Preoperative tests

• Order pertinent tests based on the patient's preoperative history and physical examination results:
  • Electrocardiogram in patients older than 45 years
  • Electrocardiogram at any age when known cardiac conditions are present
  • Complete blood count/blood chemistries, as needed, for detailed evaluation of specific diagnosis
  • Additional tests as appropriate

Expert opinion

Age

• Patients older than 60 years can be considered for ambulatory surgery but may be at increased risk for cardiac events, other complications, and unanticipated admissions.
• Cardiovascular monitoring is important; however, the level of monitoring depends on the patient's overall health, the presence and severity of cardiovascular disease, and the nature of the surgical procedure.
• Standard monitoring should include
  • Noninvasive blood pressure
  • Heart rate
  • Electrocardiography
  • Pulse oximetry
  • Respiratory rate
• Additional specialized monitoring may be needed (see Fleisher et al., 2007)

Custer & Trinkaus, 2002; Mandal et al., 2005; Aldwinckle & Montgomery, 2004; George et al., 2004; Fleisher et al., 2007; Chung, Mezei, & Tong, "Adverse events," 1999

Body mass index (BMI)

• Ambulatory surgery can be considered for patients with:
  • BMI 18.5–24.9 (normal weight)
  • BMI 25–29.9 (overweight)
  • BMI 30–34.9 (moderately obese)
• A hospital setting should be considered for patients with:
  • BMI 35–39.9 (severely obese)
• A hospital setting is recommended for patients with:
  • BMI ≥40 (morbidly obese)

Mandal et al., 2005; Kempers, Foote, & DiFlorio-Brennan, 2000; Atkins, White, & Ahmed, 2002; Chacon, Viehweg, & Ganzberg, 2004

• General management of obese patients:
  • Consider histories/comorbidities that may complicate patient management.
  • Consider prophylaxis against deep vein thrombosis (DVT) (i.e., with low-dose heparin, sequential compression devices, and postoperative ambulation).

Nielsen et al., 2005; Samama, 2000; Chacon, Viehweg, & Ganzberg, 2004; Friedman, Chung, & Wong, 2004

• Management of obese patients with respiratory abnormalities:
  • Ensure proper patient positioning and monitoring.
  • Use a semiupright position in a chair for patients under sedation.

Chung, Mezei, & Tong, "Pre-existing," 1999; Myles et al., 2002; Chacon, Viehweg, & Ganzberg, 2004

• Consider supplemental oxygen.
• Carefully sized airway adjuncts (e.g., oral/nasal pharyngeal airways, endotracheal tubes, laryngeal mask airways) should be immediately available for patients under moderate sedation or general anesthesia.
• Consider intravascular monitoring of arterial pressure (or other approaches) if blood pressure measurements and auscultation of the heart and lungs is difficult to obtain.

• Pharmacologic approaches to sedation and pain management in obese patients:
  • Use a catheter-over-needle system to prevent loss of intravenous access.
  • Short operation times and lighter levels of sedation are recommended.
  • Consider a hospital setting if deeper anesthesia is required.
  • Calculate initial doses of pharmacologic agents based on ideal body weight (as a reflection of lean body mass) rather than actual body weight.
  • Consider possible drug interactions.
    • Exercise caution for patients taking appetite suppressants or other medications.
    • Consider avoiding opioids, especially in patients with diagnosed or suspected obstructed sleep apnea (OSA); consider nonopioid analgesics and moderate sedation with reversible agents.

Chacon, Viehweg, & Ganzberg, 2004

OSA

• Patients with OSA can be considered for ambulatory surgery; however, careful patient assessment is necessary.
• For patients without a prior diagnosis of OSA, inquire about the following symptoms:
  • Airway obstruction during sleep
  • Loud and frequent snoring
  • Frequent arousal from sleep, especially with choking sensation
  • Daytime somnolence or fatigue
  • Falling asleep in nonstimulating environments (e.g., watching television, reading, driving)
• Also consider interviewing family members as to whether they have seen telltale OSA symptoms in the patient (e.g., apneic events, restless sleep, vocalizations)
• The physical examination should include an evaluation of the following:
  • The airway
  • Nasopharyngeal characteristics
  • Tonsil and tongue size
  • Neck circumference
  • BMI
• For patients with suspected OSA, consider referring the patient for additional tests (e.g., sleep studies, more extensive airway assessment) and OSA treatment prior to surgery.
• Factors to be considered in determining whether outpatient surgery is appropriate for patients with OSA:
  • Sleep apnea status
  • Anatomical and physiologic abnormalities
  • The status of coexisting diseases
  • The nature of the surgery
  • The type of anesthesia
  • The need for postoperative opioids
  • Patient age
  • Adequacy of postdischarge observation
  • Capabilities of the outpatient facility (availability of emergency difficult airway equipment, respiratory care equipment, radiology facilities, clinical laboratory facilities, and a transfer agreement with an inpatient facility)
• Discharge criteria for patients with OSA:
  • Patients can be discharged from the recovery area to an unmonitored setting (i.e., the home, unmonitored hospital bed) when they are no longer at risk for postoperative respiratory depression.
  • Because of the propensity to develop airway obstruction or central respiratory depression, OSA patients may require a longer stay as compared with non-OSA patients undergoing similar procedures.
  • Document the adequacy of postoperative respiratory function by observing patients in an unstimulated environment (preferably while asleep) to establish that they are able to maintain their baseline oxygen saturation while breathing room air.

Friedman, Chung, & Wong, 2004; Sabers et al., 2003; "Practice guidelines," 2006

Cardiovascular conditions

• Patients with a history of cardiovascular conditions can be considered for ambulatory surgery; however, the surgery location depends on the severity of disease. Patients with moderate to severe cardiovascular disease may not be appropriate candidates for surgery outside of the hospital setting.

Custer & Trinkaus, 2002; George et al., 2004; Friedman, Chung, & Wong, 2004

• General management of patients with cardiovascular conditions:
  • Evaluate the risk of bleeding and thromboembolism.
  • Adjust medications such as aspirin, warfarin, or clopidogrel bisulfate accordingly.
  • Refer patients to their cardiologist, hematologist, or internist for preoperative evaluation and treatment.

Custer & Trinkaus, 2002; George et al., 2004; Kirkorian et al., 2007; Broad et al., 2007; Ardekian et al., 2000; Dhiwakar, Khan, & McClymont, 2006; Bartlett, 1999; Partridge, Campbell, & Alvarado, 2008; Chassot, Delabays, & Spahn, 2007; Burger et al., 2005; Szalat, Erez, & Leitersdorf, 2007; Inman, Michla & Partington, 2007

Risk for thrombosis or embolism

• Assess risk factors:
  • Patient history, including the use of contraceptives and hormone replacement, stillbirth, preterm delivery, and possibly recurrent miscarriage
  • Family history, including past episodes of thrombosis or embolism
  • Genetic disposition to clotting disorders (e.g., factor V Leiden, prothrombin G20210A)
  • Edema, swelling, or other signs of venous insufficiency in the lower extremities

Samama, 2000; Reinisch et al., 2001; Spring & Gutowski; 2006; Keyes et al., 2008; Wu et al., 2006; Wu et al., "Oral contraceptives," 2005; Kocher et al., 2007; Sottilotta et al., 2006; Jauniaux et al., 2006; Wu et al., "Thrombophilia," 2005

Thromboprophylaxis

Implement thromboprophylaxis according to risk rating:

• Low risk
  • Patient education
  • Early and frequent ambulation (continue at home)
  • Flexion/extension of ankles (continue at home)
  • Optional: graduated compression stockings (GCS) (may be used at home)

Reinisch et al., 2001; Young & Watson, "The need for," 2006; Michot et al., 2002

• Moderate risk
  • Same as low risk, plus
  • Intermittent pneumatic compression (IPC) if anticoagulation is not an option (continue until good ambulation)
  • Low-molecular-weight heparin (LMWH) (30–40 mg subcutaneously [SQ] once daily [qd]; initial dose 2 hr before surgery or 12 hr after; continue until patient is fully ambulatory and evaluate need for longer prophylaxis) or low-dose unfractionated heparin (LDUH) (every [q] 12h until patient is fully ambulatory)

Handoll et al., 2002; Wille-Jørgensen et al., 2003; Urbankova et al., 2005

• High risk
  • Same as low risk, plus
  • IPC and/or GCS (until good ambulation)
  • LMWH (40 mg SQ qd; initial dose 2 hr before surgery or 12 hr after; continue for 5–10 days) or fondaparinux (2.5 mg SQ qd; initial dose 6–8 hr after surgery; do not give <6 hr postoperatively; continue for 5–10 days)

Handoll et al., 2002; Urbankova et al., 2005; Amaragiri & Lees 2000; Turpie et al., 2002; Turpie et al., 2007

• Very high risk
  • Same as low risk, plus
  • IPC and/or GCS (until good ambulation)
  • LMWH (40 mg SQ qd; initial dose 2 hr before surgery or 12 hr after; continue for 7–12 days and seriously consider longer prophylaxis) or fondaparinux (2.5 mg SQ qd; initial dose 6–8 hr after surgery; do not give <6 hr postoperatively; continue for 7–12 days and evaluate need for longer prophylaxis)
  • Longer term prophylaxis with warfarin or convert to warfarin at international normalized ratio (INR) 2–3 (if patient risk factors indicate the need for other vitamin K antagonist long-term prophylaxis)

Handoll et al., 2002; Urbankova et al., 2005; Amaragiri & Lees 2000; Turpie et al., 2002; Turpie et al., 2007

Mechanical prophylaxis

• Methods recommended for patients with a high risk of bleeding or as an adjunct to chemoprophylaxis:
  • GCS
  • IPC devices
  • Venous foot pumps (VFP)
• IPC devices or VFP are recommended for any procedure that lasts >1 hr, and for all patients receiving general anesthesia; begin 30–60 min before surgery.
• Also consider patient positioning on the operating room table.
  • Flex the patient's knees at 5 degrees or
  • Reposition the patient's legs at regular intervals throughout a procedure.

Reinisch et al., 2001; Young & Watson, "The need for," 2006; Michot et al., 2002

Chemoprophylaxis

• Use chemoprophylaxis (e.g., LMWH, fondaparinux, idraparinux, direct thrombin inhibitors) in patients undergoing:
  • Abdominoplasty
  • Circumferential body contouring
  • Thighplasty
  • Combined procedures
  • Procedures lasting >4 hr
  • Surgery requiring open-space dissection
  • Transverse rectus abdominus musculocutaneous (TRAM) flap procedures
  • Surgical procedures likely to contribute to venous stasis or compression
• Recognize the increased risk of bruising or hematoma and the possible need for blood transfusion when using chemoprophylaxis; bleeding incidence is strongly associated with dosage.

Reinisch et al., 2001; Young & Watson, "The need for," 2006; Michot et al., 2002

American Society of Anesthesiologists (ASA) status

• Patients categorized as ASA class 1–3 can be considered for ambulatory surgery; however, the setting should be determined by the ASA class, the type of procedure, and the type of anesthesia.

George et al., 2004; Friedman, Chung, & Wong, 2004; Fortier, Chung, & Su, 1998; Ansell & Montgomery, 2004

• ASA class 4 patients can be considered for ambulatory surgery; however, the setting is dependent on the type of procedure and type of anesthesia.
• Office-based procedures:
  • ASA class 1 and 2 patients are generally considered the best candidates for ambulatory surgery and reasonable candidates for the office-based surgery setting.

Expert opinion

• ASA class 3 patients may also be reasonable candidates for office-based surgery facilities when local anesthesia, with or without sedation, is planned and the facility is accredited.
• ASA class 4 patients are appropriate candidates for the office-based surgery setting only when local anesthesia without sedation is planned.

Expert opinion

If a free-standing ASC or office-based setting is chosen, it should be accredited with appropriate hospital transfer arrangements.

Expert opinion

Hypothermia

• General strategies:
  • Equip the ambulatory surgery suite so that temperatures can be adequately monitored and adjusted.
  • Have equipment available (e.g., Bair Huggers [Arizant Healthcare, Inc., Eden Prairie, Minn.]), forced-air arming blankets, intravenous fluid warmers] to warm the patient, as necessary, especially during more extensive procedures.
  • When no hypothermia prevention measures are available, the procedures performed should be of short duration (1–2 hr) and limited to no more than 20% of the body surface area.
• Recommended protocol for hypothermia prevention during general or regional anesthesia:
  • Actively prewarm patients.
  • Monitor core temperature throughout administration of general and regional anesthesia.
  • Cover as much body surface area as possible with blankets or drapes to reduce radiant and convective heat loss through the skin.
  • Actively warm patients intraoperatively with a forced-air heater or resistive-heating blanket to prevent heat loss and add heat content; rearrange covers every time the patient is repositioned to warm as much surface area as possible.
  • Minimize repositioning time as much as possible so that the active warming method can be quickly continued.
  • Warm intravenous fluids and/or infiltration fluids if large volumes are used.
  • Warm incision irrigation fluids.
  • Aggressively treat postoperative shivering with a forced-air heater or resistive-heating blanket and consider pharmacologic intervention.

Fossum, Hays, & Henson, 2001; Smith et al., 1998; Agrawal et al., 2003; Cavallini, Baruffaldi Preis, & Casati, 2005; Negishi et al., 2003; Robles-Cervantes, Martinez-Molina, & Cárdenas-Camarena, 2005; Vanni et al., 2003; Ng et al., 2003; Young & Watson, "Prevention," 2006

Intraoperative blood loss

• Procedures performed on the average-size adult patient in which blood loss >500 cc is anticipated should be performed only in facilities where adequate blood and blood components are readily available.

Junger et al., 2001

Type of anesthesia

• General anesthesia, moderate sedation, and local anesthesia can be used safely in the ambulatory setting. The type of anesthesia administered depends on the invasiveness of the procedure, the health status of the patient, and the preference of the physician and patient. The physician should discuss anesthetic options with the patient and determine the most appropriate regimen.

George et al., 2004; Fleisher et al., 2007; Perrott et al., 2003; Hoefflin, Bornstein, & Gordon, 2001; Bitar et al., 2003; Ersek, 2004; Shirakami, Teratani, & Fukuda, 2006; Shirakami et al., 2005; Liu, 2004; Marcus et al., 1999; Sungurtekin, Sungurtekin, & Erdem, 2003; Cinnella et al., 2007

• The ASA and American Association of Oral and Maxillofacial Surgeons (AAOMS) recommends the following measures for patients undergoing deep sedation/general anesthesia:
  • Continuous use of pulse oximetry
  • Recording of blood pressure every 5 min
  • Continuous cardiovascular monitoring with an electrocardioscope
  • Use of supplemental oxygen throughout the anesthesia period
  • Ventilatory monitoring should include auscultation of breath sounds and
  • ≥1 of the following:
    • Observation of the chest wall
    • Observation of the reservoir bag
    • Monitoring the color of skin, nails, mucosa, and the surgical site
    • Capnography
  • Additional monitoring should include either auscultation of heart sounds or palpation of peripheral pulses.
  • Capnography—end tidal carbon dioxide when endotracheal anesthesia or laryngeal mask airway (LMA) is inserted.

Perrott et al., 2003; American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists, 2002

Multiple procedures

• The presumed benefits of combining procedures, particularly liposuction, must be weighed against the possibility of adverse events.
• Liposuction can be performed safely in the ambulatory setting when performed in accordance with American Society of Plastic Surgeons (ASPS) recommendations to limit the total aspirant (supernatant fat and fluid) to ≤5000 cc.
• Combining large-volume liposuction with certain other procedures (e.g., abdominoplasty) should be avoided because of the possibility of serious complications.

Stevens, Vath, & Stoker, 2004; Stevens et al., 2006; Kim & Stevenson, 2006; Simon, Thaller, & Nathan, 2006; Stokes & Williams, 2007; Cárdenas-Camarena, 2005; Cárdenas-Camarena & Paillet, 2007; Stevens et al., 2005

Duration of procedures

• Long procedures should be scheduled sufficiently early in the day to allow for adequate recovery time before discharge.
• If possible, surgery should be completed by 3 pm to allow adequate time for recovery and discharge.
• The overall duration of the procedure(s) should ideally be completed within 6 hr.
• Attention to patient selection, intraoperative management, and postoperative care is of particular importance when procedures of longer duration are to be performed in the ambulatory setting.

Fleisher, Pasternak, & Lyles; 2007; Mandal et al., 2005; Fortier, Chung, & Su, 1998; Shirakami et al., 2005; Mattila et al., 2005; Gordon & Koch, 2006

Preventing unanticipated admission

• Control of pain, nausea/vomiting, dizziness, and postoperative bleeding is essential to postoperative recovery and discharge.
• Pain management should be correlated to BMI and the procedure being performed, and the patient should be sent home with sufficient medication to control pain and with adequate instructions on the use of this medication.
• Recommendations regarding the duration of procedure(s) also apply.

Mandal et al., 2005; Fortier, Chung, & Su, 1998; Shirakami et al., 2005; Tham & Koh, 2002