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PRINCIPLES > OUT-PATIENT SURGERY > Flashcards

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
Q

PONV

VOMITING CENTER

A

CTZ = chemoreceptor trigger zone

area postrema of brainstem

stimulated by noxious stimuli

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26
Q

PONV

NOXIOUS STIMULI CAUSED BY US (8)

A

OPIOIDS

PAIN

MOTRIN

HYPOVOLEMIA

LONGER ANESTHESIA TIME

TYPE OF GAS/ANESTHETIC AGENT

TYPE OF SURGICAL CASE

PREOP ANXIETY

27
Q

PONV

LABEL EACH BIG LETTER

A

A. vomiting center (medulla

B. higher cortical centers

C chemoreceptor trigger zone (area prostrema, 4th ventricle)

D. stomach & small intestine

E. labyrinths

28
Q

PONV

LABEL EACH NUMBER

A
  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
Q

PONV

LABEL EACH small LETTER

A

a. benzodiazepines
b1. histamine antagonists
b2. muscarinic antagonists

b3 dopamine antagonists

b4 cannabinoids

c 5HT3 (serotonin) antagonist

d. sphincter modulators
e. gastroprokinetic agents

30
Q

PONV

PREDICTING FACTORS

SURGICAL: 9

A

GYN / plastic / bowel / breast / tooth extraction / laparoscopies / strabismus / PE tubes / long surgery

31
Q

PONV

PREDICTING FACTORS

MEDICATIONS (7)

A

opioids / inhalation anesthetics / N2O / barbituates / etomidate / ketamine / anticholinesterases

32
Q

PONV

PREDICTING FACTORS

PATIENT (12)

A

child / female / obesity / pain / anxiety / gastroparesis / DM / pregnant / non-smoker / current menses / hx motion sickness / previous PONV

33
Q

PONV

PREDICTING FACTORS

POSOP (4)

A

hypovolemia / hypotension / rapid position changes / pain

34
Q

PONV

RISK ASSESSMENT

LOW:

MEDIUM:

HIGH:

NOTE: Tx of PONV pre & intraop will be based on risk

A

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
Q

PONV

TREATMENT BASED ON RISK & RESCURE THERAPY

A

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
Q

PONV

MEDICATIONS

5HT3 - SRA (3)

SEROTONIN RECEPTOR ANTAGONIST

A

ZOFRAN

ANZEMET

KYTRIL

37
Q

PONV

MEDICATIONS

DOPAMINERGIC ANTAGONIST (4)

A

DROPERIDOL

COMPAZINE

PROMETHAZINE

REGLAN

38
Q

PONV

MEDICATIONS

HISTAMINE ANTAGONIST (1)

A

PROMETHAZINE

39
Q

PONV

MEDICATIONS

MUSCARINIC ANTAGONIST (2)

A

PROMETHAZINE

SCOPOLAMINE

40
Q

PONV

MEDICATIONS

OTHERS (9)

A

HALDOL

BENADRYL

DRAMAMINE

ATARAX

ANTIVERT

PROPOFOL - WHEN USED AS TIVA

EPHEDRINE

MARINOL

CESAMET

41
Q

PONV

MEDICATIONS

CHILDREN (6)

A

ZOFRAN

DOLASETRON

DECADRONE

DROPERIDOL

DRAMAMINE

PERPHENAZINE

42
Q

PONV

OTHER TREATMENTS

ACCUPUNCTURE - WHERE

A

P6

BTW flexor carpi radialis tendon &

palmaris longus tendon

43
Q

PONV

PREVENTION

CONSIDERATIONS BY SOCIETY FO AMBULATORY ANESTHESIA (4)

A
  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
Q

PONV

PREVENTION (4)

A
  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
Q

PONV

PREVENTION

SAFE ANALGESICS (3)

NOTE: if use opioids then give adequate amount since pain does cause nausea

A
  1. ketorolac
  2. acetaminophen
  3. NSAIDS
46
Q

OBSTRUCTIVE SLEEP APENA

OSA

DEFINE:

DIAGNOSIS:

TYPES (3):

A

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
Q

OSA

ANATOMY

A

elongated & enlarged soft palate

recessed jaw pushes enlarged tongue posteriorly impeding the hypopharynx

hyoid bone positioned more inferiorly

48
Q

OSA

PHYSIOLOGIC CHANGES (7)

A
  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
Q

OSA

CLINICAL FEATURES (7)

A
  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
Q

OSA

TYPICAL FEATURES (8)

NOTE: 2-9% OF ADULTS

NOTE: BMI = WT/HT2

A
  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
Q

OSA

SLEEP STUDY

COMPONENTS (10)

A
  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
Q

OSA

3 IMPORTANT MEASUREMENTS

A

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
Q

OSA

IDEAL AI

IDEAL RDI

MILD / MODERATE / SEVERE SLEEP APNEA

A

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
Q

OSA

WHAT DO I DO WITH SLEEP STUDY RESULTS ACCORDING TO THE ASA GUIDLINES (4)

A
  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
Q

OSA

_SCORING SYSTEM _

SEVERITY BASED ON SLEEP STUDY

NONE =

MILD =

MODERATE =

SEVERE =

SEVERITY WITHOUT SLEEP STUDY

A

0

1

2

3

2- if have clinical s/s that point to OSA

56
Q

OSA

SCORING SYSTEM

INVASIVENESS OF SURGERY

0

1

2

3

3

A

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
Q

OSA

SCORING SYSTEM

ESTIMATED NEED FOR POSTOP OPIOIDS

0

1

3

A

0 = NONE

1 = LOW DOSE ORAL

3 = HIGH DOSE ORAL / PARENTERNAL

58
Q

OSA

SCORING SYSTEM

ADD THEM UP HOW (2 OPTIONS)

WHICH ONE WILL BE YOUR OSA SCORE

ON WHAT CONDITION CAN YOU SUBTRACT 1 POINT

A
  1. severity + invasiveness
  2. severity + opioid

which ever is highest

may subtract one point if pt on CPAP & will use it

59
Q

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.

A

4 = at increased perioperative risk

5 = significantly increased perioperative risk & not a candidate for freestanding out-pt surgery center

60
Q

OSA

MANAGING THE OSA PATIENT

  • PREOP
  • WHEN EXTUBATE
  • MEDS
  • WHICH TYPE SEDATION BETTER
A
  • 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
Q

OSA

MANAGING THE OSA PATIENT

  • IN RECOVERY (3)
  • DISCHARGE CRITERIA (3)
A
  • 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
Q

PACEMAKERS

CARDIOLOGY NOTE MUST DESCRIBE (3)

ASSESS (4)

BOVIE (2)

WHAT NEED AVAILABLE (2)

POST PROCEDURE (2)

A
  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

  1. magnet & transcutaneous pacer
  2. must assure pacemaker working properly before d/c

if put on magnet, have it interrogated to assure proper function

63
Q

AICDS

  • ASSESS (3)
  • WHAT NEED IF COMBINED PACER (3)
  • LOOK UP…OR CONSULT…
  • BOVIE (2)
  • MAGNET (2)
  • COMBO CONSIDERATION
A
  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

  1. it will turn off AICD arrhythmia detection & shocking

if used then monitor for VFib & have DeFib ready

  1. pacemaker will not be made asynchronous, can still be inhibited by EMI, dangerous in a pacemaker dependent patient
64
Q

STENTS

  • BARE METAL STENTS
  • DRUG ELUDING STENTS
  • ASA
  • PLAVIX
  • EMERGENCY SURGERY
  • S/S MI
  • PLAVIX STUDIES
A
  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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