Ambulatory surgery Flashcards
Goals of ambulatory surgery include
convenience and cost savings to patients, their families and the surgeons
The first ambulatory surgery centers were opened in
Phoenix by Dr. Wallace Reed & Dr. John Ford
Patient goals and expectations at ambulatory surgical centers:
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
When patients go home after ambulatory surgery, it is important to advise them to
not do drugs, drink alcohol, or sign any important documents for 24 hours
The focus for anesthesia in the ambulatory setting is
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”
The goal for patient, procedure, and practitioner selection is to achieve
predictability, consistent and directive guidelines**
requires collaboration of surgeon, facility & anesthesia providers
RNs in an ambulatory center should have
ACLS, PALS
Safety in the ambulatory setting is huge and involves
code cart, MH, LAST, difficult airway
frequent simulation exercises
Describe the advantages of outpatient surgery.
financial, medical, patient satisfaction, social, & staffing
Describe the financial benefits of outpatient surgery.
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
Describe the medical benefits of outpatient surgery.
- 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
Describe the patient satisfaction advantage of outpatient surgery.
shorter wait times & lower costs
reduced delays due to lack of beds
Describe the social advantages of outpatient surgery.
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
Describe the staffing advantages of outpatient surgery.
more efficient use of time
uniform work schedules
more predictable surgical outcomes
Disadvantages of outpatient surgery include
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
Monitoring outcomes for the outpatient surgery center include
postop calls on day after procedure
improve care & safety
provide assistance if there are postop problems
ideal environment for safe, efficient, low-cost practices
<1% of ambulatory cases result in
unanticipated hospital admission for ambulatory cases
The proposed surgery should have
insignificant incidence of intra & postoperative problems
also requires appropriate surgeon skills and cooperation
The patient should be ____ prior to surgery
his/her usual health & stable for 3 months before surgery
For patients with acute substance abuse in the ambulatory settings
evaluate before surgery
acute intoxication is inappropriate for ambulatory surgery due to impaired autonomic and cardiovascular responses
-regional and local are good techniques
Most perioperative complications occur in
20 to 49 year olds***
Describe how age affects selection criteria in the ambulatory setting.
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
Describe considerations for the patient with seizure disorder
schedule early in day to observe 4-8 hours postop before discharge
Describe considerations for the patient with cystic fibrosis.
protective airway measures d/t risk of GERD & pulmonary aspiration
Describe MH susceptibility for the patient presenting to the ambulatory setting.
stocked MH cart, dantrolene, activated charcoal filter to reduce VA concentration to less than 5 ppm in 2 min.
Describe special considerations for the obese patient.
an increase in adverse postop outcomes in patients with BMI 44 kg/m2
Describe special considerations for the patient with OSA.
bring CPAP, minimize benzo/opioid use
Preop evaluation and testing includes
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
An ECG is indicated for
patients over 65 years of age, or history of CHF, MI, angina, high cholesterol, valvular disease or family history of sudden death
If there is not history of unstable disease, there is
NO NEED FOR ROUTINE testing
unless: family history sudden death, potential for blood loss, contrast dye, potential pregnancy
High risk patients should be evaluated
1 week before
Preoperative considerations include
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
The most common ambulatory procedures include **
endoscopy & ophthalmologic
Suitable procedures should
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
______ is good for higher-risk procedures
23 hour observation
A case should be cancelled when:
a patient is acutely ill untreated/worsening chronic disease state noncompliance NPO status suspicion of pregnancy upper respiratory tract infection
Elective surgery can proceed in nonhospital setting if a patient has stable cardiac disease without the following:
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)
Surgery for the patient with pulmonary disease should occur in the hospital if
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
Describe what factors related to renal disease make a patient inappropriate for ambulatory center.
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
Unacceptable patient conditions for an ambulatory surgery include:
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
The goals for anesthesia in the ambulatory outcome includes:
convenient, low cost, good outcomes***
Practice guidelines for anesthesia in the ambulatory clinic include:
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)
Only ____ can provide MAC
anesthesia providers
MAC differs from sedation as those
require airway patency throughout the procedure
With MAC there is a risk of
oversedation & OR fire
hypoventilation & relative hypoxemia
vigilance & adequate monitoring are essential
If high levels of oxygen are needed with electrocautery, ______ should not be used
MAC
- need closed system for oxygen delivery
______ _decreases overall anesthesia time & turnover time
Neuraxial anesthesia
In neuraxial anesthesia,
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
With general anesthesia in the ambulatory clinic
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
The three considerations for DM patients presenting for ambulatory surgery include
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
Adults with HbA1c less than ____ have good control & are good candidates for elective outpatient surgery
7%
To avoid alterations in DM, prevent
PONV & pain
dexamethasone may be given to DM patients safely (will cause elevated blood glucose readings)
Fast-tracking involes
allowing for patients to proceed to “second stage” of PACU
- do not require airway support
- stable cardiopulmonary status
- good analgesia
Fast-tracking provides for
a more pleasant experience & decreased cost
Useful strategies to promote fast-tracking includes:
multimodal analgesia, PONV prophylaxis, BIS monitoring
If scheduled for MAC anesthesia, patients should continue
ACEIs and ARBs
-ACEI lead to profound hypotension after induction of GENERAL
Patients with treated hypertension who undergo surgery have as much as 50% increased risk of
MI, cardiac arrest, or significant dysrhythmia in first 30 days after procedure
The anesthetist should have the following to care for patients who experience MH:
ability to cool via Foley/bladder irrigation, provide “clean” airway equipment, minimum of 36 vials of dantrolene
If BMI >35 kg/m2, evaluation of
airway, cardiopulmonary, and endocrine systems by anesthesia provider is necessary
OSA creates________ activation
sympathetic neural activation
Patients with OSA have increased risk of_______ & thus caution should be used with _______
respiratory depression; opioids
Office based anesthesia occurs in
dental surgery, plastic surgery, and other anesthesia being performed in offices rather than ambulatory surgery facilities or hospitals
With office based anesthesia, there is a risk of
unqualified providers of surgery/anesthesia, lack of appropriate equipment and training for resuscitation/emergencies, lack of access to hospitals
______ should be restricted to those situations for which they are specifically indicated.
Opioids
Opioids should be avoided prior to postoperative period in an effort to avoid
PONV, sedation, and induction of higher opioid requirements associated with pre- & intraoperative opioid use
________ should be used to avoid PONV & postoperative opioid use
multimodal preemptive analgesics
______ is a frequent finding in pediatric patients undergoing outpatient surgery, especially adenotonsillectomy
OSA
Presence of OSA in children is associated with increased in
airway/respiratory events during induction & PACU
Pediatric patient procedures should be consider for hospital setting if:
less than 36 months, failure to thrive, craniofacial abnormalities, morbid obesity, cor pulmonale, hypoxemia
Pediatric patients have a risk of airway obstruction due to
tissue swelling, laryngospasm, & pulmonary edema
Children <36 months should be admitted after ______- and monitored overnight
adenotonsillectomy; due to incidence of respiratory complications
20-30% of all children display ______ for a good portion of the year
rhinorrhea
A differential diagnosis for rhinorrhea includes
allergic rhinitis, bacterial infection, flu syndrome, URTI, vasomotor rhinitis
Infectious rhinorrhea can be the result of
viral infection, nasopharyngitis, contagious disease, acute bacterial infection, streptococcal tonsillitis, meningitis–> delay for 2 weeks
_______ is helpful to serve as a rescue med for PONV in the PACU
promethazine 6.25 mg IV
_____ is used to direct effective prophylaxis against PONV
Apfel score
- useful in preventing PONV in PACU and first 24 hours
- poor predictor of N/V 24-72 hours after discharge
The following can virtually eliminate early and late PONV
dexamethasone 8 mg IV + ondansetron 4 mg IV + ondansetron 8 mg PO at discharge & on POD 1 & 2
Describe IV hydration to prevent PONV.
2 mL/kg of LR for each hour fasted infused over 20 minutes to decrease PONV/pain
_______ may lead to increase in pulmonary morbidity in perioperative period
present or recent URI*****
The following are associated with GA in patients with URI especially if an ETT is in use:
supraglottic edema, stridor, laryngospasm, desaturation, & coughing
If the patient has a current, or severe URI (fever, malaise, wheezing, & dyspnea)
or within 4 weeks of severe URI & the surgery requires intubation or affects the airway then the procedure should be postponed*****
Recent studies support the decision to proceed with elective surgery in patients with current/recent mild
URI if procedure can be safely performed with endotracheal intubation and no other cardiac/pulmonary problems
Describe discharge criteria.
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
