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
Risk factors for PONV
1) Type of surgery (especially Laparoscopy, lithotripsy, major breast surgery, ENT)
2) Types of anesthetics being given
3) Individual patient risk factors (hx of PONV and motion sickness, anxiety, non-smoker, within 1 wk of menstrual cycle, age)
Risk factors for PONV
1) Type of surgery (especially Laparoscopy, lithotripsy, major breast surgery, ENT)
2) Types of anesthetics being given
3) Individual patient risk factors (hx of PONV and motion sickness, anxiety, non-smoker, within 1 wk of menstrual cycle, age)
Medications that be used to prevent PONV
Droperidol – low dose (0.625 mg) –> remember association with QT prolongation though!! Give lowest possible dose after induction.
Dexamethasone (4-8mg)
5-HT Antagonists – Ondansetron (2-4mg), Dolasetron (12.5mg)
Phenergan (6.25mg – 12.5mg)
Metoclopramide (10-20mg)
Antihistamines (dimenhydrinate) –> works on CRTZ and vestibular pathways. Helpful in motion induced emesis and those undergoing middle ear and stabismus surgery.
Neurokinin- 1 (NK-1) antagonists (aprepitant) –> very new. Synergistic with zofran and may be even better than propofol. In trials and expensive.
Propofol use
Scopolamine patch (anticholinergic associated with SE such as dry mouth, lethargy, HA,
Hydration (Adequate hydration will minimize nausea and other side effects (dizziness, drowsiness, thirst)
What is special about propofol and midazolam related to their anti-emetic effects?
Their anti-emetic effects outlast their sedative effects
What is the most cost effective pairing of medications for PONV prophylaxis
Droperidol (.5-1mg) and decadron (4-8mg)
Outpatients with the highest risk of PONV will benefit from
5HT antagonists (Zofran)
Why is hydration good at preventing PONV?
Hypotension and hypovolemia are huge triggers for PONV
SeaBand and ReliefBand provide accupressure to this acupoint
P6, bitches!
2FB proximal to the crease of the wrist
Pain control for outpatient surgery
1) Opioids, be careful d/t resp depression and PONV
2) Neuraxial –> but may cause residual motor block or SNS block and can cayse delays in discharge
3) PNB with MAC popular for surgery
4) Pts can be sent home with perineural catheters. Stay in place for about 4 days. Pt and family must be educated on how to use the pump and s/s of LA toxicity
Pain control for outpatient surgery
1) Opioids, be careful d/t resp depression and PONV
2) Neuraxial –> but may cause residual motor block or SNS block and can cayse delays in discharge
3) PNB with MAC popular for surgery
4) Pts can be sent home with perineural catheters. Stay in place for about 4 days. Pt and family must be educated on how to use the pump and s/s of LA toxicity
If neuraxial technique is used for outpatient sx, what LAs are preferable?
Lidocaine and procaine d/t shorter DOA
Can a patient be discharged even if an extremity of theirs is still numb?
Yes, it’s usually placed in a sling and the patient is warned about their increased risk of injury until sensation returns
What types of cases may precedex be good for?
Carotid endarterectomy or neuro cases where you want a smooth wakeup. You have risk for brady and hypoTN, but may be worth the risk for a smooth wakeup.
Incidence of sore throat with ETT vs. LMA
45% vs 18%
Thermoregulation is a big issue in this type of outpatient surgery
Plastic surgery.
Often have multiple things going on at once (tummy tuck, boob stuff, etc). Enhances 3rd space losses and decreases space left to place a bair hugger. Also these cases can be lengthy.
Definitions of the different levels of sedation
Minimal Sedation (Anxiolysis) = Patients respond normally to verbal commands. Cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.
Moderate Sedation/Analgesia (Conscious Sedation) =Patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
Deep Sedation/Analgesia = Not easily aroused, respond purposefully following repeated/ painful stimulation. The ability to independently maintain ventilatory function and a patent airway may be impaired. Cardiovascular function usually maintained.
General Anesthesia = Not arousable, even by painful stimulation. Ability to independently maintain ventilatory function impaired. Require assistance in maintaining a patent airway; positive pressure ventilation may be required Cardiovascular function may be impaired.
Definitions of the different levels of sedation
Minimal Sedation (Anxiolysis) = Patients respond normally to verbal commands. Cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.
Moderate Sedation/Analgesia (Conscious Sedation) =Patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
Deep Sedation/Analgesia = Not easily aroused, respond purposefully following repeated/ painful stimulation. The ability to independently maintain ventilatory function and a patent airway may be impaired. Cardiovascular function usually maintained.
General Anesthesia = Not arousable, even by painful stimulation. Ability to independently maintain ventilatory function impaired. Require assistance in maintaining a patent airway; positive pressure ventilation may be required Cardiovascular function may be impaired.
Criteria for being able to fast-track a patient
Awake and oriented Able to move extremities on command and move into a chair VS within 15%-20% of normal SaO2 >90% Able to breath deeply No pain or nausea
Criteria for being able to fast-track a patient
Awake and oriented Able to move extremities on command VS within 15%-20% of normal SaO2 >90% Able to breath deeply No pain or nausea
Post-op, ambulatory surgical patients should be able to control pain with
PO pain meds
Discharge Criteria
Usually an institutional scoring system that looks at ability to tolerate liquids, void, walk, bleeding, VS stability, and control of pain and nausea.
Opioids may inhibit ability to void. We want them converted to NSAIDs if possible.
What are the 3 most common reasons for delay in discharge?
Drowsiness, N/V, & pain
What can’t a patient do for 24 hours after the procedure?
No driving, power tools / large machinery, or business decisions for 24 hours, even if only propofol was given.
Distention and stretching of visceral organs can lead to referred pain to
The shoulders. This can be pretty intense pain.
Distention and stretching of visceral organs can lead to referred pain to
The shoulders. This can be pretty intense pain.
Relative contraindications to laparoscopic procedures
Increased ICP (impairs venous return from the head)
Hypovolemia (d/t decreased venous return)
V/P Shunt or peritoneojugular shunt (OK if have unidirectional valve resistant to IAP)
Severe CV disease (d/t CV alterations that occur –> no AS or CHF patients should have laparoscopic sx)
Severe respiratory disease
Gases that can be used for insufflation of the abdomen
CO2
Inert gases like Argon and Helium
Can gasless laparoscopic procedures be performed?
Yes, for those who couldn’t handle insufflation (hemodynamically unstable patients. But, makes it very difficult for the surgeon.
Why is CO2 the gas of choice for insufflation?
More soluble in blood than air, N2O, O2, or He
Non-flammable
Rapid elimination from the body (CO2 embolus would therefore be better tolerated than a Helium embolus. The body is used to handling and processing CO2)
IAP should be less than _____mmHg after insufflation to avoid CV compromise
15mmHg
IAP should be less than _____mmHg after insufflation
15mmHg
If the abdomen is insufflated, and you can’t get your peak pressures down and you have poor cardiac output, what might you do?
Ask the surgeon to back off on his insufflation pressure.
Risks associated with laparoscopic procedures
1) Physiologic changes d/t pneumoperitoneum and positions requires
2) Long case durations
3) Risk of unsuspected visceral injury
4) Difficult to evaluate the amount of blood loss
5) Aspiration risk (inset OG tube at beginning of the case!)
Reasons for increase in CO2 with insufflation
1) Absorption of CO2 from the peritoneal cavity –> Main Cause ****
2) Abdominal distention – VQ mismatch, FRC ↓, decreased pulmonary compliance
3) Patient position – VQ mismatch
4) Volume-controlled mechanical ventilation – VQ mismatch
5) Depression of ventilation by anesthetic agents if spontaneous breathing
6) CO2 emphysema (SQ or body cavities)
7) Capnothorax
8) CO2 embolism
9) Selective bronchial intubation
Reasons for increase in CO2 with insufflation
1) Absorption of CO2 from the peritoneal cavity –> Main Cause ****
2) Abdominal distention – VQ mismatch, FRC ↓, decreased pulmonary compliance
3) Patient position – VQ mismatch
4) Volume-controlled mechanical ventilation – VQ mismatch
5) Depression of ventilation by anesthetic agents if spontaneous breathing
6) CO2 emphysema (SQ or body cavities)
7) Capnothorax
8) CO2 embolism
9) Selective bronchial intubation
Hemodynamic changes that occur with insufflation
Decreased CO 10-30% d/t decreased venous return (depends on CO2 insufflation, position) –> very bad in patients with a poor EF
Decreased venous return
Decreased LVEDV
Increased intrathoracic pressure
Increased right atrial and PA occlusion pressures
Minimal increase HR
Increased aBP, PVR, SVR (catecholamines, renin-angio, vasopressin)
Increase risk for arrhythmias (severe vagal response)
Activation of the RAAS
Hypercapnea is associated with
acidosis, decreased cardiac contractility, decreased threshold for arrhythmia, and decreased SVR.
Hypercapnea is associated with
acidosis and decreased cardiac contractility
How much time does it take after desufflation for hemodynamics to return to normal?
1 hour
How much time does it take after desufflation for hemodynamics to return to normal?
1 hour
If neuraxial technique is used, this level must be blocked for laparoscopic surgery
T4-5. This is risky though. SNS blockade makes it more difficult to compensate for CV and pulmonary changes.
Can you use an LMA with laparoscopic procedure?
Yes, but it’s not a great idea. Unable to prevent aspiration, control ventilation, or give muscle relaxant.
1/3 of deaths during lap surgery occurred during GA without an ETT
Can you use an LMA with laparoscopic procedure?
Yes, but it’s not a great idea. Unable to prevent aspiration, control ventilation, or give muscle relaxant.
1/3 of deaths during lap surgery occurred during GA without an ETT
What should you do after every position change when getting ready for a laparoscopic surgery?
Recheck ETT position! Listen to BS bilaterally.
Tilt of the patient shouldn’t exceed __-__ degrees so that the patient doesn’t fall out of the bed
15-20 degrees
Benefits of placing an OG tube before laparoscopic surgery begins
Decreases risk of aspiration, and decreases size of the stomach, reducing the risk of perforation during trocar placement
What to do if lap procedure is converted to open?
1) Place the patient supine
2) Consider a new fluid plan (will have more 3rd space losses)
3) Consider new pain plan (more pain)
4) Need to alter your vent settings to something more traditional.
S/S and treatment of CO2 embolism
Tachycardia, arrhythmias, hypotension, increased CVP, millwheel murmur (heard by esophageal stethoscopes), hypoxia/cyanosis. Doppler and ETCO2 most sensitive for detection of embolism. Would see a sudden drop in ETCO2 waveform. Routine CVP not indicated but may want to place a CVP for rescue (aspiration of air) if a CO2 embolus occurs.
Treatment = immediate release of pneumoperitoneum, steep trendelenberg, left lateral position, discontinue N2O, 100% FiO2, Hyperventilate, CPR – chest compression breaks up into air bubbles. Consider CPB.
S/S and treatment of CO2 embolism
Tachycardia, arrhythmias, hypotension, increased CVP, millwheel murmur, cyanosis. Doppler and ETCO2 most sensitive for detection of embolism. Would see a sudden drop in ETCO2 waveform. Routine CVP not indicated but may want to place a CVP for rescue (aspiration of air) if a CO2 embolus occurs. Treatment = immediate release of pneumoperitoneum, steep head down position, left lateral position, discontinue N2O, 100% O2, Hyperventilate, CPR – chest compression breaks up into air bubbles.
Is SQ emphysema a contraindication for extubation?
No.
What to do if you start noticing SQ emphysema?
Ask the surgeon to desufflate. Increased MV to blow off CO2, then re-insufflate at a lower pressure.
PONV and lap procedures
40-75% of patients have PONV with lap procedures Propofol decreases PONV Remember to decompress the stomach Give anti-emetics Opioids will increase incidence Give zofran and decadron together
To help reduce incisional pain, ask surgeon if
they plan on using local. Usually the attending leaves for closure and the resident may forget to give local. This is a subtle way to remind them. We’re so sneaky.
