Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ Ambulatory Surgery ++ Most peripheral procedures can be performed on an ambulatory basisRegional anesthesia, peripheral, or neuraxial:Peripheral nerve blocks, single-injection or continuous, allow:Performing surgery with block + MAC and bypassing PACU stage IPostoperative pain controlSpinal: low-dose bupivacaine, chloroprocaine; no need for voiding prior to dischargePONV prevention: main cause of unplanned admission with pain +++ Positioning Issues ++ Supine:Lumbar pain by hyperextensionRisk of ulnar nerve compression at the elbowShoulders not abducted more than 90°Fracture table (hip fracture, anterior hip replacement, hip arthroscopy):Perineal pressureUpper extremity of operative side positioned over the chest:PaddingEnsure IV patencyLateral decubitus (hip replacement, shoulder surgery, elbow surgery):Keep neck neutralEnsure 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 rollNondependent arm on board: pad well to prevent nerve compressionProne (spine):Head positioner (various devices) with eyes free of pressure and neck neutral; avoid lateral rotationRisk of visual loss if prolonged surgery (see chapter 62)Spread body weight on maximal surfaceKeep abdomen and chest free to avoid impeding respiration and venous return; supports by iliac crests and upper thoraxEnsure that genitalia and breasts are not compressedShoulders not abducted more than 90°Sitting (shoulder surgery):Ensure that head and neck are stableImproves respiratory functionBeware 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 +++ Analgesia ++ Bone and joint surgery especially painfulImportance of multimodal analgesia:Regional techniquesOpioidsNSAIDs, COX-2 inhibitors (avoid if spinal fusion)AcetaminophenGabapentin/pregabalinLow-dose ketamineAmputation:Prevention of phantom limb painUse perineural catheters placed by anesthesiologist or surgeonMultimodal analgesia +++ Blood Loss ++ Blood loss can be massive, especially in spine surgery, hip/shoulder surgery, and tumor surgeryDiscuss surgical plan with surgeonEnsure that blood is cross-matched and available prior to starting procedure with risk of major blood lossPreoperative donation (±EPO), Cell Saver; normovolemic hemodilution rarely usedTranexamic 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 procedureFor hip, 1 mg/kg/h until end of procedureFor knee, 1 mg/kg/h until 6 hours after end of surgery +++ Fat Embolism ++ Ten to 20% mortalityClassically presents within 72 hours following long bone or pelvic fractureTriad of dyspnea, confusion, and petechiaeFree 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 ARDSNeurological manifestations (agitation, confusion, stupor, or coma) due to ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Download the Access App: iOS | Android Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.