Ambulatory Anesthesia and Surgery Flashcards
What are some benefits of ambulatory surgery?
Patient preference (children and elderly)
Bed availability
Flexibility in scheduling surgery
Low morbidity/mortality
Lower incidence of infection
Lower incidence of respiratory complications
Greater efficiency/more patients
Shorter surgical waiting lists
Lower procedural costs
Less preoperative testing/postoperative medication
What is SAMBA?
Society for Ambulatory Surgery and Anesthesia - recognized anesthesia society that regulates ambulatory surgery
What advances in medicine have been made to benefit ambulatory surgery?
- Rapid onset, shorter acting drugs (anesthetic agents, analgesics, short-acting muscle relaxants)
- Minimally invasive surgical procedures (laparoscopic/arthroscopic)
- Pulse oximetry (standard of care since 1990)
- EtCO2 (standard of care since early 1990’s)
What is a hospital integrated ambulatory surgical unit?
Inpatient facility that has outpatients with a separate pre-op and recovery area
What is a hospital-based ambulatory surgical unit?
Separate ambulatory surgery center within the hospital that only does outpatients
What is a freestanding ambulatory surgical unit?
Facility that is associated with a hospital or medical center but housed in a separate building for all outpatient procedures
What is an office-based ambulatory surgical unit?
Outpatient surgical center used in conjunction with physician offices for the convenience of patients and healthcare providers
How much of all elective surgery is performed in an outpatient setting?
60-70%
What types of procedures are done in an outpatient setting?
ENT Plastics Oral/maxillofacial General surgery (lap/non-lap procedures, GYN procedures) Orthopedics Eyes Pain management
What are some pre-op considerations for ambulatory surgery?
Phone interview vs. live interview lab tests Instructions: clear and REPETITIVE Responsible party with them NPO rules Which meds to take/not take
With which patients would it be appropriate to do a phone interview?
ASA 1 adults and parents of ASA 1 peds
ASA 2-3 adults with well-controlled diseases and parents of ASA 2-3 peds
ASA 3-4 for cataract extraction/lens implant
WIth which patients would you want to do a live interview?
ASA 3-4 with questionable disease control Known or suspect difficult intubation Complex syndromes (mental disabilities) Patient having airway surgery for OSA Language barriers
Which patients are not appropriate for ambulatory surgery?
ASA 4, but some exceptions can be made for ESRD patients or COPD patients coming in for minor procedures using little anesthesia
What pre-op lab tests would you do for patients
No testing required
What lab do OB/GYN’s often order for their patients?
H/H on menstruating females or those with history of increased uterine bleeding
What patients require an EKG pre-op?
Anyone over 50 yo, although ASA feels age alone is not indication for EKG and it should be based on history and physical exam
What patients require a CBC pre-op?
All patients >60 yo
Can pre-op lab protocols/policies vary from institution to institution?
Yes
What patients require a CXR pre-op?
those with significant pulmonary or CV disease, malignancy, or as a baseline for intrathoracic surgery
With what procedures would you want to do a urinalysis before?
Hardware insertion (stents) or suspected UTI
Who decides if a patient needs medical clearance regarding a certain condition?
We do. We have to use our own judgement based on how severe the patient’s disease is and the value of the clearance (is it going to change your anesthetic plan)
What is involved with patient preparation before ambulatory surgery?
- Proper introductions/verifications (right patient, right surgery/surgeon, allergies confirmed, NPO status confirmed, responsible party present and able to drive them home)
- Informed consent (anesthetic options, anesthetic risks)
- Explanations as you go (IV insertion, PONV prevention/treatment, pain prevention/treatment)
- Anxiety relief (non-pharmacologic, pharmacologic)
What drugs can we give for PONV prevention?
Steroids Serotonin antagonists Droperidol/Butyrophenones Metoclopramide Scopolamine patch Compazine Dramamine ADEQUATE VOLUME ADMINISTRATION
What patients are at increased risk for aspiration?
obesity
DM
GI disorders
