Choice of anesthesia Flashcards
what are the three main points of outpatient/out of OR anesthesia
patient selection
type of procedure
tailored anesthetic focused on quick discharge
what is the definition of outpatient/ambulatory surgery
a surgery not requiring an overnight stay
what makes outpatient surgery possible
improved anesthetics
minimally invasive procedures
what are benefits of outpatient surgery
*Reduced surgical tissue trauma through minimally invasive techniques
*Enhanced recovery
*Minimal adverse outcomes
*More effective postop analgesia (peripheral nerve blocks)
*More efficient scheduling
*Fiscally more resourceful through eliminating overnight recovery
what is the benefit of a hospital outpatient surgery
*More cost effective from sharing of resources such as: equipment, facilities, and staff
*Flexibility in revenue generation i.e. COVID elective case cancellations can still do emergent/urgent cases
what is the disadvantage of hospital outpatient surgery
Can be inefficient due to delays and cancellations in favor of emergent inpatient procedures
what is the difference between hospital integrated and hospital self contained outpatient surgery centers
hospital self contained centers dont share an OR
what is the benefit of a hospital self contained vs a hospital integrated outpatient surgery centers
-can still share resources with hospital
More efficient than integrated due to separation from urgent/emergent inpatient surgery
what is the benefit of a free standing ambulatory surgery center
*Very efficient
*Complete separation from hospital based, inpatient surgery
-some have accommodations for overnight
what is the disadvantage of a free standing ambulatory surgery center
*Must have plan for hospital admission for additional resources if necessary
*Limited patient population in relation to acuity
-shut down during pandemic
what is the advantage of an office based outpatient surgery facility
*Rapidly expanding model
*Increased convenience for surgeon and patient
*Lower cost (facility charges lower)
what is the disadvantage of an office based outpatient surgery facility
*More limitations to patient selection and procedures
*Likely to be the sole anesthesia provider in the facility- Sometimes we need help
-no ASA 3 or higher
*Usually less and more budget minded anesthesia equipment
-must have backup plan like admission to local hospital, during covid there was very limited room
what factors should be considered for outpatient surgery
*Limited surgical trauma
*No expectation of significant blood loss, large fluid shifts, complex post-op care, or unreasonable pain (nerve blocks for ortho)
*Patient acuity. Does the risk outweigh the benefit? Will this increase the likelihood for a hospital admission? Does the facility have the resources to care for this individual?
*Social factors: Patient living arrangements/care, travel distance, somebody to drive
what is the goal of an anesthetic
safe, effective, cheap, easy to administer, no side affects
what is the most common type of anesthesia
general
what are the benefits of general anesthesia
*Complete unawareness during procedure
*Provides secure airway
*Motionless surgical field-usually
what are the negatives of general anesthesia
*Can cause post op nausea- volatile agent(iso, civo, des), N2O, narcotics
*Emergence delirium
*Propofol and volatile agents can cause dose dependent BP depression (decreased SVR)
what are the benefits of MAC (monitored anesthesia care)
*Faster recovery-usually
*No airway manipulation-usually
*Ability to bypass recovery if alert when leaving OR
*Can be combined with regional/neuraxial anesthesia
what are the negatives of MAC
*Difficult in patients with severe obstructive sleep apnea
*Difficult in patients with severe anxiety
*Difficulty providing motionless surgical field
*Unsecured airway
what are the benefits of regional/neuraxial anesthesia
-Provides intraoperative and postoperative pain control. Sometimes for several days post-op (catheters with bulbsplaced, can last 5 days)
-Speeds recovery time. Patients can leave the OR fully alert and pain free
-Ability to provide a non-narcotic anesthetic
-Can be combined with general and MAC anesthetics
what are the negatives of regional/neuroaxial anesthesia
*Can require specialized equipment like ultrasound machines
*Requires proficient training
*Sometimes requires preoperative sedation and monitoring
*Can slow down the efficiency of the facility if understaffed/undertrained
*Duration of action may not be adequate for procedure time
what must be included in consideration of anesthetic technique
*Patients consent- do they agree with the choice you recommend
-if scared of needles no blocks
-if anxious may want general over mac
*Ability of provider to administer the anesthetic in a safe, timely manner
*Equipment availability at the facility (ultrasound, nerve stimulator)
*Properly trained staff to care for the patient when anesthetic is administered
*Will the anesthetic be adequate for the procedure
*Will it provide adequate pain control for the entire length of the procedure
*Back-up plan in case the anesthetic fails, able to convert to general
what percentage of anesthesia is performed out of OR
36%
what is the percentage of death claim of out or OR anesthesia vs in OR
54% vs 29%
why is out of OR anesthesia sucky
*Trending toward older, sicker patients not suitable for OR procedures
*Often performed in remote locations- have to call for help which can be delayed
*Anesthesia is usually an afterthought (lack of room, lack of supplies, lack of equipment)
-performed under MAC so no secured airway
what are common examples of out of OR anesthesia
-bronchs
-Cath lab
-GI lab
-MRI/CT
-IR
-TEE lab/ECho
-ER to set joint or fracture
-ICU
what are the criteria for outpatient discharge
*Be alert and oriented to time and place
*Have stable vital signs
*Have pain controlled by oral analgesics, liposomal bupivacaine, or peripheral nerve block
*Have nausea or emesis controlled
*Be able to walk without dizziness
*Have no unexpected bleeding from the operative site
*Be able to take oral fluids and void
*Have discharge instructions and prescriptions from the surgeon and anesthesia provider
*Accept readiness for discharge
*Have a responsible adult escort present
ASA 3 patients may still have ambulatory procedures given
their diseases are well controlled
benefits outway risks
what BMI is thought to be of great risk to ambulatory surgical centers
50 and up
what can be done preop to decrease cardiac complications in OSA patients
CPAP
what are the ASA guidlines for OSA patients in OR
-avoid resp depressants such as opiods
-regional anesthetic techniques when possible
-no discharge until no longer at risk for resp depression
-return to baseline spO2 prior to discharge
-observe resp while unstimulated
-consider CPAP use peri op
-prolonged post op observation
what should be considered when providing anesthesia to patients with stents
antiplatelet use
surgeon and cardiologist to discuess perioperative use
what is the risk of B blocker use during anethesia
transient hypotension with induction
what is the targeted intraoperative BG level
less than 180 mg/dl
what are the two most common causes of unplanned hospital admin from ASC
PONV
uncontrolled pain
should prophylactic dantrolene be administered for patients with history of malignant hypothermia
no
what are common airway complications associated with sedation and analgesia
airway obstruction
aspiration
regurgitation
dental/soft tissue injury
what are common respiratory complications associated with sedation and analgesia
resp depression
hypoxemia
hypercarbia
apnea
what are common cardiovascular complications associated with sedation and analgesia
hypotension
arrhythmias
what are common neurological complications associated with sedation and analgesia
deeper level of sedation
unresponsiveness
who does pre op eval
CRNA
who sees patient in PAT
seen by RN
what happens in PAT
med rec
HH
paperwork
labs
radiology
EKG
follow algorithm for HH
when would CRNA see patient in PAT clinic
-difficult airway
-fam hx trouble waking up
-abnormal EKG
when is preop eval
before surgery, at center or in room, seen by CRNA
if in medically directed state who does peop eval
Anesthesiologist and CRNA
what is Qk billing
medical direction
what does MD have to doto happen for TEFRA guidelines in Qk
preop eval
prescribe plan
induction
emergence
check-in during anesthesia
is TEFRA possible
no
what happens when TEFRA isnt met
medicare fraud
what do you do in preop eval
-review labs, cxr, HP
-fasting status
-develop anesthesia plan
who do you check anesthesia plan with
surgeon
patient
what must be obtained from patient for anesthesia plan
informed consent
what is an example of an anxiolytic for anesthesia?
versed, also causes antegrade amnesia
what is an example of an analgesic for anesthesia?
fentanyl
what is an example of gastric motility for anesthesia?
reglan
