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N931 Advanced Principles of Anesthesia I > Ambulatory Surgery > Flashcards

Ambulatory Surgery Flashcards

1
Q

Goals of ambulatory surgery

A
  • convenience and cost savings to patients, families and surgeons
  • timeliness and outcomes
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2
Q

who opened the first ambulatory surgery center?

A

Dr. Wallace Reed and Dr. John Ford

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3
Q

patient goals/expectations of ambulatory surgery

A
  • safe care
  • pain relief
  • no nausea
  • ability to return to normal daily routine ASAP
  • no harm will occur during surgical experience
  • comfort in hours/days after surgery
  • not to be a burden to family/friends
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4
Q

focus for anesthesia in ambulatory surgery

A
  • selection of cases that create a predictable environment
  • attention to SAFETY that exceeds that applied in a hospital setting
  • careful monitoring of patient outcomes and best practices (do follow up calls)
  • consistent leave patients clear headed and free of nausea/pain
  • codification of best practices into standard work
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5
Q

financial advantages of outpatient surgery

A
  • economic benefit for consumers, third-party payers, and medical facilities
  • reduced medical and life costs (like daycare, and not missing work)
  • cost savings exceeding 50% reported for lap chole performed outpatient
  • more efficient operations
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6
Q

medical advantages 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/contact in hospital setting
  • decreased risk of nosocomial infection
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7
Q

patient satisfaction advantages of outpatient surgery

A
  • shorter wait time
  • lower cost
  • reduced delays due to lack of beds
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8
Q

social advantages of outpatient surgery

A
  • children less separation from parents
  • geriatric patients better cognitive and physical capacity when separation minimized
  • POCD for elderly decreased in outpatient procedures, less meds and return to familiar environment
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9
Q

staffing advantages of outpatient surgery

A
  • more efficient use of time
  • uniform work schedule
  • more predictable surgical outcomes
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10
Q

disadvantages of outpatient surgery

A
  • patient privacy may be less than inpatient setting
  • patient may have to make multiple trips to physician offices/ambulatory setting for evaluation and screening
  • adequate home care NEEDS to be arranged
  • children have less time to adapt to surgical setting
  • monitoring time for adverse events decreased
  • management of complications can be problematic due to lack of resources
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11
Q

patient selection for outpatient surgery

A
  • proper selection minimizes hospital admissions
  • proposed procedure should have insignificant incidence of intra and post op complications
  • patient should be his/her usual health (stable for 3 months prior to surgery)
  • appropriate surgeon skills and cooperation
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12
Q

acute substance abuse

A
  • not appropriate for outpatient surgery

- impaired autonomic and CV responses

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13
Q

in whom do most perioperative complications occur?

A

those aged 20-49

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14
Q

age selection criteria for outpatient surgery

A
  • children less than 2 have higher incidence of unanticipated hospital admission (apnea and bradycardia)
  • premies not appropriate
  • full term infants can be considered for MINOR outpatient procedures
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15
Q

seizure disorder + outpatient surgery

A

EARLY in day to observe 4-8 hours prior to discharge

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16
Q

CF + outpatient surgery

A

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

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17
Q

MH susceptibility + outpatient surgery

A
  • MH susceptible - had MH or relative with known MH incident
  • stocked MH cart
  • dantrolene
  • activated charcoal filter to reduce VA concentration to less than 5ppm in 2 min
  • FIRST CASE ON MONDAY
18
Q

minimum required amount of dantrolene

A

36 vials of un-expired dantrolene in house

19
Q

obesity + outpatient surgery

A
  • increase in adverse postop outcomes in those with BMI 44 kg/m2
  • no standard BMI cutoff for outpatient surgery
20
Q

OSA + outpatient surgery

A
  • bring CPAP

- minimize benzo/opioid use to decrease resp depression

21
Q

Who needs an ECG?

A
  • patients over 65 yo
  • history of CHF, MI, angina, high cholesterol, valvular disease
  • family history of sudden cardiac death
  • other than these, NO NEED for routine testing
22
Q

how long are lab values deemed current?

A

within 6 months of surgery if patient’s condition remains stable

23
Q

what are the most common procedures performed ambulatory?

A

endoscopy and opthalmologic

24
Q

suitable procedures for ambulatory surgery

A
  • list is constantly evolving
  • routine = lap chole, lumbar laminectomy, cervical laminectomy and fusion, total joints, thyroidectomy, tonsillectomy, hysterectomy, some baratric surgeries
  • 23 hour obs for more high risk
25
Q

when to cancel a case?

A
  • patient acutely ill
  • untreated or worsening chronic disease state
  • noncompliance
  • NPO status
  • suspicion of pregnancy
  • URI
26
Q

what CV conditions are NOT ok for ambulatory?

A
  • UA
  • labile HTN
  • severe valve disease
  • cardiac dysrhythmias
  • MI in past 3 months with ongoing pain
  • DES placed in last year or BMS within 1 month
  • three or more of following –> ischemic heart disease, CHF, insulin dependent DM, chronic renal insufficiency, TIA, stroke
  • ??pacemaker, AICD (depends on facility, but most will not accept AICD)
27
Q

pulmonary disease and ambulatory surgery

A
  • if patient is actively symptomatic then go to the dang hospital
  • invasive peds airway surgery SHOULD NOT be performed in free-standing center
28
Q

renal disease and ambulatory surgery

A
  • elevated Cr with other comorbidities can impact surgical outcomes
  • AV fistula NOT appropriate surgery for outpatient
  • unstable renal failure also not appropriate
29
Q

FOR SURE unacceptable patient conditions for outpatient

A
  • ASA III/IV (but will do 3’s according to pitman)
  • active substance or alcohol abuse
  • psychosocial difficulties
  • poorly controlled seizures
  • morbid obesity with significant comorbid conditions (angina, asthma, OSA)
  • ex premies less than 60 weeks PCA
  • uncontrolled DM
  • current sepsis or infection
30
Q

goals of anesthesia for outpatient

A
  • convenience
  • low cost
  • good outcomes
  • eliminate pain, PONV, POCD
31
Q

practice guidelines for anesthesia in outpatient

A
  • active and intentional management of preop eval, patient/case selection, anesthesia delivery decisions, and PACU care to provide optimal patient outcomes
  • avoid opioids prior to post-op period
  • multimodal analgesia
  • RA or RA+GA > GA
  • TIVA > inhaled anesthetics
  • preemptive antiemetics
32
Q

three considerations for DM and ambulatory surgery

A
  • whether or not long-term control is adequate to decrease risk of periop morbidity and sufficiently for surgery
  • whether or not a given blood sugar level is safe and whether or not treating it acutely may impact morbidity
  • how to best manage glucose on site
33
Q

fast-tracking

A
  • ambulatory allows for patients to proceed to second stage of PACU and bypass first stage if –> do not require airway support, stable cardiopulmonary status, good analgesia
  • fast tracking = more pleasant
  • multimodal analgesia, PONV prophylaxis, BIS monitor are all useful tools
  • decreased cost
34
Q

HTN and ambulatory surgery

A
  • 50% increased risk of MI, cardiac arrest, or significant dysrhytmia in first 30 days post-procedure
  • ACEi lead to profound hypotension with GA
  • if MAC, then ok to take ACEi and ARBs
35
Q

MH and ambulatory surgery

A
  • MUST be able to manage immediate and definitive care of those experiencing MH
  • MH occurs in healthy patients undergoing outpatient procedures having a non-triggering anesthetic in absence of family history
  • ability to cool via foley/bladder irrigation, provide clean airway equipment, and MINIMUM of 36 vials of dantrolene
36
Q

OSA and ambulatory surgery

A
  • OSA creates sympathetic neural activation
  • HTN and CV abnormalities
  • morbidity and/or sudden death after surgery
  • increased risk for CV events, MI, bleeding, resp failure, difficult intubation, death
  • patient screened preop
  • BRING CPAP
  • increased risk of resp depression - caution with opioids
37
Q

consider hospital for pediatric patients if…

A
  • less than 36 months
  • FTT
  • carniofacial abnormalities
  • morbid obesity
  • cor pulmonale
  • hypoxemia
38
Q

what can eliminate early and late PONV

A
  • dexamethasone 8 mg IV + ondansetron 4 mg IV

- ondansetron 8 mg PO at discharge and on POD 1 +2

39
Q

URI when to postpone

A
  • current, severe URI with fever, malaise, wheezing, dyspnea

- within 4 weeks of severe URI and surgery involves intubation or affects airway

40
Q

discharge from PACU criteria

A
  • VSS and age appropriate
  • oriented to person, place and time
  • appropriate ambulation
  • no resp distress
  • swallowing and coughing protective airways present
  • bleeding minimal
  • pain minimal and controlled with appropriate analgesic regimen
  • N/V minimal
  • oral intake not necessary
  • voiding not mandatory
  • reasonable caregiver should be available
  • discharge instructions (written and verbal)

N931 Advanced Principles of Anesthesia I (19 decks)

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