Case 73 - Ambulatory Surgery Flashcards
Are there patients who should never have surgery on an ambulatory basis?
- preterm infants < 60 weeks PGA &
- term infants < 44 weeks PGA
- risk for postop apnea
- severe physical or mental handicaps
are diabetic patients suitable candidates for ambulatory surgery?
- brittle diabetics should be inpatient sx
- pre-op assessment of end-organ damage (Cardiac, autonomic, renal, gastroparesis)
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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)
What are the ASA fasting guidelines, do they differ between inpatient and outpatient surgery?
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
Which patients is it recommended to administer antacids to?
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
what are examples of antacid medications?
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
What would be an ideal general anesthetic for ambulatory surgery?
- 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
what are relative or absolute contraindications to general anesthesia in ambulatory settting?
- 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.
What are advantages and disadvantages of neuraxial anesthesia in ambulatory patients?
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
Describe the Bier Block?
- 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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when should you consider an endotracheal intubation on an ambulatory patient?
- increased risk of aspiration
- failed LMA intubation
- sharing of airway between surgeon and anes
- muscle relaxation (relative indication)
what are the pros and cons of LMA?
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
Advant and Disadvant of Propofol
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
How would you describe anesthesia?
5 A’s and 1 U of Anesthesia:
- Unconsciousness
- Anxiolysis
- Akinesis (relax muscle movement)
- Autonomic Control
- Amnesia
- Analgesia (pain control)
Define Moderate Sedation
- 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
Can sucinnylcholine myalgias be avoided?
- Sux - assoc with post op myalgias and potential for MH
- pre-tx with 1mg of NDMB can ameliorate fasciculations and asscoiated myalgias
