Ambulatory Surgery Flashcards
Goals of ambulatory surgery
- convenience and cost savings to patients, families and surgeons
- timeliness and outcomes
who opened the first ambulatory surgery center?
Dr. Wallace Reed and Dr. John Ford
patient goals/expectations of ambulatory surgery
- 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
focus for anesthesia in ambulatory surgery
- 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
financial advantages of outpatient surgery
- 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
medical advantages of outpatient surgery
- 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
patient satisfaction advantages of outpatient surgery
- shorter wait time
- lower cost
- reduced delays due to lack of beds
social advantages of outpatient surgery
- 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
staffing advantages of outpatient surgery
- more efficient use of time
- uniform work schedule
- more predictable surgical outcomes
disadvantages of outpatient surgery
- 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
patient selection for outpatient surgery
- 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
acute substance abuse
- not appropriate for outpatient surgery
- impaired autonomic and CV responses
in whom do most perioperative complications occur?
those aged 20-49
age selection criteria for outpatient surgery
- 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
seizure disorder + outpatient surgery
EARLY in day to observe 4-8 hours prior to discharge
CF + outpatient surgery
protective airway measures d/t risk of GERD and pulmonary aspiration
MH susceptibility + outpatient surgery
- 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
minimum required amount of dantrolene
36 vials of un-expired dantrolene in house
obesity + outpatient surgery
- increase in adverse postop outcomes in those with BMI 44 kg/m2
- no standard BMI cutoff for outpatient surgery
OSA + outpatient surgery
- bring CPAP
- minimize benzo/opioid use to decrease resp depression
Who needs an ECG?
- 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
how long are lab values deemed current?
within 6 months of surgery if patient’s condition remains stable
what are the most common procedures performed ambulatory?
endoscopy and opthalmologic
suitable procedures for ambulatory surgery
- 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
when to cancel a case?
- patient acutely ill
- untreated or worsening chronic disease state
- noncompliance
- NPO status
- suspicion of pregnancy
- URI
what CV conditions are NOT ok for ambulatory?
- 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)
pulmonary disease and ambulatory surgery
- if patient is actively symptomatic then go to the dang hospital
- invasive peds airway surgery SHOULD NOT be performed in free-standing center
renal disease and ambulatory surgery
- elevated Cr with other comorbidities can impact surgical outcomes
- AV fistula NOT appropriate surgery for outpatient
- unstable renal failure also not appropriate
FOR SURE unacceptable patient conditions for outpatient
- 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
goals of anesthesia for outpatient
- convenience
- low cost
- good outcomes
- eliminate pain, PONV, POCD
practice guidelines for anesthesia in outpatient
- 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
three considerations for DM and ambulatory surgery
- 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
fast-tracking
- 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
HTN and ambulatory surgery
- 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
MH and ambulatory surgery
- 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
OSA and ambulatory surgery
- 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
consider hospital for pediatric patients if…
- less than 36 months
- FTT
- carniofacial abnormalities
- morbid obesity
- cor pulmonale
- hypoxemia
what can eliminate early and late PONV
- dexamethasone 8 mg IV + ondansetron 4 mg IV
- ondansetron 8 mg PO at discharge and on POD 1 +2
URI when to postpone
- current, severe URI with fever, malaise, wheezing, dyspnea
- within 4 weeks of severe URI and surgery involves intubation or affects airway
discharge from PACU criteria
- 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)
