rotation
    • Risk of visual loss if prolonged surgery (see chapter 62)
    • Spread body weight on maximal surface
    • Keep abdomen and chest free to avoid impeding respiration and venous return; supports by iliac crests and upper thorax
    • Ensure that genitalia and breasts are not compressed
    • Shoulders not abducted more than 90°
  • Sitting (shoulder surgery):
    • Ensure that head and neck are stable
    • Improves respiratory function
    • Beware of the pressure differential between arm (or sometimes calf) BP cuff and brain at the level of the circle of Willis (level of external auditory meatus); risk of cerebral ischemia


  • Bone and joint surgery especially painful
  • Importance of multimodal analgesia:
    • Regional techniques
    • Opioids
    • NSAIDs, COX-2 inhibitors (avoid if spinal fusion)
    • Acetaminophen
    • Gabapentin/pregabalin
    • Low-dose ketamine
  • Amputation:
    • Prevention of phantom limb pain
    • Use perineural catheters placed by anesthesiologist or surgeon
    • Multimodal analgesia

Blood Loss

  • Blood loss can be massive, especially in spine surgery, hip/shoulder surgery, and tumor surgery
  • Discuss surgical plan with surgeon
  • Ensure that blood is cross-matched and available prior to starting procedure with risk of major blood loss
  • Preoperative donation (±EPO), Cell Saver; normovolemic hemodilution rarely used
  • Tranexamic acid (antifibrinolytic for knee/hip replacement and spine surgery):
    • Multiple protocols, for example, 10 mg/kg IV bolus prior to incision, and then:
      • For spine, 10 mg/kg/h until end of procedure
      • For hip, 1 mg/kg/h until end of procedure
      • For knee, 1 mg/kg/h until 6 hours after end of surgery

Fat Embolism

  • Ten to 20% mortality
  • Classically presents within 72 hours following long bone or pelvic fracture
  • Triad of dyspnea, confusion, and petechiae
  • Free fatty acid levels have a toxic effect on the capillary–alveolar membrane leading to the release of vasoactive amines and prostaglandins and the development of ARDS
  • Neurological manifestations (agitation, confusion, stupor, or coma) due to ...

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