Patient Criteria for Ambulatory/Outpatient Ophthalmic Surgery: What's the real score? Richard Rivers, MD, PhD Dept. Anesthesiology Johns Hopkins

Patient Criteria for Ambulatory/Outpatient Ophthalmic Surgery: What's the real score? Richard Rivers, MD, PhD Dept. Anesthesiology Johns Hopkins

Outpatient surgery Steadily increasing since the 1970 s In 2006 there were 53 million surgical procedures (3.1 million cataract surgeries) 57% in hospitals, 43% in free standing centers < 1% were admitted to the hospital Subspecialized operating rooms centers of excellence. Surgeons, nursing, anesthesia Consumer preference National Health Statistics Report 2006

Outpatient surgery Freestanding Innovative Cost-effective Personnel must have: Initiative, flexibility, versatility, responsibility Send patients out safely to their home

Outpatient surgery Patient is expected to recover and return to home No expected complications No expected blood loss Must always have option to admit to hospital in case of complications or acute changes in health status

Criteria for outpatient surgery Patient medical status Procedure Transportation with adult Pre-op evaluation Post-op care

Patient Co-morbidities stable? optimized? Medication up to date, what side effects? Mental status combative, nursing acuity Exercise capacity lack of reserve Sleep apnea possible need for post-op monitoring Anti-coagulated usually ok. May need bridging therapy. ASA status ASA 4 or greater probably not good candidates

ASA status Class 1 Healthy patient Class 2 Mild systemic disease (old MI, hypertension) Class 3 Severe systemic disease (angina, IDDM, pulm insufficiency) Class 4 Incapacitating disease that threatens life (unstable angina, advanced disease, cardiovasc cripple) Class 5 Not expected to survive 24 hours

Problem patients Obesity drug dosing, equipment, recline, difficulty ventilating and intubating, no reserve Brochospastic exercise tolerance, recent cough, severity, lung noise Emergency patient disrupts schedule, urgent care Very young require a night in the hospital due to risk of apnea. Anemia, aspiration, sleep apnea, prematurity IDDM brittle juvenile, poor control, insulin drip

Problem patients cont. Pulmonary hypertension sleep apnea, valve dse. Common cold high incidence of laryngospasm Alcohol or drug use avoid withdrawal but minimize recent consumption Mentally retarded high nursing acuity, minimize interruption of psychologically fragile condition

Advantages Elderly Family unit Less disruption of routine sleep, diet and medications Lower anxiety Mentally retarded Greater privacy More rapid return to familiar supportive surroundings

Pediatric patients Rarely have disease Minimize seperation form parents Feeding schedule less affected Screening phone calls and pre-op evaluation

Pediatric patients URI can delay care Diarrhea Fever Undiagnosed heart disease Arrythmias Parents apprehensive about caring for post-op child

URI Non-infectious Allergic rhinitis: seasonal, perennial Vasomotor: crying, temperature History Infectious Viral: common cold Bacterial: strep New onset, contagious, fever, rales, tonsillitis Need month of recovery

Ex-premie Immature temp regulation, respiratory center, gag reflex Greatest risk: history of apnea or aspiration Stewart found that 12% prolonged apnea during 1 st 12 hours. Reports as high as 70% Must be 60 weeks post-conceptual age to be safe

Procedure Cataract - MAC Oculoplastic GA, post-op pain, airway blood Eye muscle GA, post-op pain, PONV Retina MAC and GA Glaucoma MAC, measurements of pressure Pediatric GA, repeated cases Cornea MAC

Transportation Responsible adult accompany Coming from home Coming from hospital Transfer to home Transfer to hospital

Pre-op evaluation Minimum lab requirements Type of surgery Type of anesthesia Incomplete work up Sick patient

Sick patients Benefits of hospitalization Back up anesthesia care airway, obesity, access Consultation resources cardiologist, urologist Special equipment airway, access Specialists LVAD, pediatrics, cardiac

Post-op care PONV Pain Phase 1 vs. Phase 2 Discharge criteria Family members Accompanying person home Discharge instructions

Hospitalization No longer outpatient Same day admission Extension of outpatient surgery

Cancelled cases NPO violation 6-8 hrs solids, 2 hrs liquids Hypertension crisis Chest pain unstable angina Fever unknown source Hyperglycemia 300-400 New symptoms CP, cellulitis, cold, stroke Intoxicated

Summary Safe Efficient Less cost