Ambulatory surgery

Question 1

Goals of ambulatory surgery include

Answer 1

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

Question 2

The first ambulatory surgery centers were opened in

Answer 2

Phoenix by Dr. Wallace Reed & Dr. John Ford

Question 3

Patient goals and expectations at ambulatory surgical centers:

Answer 3

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

Question 4

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

Answer 4

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

Question 5

The focus for anesthesia in the ambulatory setting is

Answer 5

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”

Question 6

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

Answer 6

predictability, consistent and directive guidelines**

requires collaboration of surgeon, facility & anesthesia providers

Question 7

RNs in an ambulatory center should have

Answer 7

ACLS, PALS

Question 8

Safety in the ambulatory setting is huge and involves

Answer 8

code cart, MH, LAST, difficult airway

frequent simulation exercises

Question 9

Describe the advantages of outpatient surgery.

Answer 9

financial, medical, patient satisfaction, social, & staffing

Question 10

Describe the financial benefits of outpatient surgery.

Answer 10

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

Question 11

Describe the medical benefits of outpatient surgery.

Answer 11

• 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

Question 12

Describe the patient satisfaction advantage of outpatient surgery.

Answer 12

shorter wait times & lower costs

reduced delays due to lack of beds

Question 13

Describe the social advantages of outpatient surgery.

Answer 13

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

Question 14

Describe the staffing advantages of outpatient surgery.

Answer 14

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

Question 15

Disadvantages of outpatient surgery include

Answer 15

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

Question 16

Monitoring outcomes for the outpatient surgery center include

Answer 16

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

Question 17

<1% of ambulatory cases result in

Answer 17

unanticipated hospital admission for ambulatory cases

Question 18

The proposed surgery should have

Answer 18

insignificant incidence of intra & postoperative problems

also requires appropriate surgeon skills and cooperation

Question 19

The patient should be ____ prior to surgery

Answer 19

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

Question 20

For patients with acute substance abuse in the ambulatory settings

Answer 20

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

Question 21

Most perioperative complications occur in

Answer 21

20 to 49 year olds***

Question 22

Describe how age affects selection criteria in the ambulatory setting.

Answer 22

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

Question 23

Describe considerations for the patient with seizure disorder

Answer 23

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

Question 24

Describe considerations for the patient with cystic fibrosis.

Answer 24

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

Question 25

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

Answer 25

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

Question 26

Describe special considerations for the obese patient.

Answer 26

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

Question 27

Describe special considerations for the patient with OSA.

Answer 27

bring CPAP, minimize benzo/opioid use

Question 28

Preop evaluation and testing includes

Answer 28

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

Question 29

An ECG is indicated for

Answer 29

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

Question 30

If there is not history of unstable disease, there is

Answer 30

NO NEED FOR ROUTINE testing | unless: family history sudden death, potential for blood loss, contrast dye, potential pregnancy

Question 31

High risk patients should be evaluated

Answer 31

1 week before

Question 32

Preoperative considerations include

Answer 32

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

Question 33

The most common ambulatory procedures include ****

Answer 33

endoscopy & ophthalmologic

Question 34

Suitable procedures should

Answer 34

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

Question 35

______ is good for higher-risk procedures

Answer 35

23 hour observation

Question 36

A case should be cancelled when:

Answer 36

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

Question 37

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

Answer 37

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)

Question 38

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

Answer 38

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

Question 39

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

Answer 39

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

Question 40

Unacceptable patient conditions for an ambulatory surgery include:

Answer 40

``` 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 ```

Question 41

The goals for anesthesia in the ambulatory outcome includes:

Answer 41

convenient, low cost, good outcomes***

Question 42

Practice guidelines for anesthesia in the ambulatory clinic include:

Answer 42

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)

Question 43

Only ____ can provide MAC

Answer 43

anesthesia providers

Question 44

MAC differs from sedation as those

Answer 44

require airway patency throughout the procedure

Question 45

With MAC there is a risk of

Answer 45

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

Question 46

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

Answer 46

MAC | - need closed system for oxygen delivery

Question 47

______ _decreases overall anesthesia time & turnover time

Answer 47

Neuraxial anesthesia

Question 48

In neuraxial anesthesia,

Answer 48

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

Question 49

With general anesthesia in the ambulatory clinic

Answer 49

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

Question 50

The three considerations for DM patients presenting for ambulatory surgery include

Answer 50

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

Question 51

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

Answer 51

7%

Question 52

To avoid alterations in DM, prevent

Answer 52

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

Question 53

Fast-tracking involes

Answer 53

allowing for patients to proceed to "second stage" of PACU - do not require airway support - stable cardiopulmonary status - good analgesia

Question 54

Fast-tracking provides for

Answer 54

a more pleasant experience & decreased cost

Question 55

Useful strategies to promote fast-tracking includes:

Answer 55

multimodal analgesia, PONV prophylaxis, BIS monitoring

Question 56

If scheduled for MAC anesthesia, patients should continue

Answer 56

ACEIs and ARBs | -ACEI lead to profound hypotension after induction of GENERAL

Question 57

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

Answer 57

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

Question 58

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

Answer 58

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

Question 59

If BMI >35 kg/m2, evaluation of

Answer 59

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

Question 60

OSA creates________ activation

Answer 60

sympathetic neural activation

Question 61

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

Answer 61

respiratory depression; opioids

Question 62

Office based anesthesia occurs in

Answer 62

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

Question 63

With office based anesthesia, there is a risk of

Answer 63

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

Question 64

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

Answer 64

Opioids

Question 65

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

Answer 65

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

Question 66

________ should be used to avoid PONV & postoperative opioid use

Answer 66

multimodal preemptive analgesics

Question 67

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

Answer 67

OSA

Question 68

Presence of OSA in children is associated with increased in

Answer 68

airway/respiratory events during induction & PACU

Question 69

Pediatric patient procedures should be consider for hospital setting if:

Answer 69

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

Question 70

Pediatric patients have a risk of airway obstruction due to

Answer 70

tissue swelling, laryngospasm, & pulmonary edema

Question 71

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

Answer 71

adenotonsillectomy; due to incidence of respiratory complications

Question 72

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

Answer 72

rhinorrhea

Question 73

A differential diagnosis for rhinorrhea includes

Answer 73

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

Question 74

Infectious rhinorrhea can be the result of

Answer 74

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

Question 75

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

Answer 75

promethazine 6.25 mg IV

Question 76

_____ is used to direct effective prophylaxis against PONV

Answer 76

Apfel score - useful in preventing PONV in PACU and first 24 hours - poor predictor of N/V 24-72 hours after discharge

Question 77

The following can virtually eliminate early and late PONV

Answer 77

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

Question 78

Describe IV hydration to prevent PONV.

Answer 78

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

Question 79

_______ may lead to increase in pulmonary morbidity in perioperative period

Answer 79

present or recent URI*****

Question 80

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

Answer 80

supraglottic edema, stridor, laryngospasm, desaturation, & coughing

Question 81

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

Answer 81

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

Question 82

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

Answer 82

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

Question 83

Describe discharge criteria.

Answer 83

``` 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 ```