ANESTHESIA FOR DAY CARE

DENTAL PROCEDURES
 Day care procedures
• Patients discharged form hospital same day of
the surgery/procedure
• Has been routinely used for minor procedures
• More complex procedures are being done on
day care basis
Advantages
 Procedure selection
• The procedure planned should carry minimal risk of
major post-operative complications needing immediate
intervention (haemorrhage, cardiovascular instability).
• There should be no requirement of prolonged specialist
post-operative care or observation
• Post-operative pain is amenable to oral analgesics with
or without regional anaesthetic techniques
• Rapid resumption of normal functions such as oral
nutrition, early and safe mobilisation should be possible
• Anaesthesia-related side effects delaying discharge must
be minimal (post-operative nausea, vomiting (PONV),
drowsiness, urinary retention, etc.).
 Patient Selection
• ASA grade 1 or 2 patient
• Medically stable ASA grade 3
• Age: All age groups excluding preterm infants with post-
conceptual age less than 60 weeks.
• BMI: contraindicated if >50kg/m2,
– >40 Kg/m2- can be taken up if comorbid medical conditions are
well controlled
• Severe obstructive sleep apnea- C/I
• Controlled diabetes mellitus
• After surgery under GA, patients should have a responsible
adult to accompany them home and remain with them for
24 h after surgery
• the patient should stay within 1 hr travelling distance from
the hospital and have readily available telephone/mobile
 Contraindications
1. Emergency procedures
2. ASA III patients and above, with certain
exceptions
3. Poor cardiac risk such as cardiac failure,
significant arrhythmia
4. Severe aortic and mitral stenosis
5. Severe obstructive sleep apnea
6. Long duration and extensive procedures
 Conduct of anaesthesia
• Patients should be assessed for fitness for
surgery
• All co-morbid conditions should be optimised
• Relevant tests done
• Written & verbal Preoperative advice clearly
given:
– Nil per oral
• Clear liquids: 2 hrs, Breast milk: 4 hrs, other: 6-8 hrs
– Drugs- to be continued/discontinued/started
• To come to hospital/day care facility in morning
of surgery
 On the day of surgery
• Patient re-evaluated breifly: pulse, BP, co-
morbid conditions
• Premedication:
– short acting sedatives(midazolam) can be given
– Antiemetic
• Anaesthetic plan reviewed
• Patient is shifted to OT
 Choice of anaesthesia
• Regional anaesthesia:
– Nerve Blocks/LA infiltration
• Patient can be discharged early
• Better pain management
• Lower systemic side effects
• May be unsuitable for uncooperative patients
• General Anesthesia:
CONTINUUM OF DEPTH OF
SEDATION/ANALGESIA:
Increasing Depth of Anesthesia
 Postoperative
• Pain: Use of multimodal analgesia
– Combination of simple analgesics, NSAIDs,
Opioids, regional block
– Use paracetamol, NSAIDs, and small dose opioids
• Opioids aggravate PONV
– May add regional blocks- single shot/elastomeric/
infusion pumps
– Physical therapy
• PONV:
– Control of PONV is essential before discharge
– High risk procedures- breast, Squint ……
– Avoid/minimise intraoperative use of drugs
causing PONV
– Prophylactic antiemetics Patients with high risk of
PONV:
• Female sex
• History of PONV or
motion sickness
• Nonsmoking
• Younger age
• Urinary Retention:
– May cause re-admission
– Neuraxial/GA with high anticholonergics/dose
opioids
– Older age
• Other considerations:
– Bleeding controlled
– Side effects of regional anaesthesia evaluated/
managed
 Discharge Criteria
• Stable vital signs.
• Fully awake and orientated.
• Able to eat and drink.
• Ambulatory
• Pain and nausea well controlled.
• Must void (urological surgery) and after spinal/caudal.
 Discharge Protocol
• IV cannula removed and wound checked.
• Written and verbal discharge information.
• Discharge prescriptions.
• Contact telephone number.
• Accompanied by responsible adult.
 Anaesthetic drugs & Techniques
• TIVA: only iV anesthetics used
– Quick recovery and discharge
– Low PONV
– Less OT pollution
• GA with newer volatile agents in combination
with IV agents: Sevoflurane, desflurane
 Drugs
• Propofol:
– Drug of choice
• Fentanyl
• Sevoflurane
• Desflurane
THANKS
• Jaw Surgeries – single jaw procedures
• Conservative management of lower/ upper
jaw fracture
• Cysts removal
• Full mouth dental implants placement
• All third molars surgical removal under general
anaesthesia
• Multiple teeth removal