Ambulatory and Laparoscopic Surgery Flashcards
What is the difference between ambulatory surgery, same day surgery, and outpatient surgery?
Nothing! They are all terms for the same thing.
__% of all elective surgeries are performed as outpatient surgeries
70%
Why are more surgeries able to be performed on an outpatient basis?
1) Anesthesia wise, shorter acting drugs have been developed
2) Advances in surgical technique that are less invasive
What are some benefits of ambulatory surgery?
Increased patient satisfaction
More efficient
Decreased cognitive dysfunction in the elderly
Decreased post-op infection rates (better for immunocompromised patients)
Decreased pulmonary complications (PE and pneumonia)
Decreased cost (minimally invasive surgeries have decreased cost up to 50%)
Why is ambulatory surgery good for children and the elderly?
It offers less stress and less interruption in their daily schedules
Why is ambulatory surgery more efficient than general surgery
Lack of dependence on availability of hospital beds
Greater flexibility in scheduling operations
Higher volume of patients results decreased surgical wait times (don’t need to wait for weeks in order to have your surgery)
Are ambulatory surgery patients usually healthy?
Not necessarily. Even some ASA 3 and 4s are having ambulatory surgery.
The four design schemes for outpatient surgeries
1) 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]
2) Hospital Based: A separate ambulatory surgical facility within a hospital handles only outpatients.
3) 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.
4) 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. Safe recovery of patients can be an issue here due to lack of a PACU.
Who sets the standards for quality of care in outpatient centers?
1) Governmental Licensing
2) Accreditation bodies (AAAHC, JCAHO –> Accreditation is required for medicaid/medicare reimbursement)
3) Professional organizations (AANA, ASA)
- -> Know the AANA standards for office based anesthesia practice for the exam!!**
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. Patients undergoing procedures that are likely to be associated with postoperative surgical complications or major fluid shifts should be admitted to the hospital overnight.
Does obesity alone increase risk associated with ambulatory surgery?
No. 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.
Procedures requiring prolonged immobilization and IV opioid analgesic therapy are more ideally suited to a
23-hour stay
Procedures requiring prolonged immobilization and IV opioid analgesic therapy are more ideally suited to a
23-hour stay
Elderly patients are at more risk for ____, but less risk for ___ & ____
More CV events
Less pain and PONV
Can those susceptible to MH have outpatient surgery?
Yes, as long as a non-triggering technique is used and the family is educated to monitor for s/s of MH
Is OSA alone associated with increased risk of hospital admission?
No.
SDS recommendations for those with OSA
OK –> superficial surgery or minor ortho w/local or regional, lithotripsy
“Equivocal” –> Superficial surgery with GA, tonsillectomy for those >3 yr old, gynecologic laparoscopic
Avoid SDS –> Airway surgery, tonsillectomy for those s a small surgery, those with OSA are fine to go home.
Factors that will increase the risk of post-op hospital admission following SDS
>65 years OR time >120 minutes (results in more PONV) CV diagnosis (CAD, PVD, etc.) Malignancy HIV Regional and general anesthesia
In a free-standing facility, the CRNA or MDA cannot leave the facility until when?
Until the last patient has been discharged.
Can alcoholics have SDS?
No. They often have too many other comorbidities.
Can alcoholics have SDS?
No. They often have too many other comorbidities.
Fasting guidelines for healthy patients
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
Half life of clear fluids in the stomach
10-20 minutes
Studies show up to 150ml of orange juice or coffee 2 hours before surgery had this effect on gastric volume and pH
No effect. But remember, this is for healthy patients! The same rules wouldn’t really apply for those with DM or GERD.
Studies show up to 150ml of orange juice or coffee 2 hours before surgery had this effect on gastric volume and pH
No effect.
Why is patient education before surgery important?
So that the patients know what to expect. Educated patients tend to have less anxiety, pain and post-op complications. This should occur as early as possible before the patient goes to the OR (1-2 weeks if possible).
What is the main purpose of the pre-op examination?
To identify patients who have concurrent medical problems requiring further diagnostic evaluation of active treatment before surgery.
People who are highly anxious are at higher risk for this post-op.
Nausea and vomiting.
What should determine the types of testing that a patient needs before surgery?
Their physical exam and medical history.
Surgery should be postponed after an URI for ___ weeks.
6 weeks
Because airflow obstruction has been shown to persist for 6 wks post URI. However, 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. Really, it seems like you just need to use your clinical judgement.
Use of benzos in SDS
Can reduce anxiety, pain, and PONV. But, use clinical judgement. Can cause cause significant amnesia, which isn’t the greatest if the person is gonna go home. Aim towards lower doses of versed (1-2mg)
Use of benzos in SDS
Can reduce anxiety, pain, and PONV. But, use clinical judgement. Can cause cause significant amnesia, which isn’t the greatest if the person is gonna go home. Aim towards the lower doses of versed (1-2mg)
Use of opioids in SDS
Remember to compare risk of post-op pain with PONV. If minimal pain is expected or surgeon is very good about injecting local, etc., then use lower doses of opioids. Remember that most people would rather have pain than be nauseous.
These procedures are highly associated with PONV
Laparoscopy, lithotripsy, major breast surgery, ENT
