TotalMED Outpatient Surgery Center

Outpatient Surgery Introduction
Outpatient surgery allows a person to return home on the same day that a surgical procedure is performed. Outpatient surgery is also referred to as ambulatory surgery or same-day surgery.

• Outpatient surgery eliminates inpatient hospital admission, reduces the amount of medication prescribed, and uses a doctor's time more efficiently. More procedures are now being performed in a surgeon's office, termed office-based surgery, rather than in an operating room.
• Outpatient surgery is suited best for healthy people undergoing minor or intermediate procedures (limited urologic, ophthalmologic, or ear, nose, and throat procedures and procedures involving the extremities). Recently, people with more complex medical problems are undergoing outpatient surgery, and the types and complexity of surgical procedures have expanded significantly.

• More than 60% of elective surgery procedures in the United States are currently performed as outpatient surgeries. Health experts expect this percentage will increase to nearly 75% over the next decade.
• Outpatient surgery has developed over the past 3 decades for a number of reasons, including the following:

o Improved surgical instruments
o Less invasive surgical techniques
o A team approach in preparing a person for surgery and home recovery that involves both a surgeon and an anesthesiologist (a medical doctor who specializes in administering anesthesia medications so the patient feels no pain and does not remember the surgery)
o The desire to reduce health care costs

Outpatient Surgery Preparation

Before the surgery
• A surgeon evaluates the person before the operation. If a surgeon finds medical issues that need attention, a family doctor or an internist also sees the person before the operation.
• Although most people do not meet with their anesthesiologist until the day of surgery, this doctor plays an active and important role in assessing and preparing people with complex medical conditions for surgery. Either before or on the day of surgery, an anesthesiologist reviews available medical information, completes an examination, and discusses the anesthetic plan with the person who is undergoing the operation and his or her family. The anesthesiologist can answer any questions or concerns at this time.
• People with medical problems, such as prior heart attacks or strokes, high blood pressure, diabetes, asthma, or chronic obstructive pulmonary disease, should visit with their doctor or anesthesiologist before the day of their surgery. At this visit, the doctor may also require the following information:

o Copies of medical records, especially ECGs and results of heart and lung testing and recent lab tests
o A list of medical problems and past surgical procedures, including any problems that occurred during prior surgeries
o A complete list of medications (both prescription and over-the-counter), including vitamins, herbs, or other supplements, and their dosages
o A clearly identified list of medications that cause allergic reactions or other problems

• The evaluation before surgery seeks to address questions, to help calm fears and anxiety regarding anesthesia and surgery, and to ensure that a person understands his or her existing medical problems. This evaluation also confirms that the person is in the best condition prior to surgery.
• Sometimes, medication changes or additions are recommended or more testing is required before surgery. Rarely, an anesthesiologist may delay or cancel the surgery for further evaluation.
Before arrival at the surgery center
• Do not eat or drink before the procedure. Otherwise, vomiting may occur under anesthesia, causing aspiration pneumonia (when matter gets into your lungs) or breathing problems. A surgeon or an anesthesiologist should give specific information about when to stop eating and drinking.
• Specific instructions may be given to continue certain medications, such as heart medications, or to discontinue certain medications, such as aspirin or blood thinners, several days before the procedure. These recommendations should be followed carefully. A violation could delay or cancel the surgery.
• Do not wear jewelry because it may get lost or cause skin irritation if it becomes too tight.
• Do not wear makeup because it tends to smear or cause tape not to stick.
• Do not wear contact lenses because they may get lost, dry out, or scratch the eyes.
• Remove dentures before the procedure.

Special Cases: Children

For parents or caregivers, surgery performed on their children is much more stressful than if they were having surgery performed on themselves. In these instances, speaking to the anesthesiologist regarding the anesthetic plan is even more important. Children benefit significantly from surgery in the outpatient setting because it decreases separation from their family and the home.

• A parent or other responsible adult must accompany all children.
• Many surgery centers sedate a child in the waiting room to help with anxiety.
• A parent may be invited into the operating room with the child for the first part of anesthesia to comfort the child in this strange environment. If a parent is unable to do this, someone else might be available to assist if possible. If invited into the operating room, the parent must remain calm to keep from alarming the child.
• Children often inhale anesthetic gases as they go to sleep. Every child is different. Some go to sleep quietly, and others cry and try to fight the anesthesia.
• Once the child is asleep, doctors insert an IV and begin the surgical procedure.
• The adult is reunited with the child early in the recovery period to provide comfort and added security—for both of them. Children must also meet discharge criteria before they can be sent home.

Going Home
All outpatient centers have strict discharge criteria. The individual must meet the following criteria before being released:
• Have stable vital signs (heart rate, blood pressure, breathing rate, temperature, and pain level)
• Tolerate food and drink (Tolerating food and drink is important because oral medications may need to be taken to relieve pain or to prevent infection.)
• Be able to empty bladder
• Walk unassisted
A responsible adult must be present at the time of discharge to assist the individual in going home. In addition, this adult should be with the individual at all times for the first 24 hours to provide help when necessary and to call for help should a problem arise.
• Before going home, the person should have written instructions on the following:
o Whom to contact in the hospital if a problem or complication occurs
o What medication to take for pain
o Activity level, and when a return to work is possible
o When to start eating
o Where to go if evaluation or admission to a hospital is necessary

• Most outpatient centers ask that the individual undergoing surgery arrives 1-2 hours before surgery to allow time for the following: checking in, placing the IV, and administering antibiotics or other medications. These activities usually occur in a preoperative waiting area, where the anesthesiologist and possibly nurse anesthetists (nurses trained to participate in anesthesia care) may be present.

• The individual is then escorted from the preoperative area to the operating room, which is usually chilly. The operating table (or bed) is well padded, but it is not nearly as comfortable as a bed at home.

• Anesthesia monitors are placed at this time, including heart monitors on the chest, a blood pressure cuff on the arm to monitor blood pressure, and a soft rubber clip on the finger to monitor oxygen level. Extra oxygen is given by face mask or nasal tube while the individual is in the operating room.

• The anesthesiologist begins sedating the individual and perhaps starts an additional IV line. Depending on the procedure, the individual may be given general anesthesia, local anesthesia, regional anesthesia, or spinal or epidural anesthesia.
o General anesthesia, given through an IV or gases to breathe, allows the individual to be completely unconscious during the surgery.

o With local anesthesia, doctors inject local anesthetics (numbing medication) directly around the operative area.

o With regional anesthesia, doctors place local anesthetics (numbing medication) and other medications directly around the nerves that supply sensation to a particular area of the body. Regional anesthesia is similar to a numbing injection the dentist uses to numb a tooth for drilling and fillings. The anesthetic block may be placed in the shoulder, arm, leg, or back. Regional anesthesia requires some cooperation on the part of the individual and may not be suitable for small children.

o Most people receiving regional or local anesthesia also receive additional medications for sedation during the procedure. Some procedures can be done with just sedation. Spinal or epidural anesthesia is the injection of a local anesthetic to numb the skin. Before the anesthesiologist injects the anesthetic, the person is asked to sit up and lean forward over a pillow or to lie on his or her side in a curled-up position. The person’s back is also cleaned. With spinal anesthesia, which acts more rapidly, the anesthetic is placed into the fluid that surrounds the spinal cord. Epidural anesthesia involves placing a small catheter in the area outside of the spinal cord sac. Anesthetics used for spinal or epidural anesthesia initially cause a feeling of warmth, followed by a complete loss of sensation in the lower body.