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OUT-PATIENT SURGERY Flashcards

1
Q

FACTS (5)

A
  1. 60-70% surgical procedures in US done in ASC
  2. popular in 1980s with response to rising health care cost
  3. cases increased with new anesthetics & less invasive procedures
  4. “fast tracking” b/c rapid recovery agents = less nursing hours = saving hospital money
  5. less disruptive to pt life
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2
Q

OUTPATIENT SURGICAL SERVICES

GENERAL

ORTHOPEDICS

PLASTICS

GASTROINTESTINAL

HEAD & NECK

OPHTHALMOLOGY

NEUROLOGY

GYNOCOLOGY

UROLOGY

A

GEN: laparoscopies, excision of mass, biopsies, cholecystectomies

ORTHO: carpel tunnel release, ORIFs, arthroscopies, ACL repairs

PLASTIC: breast, lipo, brow lifts, face lifts, rhinoplasty

GI: colonscopies, EGDs, dilatations

HEAD/NECK: tonsillectomies, ESS, dilatations, DLs

OPHTHAL: strabismus repair, oritotomies, citrectomies, corneal transplants

NEURO: pain pumps, stimulators, battery changes

GYN: D & Cs, recto/cystocele repair, hysteroscopies

URO: cystoscopies, biopsies, ereteral stents, bladder slings

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3
Q

WHAT NEED TO KNOW (4)

A
  1. FACILITY
  2. PATIENT
  3. SURGEON
  4. YOUR LIMITATIONS
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4
Q

WHAT YOU MUST KNOW

FACILITY

  • TYPES (2)
  • QUESTIONS TO ASK ABOUT ONE
  • FACTS ABOUT THE OTHER
A
  1. ATTACHED TO LARGER INSTITUTION
    - what is relationship
    - can specialist be called upon to consult electively or emergently
    - can patients be transferred directly
    - if so, you can do bigger cases for sicker patients
  2. FREE STANDING
    - limit type of surgery to manageable cases
    - no transfusions
    - no post op ventilation or ICU
    - STILL need std monitors, difficult airway equip, crash cart, MH cart
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5
Q

WHAT NEED TO KNOW

PLANNED SURGERY & ASSOCIATED REQUIREMENTS

POSSIBLITIES (3)

A

TRANSFUSION

POSTOP VENTILATION

POSTOP ICU

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6
Q

WHAT NEED TO KNOW

WHAT IS KEY?

A

PATIENT SELECTION

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7
Q

WHAT YOU MUST KNOW

PATIENT SELECTION (6)

A
  1. HEALTHY
  2. NO LIFE THREATENING ILLNESS
  3. OPTIMAL CONTROL OF SERIOUS MED ILLNESS
  4. SAFE POSTOP SITUATION/PLAN
  5. DISCHARGE TO RESPONSIBLE ADULT
  6. PATIENT NEEDS TO GO HOME AT END OF DAY
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8
Q

PREOP EVALUATION

THOROUGH BUT QUICK

TIME IS MONEY, BUT SAFETY IS KEY

CONSIDERATIONS (6 of 11)

A
  1. age

pediatric >45 weeks, preemie >60 weeks PCA

  1. weight

cachexia, obesity (OSA)

  1. sex

women LMP, risk of PONV

  1. V/S

hi/lo BP, irregular pulse, murmur, febrile

  1. labs

anything irregular

  1. Preop diagnosis

how does this affect anesthetic

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9
Q
A
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10
Q

PREOP EVALUATION

THOROUGH BUT QUICK

TIME IS MONEY, BUT SAFETY IS KEY

CONSIDERATIONS (last 5 of 11)

A
  1. planned procedure

peripheral, invasiveness, position, EBL

  1. med history

last dose, side effects w/ anesthetic

  1. allergy or sensitiity to meds
  2. past anesthetic / surgical history

problems, difficult airway, special request

  1. NPO status
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11
Q

PREOP EVALUATION

CARDIOVASCULAR CONSIDERATIONS (8)

A
  1. cv disease should be stable
  2. murmur requires abx
  3. stent?
  4. pacemaker/AICD?
  5. No uncontrolled CP
  6. CHF
  7. no MI w/in 3 months
  8. excercise tolerance
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12
Q

PREOP EVALUATION

RESPIRATORY CONSIDERATIONS (12)

A
  1. URI 2. cough
  2. rhinorrhea 4. TB
  3. recent bronchitis/pneumonia 6. asthma
  4. tobacco history 8. COPD
  5. DOE 10. RA sats
  6. PFTs 12. sleep study
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13
Q

PREOP EVALUATION

ENDOCRINE CONSIDERATIONS

A
  1. stable thyroid
  2. diabetes (BS controlled)
  3. hold/partial insulin
  4. CV/renal impairment
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14
Q

PREOP EVALUATION

HEPATORENAL CONSIDERATIONS (9)

A
  1. cirrhosis
  2. hepatitis
  3. ascitis
  4. ETOH history
  5. significant liver dz is contraindicated
  6. CRF
  7. HD
  8. last K+
  9. fluid balance
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15
Q

PREOP EVALUATION

HEME CONSIDERATIONS (5)

A
  1. hemophilia
  2. VWBs
  3. sickle cell
  4. low platelets
  5. chronic ASA or ibuprofen use
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16
Q

PREOP EVALUATION

NEURO CONSIDERATIONS

A
  1. seizure history
  2. meds
  3. CVA
  4. deficits
  5. aspiration risk
  6. TIAs
  7. syncope
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17
Q

PREOP EVALUATIONS

CHRONIC HABITS CONSIDERATIONS

A
  1. tobacco
  2. ETOH
  3. DA
  4. intoxicated or high
  5. unpredictable NPO
  6. drug interactions
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18
Q

PREOP EVALUATION

PHYSICAL EXAM (5)

A
  1. general appearance
  2. airway
  3. lungs
  4. heart
  5. extremeties

inspect & discuss for regional techniques

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19
Q

PREOP EVALUATION

SCREENING TEST (3)

NOTE: testing done before elective low-risk surgeries changes management in less than 3% of cases - so no more “ROUTINE” test

A
  1. BS for DM
  2. K+ for renal patients
  3. pregnancy according to institution
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20
Q

PREOP EVALUATION

SCREENING TEST

OTHER TEST FOR SPECIFIC PT POPULATIONS

Hgb/CBC for (4)

Electrolyes for (2)

Coags for (4)

A
  1. advanced age /. anemia / bleeding disorders / other hematologic disorders
  2. renal dz / endocrine dz
  3. bleeding disorders / renal dz / liver dz / endocrine dz / anticoag therapy
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21
Q

POSTOP MANAGAEMENT

PHASE 1

MONITORING (4)

MED ROUTE

DISCHARGED WHEN (5)

A
  1. ECG / O2 sat / BP / Oxygen

suction

  1. IV pain / nausea meds
  2. VS baseline / alert / intact reflexes / room air / return of sensory & motor function
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22
Q

POSTOP MANAGAEMENT

PHASE II

MONITORING (1)

MED ROUTE

DISCHARGED WHEN (5)

A
  1. BP in all positions
  2. PO pain meds
  3. ambulating / PO meds / voiding / instructions given / d/cd to responsible adult
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23
Q

POSTOP MANAGEMENT

ALDRETE SCORING SYSTEM

MUST BE > OR = 8 BEFORE DISCHARGE

WHAT ARE PATIENTS SIGNS (5)

WHAT IS HIGHEST SCORE

NOTE: 3 criterion for each with scores of 2, 1, or 0

A
  1. OXYGENATION
  2. RESPIRATION
  3. CIRCULATION
  4. CONSCIOUSNESS
  5. ACTIVITY

10

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24
Q

PONV

CONSIDERATIONS (5)

A
  1. >30% pt will have it
  2. delays discharge = >nursing care = >hospital cost
  3. compromise integrity of sutures
  4. distressing for patients and families
  5. may require admission
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25
PONV VOMITING CENTER
CTZ = chemoreceptor trigger zone area postrema of brainstem stimulated by noxious stimuli
26
PONV NOXIOUS STIMULI CAUSED BY US (8)
OPIOIDS PAIN MOTRIN HYPOVOLEMIA LONGER ANESTHESIA TIME TYPE OF GAS/ANESTHETIC AGENT TYPE OF SURGICAL CASE PREOP ANXIETY
27
PONV LABEL EACH BIG LETTER
A. vomiting center (medulla B. higher cortical centers C chemoreceptor trigger zone (area prostrema, 4th ventricle) D. stomach & small intestine E. labyrinths
28
PONV LABEL EACH NUMBER
1. memory / fear / anticipation 2. sensory input (pain / smell / sight) 3. chemotherapy 4. anaesthetics 5. opioids 6. chemotherapy 7. surgery 8. radiotherapy 9. surgery
29
PONV LABEL EACH small LETTER
a. benzodiazepines b1. histamine antagonists b2. muscarinic antagonists b3 dopamine antagonists b4 cannabinoids c 5HT3 (serotonin) antagonist d. sphincter modulators e. gastroprokinetic agents
30
PONV PREDICTING FACTORS SURGICAL: 9
GYN / plastic / bowel / breast / tooth extraction / laparoscopies / strabismus / PE tubes / long surgery
31
PONV PREDICTING FACTORS MEDICATIONS (7)
opioids / inhalation anesthetics / N2O / barbituates / etomidate / ketamine / anticholinesterases
32
PONV PREDICTING FACTORS PATIENT (12)
child / female / obesity / pain / anxiety / gastroparesis / DM / pregnant / non-smoker / current menses / hx motion sickness / previous PONV
33
PONV PREDICTING FACTORS POSOP (4)
hypovolemia / hypotension / rapid position changes / pain
34
PONV RISK ASSESSMENT LOW: MEDIUM: HIGH: NOTE: Tx of PONV pre & intraop will be based on risk
LOW: 20-40% = 1-2 episodes/risk factors/no history MEDIUM: 40-80% = \>2 episodes/historical risk factors HIGH: \>80% = multiple episodes & risk factors
35
PONV TREATMENT BASED ON RISK & RESCURE THERAPY
LOW: no treatment, reserve meds for rescue tx, save money MEDIUM: multimodal w/ 2 drugs (decadron & 5HT3 antagonist) or 5HT3 antagonist & droperidol preventive measures = avoid meds that cause PONV HIGH: regional anesthesia / TIVA / 3 drugs / prevention RESCUE: 5-HT3 if no prophylaxis Give remaing class of drug if combo prophylaxis given
36
PONV MEDICATIONS 5HT3 - SRA (3) SEROTONIN RECEPTOR ANTAGONIST
ZOFRAN ANZEMET KYTRIL
37
PONV MEDICATIONS DOPAMINERGIC ANTAGONIST (4)
DROPERIDOL COMPAZINE PROMETHAZINE REGLAN
38
PONV MEDICATIONS HISTAMINE ANTAGONIST (1)
PROMETHAZINE
39
PONV MEDICATIONS MUSCARINIC ANTAGONIST (2)
PROMETHAZINE SCOPOLAMINE
40
PONV MEDICATIONS OTHERS (9)
HALDOL BENADRYL DRAMAMINE ATARAX ANTIVERT PROPOFOL - WHEN USED AS TIVA EPHEDRINE MARINOL CESAMET
41
PONV MEDICATIONS CHILDREN (6)
ZOFRAN DOLASETRON DECADRONE DROPERIDOL DRAMAMINE PERPHENAZINE
42
PONV OTHER TREATMENTS ACCUPUNCTURE - WHERE
P6 BTW flexor carpi radialis tendon & palmaris longus tendon
43
PONV PREVENTION CONSIDERATIONS BY SOCIETY FO AMBULATORY ANESTHESIA (4)
1. no diff in efficacy of 5HT3 antagonist, droperidol,decadron 2. combo better than monotherapy 3. reglan is ineffective for PONV 4. older agents may be useful but have side effects dimenhydrinate, scopolamine, promethazine
44
PONV PREVENTION (4)
1. aggressive hydration - avoid hypovolemic baroreceptor-mediated BP swings with motion & ambulation. Prevent sympathetic activation of vomit center caused by hypoTN, & motion during hypovolemia 2. Avoid GA - use MAC or regional 3. Avoid neuromuscular blockade reversal - PONV via cholinergic mechanism 4. Positive pressure ventilation & intubation: risk for air in stomach, irritation of vagal receptors upper airway, pharynx, most important risk is reversal (neostigmine)
45
PONV PREVENTION SAFE ANALGESICS (3) NOTE: if use opioids then give adequate amount since pain does cause nausea
1. ketorolac 2. acetaminophen 3. NSAIDS
46
OBSTRUCTIVE SLEEP APENA OSA DEFINE: DIAGNOSIS: TYPES (3):
intermittent cessation of airflow at the nose and mouth during sleep apneas of 10sec duration 5x an hour 20-30 sec apneas, maybe 2-3min obstructive - physiologic central - cns mixed - both
47
OSA ANATOMY
elongated & enlarged soft palate recessed jaw pushes enlarged tongue posteriorly impeding the hypopharynx hyoid bone positioned more inferiorly
48
OSA PHYSIOLOGIC CHANGES (7)
1. Dec pleural pressure, increased afterload 2. vagal / brady / ectopic beats 3. systemic vasoconstriction 4. acute CO2 retention 5. cerebral dysfunction 6. loss of REM sleep 7. excessive motor activity
49
OSA CLINICAL FEATURES (7)
1. left heart failure 2. "unexplained" nocturnal death 3. pulmonary HTN 4. chronic hypoventilation 5. excessive daytime sleepiness 6. behavioral changes 7. restless sleep
50
OSA TYPICAL FEATURES (8) NOTE: 2-9% OF ADULTS NOTE: BMI = WT/HT2
1. male (4x more prevalent in med) 2. middle age 3. snoring 4. daytime sleepiness (picwickian syndrome) 5. witness apneas 6. moderate obesity BMI\>30 (7x more common in obese) 7. large neck circumference \>43cm 8. mild to mod HTN
51
OSA SLEEP STUDY COMPONENTS (10)
1. EEG 2. EOG (NREM vs REM) 3. oral, nasal airlfow 4. capnography 5. esophageal pressure 6. chest/abdominal movements 7. submental/extremity EMG 8. Pulse ox 9. NIBP 10. EKG
52
OSA 3 IMPORTANT MEASUREMENTS
AHI - apnea-hypopnea index = total # apneas/hypoapneas per hour lasting \>10sec -defines severity AI - total # of arousals from sleep/hr RDI - resp disturbance index = AHI + AI
53
OSA IDEAL AI IDEAL RDI MILD / MODERATE / SEVERE SLEEP APNEA
AI=5 or =10 for diagnostic purposes RDI = 5 MILD - AHI 6-20. lowest O2 sat \>85% MOD - AHI 21-40. lowest 80-85% SEVERE - AHI \>40 lowest \<80%
54
OSA WHAT DO I DO WITH SLEEP STUDY RESULTS ACCORDING TO THE ASA GUIDLINES (4)
1. identify patients at risk using sleep study or presume 2. determine severity 3. assess perioperative risk for procedure 4. recommend specific perioperative management
55
OSA _SCORING SYSTEM _ SEVERITY BASED ON SLEEP STUDY NONE = MILD = MODERATE = SEVERE = SEVERITY WITHOUT SLEEP STUDY
0 1 2 3 2- if have clinical s/s that point to OSA
56
OSA SCORING SYSTEM INVASIVENESS OF SURGERY 0 1 2 3 3
0=superficial / nerve block / no sedation 1 = superficial w/ GA / peripheral / block / mild sedation 2 = peripheral w/GA / airway surgery w/ mod sedation 3 = major with GA 3 = airway surgery w/ GA
57
OSA SCORING SYSTEM ESTIMATED NEED FOR POSTOP OPIOIDS 0 1 3
0 = NONE 1 = LOW DOSE ORAL 3 = HIGH DOSE ORAL / PARENTERNAL
58
OSA SCORING SYSTEM ADD THEM UP HOW (2 OPTIONS) WHICH ONE WILL BE YOUR OSA SCORE ON WHAT CONDITION CAN YOU SUBTRACT 1 POINT
1. severity + invasiveness 2. severity + opioid which ever is highest may subtract one point if pt on CPAP & will use it
59
OSA SCORING SYSTEM WHAT DOES SCORE MEAN IF 4 \>5 Keep in mind that this is ONLY a suggested tool for practitioners. It is not validated nor is it a recognized scoring system, it’s meant to help gauge what types of cases and patients with OSA are appropriate candidates for the out-patient setting.
4 = at increased perioperative risk 5 = significantly increased perioperative risk & not a candidate for freestanding out-pt surgery center
60
OSA MANAGING THE OSA PATIENT - PREOP - WHEN EXTUBATE - MEDS - WHICH TYPE SEDATION BETTER
- know what getting into. assess AFOI - have difficult airway equip ready - extubate full awake - GA better than deep sedation d/t loss of airway and epidural/regional better than IM/IV opioids w/ light sedation - short acting - use ketorolac, acetaminophen, oral NDSAIDS
61
OSA MANAGING THE OSA PATIENT - IN RECOVERY (3) - DISCHARGE CRITERIA (3)
- pulse ox until RA sat 90% during sleep - CPAP in PACU if possible - Sit patient up if possible - Room air O2 sat baseline - no hypoxemia at rest if left at rest for 3 hours - no airway obstruction at rest if left at rest for 3 hours (if it does occur, then need another 7 hours of monitoring)
62
PACEMAKERS CARDIOLOGY NOTE MUST DESCRIBE (3) ASSESS (4) BOVIE (2) WHAT NEED AVAILABLE (2) POST PROCEDURE (2)
1. indication for pacemaker / type,mode, settings / what happens with magnet application / pacer dependent? 2. no escape rhythm / capture / sense / pace properly 3. unipolar - inhibit pacemaker & cause device failure or malfunction with EMI - so put grounding pad far away use bipolar if possible 4. magnet & transcutaneous pacer 5. must assure pacemaker working properly before d/c if put on magnet, have it interrogated to assure proper function
63
AICDS - ASSESS (3) - WHAT NEED IF COMBINED PACER (3) - LOOK UP...OR CONSULT... - BOVIE (2) - MAGNET (2) - COMBO CONSIDERATION
1. med history / cause of insertion / implication to care 2. device info / cardiology not / or CXR to see ID 3. manufacturers recommendations or get cardiac lab to interrogate & manage device 4. unipolar- AIC may fire 2ndary to EMI - VFib bipolar or harmonic knife to avoid EMI interference 5. it will turn off AICD arrhythmia detection & shocking if used then monitor for VFib & have DeFib ready 6. pacemaker will not be made asynchronous, can still be inhibited by EMI, dangerous in a pacemaker dependent patient
64
STENTS - BARE METAL STENTS - DRUG ELUDING STENTS - ASA - PLAVIX - EMERGENCY SURGERY - S/S MI - PLAVIX STUDIES
1. no elective surgery \<1 mo post implant 2. no elective surgery \< 1 year post implant 3. continue if possible 4. D/C plavix as close to surgery as possble (5-7days) & resume immediately 5. if on plavix - give DDAVP, plt transfusion 6. assume stent thrombosis, rush to cath lab for angioplasty 7. no studies for ideal time to d/c plavix but at increased risk for cardiac events

PRINCIPLES (5 decks)

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