Anesthesiology clinics of North America
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This article summarizes current guidelines in pediatric ambulatory anesthesia and surgery. The reader is provided with our department's current outpatient guidelines at Children's Hospital of Philadelphia and the rationale behind them. Whenever possible, the differences in anesthetic management for the freestanding surgicenter will be discussed. Appropriate patient and procedure selection, preoperative assessment, intraoperative and postoperative considerations, and protocols for follow-up are discussed.
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Anesthesiol Clin North America · Jun 2003
ReviewManagement of postoperative nausea and vomiting in ambulatory surgery.
The management of PONV has improved significantly over the years but remains a frequent occurrence in postoperative patients. Evaluation of individual patient risk and the consideration for prophylactic antiemetic in high-risk populations should reduce these unpleasant symptoms and help direct appropriate clinical strategies. Treatment following failure of prophylactic antiemetic therapy requires knowledge of previously used antiemetics and the time of their administration.
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The growing importance of ambulatory surgery during the past decade has led to the development of efficient anesthetic techniques in terms of quality and safety of anesthesia and recovery. In these challenging objectives, intravenous techniques have played an important role, as they provide safe, efficient, and cost-effective anesthesia in the ambulatory setting. Among the numerous intravenous drugs, propofol, with its fast and smooth onset of action, short duration of action, and low incidence of postoperative side effects appears to be the anesthetic of choice in this situation. The recent development of new techniques of administration (such as TCI, monitored anesthesia care, or patient-controlled sedation) and monitoring (such as the BIS and the availability of "hit and run" drugs such as remifentanil) will optimize intraoperative conditions and recovery, thus allowing faster home readiness in the ambulatory setting.
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In the current health care environment, anesthesia practitioners are frequently required to reevaluate their practice to be more efficient and cost-effective. Although IV induction with propofol and inhalational induction with sevoflurane are both suitable techniques for outpatients, patients prefer IV induction. Maintenance of anesthesia with the newer inhaled anesthetics (ie, desflurane and sevoflurane) provide for a rapid early recovery as compared with infusion of propofol (ie, TIVA), while allowing easy titratability of anesthetic depth. ⋯ Although clinical differences between desflurane and sevoflurane appear to be small, desflurane may be associated with faster emergence, particularly in elderly and morbidly obese patients. Balanced anesthesia with IV propofol induction and inhalation anesthesia with N2O for maintenance, and an LMA for airway management, may be an optimal technique for ambulatory surgery. Inhalational anesthesia may have an economic advantage over a TIVA technique.
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Severe pre-eclampsia is a complex disease, which taxes the expertise of even the most experienced obstetric anesthesiologist. The treatment should focus on stabilization of blood pressure, optimization of fluid status, and prevention of convulsions. ⋯ If general anesthesia is needed, careful preanesthetic preparation and meticulous airway management is essential. The successful and safe peripartum management of the pre-eclamptic patient and her infant is a team effort among the anesthesiologist, obstetrician, and neonatologist.