Mod11: Office-Based Anesthesia Flashcards
Office-Based Anesthesia
What is Office-Based Anesthesia (OBA)?
Anesthesia that is performed in a location, usually an office or procedure room, that is not accredited or regulated by a state agency as an ambulatory surgery center, and may have no accreditation at all
Office-Based Anesthesia
Who is doing office-based procedures?
Plastics - Dental - Ortho/podiatry
GI endoscopy - GYN/GU
Ophthalmology/Otolaryngology
Office-Based Anesthesia
In 2005 (13 years ago), what percentage of outpatient procedures were office-based?
24%
Office-Based Anesthesia
What are advantages of Office-Based Anesthesia?
Cost containment (facility fee)
Ease of scheduling (avoids multiple layers of scheduling)
Convenient for both patient & surgeon
Decrease exposure to nosocomial infections
Improved patient privacy
Continuity of care
Office-Based Anesthesia
Disadvantages of Office-Based Anesthesia mainly relate to issues addressing patient safety & peer review. What are some of those issues?
Absence of regulations regarding certification of surgeon or anesthesia provider
Surgeon/anesthesia provider performing procedures for which they have little or no training
Should be a system in place for monitoring CME, PEER reviews, performance improvement (Quality Assurance Committee)
May be absence of documentation, policies, & procedures, and of reporting adverse outcomes
Office-Based Anesthesia
True or False: GA is a state that does not regulate office-based surgery
True
Office-Based Anesthesia - Office Safety
What are the various causes of injury & death?
Obsolete and/or malfunctioning anesthesia machines
Not serviced routinely - Alarms malfunction
Inadequate monitoring
Lack of pulse oximetry most common
Inadequate resuscitation equipment
Inadequate pre- or postoperative evaluation
Pts not optimized to be done in an office
Local anesthesia toxicity (plastics)
Human error*
Use of reversal drugs with short-half lives
Office-Based Anesthesia - Office Safety
What is the most common monitoring deficiciency in office setting?
Lack of pulse oximetry
Office-Based Anesthesia - Office Safety
What is a common safety concern in plastic centers?
Local anesthesia toxicity
Office-Based Anesthesia - Office Safety
What is the biggest cause of injury and death?
“Human error”
Office-Based Anesthesia - Office Safety
What safety concern is associated with the Use of reversal drugs with short-half lives
Resedation after the reversal wares of
Office-Based Anesthesia - Office Safety
Which specific human errors are a major safety concern?
Slow recognition/response to an event
Hyoxemia - Hypovolemia - Occult blood loss during lengthy procedure
Lack of experience
Drug overdosage (most commonly local anesthetics)
Office-Based Anesthesia - Office Safety
What’s the most common drug overdose in Office-Based Anesthesia
Local anesthetics
Office-Based Anesthesia - Patient Selection
Why must patients be “medically optimized”
Because of the risks associated with OBA
Office-Based Anesthesia - Patient Selection
When should a Preoperative evaluation be completed prior to office-based procedure? What should it include?
Within 30days
Should include:
History & physical examination
Pertinent labs obtained
Medically indicated consults completed
Office-Based Anesthesia - Patient Selection
Why must ANESTHETIC COMPLICATIONS BE AVOIDED?
Office location is often remote
Anesthesia provider may be unable to get assistance should it be required
Office-Based Anesthesia - Patient Selection
Which patients are poor candidates for Office-Based Anesthesia?
Poorly controlled DM
Anticipated significant blood loss
Significant postoperative pain
History of substance abuse
Seizure disorder
MH susceptibility
Potential difficult airway (Mallampati IV)
Morbidly obese/OSA: Unable ventilate - Sensitive to respiratory depressant effects of sedatives/analgesics
NPO < 8hrs
Significant drug allergies
Risk for pulmonary aspiration
Office-Based Anesthesia - Patient Selection
What ASA score is ideal candidates for Office-Based Anesthesia?
ASA 1 or 2
Office-Based Anesthesia - Office Selection
Which type of anesthetic technique must the ideal office setting be appropriately equipped and stocked to perform?
General Anesthesia
Office-Based Anesthesia - Office Selection
Which Airway supplies must be available?
Nasal cannulas - Oral/nasal airways - Face masks
Self-inflating bag-mask ventilation devices (Ambu)
Laryngoscopes (multiple sizes & styles)
Various sizes tracheal tubes
Intubating stylettes
Office-Based Anesthesia - Office Selection
Which Emergency/difficult airway equipment (ASA Difficult Airway Algorithm) equipments must be available?
LMA’s
Cricothyroidotomy kit
Means for transtracheal jet ventilation
Office-Based Anesthesia - Office Selection
What do you have along with your Anesthetic drugs, which would allow you to administer IV drugs?
Vascular cannulation equipment
Office-Based Anesthesia - Office Selection
Which Emergency drugs must you have available?
ACLS
Dantrolene & MH supplies
Office-Based Anesthesia - Office Selection
Which drugs must you have available if you suspect a potential for an MH crisis?
Minimum 12 bottles of Dantrolene (per MHAUS)
Must be prepared to begin the initial treatment
Office-Based Anesthesia - Office Selection
What are Perioperative monitoring standards for Office-Based Anesthesia?
NIBP
(with assortment of cuff sizes)
Heart rate/EKG
Pulse oximetry
Temperature
Perioperative monitoring must adhere to the ASA &/or AANA Standards for Basic Anesthetic Monitoring
Office-Based Anesthesia - Emergencies
What should you have in place if a complication or Emergency occurs?
Establishment of a written plan for emergency transport of the patient to a comprehensive care center if a complication occurs
Office-Based Anesthesia - Emergencies
Which Emergencies must you have contingency plans for?
Bomb threat
Power loss/electrical failure
Equipment malfunction
Loss of O2 supply pressure
Cardiac/respiratory arrest
Natural disaster (fire/earthquake/hurricane)
MH - Massive blood loss
Office-Based Anesthesia - Procedure Selection
What should the maximum lenght for an Office-Based procedure be?
6hrs
Office-Based Anesthesia - Procedure Selection
When should and Office-Based procedure be completed?
By 3pm
Must be completed ideally when there is still staff in the office
Office-Based Anesthesia - Procedure Selection
Which potential intraop complications are contraindications for Office-Based procedure?
Hypothermia
Anticipated blood loss
Significant fluid shifts
Common Office-Based Procedures
Which anesthetic techniques are appropriate for Office-Based Ophthalmology/otolaryngology procedures?
Topical anesthesia
Periorbital/retrobulbar block frequently used
Supplemental sedation may be required
Common Office-Based Procedures
What’s the minimum age requirements for a child to undergo OBA?
No minimum age requirements for a child to undergo OBA is established
Common Office-Based Procedures
Although there is No established minimum age requirements for a child to undergo OBA, what age should reasonable candidates be? with what ASA score?
> 6mos
ASA 1 or 2
Office-Based Anesthesia - Anesthetic Agents &Techniques
Why should you use anesthetic agents and techniques that allow the patient to be ready for discharge home soon after the completion of the procedure?
Maximize alertness & mobility
Minimize risks for the need for a prolonged PACU stay
(PONV - Pain)
Office-Based Anesthesia - Anesthetic Agents &Techniques
True or False: Any type of anesthesia may be used in the office setting.
True
MAC → Regional → General
Continuum, impossible to predict how patient will react
Office-Based Anesthesia - Anesthetic Agents &Techniques
What is the most commonly used anesthetic technique?
MAC sedation (IV)
Office-Based Anesthesia - Anesthetic Agents &Techniques
What are the beneficial characteristics of drugs used during MAC (IV sedation)?
Short half-lives
Inexpensive
Void of undesirable side effects (PONV)
Office-Based Anesthesia - Anesthetic Agents &Techniques
What are the most commonly used drugs for MAC (IV sedation)?
Midazolam - Fentanyl - Propofol - Meperidine
Office-Based Anesthesia - Anesthetic Agents &Techniques
Which Ultra-short acting analgesic used for MAC (IV sedation) increases the risk of PONV?
Remifentanil
Office-Based Anesthesia - Anesthetic Agents &Techniques
Which drug could be used for Anesthesia & analgesia
Does not depress respirations
is Not associated with N/V
is inexpensive
is a/w Hallucinations/secretions*?
Ketamine
Office-Based Anesthesia - Anesthetic Agents &Techniques
Which drug decreases propofol requirements and can be used fo BP control during MAC (IV sedation)?
Clonidine
Office-Based Anesthesia - Anesthetic Agents &Techniques
True or False: MAC anesthesia is safer than GA in Office-Based Anesthesia
False
This is a False impression
Office-Based Anesthesia - Anesthetic Agents &Techniques
True or False: General Anesthesia cannot be administered safely in the office setting
False
General Anesthesia can be administered safely in the office setting
Office-Based Anesthesia - Anesthetic Agents &Techniques
What are advantages of GA in office settings?
Decreases risk of intraoperative airway obstruction
Pt movement does not distract surgeon
Eliminates “seesaw effect” of IV sedation
(especially if doing boluses over infusion)
Office-Based Anesthesia - Anesthetic Agents &Techniques
Which airway device could be used for “Light general anesthesia”?
Mask (TIVA + O2 mask, or Regular O2 mask w/ circuit strapped to the pt’s face
LMA (volatile agents through LMA, Typically Sevo: less irritating along with N2O)
Office-Based Anesthesia - Anesthetic Agents &Techniques
Which airway device is used to deliver Desflurane & Sevoflurane (N20)?
ET Tube
Office-Based Anesthesia - Anesthetic Agents &Techniques
Which drug is used to deliver TIVA?
Propofol
Office-Based Anesthesia - Anesthetic Agents &Techniques
What’s “Room Air General”?
Oxygen mask
Propofol (large dose) + Remifentanil
Office-Based Anesthesia - Anesthetic Agents &Techniques
Why is the use of BIS monitoring a/w decrease time to extubation & discharge readiness during MAC?
It leads to a Decrease total propofol usage during MAC
Office-Based Anesthesia - PACU
True or False: since Office-Based setttings often lack a Formal PACU, ASA/AANA standards for monitoring and documentation throughout the postoperative period may not be adhered to.
False
ASA/AANA standards for monitoring and documentation throughout the postoperative period must be adhered to regardless
Office-Based Anesthesia - PACU
In the absence of a recovery nurse, who should recover the patient?
Anesthesia
Staffing in recovery area must be adequate
Office-Based Anesthesia - PACU
Which monitoring is imperative in the PACU?
Pulse oximeter
Office-Based Anesthesia
True of False: Office-Based Anesthesia is slowing down
False
OBA rapidly expanding and poses unique challenges to the anesthesia provider
Office-Based Anesthesia
True or False: Regulation of office-based surgery have kept pace with the growth of OBA
False
Regulation of office-based surgery have not kept pace with the growth of OBA
Office-Based Anesthesia
What’s the main responsibility of the anesthesia provider in OBA?
To ensure every possible safety measure is afforded to their patients
Office-Based Anesthesia
Important websites
AANA Standards for Office Based Anesthesia.pdf
ASA Office Based Anesthesia Guidelines.pdf
