2612 Chapter 89 Ambulatory (Outpatient) Anesthesia IAN SMITH • MARK SKUES • BEVERLY K. PHILIP K EY P OINTS • The use of ambulatory surgery continues to increase, mostly as a result of less invasive surgery, improved patient selection and preparation, and an expansion in office-based practice. • Few absolute contraindications exist to ambulatory surgery. Patients should not be excluded on the basis of arbitrary limits, such as age, body mass index, or American Society of Anesthesiologists physical status classification system. • Effective preoperative assessment is required to evaluate and prepare patients and is essential for the delivery of safe, high-quality, and efficient ambulatory surgery. • Many anesthetics and techniques can be used for ambulatory surgery. Of prime importance, experience and careful attention to detail are required to deliver high- quality rapid recovery with minimal side effects. • Spinal anesthesia may extend the range of patients and procedures suitable for ambulatory surgery, but it requires the use of small doses of bupivacaine combined with opioids or short-acting local anesthetics to avoid prolonged recovery. • Sedative techniques can facilitate a wide variety of procedures performed in the hospital, office, or remote settings. However, sedation is no safer than general anesthesia and requires the same standards of personnel, monitoring, and perioperative care as for patients undergoing general or regional anesthesia. • Multimodal analgesia, using combinations of local or regional anesthesia, acetaminophen, and nonsteroidal antiinflammatory drugs, provide effective relief of pain. The reduced need for opioids decreases the incidence and intensity of adverse effects. • Antiemetic prophylaxis should be based on individual patient risk. Multimodal regimens are required for patients and procedures known to be associated with increased risk for complications. • Patients should be discharged with written information concerning aftercare, return to normal activities, follow-up evaluation, and a contact telephone number. This advice must include early warning signs and the appropriate action to take. • Ambulatory surgery remains very popular with patients with infrequent rates of adverse events and complications. One important component of success in ambulatory surgery and anesthesia is minimal postoperative nausea and vomiting. Ambulatory surgery has its origins in Glasgow, Scotland, where, between 1898 and 1908, James Henderson Nicoll performed almost 9000 ambulatory surgery procedures on children, nearly half of whom younger than 3 years of age. 1 Contrary to the prevailing philosophy, which advocated prolonged bed rest after surgery, Nicoll encour- aged early mobilization and home follow-up by a visiting nurse to reduce high cross-infection rates and overcome bed shortages and financial constraints. A few years later, Ralph Milton Waters opened his Downtown Anesthesia Clinic in Sioux City, Iowa, allowing adult patients to return home within a few hours of difficult dental extrac- tions, abscess drainage, or reduction of minor fractures. 2 Further progress was slow until the dangers of prolonged bed rest and the economic advantages of shorter stays began to be recognized toward the middle of the twentieth century. The first hospital-based ambulatory surgical units were opened in Grand Rapids, Michigan, in 1951 and in Los Angeles, California, in 1952, and somewhat later at London’s Hammersmith Hospital in the United Kingdom in 1969. 3 At the same time, the first free-standing ambula- tory surgery center opened in Phoenix, Arizona, 4 rapidly followed by many others across North America in the 1970s and 1980s. The development of ambulatory anesthesia as a rec- ognized subspecialty was enhanced by the formation of Acknowledgment: The editors and the publisher would like to thank Drs. Paul F. White and Matthew R. Eng, who were contributing authors to this topic in the prior edition of this work. It has served as the foundation for the current chapter. Downloaded from ClinicalKey.com at Universidad Francisco Marroquin January 31, 2017. For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved.