Ambulatory

Question 1

What is good about having ambulatory surgery?

Answer 1

Patient satisfaction / preference More efficient (at least in theory) ↓cognitive dysfunction in elderly ↓ post op infection ↓ post op pulmonary complications ↓ cost (not always) Not necessarily “healthy patients” – good pre-op assessment critical to avoid day of surgery surprises

Question 2

Who prefers ambulatory surgery the most? and Why?

Answer 2

Patient preference especially children and elderly = allows for a less change from routine which can complicate timing of the procedure and stress

Question 3

Why is ambulatory more efficient?

Answer 3

More efficient due: Lack of dependence on availability of hospital beds Greater flexibility in scheduling operations Higher volume of patients decreased surgical wait times

Question 4

What are some pros about ambulatory surgery?

Answer 4

Low morbidity and mortality Lower incidence of infection Lower incidence of respiratory complications Lower overall procedural costs Less preoperative testing Decreased postoperative medication lower overhead and decreased ancillary personal in a free standing facility

Question 5

What type of pt has shown not to be higher risk? Who are the exceptions?

Answer 5

Miller 7th cites some interesting study results OSA patients not shown to be higher risk, PE and pneumonia lower in ambulatory surgery, better for patients who are immunocompromised. Minimially invasive surgical techniques have decreased costs up to 50% and most operations performed outpatient instead of inpatient cost 25-75% less. Exceptions are patients who require intensive physical therapy and maybe those who needs IV pain and antibiotic therapy.

Question 6

What are the 4 basic facility design themes?

Answer 6

Four basic design schemes Hospital Integrated (usually 24 hr OR/PACU) Hospital Based Freestanding (no next shift 4-7 min turn-over) Office based (recovery of patient an issue)

Question 7

Describe hospital integrated (usually 24 hour OR/PACU) THEME.

Answer 7

Hospital Integrated: Ambulatory surgical patients are managed in the same surgery facility as inpatients. Outpatients may have separate preoperative preparation and second-stage recovery areas [vast majority of cases that are done in hospitals like GUH and WHC]

Question 8

Describe hospital based theme.

Answer 8

Hospital Based: A separate ambulatory surgical facility within a hospital handles only outpatients.

Question 9

Describe freestanding theme (no next shift 4-7 minutes turnover)

Answer 9

Freestanding: These surgical and diagnostic facilities may be associated with hospitals but are housed in separate buildings that share no space or patient care functions. Preoperative evaluation, surgical care, and recover occur within this unit.

Question 10

Describe office based theme.

Answer 10

Office based: These operating or diagnostic suites (or both) are managed in conjunction with physicians’ offices for the convenience of patients and health care providers.

Question 11

The quality and safety standards for ambulatory surgery are set by?

Answer 11

Governmental licensing Accreditation -Accreditation Association for Ambulatory Health Care (AAAHC) -JCAHO (hospital based facilities) Professional Organizations -AANA -Standards for Office Based Anesthesia Based Practice On Blackboard – Know this document well for the exam! -ASA

Question 12

What is the AAAHC?

Answer 12

AAAHC is a independent organization that sets quality standards for office based/mobile anesthesia organizations.

Question 13

What are the ASA guidelines similar to? Describe.

Answer 13

ASA guidelines similar to AANA – availablity of personnel and equipment for unexpected emergencies, in-service review of procedures for rare sentinel events (MH, airway emergency, etc.) Need crash cart, suction, ECG, blood, etc.

Question 14

Describe the AANA standards.

Answer 14

AANA standards are spelled out by restating the AANA professional standards of practice and then adding an “ application to office practice” for each standard. Also checklists are provided: “Minimum elements for providing anesthesia services in the office based practice setting” and “Anesthesia Equipment and Supplies Checklist.” Also a position statement on MH preparedness and treatment.

Question 15

What is the pt selection criteria and selection of procedures?

Answer 15

Degree of physiologic disturbance Surgical procedure Physiologic response Pain management (regional a good option

Question 16

What should surgical procedures suitable for ambulatory surgery be accompanied with?

Answer 16

Surgical procedures suitable for ambulatory surgery should be accompanied by minimal postoperative physiologic disturbances and an uncomplicated recovery. Potential for blood loss, pain , PONV, all important

Question 17

What pts that are undergoing procedures should be admitted to the hospital overnight?

Answer 17

Patients undergoing procedures that are likely to be associated with postoperative surgical complications or major fluid shifts should be admitted to the hospital overnight.

Question 18

What type of pts should have a 23 hour stay?

Answer 18

Procedures requiring prolonged immobilization and IV opioid analgesic therapy are more ideally suited to a 23-hour stay. M72421-2

Question 19

What are NOT contraindications for ambulatory surgery?

Answer 19

Length of surgery and need for transfusion are not contraindications.

Question 20

What types of procedures are indicated for ambulatory surgery?

Answer 20

Specialty Types of Procedures

Dental - Extraction, restoration, facial fractures

Dermatology - Excision of skin lesions

General - Biopsy, endoscopy, excision of masses, hemorrhoidectomy, herniorrhaphy, laparoscopic procedures, varicose vein surgery

Gynecology - Cone biopsy, dilatation and curettage, hysteroscopy, laparoscopy, polypectomy, tubal ligation, vaginal hysterectomy

Ophthalmology - Cataract extraction, chalazion excision, nasolacrimal duct probing, strabismus repair, tonometry

Orthopedic - Anterior cruciate repair, arthroscopy, bunionectomy, carpel tunnel release, closed reduction, hardware removal, manipulation under anesthesia

Otolaryngology - Adenoidectomy, laryngoscopy, mastoidectomy, myringotomy, polypectomy, rhinoplasty, tonsillectomy, tympanoplasty

Pain clinic - Chemical sympathectomy, epidural injection, nerve blocks

Plastic surgery - Basal cell cancer excision, cleft lip repair, liposuction, mammaplasty, otoplasty, scar revision, septorhinoplasty, skin graft

Urology- Bladder surgery, circumcision, cytoscopu, lithotripsy, orchiectomy, prostate biopsy, vasovasostomy

Question 21

What are pt characteristics of ambulatory surgery?

Answer 21

.ASA classification
-ASA I & II
-ASA III and possibly IV if medically stable
.Extremes of age (relative – consider whole picture)
-<6 months & >70 years
.Co-existing disease
-Stable physiologic disease

Question 22

What by itself does not exclude a person from SDS?

What does not preclude Sds?

What does no alone increase risk with ambulatory surgery?

Who are at higher risk for CV events but less pain, PONV in general? In these pts, what is better if SDS is utilized? What should this pt have when they go home?

Answer 22

• Advanced age by itself does not exclude a person from SDS. Organ dysfunction associated with peri-op adverse effects related to ambulatory anesthesia.
• “Disease label itself” does not preclude SDS.
• Obesity does not alone increase risk w/ambulatory anesthesia. B1230-1, B6834.

24% of outpatient surgeries are done on ASA III, with a similar incidence of morbidity as with ASA I and II [always pushing]

Due to improved anesthetic and surgical care, increasing number of medically stable ASA physical status III (and some IV) patients are able to undergo operations away from conventional medical centers. Elderly at higher risk for CV events but less pain, PONV in general. Also cognitive function better if SDS utilized. Must have strong social support though when going home

Question 23

What are social factors that influence decisions on PT SUITABILITY FOR SDS?

Answer 23

ASA physical status should not be considered in isolation because the type of surgical procedure, the anesthetic, technique, and a multitude of social factors can also influence decisions regarding patient suitability

Question 24

IF a pt has a history of MH in the past can they still have SDS?

Answer 24

MH susceptible OK to have SDS if non triggering technique used and patient family educated to monitor for signs and symptoms.

Question 25

What factors “alone” should not be considered a deterrent in teh selection of pts for ambulatory surgery?

Answer 25

Although acceptability of patients at the extremes of age (<6mo. and >70) has been questioned, age alone should not be considered a deterrent in the selection of patients for ambulatory surgery. Morbid obesity [BMI > 35] alone not a sole contraindication to outpatient surgery, exception being adding other co-morbidities such as HTN, CAD, ASTHMA, and COPD = DO HAVE a higher incidence of postop morbidity with SDS. Also, OSA not associated with increased risk of hospital admission.

My impression is due to the ability to tailor and anesthetic and return the pt to their physiologic baseline so quickly, you avoid many postoperative complications

Question 26

What procedures are OKAY with OSA and ASA guidelines?

Answer 26

.OK
-superficial surgery or minor ortho w/local or regional, lithotripsy
.“Equivocal”
-Superficial surgery with GA, tonsillectomy for >3 yr old, gynecologic laparoscopic
.Avoid SDS
-Airway surgery, tonsillectomy <3 years old, upper abdominal laparoscopic

Question 27

Factors that increase need for post op admission following SDS?

Answer 27

>65 years
OR time >120 minutes
CV diagnosis (CAD, PVD, etc.)
Malignancy
HIV
Regional and general anesthesia

Question 28

When can an MD or CRNA leave a freestanding facility?

Answer 28

Usually the MDA or CRNA can not leave a freestanding facility until the last patient has been discharged.

Question 29

Contraindications for outpt surgery.

Answer 29

.Uncontrolled systemic disease
- lDM, unstable angina, severe asthma, Pickwickian (OHS)….
.Central acting therapies
-MOAI’s & cocaine (Pre-op history- Multiple chronic centrally active drug therapies (e.g., use of monoamine oxidase inhibitors such as pargyline and tranylcypromine) and active cocaine abuse because of the increased risk of intraoperative cardiovascular complications including death. Also the use of diet aids like ephedra or alcoholism.
.Infants:
- <46 wks or <60 wks with lung or neurologic disease, anemia (<6g/Dl), or formerly premature observation for at least 12 hours
- >46 weeks but <60 wks without disease observation for 6 hours
.Morbid obesity + symptomatic CV or pulmonary disease
.Lack of support at home post-operatively

Question 30

what is the assessment of the SDS pt?

Answer 30

• Preoperative assessment (same standards as in-patients. Patient may visit the screening center or be called on the telephone. Less likely to cancel surgery if called ahead of time. Can remind patient of medication and dietary restrictions/recommendations. Can help alleviate patient anxiety.)

It is essential to develop an effective method of screening these patients preoperatively to avoid costly delays and last-minute cancellations.

The use of computerized questionnaires before preoperative evaluation by the anesthesiologist/CRNA/NP can also be a time-saving and efficient practice – these standard computer questionnaires have been shown to be more accurate than physician interview!

• Fasting guidelines in “healthy patients”: ASA recommends fasting 2 hours for clear liquids, 4 hours for breast milk, 6 hours for non-human milk/formula, 6 hours for a light solid meal, 8 hours heavy meal

Question 31

What are the fasting guidelines for the SDS pt?

Answer 31

-Fasting guidelines in “healthy patients”: ASA recommends fasting 2 hours for clear liquids, 4 hours for breast milk, 6 hours for non-human milk/formula, 6 hours for a light solid meal, 8 hours heavy meal

½ life of clear fluids in the stomach = 10-20 minutes, residual volume after 2 hours is less than a patient that fasted twice as long

14% of young women had glucose levels < 45 in early afternoon procedures [after NPO after MN]

Studies show up to 150ml of orange juice or coffee made no difference in gastric volume or PH 2 hours before surgery

However- keep in mind comorbidities… unclear if GERD, DM, etc can follow these relaxed guidelines safely. Coffee and tea considered clear liquids B6836

Question 32

Describe the preop evaluations (ID and examination)

Answer 32

.Identification and examination

• Education: reduce patient anxiety (Patients who are educated as to what to expect tend to have less anxiety, pain and post-op complications. This should occur before the patient is taken to the OR – i.e. as early as possible 1-2 weeks before best. The primary objective of the preoperative assessment is to identify patients who have concurrent medical problems requiring further diagnostic evaluation of active treatment before surgery.)
• Medical history (most valuable)
• Physical examination
• Laboratory testing (minimize!)
• Pre-op specialist consultation (examples: Cardiac or COPD patients)

Testing should be governed by information obtained from the patient’s history and physical examination. Estimated that over 60% of currently ordered lab test could be eliminated if testing were based solely on recognizable indications. Then do we pay attention, another site suggested that 57% of laboratory results were even noted on the chart prior to surgery. The same study suggested that the postoperative complications that were present could not have been predicted by extensive lab tests.

Patients with chronic diseases (e.g., hypertension, diabetes) require addition laboratory studies (e.g., electrolytes, glucose). Hgb of women who are of child bearing age.

6th edition of Barash suggests that in adults should consider delaying surgery for 6 weeks s/p URI because airflow obstruction has been shown to persist for 6 wks post URI. Then at the end of the section they say….If a patient with a URI has a normal appetite, does not have a fever or elevated RR and does not appear toxic it is probably safe to proceed with the planned procedure. I think that you have to look at this case by case. I would hate to cancel a colonoscopy after a patient has taken a day off of work AND been NPO + bowel prep for 24 hours if they had a cold 4 weeks ago… of course if they were febrile had a RR of 30 I would probably delay.. Have to use clinical judgement.

Question 33

Of the three primary components of a preoperative assessment (i.e., history, physical examination, and laboratory testing), what is clearly the most valuable

Answer 33

medical history

Question 34

Describe preoperative prep

Answer 34

.Continue current regimen
-Small H20 with meds up to 30 minutes before
.Non-pharmacologic Anxiety Control
-Detailed instructions for day of surgery routine
.Pharmacologic
-Midazolam +/-
-Opioids +/-
-NSAIDS (consider anti-plt, gastric mucosal, renal side effects first)

Question 35

How long can fentanyl and midazolam sedate a patient?

Pts should be encouraged to do what with their chronic meds?

Answer 35

– fentanyl + midazolam can sedate the patient for 8 hours. Also have to consider antegrade amnesia issues.

Patients should be encouraged to continue all their chronic medications up to the time that they arrive at the surgery center.

Question 36

What are NON pharmacologic prep

Answer 36

NON PHARMACOLOGIC PREPERATION

Proper preoperative preparation should also include written and verbal instructions regarding:

arrival time and place,

fasting instructions,

information concerning the postoperative course,

limitations in driving skills,

the need for a responsible adult to care for the patient during the postoperative period.

Premedication is not routinely used at many ambulatory surgery facilities in the United States.

Most prospective studies have not found recovery to be prolonged after the use of appropriate doses of sedative premedication in the outpatient setting (e.g., midazolam, 1 to 2 mg intravenously [IV])

Midazolam premedication not only decreased preoperative anxiety but was also associated with a reduction in postoperative pain.

Question 37

What are risk factors for PONV?

Answer 37

These symptoms can delay discharge and result in unplanned overnight hospital admission.

.Additive risk factors for PONV:

• The choice of anesthetic technique, [premed, opioid use, inhaled agent use, anticholinesterase use, hydration status, hypotension]
• type of surgery [length of procedure, operative procedure itself, pain management, gastric distention]
• Patient factors [hx of PONV and motion sickness, anxiety, non-smoker, within 1 wk of menstrual cycle, age]

Question 38

What procedures are highly associated with PONV?

Answer 38

Procedures highly assoicated with PONV are laparoscopy, lithotripsy, major breast surgery, ENT.

Question 39

How can you prevent PONV?

Answer 39

.Droperidol – low dose (0.625 mg)
.Dexamethasone (4-8mg)
.5-HT Antagonists – Ondansetron (2-4mg), Dolasetron (12.5mg)
.Phenergan (6.25mg – 12mg)
.Metoclopramide (10-20mg)
.Antihistamines (dimenhydrinate)
.Neurokinin- 1 (NK-1) antagonists (aprepitant)
.Propofol use
.Scopolamine patch
.Hydration

Question 40

OUTPT with the highest risk of PONV will benefit from what>?

Answer 40

Outpatients at the highest risk of PONV will benefit from the addition of a 5-HT antagonists (e.g. ondansetron, dolasetron, granisetron) or an acustimulation devise (e.g., SeaBand, ReliefBand)

Question 41

DROP: central dopamine antagonist, Small doses of 10mcg/kg have been more effective than ondansetron in some studies. The cardiac risk associated with prolonged QT interval is associated with increase dosing. Recommend the lowest possible effective dose just after induction

PHENOTHIAZINES: used successfully for many years to treat the PONV associated with opioid use but can have a significant impact on anesthetic requirements and also cause delayed awakening, extrapyramidal effects (restlessness oculogyric crisis) and discharge, not used in outpatient setting very often.

PROKINETIC: Reglan [increased LES tone and increase motility]

ANTICHOLINERGICS: scopolamine patch centrally acting can reduce severe PONVand can have a high incidence of side effects (dry mouth, somnolence, mydriasis, and dizziness)

Antihistamines are helpful because they act on the central vomiting center and vestibular pathways to prevent PONV. - helpful in motion induced emesis and those undergoing middle ear and stabismus surgery.

Neurokinin- 1 (NK-1) antagonists (aprepitant) – early studies show may be longer acting than zofran and synergistic with zofran – cost-benefit analysis needed as well as additional studies before wide-spread use.

5ht3’s are still most widely used due to efficacy and lack of side effects

Question 42

Seaband & ReliefBand
Accustimulation at P-6 acupoint
can be MORE effective than antiemetic drugs

Question 43

What are the standards of care for outpt?

What is the ideal anesthetic?

Answer 43

.“Standards of care”
-Equipment
-Monitoring
-Resuscitation
.Ideal anesthetic
-Rapid onset and elimination
-Cerebral Monitoring – controversial may prevent “over-dosing”
-Cost effective
-Pain management
•Use opioids carefully (respiratory depression; repeated doses increase PONV)
•Neuraxial techniques can be problematic – residual motor, SNS block delays discharge with longer acting agents….consider continuous peripheral neural blockade as an alternative
•PNB or local infiltration by surgeon with MAC popular
•Perineural catheters with continuous infusion (ex. Interscalene, paravertebral, etc.)

Question 44

As the primary anesthesia technique the PNB was associated with?

Answer 44

As the primary analgesic technique PNB associated with faster D/C time, improved pain control, decreased need for opioids, improved patient satisfaction and mobility, fewer SE for hand, shoulder, anorectal, hernia and knee surgery.