Case 73 - Ambulatory Surgery Flashcards

1
Q

Are there patients who should never have surgery on an ambulatory basis?

A
  • preterm infants < 60 weeks PGA &
  • term infants < 44 weeks PGA
    • risk for postop apnea
  • severe physical or mental handicaps
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2
Q

are diabetic patients suitable candidates for ambulatory surgery?

A
  • brittle diabetics should be inpatient sx
  • pre-op assessment of end-organ damage (Cardiac, autonomic, renal, gastroparesis)
  • goal - avoid extremes of plasma glucose
    • serial glucose checks
    • insulin therapy as needed (consider ultra-rapid acting due to short half life)
    • critical that diabetic pts are eat prior to discharge (if naseated at home, won’t eat –> hypoglycemia)
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3
Q

What are the ASA fasting guidelines, do they differ between inpatient and outpatient surgery?

A

ASA fasting guidelines hold true for both inpatient and outpatient surgery.

  • 2 hrs - clear liquid (water, oj no pulp, coffee no milk)
  • 4 hrs - breast milk
  • 6 hrs - light mean (tea and toast, formula milk)
  • 8 hrs - solid food
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4
Q

Which patients is it recommended to administer antacids to?

A

Goal: reduce gastric regurgitation and aspiration + reduce risk of chemical pnuemoitis if aspiration does occur.

  • routine prophylaxis not recommended for all.

High risk patients

  • DM with autonomic dysfunction (gastroparesis)
  • symptomatic hiatal hernia
  • untreated GERD
  • pregnancy in active labor
  • acute abdomen
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5
Q

what are examples of antacid medications?

A

1) Sodium bicitrate

  • non-particulate antacid
  • increase pH of stomach immedietly

2) metoclopramide

  • increase lower esophageal sphincter tone
  • increase GI motility (facilitate gastric emptying)

3) H2 receptor blocker (ranitidine)

  • inhibit gastric acid production
  • decrease gastric volume
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6
Q

What would be an ideal general anesthetic for ambulatory surgery?

A
  • rapid onset
  • permit quick return to baseline levels of lucidity and equilibirum
  • free from deleterious cardiovascular and respiratory efects
  • amnesia, analgesia, muscle relxation, antiemetic therapy
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7
Q

what are relative or absolute contraindications to general anesthesia in ambulatory settting?

A
  • poorly controlled asthma
  • documented bullous emphysema.
    • in terms of risks vs benefit, it may be more beneficial to perform neuraxial than the associated risk of PDPH in these patients.
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8
Q

What are advantages and disadvantages of neuraxial anesthesia in ambulatory patients?

A

Advant

  • little or no sedation required –> patient’s do not feel groggy or “hungover” in PACU
  • no intubation required –> sore throat, cut lip, tracheal damage, hoarseness

Disadvant

  • PDPH
  • sensory and motor weakness post-op may delay discharge
  • autonomic blockade –> inability to urinate
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9
Q

Describe the Bier Block?

A
  • useful for providing anesthesia of extremities
    • ganglion cyst exicsion, trigger finger, carpal tunnel release
  • IV placed in extremity
  • esmarch (elastic) bandage applied to exsanguiate extremity
  • proximal tourniquet inflated to 100 mm Hg
  • 50 mL of 0.5% preservative-free lidocaine injected
  • surgical anesthesia achieved after 10 min
  • continuous monitoring of BP and CNS status (lidocaine can enter systemic circulation
  • after sx, release tornique slowly
    *
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10
Q

when should you consider an endotracheal intubation on an ambulatory patient?

A
  • increased risk of aspiration
  • failed LMA intubation
  • sharing of airway between surgeon and anes
  • muscle relaxation (relative indication)
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11
Q

what are the pros and cons of LMA?

A

Pros

  • deep anesthesia required for placement, muscle relaxation not required
  • low pressure seal via inflation of ballon allows for spont ventilation and PPV
  • less sore throat
  • since no muscle relaxants like Sux = no myalgia
  • can be a life saving device during emergent situations

Cons/contraindications

  • does not protect airway like ETT from aspiration
  • oral pathology
  • low pulmonary compliance
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12
Q

Advant and Disadvant of Propofol

A

overview

  • IV anesthetic agent
  • lipophilic
  • termination of action via redistribution to muscle and fat
  • metabolism via hepatic and extrahepatic (pulmonary) clearance

Advant:

  • rapid onset, easy titration, short duration of action, early recovery
  • unconsciousness
  • sedation
  • anti-emetic
  • smooth emergence / less drowsy feeling in PACU

Disadvant:

  • does not provide amneisa, muscle relaxation, analgesia
    • awareness possible due to lack of amnestic effects
  • pain on injection
  • composed of egg lecithin = excellent culture medium for bacterial growth
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13
Q

How would you describe anesthesia?

A

5 A’s and 1 U of Anesthesia:

  • Unconsciousness
  • Anxiolysis
  • Akinesis (relax muscle movement)
  • Autonomic Control
  • Amnesia
  • Analgesia (pain control)
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14
Q

Define Moderate Sedation

A
  • decreased consciousness with airway patent, gag reflx intact, ability to respond to verbal commands
  • ASA standard monitors
  • careful titration of meds –> can lead to deep sedation or general anesthsia
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15
Q

Can sucinnylcholine myalgias be avoided?

A
  • Sux - assoc with post op myalgias and potential for MH
  • pre-tx with 1mg of NDMB can ameliorate fasciculations and asscoiated myalgias
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16
Q

can overdose of BZD be safely antagonized?

A

Flumazenil - IV competitive BZD receptor antagonist.

  • can carefully titrate flumazenil to allow partial antagonism of excesive bzd effect
  • **SHORT LIVED AGENT (like naloxone) therefore either start an infusion, or closely observe prior to discharge**
17
Q

Compare Desflurane with Sevoflurane

A

Desflurane

Pros

  • low blood and tissue solubility (low blood to gas partition coefficient) -
    • Result: fast induction and fast emergence &
    • rapid titration of anesthetic depth

Cons

  • rapid increase in conc = sympathetic stim - HTN, tachy
  • gas has an odor –> airway irritant, coughing, breath-holding
    • not used for inhalation induction

Sevo

  • odorless
    • not an airway irritant
    • no coughing, no breath holding
    • bronchodilation
    • good inhaled induction anes
  • rapid titration of depth of anesthesia (not as rapid as des b/c a little higher blood to gas part coef)
    *
18
Q

what are negative aspects of PONV?

A
  • dec patient satisfaction
  • unplanned admission
  • disrupt surgical repairs (retching can increase intrathoracic pressure, and CVP)
  • increase bleeding
  • dehydration
  • electrolyte imbalances
19
Q

what are risk factors for PONV?

A

Apfel score - risk score for PONV; 20%, 40, 60, 80

  • Female
  • previous PONV
  • non-smoker
  • opiod use perioperatively
  • surgical procedure
    • laparoscopy
    • D&C
    • orchiopexy
    • ear surgery
    • strabismus correction
20
Q

what are anesthesia releated risk factors for PONV?

A
  • inhaled anesthetics
  • nitrous oxide = controversial
  • etomidate or ketamine use
  • PPV mask ventilation –> forace air into GI tract
  • anticholinesterases (reversal of neuromusclar block)
21
Q

What are ways to reduce the risk of PONV?

A

Non-pharamacologic

  • regional anesthesia > general anesthsia
    • limits opioid use
  • TIVA > inhaled anes
  • Propofol > ketamine or etomidate
  • adequate hydration

Meds to prevent and tx PONV

  • serotonin antangonists, dopamine antagonists, AcH antagonists (anticholinergics)
  • multimodal approach using different drugs form different pharamcologic classes:
    • droperidol
    • prochlorperazine
    • dexamethasone
    • ondansetron
    • scopolamine
    • ephedrine
    • propofol infusion in PACU (small dose)
22
Q

what are some guidelines for safe discharge from same-day surgery?

A

1) Hemodynamically stable
2) AOx3 (or at least to pre-op baseline)
3) capabale of walking with minimal assistance

  • unless unable to preoperatively
  • unable to due to surgery
  • unable to due to regional anes
  • motor and sensory from neuraxial anes must be resolved prior to discharge

4) no N/V
5) pain controlled
6) tolerate oral fluid (few sips without vomiting)
7) able to void

  • after gyn, GU, groin procedures
  • after neuraxial anesthesia (evidence that residual symp blockade as dissipated)

8) escort home, adult to take care of pt at home, adult able to comprehend postop instruction

23
Q
A