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931: Advanced Principles of Anesthesia I > Ambulatory surgery > Flashcards

Ambulatory surgery Flashcards

1
Q

Goals of ambulatory surgery include

A

convenience and cost savings to patients, their families and the surgeons

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2
Q

The first ambulatory surgery centers were opened in

A

Phoenix by Dr. Wallace Reed & Dr. John Ford

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3
Q

Patient goals and expectations at ambulatory surgical centers:

A

patients expect safe care, excellent pain relief, absence of nausea and ability to return to normal daily routines as quickly as possible

  • safety during anesthesia
  • no harm will occur during surgical experience
  • comfort in hours/days after surgery
  • not to be a burden to families and friends
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4
Q

When patients go home after ambulatory surgery, it is important to advise them to

A

not do drugs, drink alcohol, or sign any important documents for 24 hours

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5
Q

The focus for anesthesia in the ambulatory setting is

A

selection criteria for cases and patients that create a predictable environment

  • attention to safety that exceeds that applied in hospital setting
  • careful monitoring of patient outcomes and best practices
  • consistently leave patients clear-headed and as free of nausea and pain as possible
  • codification of best practices into “standard work”
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6
Q

The goal for patient, procedure, and practitioner selection is to achieve

A

predictability, consistent and directive guidelines**

requires collaboration of surgeon, facility & anesthesia providers

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7
Q

RNs in an ambulatory center should have

A

ACLS, PALS

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8
Q

Safety in the ambulatory setting is huge and involves

A

code cart, MH, LAST, difficult airway

frequent simulation exercises

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9
Q

Describe the advantages of outpatient surgery.

A

financial, medical, patient satisfaction, social, & staffing

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10
Q

Describe the financial benefits of outpatient surgery.

A

economic benefit for consumers, third-party payers, and medical facilities

  • reduced medical cost and “life costs” (daycare, return to normal function)
  • cost savings exceeding 50% reported for lap chole performed on outpatient basis
  • ambulatory centers operate more efficiently than hospital-based ORs in regard to surgical volume
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11
Q

Describe the medical benefits of outpatient surgery.

A
  • increased availability of hospital beds for patients who require hospital admission
  • patients who are susceptible to infection can have reduced time and contact in inpatient hospital setting
  • decreased risk of nosocomial infection
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12
Q

Describe the patient satisfaction advantage of outpatient surgery.

A

shorter wait times & lower costs

reduced delays due to lack of beds

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13
Q

Describe the social advantages of outpatient surgery.

A

children may have less separation from parents

  • geriatric patients may have better cognitive and physical capacity when separation is minimized
  • POCD decreased in outpatient procedures- less medication and return to familiar environment sooner
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14
Q

Describe the staffing advantages of outpatient surgery.

A

more efficient use of time
uniform work schedules
more predictable surgical outcomes

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15
Q

Disadvantages of outpatient surgery include

A

patient privacy may be less than inpatient setting
patient may have to make multiple trips to physician offices/ambulatory setting for eval & screening
adequate home care must be arranged
children have less time to adapt to surgical settings
monitoring time for adverse events are decreased
management of complications can be problematic due to lack of resources

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16
Q

Monitoring outcomes for the outpatient surgery center include

A

postop calls on day after procedure
improve care & safety
provide assistance if there are postop problems
ideal environment for safe, efficient, low-cost practices

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17
Q

<1% of ambulatory cases result in

A

unanticipated hospital admission for ambulatory cases

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18
Q

The proposed surgery should have

A

insignificant incidence of intra & postoperative problems

also requires appropriate surgeon skills and cooperation

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19
Q

The patient should be ____ prior to surgery

A

his/her usual health & stable for 3 months before surgery

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20
Q

For patients with acute substance abuse in the ambulatory settings

A

evaluate before surgery
acute intoxication is inappropriate for ambulatory surgery due to impaired autonomic and cardiovascular responses
-regional and local are good techniques

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21
Q

Most perioperative complications occur in

A

20 to 49 year olds***

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22
Q

Describe how age affects selection criteria in the ambulatory setting.

A

children <2 have higher unanticipated hospital admission rates due to apnea & bradycardia
premature infant is inappropriate for outpatient surgery
full term infants can be considered for minor outpatient surgery

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23
Q

Describe considerations for the patient with seizure disorder

A

schedule early in day to observe 4-8 hours postop before discharge

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24
Q

Describe considerations for the patient with cystic fibrosis.

A

protective airway measures d/t risk of GERD & pulmonary aspiration

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25
Q

Describe MH susceptibility for the patient presenting to the ambulatory setting.

A

stocked MH cart, dantrolene, activated charcoal filter to reduce VA concentration to less than 5 ppm in 2 min.

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26
Q

Describe special considerations for the obese patient.

A

an increase in adverse postop outcomes in patients with BMI 44 kg/m2

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27
Q

Describe special considerations for the patient with OSA.

A

bring CPAP, minimize benzo/opioid use

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28
Q

Preop evaluation and testing includes

A

review patient’s medical and social history
physical exam- airway, lungs, heart
clinical history drives the preop eval
elimination of routine preop testing
patients of any age can receive outpatient anesthesia

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29
Q

An ECG is indicated for

A

patients over 65 years of age, or history of CHF, MI, angina, high cholesterol, valvular disease or family history of sudden death

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30
Q

If there is not history of unstable disease, there is

A

NO NEED FOR ROUTINE testing

unless: family history sudden death, potential for blood loss, contrast dye, potential pregnancy

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31
Q

High risk patients should be evaluated

A

1 week before

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32
Q

Preoperative considerations include

A

patient orientation
patient screening should take place sufficiently in advance of scheduled surgery
H&P available before surgery performed
lab tests and dx procedures are deemed current if performed within 6 months of surgery***** if patient’s physical condition remains stable

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33
Q

The most common ambulatory procedures include **

A

endoscopy & ophthalmologic

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34
Q

Suitable procedures should

A

not involve extensive blood loss or large shifts of fluid volumes
lap chole, lumbar laminectomy, cervical laminectomy & fusion, total joint arthroplasty, thyroidectomy, hysterectomy, tonsillectomy, & select bariatric procedures are routinely performed

35
Q

______ is good for higher-risk procedures

A

23 hour observation

36
Q

A case should be cancelled when:

A 
a patient is acutely ill
untreated/worsening chronic disease state
noncompliance
NPO status
suspicion of pregnancy
upper respiratory tract infection
37
Q

Elective surgery can proceed in nonhospital setting if a patient has stable cardiac disease without the following:

A

unstable angina, labile HTN, severe valvular disease
-cardiac dysrhythmias
myocardial infarction in past 3 months with ongoing pain or at risk myocardium
DES placed within last year or BES within 1 month
Three or more of the following: IHD, CHF, insulin dependent DM, chronic renal insufficiency (creat >2.0 mg/dL), transient ischemic attack, stroke
-pacemaker/AICD- (facility dependent)

38
Q

Surgery for the patient with pulmonary disease should occur in the hospital if

A

patient is still symptomatic (wheezing at rest, dyspnea when walking up a flight of stairs, pHTN)
invasive pediatric airway surgery not appropriate for free-standing center

39
Q

Describe what factors related to renal disease make a patient inappropriate for ambulatory center.

A

AV fistula surgery not appropriate for free-standing outpatient surgery
unstable renal failure not appropriate for free-standing outpatient facility
- elevated creat in presence of other comorbidities may impact the outcome of outpatient surgery

40
Q

Unacceptable patient conditions for an ambulatory surgery include:

A 
ASA III/IV
active substance or alcohol abuse
psychosocial difficulties
poorly controlled seizures
morbid obesity with significant comorbid conditions (angina, asthma, OSA)
-Ex-premature infants less than 60 weeks post conceptual age requiring GA
uncontrolled DM
current sepsis or infectious disease
41
Q

The goals for anesthesia in the ambulatory outcome includes:

A

convenient, low cost, good outcomes***

42
Q

Practice guidelines for anesthesia in the ambulatory clinic include:

A

active & intentional management of preop evaluation, patient/case selection, anesthesia delivery decisions, and PACU care to provide optimal patient outcomes
-avoid opioids prior to postop period and use multimodal analgesia
-RA or RA+GA>GA alone for patient satisfaction
TIVA>inhaled anesthetics
-Preemptive antiemetic therapy (zofran & decadron)

43
Q

Only ____ can provide MAC

A

anesthesia providers

44
Q

MAC differs from sedation as those

A

require airway patency throughout the procedure

45
Q

With MAC there is a risk of

A

oversedation & OR fire
hypoventilation & relative hypoxemia
vigilance & adequate monitoring are essential

46
Q

If high levels of oxygen are needed with electrocautery, ______ should not be used

A

MAC

- need closed system for oxygen delivery

47
Q

______ _decreases overall anesthesia time & turnover time

A

Neuraxial anesthesia

48
Q

In neuraxial anesthesia,

A

PACU discharge may be shortened
more pleasant postop period
regional catheters allow for reductions in pain for days
reduced PONV and pain
paravertebral block may decrease incidence of tumor recurrence/metastasis via immunologic damping process in mastectomy

49
Q

With general anesthesia in the ambulatory clinic

A

more frequent risk of PONV, post discharge nausea & vomiting, airway injury, hypothermia, postop cognitive dysfunction & delayed discharge

  • TIVA
  • avoid ETT intubation
  • multimodal analgesia
  • preemptive antiemetic therapy
50
Q

The three considerations for DM patients presenting for ambulatory surgery include

A

how to best manage glucose on site (subq is suggested)

  • whether or not a given blood sugar level is “safe” and whether or not treating it acutely may impact morbidity
  • whether or not long-term control is adequate to decrease the risk of perioperative morbidity sufficiently for surgery
51
Q

Adults with HbA1c less than ____ have good control & are good candidates for elective outpatient surgery

A

7%

52
Q

To avoid alterations in DM, prevent

A

PONV & pain

dexamethasone may be given to DM patients safely (will cause elevated blood glucose readings)

53
Q

Fast-tracking involes

A

allowing for patients to proceed to “second stage” of PACU

  • do not require airway support
  • stable cardiopulmonary status
  • good analgesia
54
Q

Fast-tracking provides for

A

a more pleasant experience & decreased cost

55
Q

Useful strategies to promote fast-tracking includes:

A

multimodal analgesia, PONV prophylaxis, BIS monitoring

56
Q

If scheduled for MAC anesthesia, patients should continue

A

ACEIs and ARBs

-ACEI lead to profound hypotension after induction of GENERAL

57
Q

Patients with treated hypertension who undergo surgery have as much as 50% increased risk of

A

MI, cardiac arrest, or significant dysrhythmia in first 30 days after procedure

58
Q

The anesthetist should have the following to care for patients who experience MH:

A

ability to cool via Foley/bladder irrigation, provide “clean” airway equipment, minimum of 36 vials of dantrolene

59
Q

If BMI >35 kg/m2, evaluation of

A

airway, cardiopulmonary, and endocrine systems by anesthesia provider is necessary

60
Q

OSA creates________ activation

A

sympathetic neural activation

61
Q

Patients with OSA have increased risk of_______ & thus caution should be used with _______

A

respiratory depression; opioids

62
Q

Office based anesthesia occurs in

A

dental surgery, plastic surgery, and other anesthesia being performed in offices rather than ambulatory surgery facilities or hospitals

63
Q

With office based anesthesia, there is a risk of

A

unqualified providers of surgery/anesthesia, lack of appropriate equipment and training for resuscitation/emergencies, lack of access to hospitals

64
Q

______ should be restricted to those situations for which they are specifically indicated.

A

Opioids

65
Q

Opioids should be avoided prior to postoperative period in an effort to avoid

A

PONV, sedation, and induction of higher opioid requirements associated with pre- & intraoperative opioid use

66
Q

________ should be used to avoid PONV & postoperative opioid use

A

multimodal preemptive analgesics

67
Q

______ is a frequent finding in pediatric patients undergoing outpatient surgery, especially adenotonsillectomy

A

OSA

68
Q

Presence of OSA in children is associated with increased in

A

airway/respiratory events during induction & PACU

69
Q

Pediatric patient procedures should be consider for hospital setting if:

A

less than 36 months, failure to thrive, craniofacial abnormalities, morbid obesity, cor pulmonale, hypoxemia

70
Q

Pediatric patients have a risk of airway obstruction due to

A

tissue swelling, laryngospasm, & pulmonary edema

71
Q

Children <36 months should be admitted after ______- and monitored overnight

A

adenotonsillectomy; due to incidence of respiratory complications

72
Q

20-30% of all children display ______ for a good portion of the year

A

rhinorrhea

73
Q

A differential diagnosis for rhinorrhea includes

A

allergic rhinitis, bacterial infection, flu syndrome, URTI, vasomotor rhinitis

74
Q

Infectious rhinorrhea can be the result of

A

viral infection, nasopharyngitis, contagious disease, acute bacterial infection, streptococcal tonsillitis, meningitis–> delay for 2 weeks

75
Q

_______ is helpful to serve as a rescue med for PONV in the PACU

A

promethazine 6.25 mg IV

76
Q

_____ is used to direct effective prophylaxis against PONV

A

Apfel score

  • useful in preventing PONV in PACU and first 24 hours
  • poor predictor of N/V 24-72 hours after discharge
77
Q

The following can virtually eliminate early and late PONV

A

dexamethasone 8 mg IV + ondansetron 4 mg IV + ondansetron 8 mg PO at discharge & on POD 1 & 2

78
Q

Describe IV hydration to prevent PONV.

A

2 mL/kg of LR for each hour fasted infused over 20 minutes to decrease PONV/pain

79
Q

_______ may lead to increase in pulmonary morbidity in perioperative period

A

present or recent URI*****

80
Q

The following are associated with GA in patients with URI especially if an ETT is in use:

A

supraglottic edema, stridor, laryngospasm, desaturation, & coughing

81
Q

If the patient has a current, or severe URI (fever, malaise, wheezing, & dyspnea)

A

or within 4 weeks of severe URI & the surgery requires intubation or affects the airway then the procedure should be postponed*****

82
Q

Recent studies support the decision to proceed with elective surgery in patients with current/recent mild

A

URI if procedure can be safely performed with endotracheal intubation and no other cardiac/pulmonary problems

83
Q

Describe discharge criteria.

A 
vital signs stable and age appropriate
oriented to person, place & time
appropriate ambulation 
no respiratory distress
swallowing and coughing protective airways present
bleeding minimal/appropriate for surgery
pain minimal and controlled with appropriate analgesic regimen
N/V should be minimal
oral intake is not necessary
voiding is not mandatory 
reasonable caregiver should be available
discharge instructions

931: Advanced Principles of Anesthesia I (22 decks)

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