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Chapter: Clinical Anesthesiology: Anesthetic Management: Ambulatory, Non operating Room, & Office-Based Anesthesia

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Advances in Ambulatory Anesthesia and Surgery

Most patients are no longer admitted prior to the day of elective surgery.

ADVANCES IN AMBULATORY ANESTHESIA AND SURGERY

 

Most patients are no longer admitted prior to the day of elective surgery. The trend for same-day admittance has been facilitated by advancements in surgical technique and technology (eg, laparoscopy), resulting in less invasive surgery, advancements in anesthesia care (eg, shorter acting medications) and improved postoperative pain and nausea manaagement. The underlying reason for ambula-tory anesthesia and surgery is that it is less expensive and more convenient for the patient than inpatient admission. The transition from open cho-lecystectomy to a laparoscopic approach represents the type of development that permits a shortened postoperative course and ambulatory patient man-agement. Consequently, a common procedure that once required hospital admission is now performed as outpatient surgery.

 

The use of short-acting anesthetic agents (eg, propofol, desflurane, and rocuronium) has likewise contributed to making ambulatory surgery easier; however, such cases were performed successfully using thiopental, isoflurane, and succinylcholine when the newer agents were not available. Although inhalational agents (eg, sevoflurane and desflurane) lead to prompt emergence, they also contribute to postoperative nausea and vomiting (PONV). Propofol, which may have antiemetic effects as a part of total intravenous anesthesia (TIVA), can potentially reduce PONV; however, TIVA may require more time for patients to meet discharge criteria. Regional and local anesthetic techniques are becoming increasingly popular in managing ambulatory orthopedic surgery. The use of ultra-sound and nerve stimulation has improved regional block success rates. The use of regional techniques decreases postoperative opioid requirements, poten-tially reducing the likelihood of PONV. For example, paravertebral blocks are increasingly used to man-age office-based breast augmentation surgery. Improved airway management using devices, such as the laryngeal mask airway (LMA) and video laryngoscopy, have likewise contributed to improved patient care. Consequently, anesthesia personnel working as solo providers in an office-based setting are better able to avoid airway catastrophes.

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