As the number of cases being performed in the outpatient arena grows, so does the number of patients presenting with morbidities that require special attention and care. Use the acronym "HONDA" to remember these 5 complex conditions you're likely to face.

1. Hypertension. Closely monitor and control the cardiovascular system of patients with abnormally high arterial blood pressure using 1 or more of these tools:

• EKG. Emphasis on close hemodynamic, cardiac and especially ST segment monitoring from this routine monitor can help detect cardiac strain early so you'll be ready to intervene pharmacologically.
• Ultrasound-guided catheter and needle placements. This increases the safety of central venous and peripheral vascular cannulation and also helps with the accurate placement of needles or catheters for regional anesthetic nerve blockades.
• Transesophageal echocardiogram. A relatively non-invasive technology, the basic TEE exam provides a spectrum of useful information about patients' cardiac and hemodynamic functions, such as accurate definitions of their volume status, ventricular wall motion and contractility.
• Perioperative statin therapy. A growing body of data suggests that this may benefit patients with an increased cardiac risk undergoing surgery.

2. Obesity. You may want to offer pre-op testing for the severity of sleep apnea to decide which setting is the safest for the patient to receive anesthesia and undergo surgery. When they present for surgery, obese patients should bring equipment that they're using at home, such as BiPAP machines, to the facility. Airway maintenance may prove difficult with both bag-mask ventilation and intubation, so be sure to have various tools for managing difficult airways, such as video-assisted laryngoscopes, on hand. You can also assist airway management by positioning patients on wedge pillows that elevate the back and keep the abdominal mass from compromising diaphragmatic movement.

Post-operatively, obese patients are at a high risk for respiratory depression and airway obstruction. IV agents such as the alpha-2 agonist dexmedetomidine, which causes little respiratory depression and reduces the need for opioids, can help manage these risks intraoperatively and post-operatively.

Monitor obese patients with:

• End-tidal CO2. Use both intraoperatively (for general anesthesia and moderate sedation cases) and post-operatively in the PACU to assess the adequacy of ventilation in obese patients. ETCO2 monitoring requires adequate alveolar gas mixing to give an accurate indication of ventilation, so hypoventilating or poorly breathing patients will often display a low ETCO2 value. The loss of a signal may indicate complete airway obstruction and the need for an immediate intervention. Patient-controlled analgesia pumps can be co-linked with ETCO2 monitoring, providing a further safety control for the post-operative patient.
• Transcutaneous CO2 monitors. These devices, which monitor arterialized capillary carbon dioxide tension, may help detect respiratory depression after most surgeries. This technology has some advantages because the measurement doesn't rely on adequate alveolar gas mixing but rather gives a true reflection of systemic carbon dioxide levels: the PaCO2. Yet, it also has a slower response time than ETCO2, since PaCO2 takes time to build up as respiratory depression develops or complete apnea occurs. The newer models are often combined with pulse oximetry, allowing practitioners caring for patients at high risk for respiratory depression to gather more useful clinical information through a single ear probe.
• Pulse oximetry. Beware: When you administer supplemental nasal oxygen to sedation patients, the pulse oximeter becomes a very late sensor of hypoventilation. Arterial carbon dioxide levels can reach very high levels before oxygen desaturation occurs.

3. Noncompliant. Many patients don't take their medications as prescribed and therefore may not be beta-blocked or may not have well-controlled hypertension or diabetes. Other patients may be taking multiple over-the-counter medications. Bottom line: Some patients will not respond to agents the way you'd expect, so you may need to adjust the medications given during a procedure to optimize their well-being. Smart infusion pumps can help you get the right drug in the right amount to the right patient via the right route, and their technology effectively reduces common medication mistakes. Some systems also offer wireless technology so they can interact with the patient database and warn about allergies or potential adverse drug interactions.

4. Diabetic. Accurate glucose control is key here. Use point-of-service glucose monitoring to keep a close eye on the patient's blood glucose levels and carefully control hyperglycemia. Inadvertent hypoglycemia can also occur, especially under anesthesia when insulin is administered to control hyperglycemia in insulin-naive patients. This risk may temper very aggressive control of glucose perioperatively unless good glucose monitoring is readily available.

5. Alcoholic. Consider using cerebral function monitors to control the alcoholic patient's response to anesthesia and sedation. In most of these monitors, an algorithm converts the EEG signal to provide an index that will correlate with the depth of anesthesia or sedation, but you should look for artifact signals, such as the EMG, that can cause a falsely elevated score. Pattern recognition of the EEG signal is relatively easy and can prevent reliance on a score that may be inaccurate. With this simple precaution, these monitors can be valuable aids in patient anesthetic management, especially in avoiding over- or under-sedation and planning a rapid return to consciousness.