Lap Surg / AmbSurg

Question 1

surgical procedures suitable for ambulatory surgery should be

Answer 1

accompanied by minimal postoperative physiological disturbances and an uncomplicated recovery.

Consider potential for: blood loss, pain, PONV,

Question 2

procedures requiring prolonged immobilization and IV opioid analgesic therapy are more ideally suited

Answer 2

to a 23 hour stay “short stay”

Question 3

pain, emesis, delayed discharge, and hospital admission rates are higher

Answer 3

the longer the surgery

Question 4

age alone

Answer 4

should not be considered a deterrent in the selection of patients for ambulatory surgery

Question 5

premature infants have an increased risk for

Answer 5

apnea

Question 6

major risk factors for post operative complications with extremes of age include

Answer 6

very advanced age >85y/o
more invasive surgery
recent inpatient hospital care

Question 7

advanced age by itself

Answer 7

does not exclude a person from SDS

elderly at 2x risk for intra-op CV events but less post-op pain, NV, dizziness risk. In general, have a lower rate of unanticipated admission

Question 8

factors that increase need for post-op admission following SDS - 6

Answer 8

1. > 65 y/o
2. OR time >120 minutes
3. +CV diagnosis (CAD, PVD, etc)
4. Malignancy - #cancerbleeds
5. HIV - r/t meds, give smaller doses of meds and monitors (midazolam)
6. GA or RA

Question 9

RELATIVE contraindications for outpatient surgery

Answer 9

1. uncontrolled systemic disease (DM, unstable angina, severe asthma, Pickwickian syndrome)
2. Central acting therapies (MAO-Is, cocaine, diet aids, ephedra)
3. Alcoholism
4. Morbid Obesity + Symptomatic CV/pulm dx (angina,asthma)
5. Morbid obesity + other co-morbidities
6. Lack of support at home post-op

Question 10

Post Gestational Age Cut-Offs for monitoring

Answer 10

Term infant: born after 37 weeks
PGA <46 weeks = 12 hrs monitoring

Pre-Term Infant: born before 37 weeks
PGA <60 weeks = 12 hrs monitoring

Question 11

fasting guidelines

Answer 11

2 hours for clear liquids 
4 hours for breast milk 
6 hours for formula, non-human milk
6 hours for a light solid meal 
8 hours heavy meal

Question 12

goals of laboratory testing

Answer 12

minimize lab testing - testing should be governed by information obtained from the patient’s history and physical examination

Question 13

after an URI

Answer 13

adults should consider delaying surgery for 6 weeks s/p URI because a inflow obstruction has been shown to persist for 6 weeks post URI

• but if a pt with a URI has a normal appetite, does not have a fever, or elevated RR, and does not appear toxic it is probably safe to proceed with the planned procedure

Question 14

meds before surgero

Answer 14

small water sips with meds up to 30 minutes before surgery

Question 15

IV acetaminophen details

Answer 15

give at end of case so that it is working in post-op period.

Peak 30-60 minutes,
DOA: 4-6 hours,
block substance P in SC and NMDA receptor antagonist.

Question 16

surgeries that increase the risk of PONV

Answer 16

Breast/obGYN
laparoscopy
lithotripsy 
major breast surgery 
ENT

Question 17

factors that increase PONV

Answer 17

young women, 
non-smoker 
hx of motion sickness
hx of PONV 
within 1 week of menstraul cycle 
anxiety

Question 18

versed will reduce

Answer 18

PONV

Question 19

anti-cholinesterase will increase

Answer 19

r/f PONV (neostigmine)

Question 20

phenothiazines for nausea (promethazine/phenergan)

Answer 20

are not used because: they can affect anesthetic, caused delayed awakening, and EPS.

Also are C/I in children under 2

Question 21

seabed and relief band work by

Answer 21

accustimulation of P-6 accupoint, can be more effective than anti-emetic drugs.

Question 22

for d/c from amb. surg, pt V/S must be

Answer 22

within 20% of normal

Question 23

bier block is used for

Answer 23

upper or lower extremity surgery lasting <60 minutes

Question 24

functional balance after a spinal may be impaired

Answer 24

for 150-180 minutes

Question 25

criteria for fast track eligibility

Answer 25

awake, alert, oriented
able to move extremities on command 
VS within 15% - 20% of normal 
Sa02 >94% on RA
able to breathe deeply 
no pain, nausea, or vomiting 
5 second head lift, if given NMB

Question 26

most common reasons for delayed surgery

Answer 26

1. drowsiness
2. nausea/vomiting
3. pain

Question 27

benefits to lap surgery

Answer 27

1. lower pain scores/opioid requirement
2. earlier ambulation
3. lower incidence of post-op ileum
4. usually faster recovery
5. reduce post-op pulm/diaphragmatic dysfunction
6. lower stress response “theoretical”
7. lower cost

Question 28

relative contraindications to lap surgery

Answer 28

1. increase ICP
2. hypovolemia
3. V/P shunt- peritoneal jugular shunt, ok if there is a unidirectional valve
4. severe CV disease
5. severe respiratory disease

Question 29

intra-abdominal pressure less than

Answer 29

15 mmHg or 20 cmH20 minimize CV and respiratory impacts

Question 30

PaCO2 progressively rises with insufflation

Answer 30

to reach a plateau of 15-30 min,

Question 31

greater absorption of CO2 with certain procedures

Answer 31

pelvic > gastric