AMBULATORY SURGERY 门诊手术麻醉
Laurence M. Hausman, MD
James N. Koppel, MD
A 38-year-old woman is scheduled for an ambulatory diagnostic pelvic laparoscopy at 3 o’clock in the afternoon. She arrives 1 hour before scheduled surgery with her 11-year-old son and appears to be extremely apprehensive. Prior medical history is significant for asymptomatic esophageal reflux, long-standing stable asthma that has been successfully treated with inhaled sympathomimetics and steroids, and juvenile-onset diabetes mellitus, currently controlled with 25 U neutral protamine Hagedorn (NPH) and 6 U regular insulin every morning and 10 U NPH and 3 U regular insulin every night.
一个38岁妇女安排下午3点做盆腔镜诊断性检查术。术前1小时和11岁的儿子一起到了，但是看起来非常不安。先前的病史显示她有明显的无症状性食管返流，哮喘经过吸入拟交感神经药物和甾体类激素治疗处于长期稳定状态，青少年型糖尿病用25U低精蛋白锌胰岛素（NPH）和每天早上6U常规胰岛素，夜里10UNPH和3U常规胰岛素控制。
QUESTIONS
1.Are there advantages to performing surgery on an ambulatory basis?
2.Which patients are considered acceptable candidates for ambulatory surgery?
3.Are there any patients who should never have surgery on an ambulatory basis?
4.Are diabetic patients suitable candidates for ambulatory surgery?
5.What types of surgical procedures are appropriate for ambulatory surgery?
6.What is the appropriate fasting time before ambulatory surgery that necessitates an anesthetic?
7.Should drugs be administered to empty the stomach or change gastric acidity or volume before the administration of an anesthetic?
8.How can patients be appropriately screened for anesthesia when ambulatory surgery is planned?
9.What preoperative laboratory studies should be obtained before surgery?
10.Should an internist evaluate each patient before ambulatory surgery?
11.Is anxiolytic premedication advisable before ambulatory surgery, and what agents are appropriate?
12.What are the reasons for last-minute cancellation or postponement of surgery?
13.What is the ideal anesthetic for ambulatory surgery?
14.Are there relative or absolute contraindications to the administration of a general anesthetic in the ambulatory setting?
15.What are the advantages and disadvantages to performing a conduction anesthetic in the ambulatory patient?
16.What are the advantages and disadvantages of selecting a nerve block technique for the ambulatory patient?
17.Describe the intravenous regional anesthetic technique (Bier block) for surgery on the extremities.
18.What sedatives can be administered to supplement a regional anesthetic?
19.What complications of nerve block anesthesia are of special concern to the ambulatory patient?
20.Should patients having ambulatory surgery be tracheally intubated?
21.What is the role of propofol in ambulatory surgery?
22.What is total intravenous anesthesia (TIVA), and what are its advantages and disadvantages?
23.What is moderate sedation, when is it employed, and what advantages does it offer?
24.When tracheal intubation is required for a short procedure, can one avoid the myalgias associated with succinylcholine?
25.Can a relative overdose of benzodiazepines be safely antagonized?
26.Do the newer volatile agents offer advantages over enflurane and isoflurane?
27.What are the etiologies of nausea and vomiting, and what measures can be taken to decrease their incidence and severity?
28.How is pain best controlled in the ambulatory patient in the postanesthesia care unit (PACU)?
29.What discharge criteria must be met before a patient may leave the ambulatory surgery center?
30. What are the causes of unexpected hospitalization following ambulatory surgery?
31.When may patients operate a motor vehicle after receiving a general anesthetic?
32.What is the role of aftercare centers for the ambulatory surgery patient?
33.Are quality assurance and continuous quality improvement possible for ambulatory
1. 在门诊手术的优点在哪里？
2. 哪些病人可以接受门诊手术？
3. 哪些病人一定不能在门诊进行手术？
4. 糖尿病人适合门诊手术吗？
5. 门诊手术包括的种类有哪些？
6. 门诊手术麻醉合适的禁食时间是多少？
7. 麻醉前是否使用药物促进胃排空，改变胃液酸度和胃液量？
8. 怎么适当拒绝对已经安排门诊手术的病人进行麻醉？
9. 术前需要知道那些实验室检查结果？
10. 每个门诊手术病人都要进行内科评估吗？
11. 门诊手术前建议给抗焦虑药吗？哪些药物合适呢？
12. 最后一次取消或推迟手术的原因？
13. 什么是门诊手术的理想麻醉？
14. 有没有门诊手术全麻的相对或绝对禁忌证？
15. 对门诊手术施行部位麻醉的优缺点？
16. 对门诊手术选择神经阻滞的优缺点？
17. 描述四肢手术的静脉区域麻醉技术。
18. 哪些镇静药可以强化区域麻醉？
19. 门诊手术进行神经阻滞麻醉需要特别关注的并发症是什么？
20. 门诊麻醉需要气管插管吗？
21. 异丙酚在门诊麻醉的地位？
22. 什么是全静脉麻醉（TIVA），优缺点是什么？
23. 什么是适度镇静，给药时机和镇静的优点是什么？
24. 短小手术何时需要气管插管，能避免司可林相关的术后肌痛吗？
25. 相对大剂量的地西泮能被安全拮抗吗？
26. 新型挥发性麻醉药相对于安氟醚和异氟醚优越吗？
27. 恶心、呕吐的病因学是什么？哪些措施可以减少发生率和降低发作程度？
28. 怎么使门诊手术病人在麻醉后恢复室（PACU）得到最好的镇痛？
29. 病人离开门诊手术中心必需达到的标准是什么？
30. 门诊手术后意外住院的病人怎么处理？
31. 全麻后的病人何时能进行机动车驾驶？
32. 门诊手术病人术后服务中心的地位是什么？
33. 门诊手术安全吗？质量能持续提高吗？
1.Are there advantages to performing surgery on an ambulatory basis?
There are multiple advantages to performing surgery on an ambulatory basis. Most obviously, the patient returns much more quickly to the familiar home environment. This is especially important for both pediatric and geriatric surgical patients. Formerly, patients might have remained hospitalized for days, rather than a few hours. A reduction in the acquisition of nosocomial infections has also been noted. This is an extremely important consideration when dealing with immunocompromised patients such as organ transplant recipients or patients who are receiving chemotherapeutic agents. Furthermore, in the ambulatory model, the incidence of medication errors related to either faulty prescribing or dispensing of drugs has decreased. In addition, overall costs are usually significantly reduced. This cost saving is due in part to a decrease in the number of laboratory tests requested and medical consultations obtained, as well as pharmaceuticals dispensed. Of course, the significant expense of both the inpatient hospitalization as well as the hospital facility fee is avoided. Other less tangible advantages include ease of scheduling procedures, without having to consider variables such as operating room block time, and an improved sense of patient privacy. This occurs because most offices are staffed by a small consistent group of personnel.
As a group, ambulatory patients tend to be more aware of the effects of the anesthetic they receive than the inpatient population. Because ambulatory patients usually undergo less intrusive surgical procedures and are less ill postoperatively, an attempt is made to resume usual preoperative activities at an earlier time. Therefore, nausea, vomiting, myalgias, headache, as well as disordered sensorium and vertigo may appear to be more significant to this group of patients. Unpleasant symptoms are spontaneously reported with greater frequency than in the inpatient group, and patients may tend to focus their attention on them. These discomforting symptoms, if present postoperatively, may be recalled in a vivid fashion if an additional surgical procedure is required. The negative recall may predispose the patient to extreme anxiety.
Only a small subgroup of patients may actually prefer hospitalization to ambulatory surgery.
1. 在门诊手术的优点在哪里？
门诊手术有很多优点。首先，病人可以尽快地回到熟悉的家庭环境。这对小儿和老年病人特别重要。以前病人需要在医院呆几天而不是几个小时。减少院内感染也得到了关注。这对免疫耐受的病人如器官移植和接受化疗的病人尤其重要。而其在门诊模式下，因开错药和发错药造成错误给药的机率也降低。另外，花费也显著降低。部分原因是降低了要求的实验室检查的数量，医疗咨询费用和给药费用。住院病人治疗费和医院相关设施费用支出也得到避免。其他的包括简化手续，不必考虑手术等待时间，保护病人隐私。因为门诊手术只是一个小的团队。
作为一个群体，门诊手术病人比住院病人更加关注麻醉效果，因为门诊病人大多进行的是创伤较小，术后并发症较少的操作，他们试图尽早恢复到术前的活动状态。因此，恶心、呕吐、肌痛、头痛及意识错乱、眩晕的发生率更加显著，他们发生不愉快症状自发报告的机率也较住院病人显著频繁，这些不适症状如果在术后发生，当在需要进行另外手术时会被回忆的栩栩如生，这些回忆可能造成病人额外的焦虑。
只有很小一部分病人选择住院来接受门诊手术，
2.Which patients are considered acceptable candidates for ambulatory surgery?
For patients to be considered acceptable candidates for ambulatory surgery, generally they should have a relatively stable medical condition. However, many centers now routinely accept American Society of Anesthesiologists (ASA) physical status III and IV patients for selected, relatively noninvasive surgical procedures or diagnostic studies. Generally, less invasive surgery is performed on patients who are less healthy, while more invasive surgery is performed only on ASA physical status I or II patients. Patients with cardiovascular disease have an increased risk of perioperative complications. Those with severe physical or mental handicaps are often excluded from consideration as candidates for ambulatory surgery. The ability to comprehend and comply with postoperative instructions is mandatory to the success of ambulatory surgery.
Ambulatory surgery is well suited for the pediatric patient population. Generally, ambulatory surgical procedures commonly performed on children are shorter in duration, less extensive, and less invasive than the majority of procedures performed on adults. Additional benefits to the pediatric group include less disruption of the child’s normal feeding schedule and decreased separation time from parents. Exposure to the unfamiliar and frightening hospital milieu can be reduced to the bare minimum. Additionally, because recovery times are short for procedures such as myringotomy and tubes, circumcision, and inguinal herniorrhaphy, early discharge from the facility is feasible.
Preoperative communication and collaboration between anesthesiologists and their surgical colleagues are essential in the case of the questionable or problem patient. The surgeon who is to perform the procedure, the patient, and the family must be agreeable to the concept of ambulatory surgery. However, reimbursement schedules created by insurance carriers will often convince the occasional skeptic, because costs associated with hospitalization for procedures that can be readily performed on an ambulatory basis will usually not be covered. Overwhelming and incontrovertible evidence of medical necessity for inpatient care must be presented to obtain authorization for postoperative hospitalization.
2. 哪些病人被认为可以接受门诊手术？
对认为可以接受门诊手术的病人，一般认为需要有相对稳定的医疗状况。事实上，很多中心常规接受ASA III-IV级的病人接受相对无创或诊断性检查。一般健康条件差的病人进行创伤小的操作，而只对ASA I – II级病人施行较大创伤的手术。伴有心血管疾病的可以增加围术期并发症。那些有身体或精神残疾的病人通常被排除在考虑之外。判断预后的综合能力是门诊手术成功的关键。
门诊手术很适合儿科病人，一般，门诊手术适于相对于成人大手术时间短，范围小，创伤少的小手术。其他的包括尽量减少对儿童的进食时间的干扰，缩短和父母分开的时间，使暴露在不熟悉的和令人惊怕的医院环境中的时间减少到最小。恢复时间短的手术如鼓膜切开与置管术，包皮环切术和腹股沟疝修补术早期离开医院都是可行的。
对一些有疑问的或有问题的病人术前麻醉医生和外科同事的交流是必要的。手术医生、病人和病人家属都必须同意进行门诊手术。事实上保险公司制定的赔偿计划要说明可能发生的意外，因为住院消费将会得到更好门诊手术的还没有消除。需要术后住院治疗的证据必须明白无误地提出来并得到批准进行术后住院治疗。
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