NORA Flashcards
Pros of ambulatory/office anesthesia
- cost 2. free up hospital beds 3. decrease waiting times 4. minimizes separation of children from parents 5. POCD decreased in elderly 6. benefit to staff: more uniform hours, and more predictable surgical outcomes
cons of ambulatory and office based anesthesia
- difficult to assess adequate post op care / compliance 2. more trips for pt to pre-op clinic for testing 3. less time to monitor pts for post-op complicatiosn 4. less time for children to build relationship/trust with provider
goals of ambulatory anesthesia
- provide fast, smooth onset of anesthesia 2. minimize s/e 3. allow rapid offset by using rapid acting, short half life drugs 4. provide analgesia and amnesia 5. get pts home quickly and back to regular eating and sleeping schedules
surgeries that appropriate for the outpatient setting?
- those without frequent complications 2. those without a lot of post-op maintenace 3. those that are not associated with lg EBL/fluid shifts
patient status that is appropriate for outpatient anesthesia
- physical status stable for at least 3 months 2. medical issues not c/i for outpatient 3. pt has access to assistance at home/caregiver over night
surgeon skills/cooperation that is appropriate for outpatient anesthesia
- early referral to anesthesia for judgement of questionable patients 2. take into consideration skills and speed of surgery 3. anesthesia plan
what patients/situations are NOT appropriate for outpatient surgery/anesthesia
- Unstable ASA physical status classification (III/IV) 2. active substance/etoh abuse 3. psychosocial difficulties: caregiver not avail to observe on evening of surgeyr 4. poorly controlled seizures 5. morbidly obese with severe comorbidities 6. previously unevaluated and poorly managed mod to severe OSA 7. ex premature infants < 60 wks gestational age 8. uncontrolled DM 9. current sepsis or infectious dz requiring separate isolation 10. post op pain not expected to be controlled with oral or local analgesics
as an anesthesia provider, what questions would one ask for providing services in a new ambulatory facility or office?
- is the facility licensed? by whom? 2. is the facility accredited? by whom? 3. size of OR, recovery room, and preop are adequate for anesthesia and surgical procedures 4. is there a transfer agreement? 5. does the facility have an emergency service agreement? 6. available communication resources: telephone numbers accessible and posted for: EMS, MH hotline, and nearby hospital
special considerations with outpatient anesthesia: sickle cell dz
- ask all AA 2. no sickle cell crisis within 1 year 3. must be followed closely post-op 4. pt should live within 15 min of hospital or facility that can care for them 5. pt should be compliant with prescribed medical care
what is the test for sickle cell
sickledex
T/F: pts with sickle cell trait are still high risk for outpatient anesthesia
TRUE
sickling with sickle cell pts occurs with?
- hypoxia 2. dehydration 3. hypothermia 4. stress 5. pain
who is susceptible to malignant hyperthermia (in outpatient setting)?
- those with previous episode 2. massester rigidity 3. first degree relative with positive biopsy 4. dzs with known mutations to chromosome 19 5. heat induced rhabdomyolysis
what dzs have known mutations to chromosome 19 which make them more susceptible to malignant hyperthermia
- central core myopathy 2. native american myopathy 3. hypokalemic periodic paralysis 4. king denborough dz
there must be ____________ vials of dantrolene available in the outpatient setting in the case of malignant hyperthermia
36
if a patient develops malignant hyperthermia in the outpatient setting, what should you do?
- help to draw up vials of dantrolene 2. emergency transfer to hosptial
s/sx of malignant hyperthermia
- increased HR and BP 2. masseter rigidity 3. dark urine 4. increased EtCO2 5. elevated Temp (late sign)
if a patient presents to outpatient setting for surgery and you ask why they have their pacemaker, and their response is “to prevent my heart stopping” or “to prevent lethal arrhythmias” how should you proceed
cancel the case - this pt’s procedure should only be done in the hosptial
what is the most common interference to pacemakers and AICDs
monopolar electrocautery
if a patient presents to the outpatient setting for surgery/anesthesia with a cardiac electronic device, what questions should you ask them about it?
- why do you have the device 2. are there underlying issues 3. how often are you paced?
if a pt presents with pacemaker to outpatient surgery, what things must the anesthesia provider ensure?
- there is over 3 months of battery left on pacemaker (through records) 2. a magnet is readily available for the surgery 3. if bipolar cautery is used grounding pad is below the umbilicus 4. pacer should have been interrogated in the last year
anesthesia should ensure of what things when a pt presents for outpatient surgery with an AICD
- magnet available for surgery 2. AICD was integrated within last 6 months (identify through records) 3. bipolar cautery is used, grounding pad below umbilicus
how do you know a magnet has placed an AICD or pacemaker in asynchronous mode
you will put your stethoscope down and hear beeping
T/F: uncomplicated morbidly obese patient is an appropriate candidate for select outpatient surgery
TRUE
questions to ask when pt presenting for outpatient surgery/anesthesia is obese?
- are there comorbidities optimized? 2. do they use CPAP machine? 3. how invasive is the surgery? 4. is the surgery associated with high post-op pain which requires opioids?
STOP-BANG score of > ________ is highly suggestive of OSA?
3
you can safely do outpatient surgery/anesthesia in the obese patient with BMI of = ___________
44
when is the outpatient surgery, pre-op anesthesia assesment usually performed
day of surgery
what questions do you ask in a pre-op pt phone interview for patient presenting for outpatient surgery?
- any cardiac issues? - MI in the past 60 days? 2. cardiac clearance - implanted devices? Able to lie flat? SOB? 3. any pulmonary issues? smoking hx 4. neuro - SC injury? MG, MS, MD, strokes, brain tumor, dementia or seizures? 5. DM? thyroid issues? 6. any blood thinners or coagulation dz? 7. cancer? 8. addiction issues? 9. anesthesia issues? - difficult airway, trach, prolonged intubation, MH
what is the number one reason for hospital admission after outpatient anesthesia?
nausea and vomiting
what is the 2nd most common reason for hospital admissions after outpatient anesthesia?
pain
a pt presents for outpatient surgery, and has chronic pain, you know this patient may have to be admitted to the hospital post-op due to what?
- over sedation issues 2. inadequate pain control
most common pediatric outpatient surgeries?
- myringotomy 2. tonsillectomy 3. adenoidectomy
outpatient, pediatric ear tube surgery (myringotomy), are very fast thus can be done with or without __________________
PIV
pediatric outpatient dental procedures, anesthesia considerations
- N20 2. oral midazolam 3. some may have to have full oral rehab requiring ETT 4. some surgeries require throat packs (aspiration)
outpatient anesthesia considerations for the pediatric strabismus surgery/eye muscle surgeries
high incidence of postop N/V
outpatient pediatric orthopedic procedure anesthetic technique
- MAC 2. regional 3. LMA 4. ETT
pediatric outpatient preop
- check teeth for food/gum to ensure NPO status 2. allergies - ask about balloons at bday parties for latex 3. any congenital heart issues? - if yes, are they corrected? 4. ASthma? when was last exacerbation? 5. Acute respiratory infection?
pediatric outpatient preop may be done over the phone with parent if the child is a ASA ___________ or _________
I/II
pediatric outpatient pre-op assessment the parent says the childs last asthmas exacerbation was 2 weeks ago, how should you proceed?
delay or move surgery to inpatient - last exacerbation cannot be within a month for outpatient setting
in pediatric outpatient pre-op assessment the pt has what looks like cookies in their teeth, how should you proceed?
delay for 8 hours minimum
what is the risk with doing a pediatric outpatient procedure if they have had an upper respiratory infection in the last 6 weeks?
more likely to have some kind of airflow obstruction
why are surgeries on premie babies that are under 50-60 weeks post gestational age not done in the outpatient setting?
- apnea risk d/t immature brainstem/periodic breathing –> apnea up to 12 hours 2. anemic associated apnea 3. immature temperature control
T/F: PACU must be available to recover the outpatient pediatric patient post op or you have to stay with the pt until PACU RN is available
TRUE
Advantages to regional anesthesia in ambulatory surgery?
- peripheral nerve block recovery times are shorter than with GA 2. unanticipated admission to the hospital is reduced 3. phase I recovery bypass eligibility is high 4. provides adequate postop pain relief and better than with GA 5. good alternative for pt who does not like loss of control with GA
what are some guidelines of outpatient plastic surgery?
- pt must have compression stockings on prior to induction 2. ASA I and II appropriate 3. ASA III must be seen preoperatively 4. females of menstrual age = blood hcg NOT urine 5. if surgery >4 hours, foley placement
Anesthesia considerations with breast augmentation
- secure arms when sitting up to check breast symmetry 2. Local MAC or GA appropriate
anesthesia considerations with nose reshaping/rhinoplasty
- can be difficult mask ventilation d/t no pressure allowed on the nose 2. Oral RAE ETT 3. Local MAC
anesthesia considerations with facelift, midface, or neck plastic procedure
- local MAC or GA 2. full face/neck procedure - no LMA d/t disortion of neck 3. must keep HD stable at conclusion of the case 4. multimodal PONV control 5. HOB 90 degrees
rule of thumb on EBL with liposuction?
blood loss = 1% of aspirate
complications with liposuction
- local anesthetic toxicity 2. PE/DVT 3. massive fluid/electrolyte shifts
liposuction aspiration must be limited to ________ L
5
peak lidocaine levels after liposuction are ___________ hours after injection
14-Dec
what is the maximum lidocaine dose for office based liposuction
7 mg/kg
what is the tumescent liposuction technique
- 1 L of LR or NS with epi 1:1,000,000 and lidocaine 0.025-0.1% 2. you do 1-4 mL of the infiltrate above per 1 ml of fat removed
___________________ is the most cardio-toxic local anesthesic
bupivicaine
what is local anesthetic systemic toxicity (LAST)
- when large amounts of local anesthetic reach systemic circulation 2. likely to cause cardiac toxicity d/t electrophysiological and contractile dysfucntion
what are the early s/sx of local anesthetic systemic toxicity (LAST)
- perioral numbness 2. tinnitus 3. agitation 4. confusion
what are the late s/sx of local anesthetic systemic toxicity (LAST)
- CNS depression 2. seizures 3. coma 4. complete CV collapse
how do you tx pt with Local anesthetic systemic toxicity (LAST)
- supportive care 2. infusion of 20% intralipid emulsion
if your patient is > 70 kg, and you suspect LAST, how would you administer the lipid emulsion infusion
- bolus 100 mL over 2-3 min 2. infusion of 200-250 mL over 15-20 min
if you patient is < 70 kg and you suspect LAST, how would you administer the lipid emulsion infusion?
- rapid bolus of 1.5 mL/kg over 2-3 min 2. infusion of 0.25 mL/kg/min
anesthetic considerations for dental anesthesia
- state dental boards requirements for dentist to hold sedation permits may limit the types of drugs that can be administered by CRNA 2. shared airway 3. throat packs must be changed before they are saturated 4. trigeminal nerve pain may require more sedation 5. glycopyrolate may be necessary 6. no water boarding 7. HOB > 30 8. dentists/surgeons are not doing anesthesia preop - thus CRNA must perform it
