Ambulatory Flashcards
1
Q
What surgery locations are considered ambulatory?
A
- Ambulatory
- same day surgery
- must be admitted and d/c on same calendar day
- 23 hour is a “short stay”
- outpatient surgery
2
Q
What are the four different facility design types?
A
- Hospital integrated- usually with 24 hr OR/PACU
- same facility as inpatients
- SDS pts may have separate pre-op or recovery area
- SDS pts may get bumped for emergencies
- Hospital based
- separate ambulatory facility within a hospital. Everything separate
- freestanding
- no next shift, very efficient with short turnovers
- if unplanned admission required, pt must be transported
- office based
- recovery of patient can be an issue/responsibility of CRNA
3
Q
How are patients selected for SDS?
What criteria do they need to meet?
A
- Now based on degree of physiologic disturbance instead of length of procedure
- N/V extends hospital stays more often than long surgical time
- SDS can be offered more commonly now that we have:
- less invasive surgical techniques
- better pain control methods
- shorter acting anesthetics
- no longer assume pts are better off in hospital
- Surgical procedure
- physiologic response
- potential for blood loss, pain, PONV, major fluid shifts–too much not ideal for SDS
- Pain management
- regional- good option but prolonged immobilization not ideal for pt alone at home
- pts requiring opioids may require 23 hr stay
- ASA classification I & II (possibly III and IV if medically stable)
- Extremes of age not ok for SDS
- <6mo or >70 years
4
Q
What are the ASA recommendations for OSA patients and SDS?
A
- SDS ok in pt with OSA if surgery is superficial or minor ortho with local or regional
- SDS is “equivocal” for superficial surgery with GA, tonsillectomy for >3 yrs old, or gynecologic laparoscopic procedures
- Avoid SDS for airway surgery, tonsilectomy < 3years, and upper abdominal laparoscopic
- ***consider need for opioids
- **chest and airway surgery at higher risk with OSA
5
Q
What factors increase need for post op admission following SDS?
A
- > 65 years old
- OR time > 120 minutes
- CV diagnosis (CAD, PVD, ect)
- Malignancy
- Higher concern for bleeding
- HIV
- HIV pts behave physiologically much older than they look physically d/t the meds they take
6
Q
What are contraindications for SDS?
A
- uncontrolled systemic disease
- DM
- unstable angina
- severe asthma
- Pickwickian (OHS)
- pain, etc
- Central acting therapies
- MOAI’s & cocaine
- morbid obesity + symptomatic CV or pulmonary disease
- Lack of support at home post operatively
- cannot drive themselves home
- live close enough to return to hospital
7
Q
What are the guidelines for outpatient surgery of neonates/infants?
A
- <46 weeks post conceptual age = 12 hours of monitoring
- 46-60 weeks post conceptual age with comorbidity = 12 hours of monitoring
- cardiac
- pulmonary
- documented apnea
- neuroogic disease
- anemia (Hct <30%)
- 46-60 weeks post conceptual age with no co-morbidity = 6 hours of monitoring
- ***caffeine can reduce risk of post-op apnea in infants
8
Q
How is a pre-op assessment done for same day surgery?
What are the NPO guidelines?
A
- Pre-op assessment must meet the same standards as for in-patients
- Ideal to come to pre-op clinic, not always realistic
- can do phone interview instead
- NPO guidelines:
- clears- 2 hours
- breastmilk- 4 hours
- non human milk/formula- 6 hours
- light solid meal- 6 hours
- heavy meal- 8 hours
9
Q
What medications should be given pre-operatively?
How is anxiety controlled?
A
- Continue with current regimen with small sip of water up to 30 minutes before
- Midaz- controversial
- current evidence says it helps with anxiety, pain, and nausea without prolonging discharge
- decreaseases requirement of propofol
- pre-op directions and education
10
Q
What are the risk factors for PONV?
A
- type of anesthetic technique
- opioid use
- inhaled agents
- anticholinesterase
- hydration status
- hypotension
- Type of surgery
- length of procedure
- pain management
- gastric distension
- Patient factors
- hx of PONV and motion sickness
- anxiety
- non-smoker
- within 1 wk of menstural cycle
- age
- genetic predisposition
11
Q
How can PONV be prevented?
A
- Droperidol- low dose 0.625-1.2
- black box prolonged QT risks are associated with higher doses
- Dexamethasone: 4-8 mg
- 5-HT antagonists:
- Ondansetron 2-4 mg
- Dolasetron 12.5 mg
- Promethazine/phenergan 6.25-12 mg
- may prolong awakening
- Metoclopramide: 10-20 mg
- can cause extrapyramidal side effects, give at beginning of case
- Antihistamines
- Neurokinin 1 antagonists (aprepitant)
- longer acting and synergistic with zofran
- interferes with substance P
- propofol and midazolam
- antiemetic properties outlast sedative effects
- scopalomine patch
- 1 mg over 3 days, not effective for first 2-4 hours after application
- hydration
- Accustimulation at P6 acupoint
- can be more effective than drugs!
12
Q
What are the standards of care for outpatient surgery?
What are the qualities of the ideal outpatient anesthetic?
A
- Same as inpatient surgery
- ECG, BP, pulse ox, capnograph
- Ideal outpatient anesthetic:
- rapid ans smooth onset
- intraoperative amnesia and analgesia
- good surgical conditions with short recovery
- no adverse effects
13
Q
How do you manage pain for the ideal outpatient anesthetic?
A
- Use opioids carefully b/c they cause resp depression and increase N/V
- Consider continuous PNB
- Perineural, incisional, and intraarticular catheters with continuous balloon pump
- have been reported to cause chondrolysis (severe joint arthritis)
14
Q
What do you need to consider regarding Epidural and spinal anesthesia for SDS patients?
(6)
A
- Better post op pain with shorter pacu stays, but that is balanced out by longer time in pre-op
- Success rate is not 100%
- can cause side effects like HA and backache
- Can use mini doses with added narcotics for quicker recovery
- Consider shorter acting agents like chloroprocaine
- need to follow up with call to rule out HA
15
Q
How does the addition of fentanyl to a neuraxial block affect it?
A
It prolongs sensory but not moror blockade and appears to decrease the time to voiding and full recovery
