Patient and procedure selection

This chapter discusses patient selection and procedures that can be performed safely in an ambulatory setting. Even patients with multiple comorbidities can be cared for safely in ambulatory settings if they are undergoing anesthesia for a minor procedure such as cataract surgery. On the other hand, those patients undergoing more invasive surgery in an ambulatory setting should be stable and as optimized as possible. If information about comorbidities is obtained preoperatively, the anesthesiologist can plan ahead to safely care for the patient on the day of surgery. When planning for ambulatory care it is important and useful to have a specified list of discharge criteria in mind. Both the Aldrete Scoring System (Table 3.1) and the Post Anesthesia Discharge Scoring System (PADSS) (Table 3.2) are widely accepted tools for evaluating patients for discharge. Among the various discharge assessment tools, most include the evaluation of vital signs, mental status/consciousness, pain, nausea, vomiting, mobilization, and ability to function in a home environment. If a patient will not likely fulfill discharge requirements by the late afternoon or evening of the day of the operation, the procedure should not be performed in an ambulatory facility, although the 23-hour option and overnight stay is a rescue in some institutions. Complications that may arise during travel home also should be considered. These depend on the nature of the patient's surgery and anesthetic. Ambulatory settings range from free-standing centers remotely located to centers that are attached to larger hospitals with readily available resources. Each center will have different guidelines for managing discharge requirements. According to the guidelines of the American Society of Anesthesiologists (ASA), “Patients who receive other than unsupplemented local anesthesia must be discharged with a responsible adult.” In other words, anyone who receives oral or intravenous anesthesia cannot be discharged without a companion. Procedure selection Suitability of a procedure depends on the resources within the ambulatory center, the patient's anticipated condition within the first few hours after the procedure and the risk for serious complications or need of professional health care within the next days. The objective should be to discharge the patient before the end of the day.