Anesthesia: Intraoperative Considerations

INTRAOPERATIVE CONSIDERATIONS

Intraoperative management in the ambulatory patient undergoing surgery is aimed at providing rapid emer-gence, good analgesia, and minimal PONV while creating acceptable operating conditions. Often these goals compete with one another. Although inhala-tional anesthesia with sevoflurane may speed emer-gence, compared with total intravenous anesthesia (TIVA), the likelihood of PONV may be greater, if an additional prophylactic drug is not administered. Numerous studies conducted by regional anesthe-siologists have shown how regional anesthesia can speed discharge time, compared with general anes-thetics, in the ambulatory population—in part, by potentially reducing the incidence of PONV. Nitrous oxide increases the likelihood of PONV, but this effect can be overcome by adding a prophylactic agent. Likewise, multimodal perioperative analgesia can be approached using a variety of drugs, including local anesthetics, acetaminophen, and nonsteroidal anti-inflammatory agents (NSAIDs) to reduce the use of opioids, which contribute to PONV risk.

Th romboembolism remains a risk after ambu-latory and office-based surgery, as with inpatient surgery. Pneumatic compression devices and phar-macologic thromboprophylaxis should be used in patients at increased risk. During monitored anes-thesia care, supplemental oxygen can contribute to operating room fires by creating an oxygen-rich environment that facilitates ignition by cautery devices. During head and neck surgery, anesthesia providers must be especially vigilant not to create an environment where fire becomes more likely. When oxygen is administered via a nasal cannula or face mask, the minimal amount of supplemental oxygen should be delivered, if any, and tenting of the drapes around the patient’s head should be prevented.