Outpatient Flashcards
How is cost affected by outpatient facilities?
- Deceased financial burden to patient
- 3rd party payer can identify suitable procedures to reduce costs
How is the medical field affected outpatient centers?
- ↑ inpatient beds
- ↓ noscomial infections
What are some social advantages of outpatient?
- ↓ interuption of ADLs
- Care from parents/caretakers ↓ anxiety,confusion and pain
Staffing advantages of outpatiens.
- Uniform schedules
- Efficient time utilization
- Predictable outcomes
Disadvantages of outpatient facilities.
- ↓ privacy
- Multiple screening trips
- Need for home care
- Patient compliance
- ↓ orientation time
- ↓ post op observation
What is the only age limit for outpatient?
Premature babies
What is the typical length of surgery for outpatient
- Less than 2 hours
- Not to exceed 4 hours
Most common surgeries at outpatient facilities?
- Opthalmologic
- Gynecological
What procedures are acceptable for outpatient?
- Minimal blood loss
- Minimal fluid shifts
- High surgeon skill
- Low post op pain
Why are premies not appropriate for outpatient?
- Anemia
- Underdeveloped gag reflexes
- Temperature control
- Apnea
3 types of premie apnea.
- Short (6-15 sec)
- Prolonged (>15)
- Periodic breathing
What can apnea lead to, and when?
- Hypoxemia and bradycardia
- As late as 12 hours post op
When can a premie be an outpatient?
-50-60 weeks post conceptual age
What disorders of an infant prevent them from being outpatient?
- Bronchopulmmonary dysplasia
- SIDS risk (until 1 year)
Children should be free from bradycardia and apnea for how long before surgery?
6 months
What kind of age should you consider?
Physiologic not chronologic age
Those 85 yo and greater are at a great risk of what the week following surgery?
-Hospital admission and death
A patient w/ convulsive disorder or MH susceptibility must be scheduled when?
-Early in the day for longer obs
What must be managed carefully w/ cystic fibrosis?
- Respiratory distress
- Hydration
When is obese patients acceptable for outpatient?
ASA class 1 or 2
When can sickle cell crisis begin?
- Hypoxia
- Acidosis
- Dehydration
Sickle cell criteria for outpatient
- No organ disease
- No crisis in the past year
- Compliant medical care
Social considerations for outpatient
- Patient compliance
- Responsible caregiver
- Discharge accomadations
Unacceptable patients conditions for outpatient?
- Unstable ASA 3 or 4
- Active substance abuse
- Physcosocial problems
- Seizures
- Untreated sleep apnea
- Uncontrolled diabetes
- Isolation needs
- Pain not controlled w/ oral meds
How old can the H&P be?
- 30 days for stable
- 72 hours for high risk
Lab values can be how old?
60 days if stable
- K 7 days if on diuretic/digitalis
- Glucose morning of surgery
CXR in downs is looking for what?
subluxation of atlantoaxial junction
Indications for EKG
- CV disease
- Murmur
- HTN
- Over 40 yo
- Family history long QT
- Sleep apnea
- Anatommic airway obstruction
Patients that take ACE inhibitors may need what?
Vasoprressin for low BP
2 types of noninfectious runny nose?
- Allergic (seasonal)
- Vasomotor (crying)
2 types of infectious runny nose?
- Viral (common cold)
- Bacterial (strep)
Symptomatic URTI should be rescheduled when?
4 weeks later
Asymptomatic URTI can be done if?
- Child older than one
- Surgery not on thorax or abd
- No ETT planned
Anesthesia can increase respiratory complication how much?
2-7 fold
Risk factors for URTI bronchspasm / comlications?
- < 5 yo
- Premature
- 2nd hand smoke
- Secretions
- Nasal congestion
- ENT sx
- Reactive airway disease
Common aspiration prophylaxis?
- Antacids
- Gastrokinetics
- H2 agonists
- PPI
General anesthesia in SDS.
- Short acting
- Rapid onset / offset
- NSAIDS
- Minimize physiologic changes
- Minimize post op side effects
Why is ETT use minimized?
- Post op croup
- Sore throat
- ↓ ability to resume PO
When to give fluids?
- Procedure > 30 min
- Procedures with ↑ PONV and pain
- Prolonged fasting
- Bleeding
- ABX
Advantages of regional anesthesia.
- Shorter recovery
- ↓ inpatient admission
- Post op pain relief
- GA alternative
Regional disadvantages.
- Patient / surgeon cooperation
- More time needed
- Orthostatic Hypotension
- Inability to pee
- PDPH
Common post op complications
- Nausea / vomiting
- Pain
- Peds
- Certain Procedures
Major postop morbidities
- MI
- Stroke
- PE
- Respiratory failure
What increases PONV
- Ambulation
- Postural Hypotension
- Pain
- Meds
- Oral intake
- low O2
- Reversal agents
What increases PONV?
- HX of PONV
- Mandibular sx
- Eye sx
- Plastic sx
What can help PONV?
- Decadron
- Droperidol
- Ephedrine
- Reglan
- Zofran
- Phenergan
- OG tube
4 items to help post op pain
- Regional
- NSAIDS
- LA wound infiltration
Post op phase 1
- VSS
- Off O2
- Sit in chair
- Protect airway
- Oriented
Post op phase 2
- Responsible caregiver
- pain controlled
- PONV minimal
- Void
- No resp distress
In MAC case, a patient must be able to
- Protect airway
- Breathe independently
- No LOC
ASA guideline for MAC
- Pulse Ox
- ECG
- BP
- Temp
- Capnography
Incidence of brain damage / death is higher in MAC or General?
MAC
Deep sedation is signified by what?
- Not easily aroused
- Responds to painful stimuli
- May need assistance w/ airway
- CV unaltered
What is the difference between MAC and moderate sedation?
- Moderate sedation can be directed by physician performing procedure
- MAC must have anesthesia personal
What things can cause delayed awakening
- Prolonged anesthesia
- Metabolic causes
- Neurologic injury
Most common cause of hypotension?
Hypovolemia
Hypothermia causes what?
Venoconstriction
What causes PAC and PVC’s
- Hypomag
- Hypokalemia
- ↑ sympathetic tone
- Myocardial ischemia
What is first line / 2nd line treatment for laryngospasm?
- Positive pressure
- Succs
Droperidol concerns
dont give QT prolongation
What is a D&C used for?
- Removal of endometrial lining
- Spontaneous abortion
- Cervical stenosis
- Bleeding
What position of D&C?
Dorsal lithotmy (<40 degrees)
Meds for D&C bleeding?
- Methergine
- Oxycotcin (uterus contraction)
Causes of severe post op bleeding in D&C?
- Cervical injury
- Uterine atony / Perf
- Retained conception products
What is a hysteroscopy?
- Allows exam of endometrial cavity
- Diagnose uterine bleed
Distension may be needed in hysteroscopy, what can be used?
- NS
- Sorbitol
- Mannitol
- CO2
What type of needle reduces risk of PDPH?
-pencil point
What sensory level for hysteroscopy?
T10 belly button
Reasons for TMJ surgery?
- Ankylosis
- Tumor
- Chronic dislocation
- osteoarthtitis
- Painful disc dislocation
TMJ Complication
- Facial and trigeminal nerve damage
- Hearing loss
- Vertigo
- Ear fullness
- Hemorrhage
Why TMJ arthroscopiclly?
- Better blood and lymphatic flow
- Less periarticular tissue disruption
People needing GA for dental surgery?
- MR
- Children
- Oral sepsis
- Seizures
- TMJ
What will lingual nerve damage cause?
Tongue numbness
What will alveolar nerve damage cause?
Lip numbness
What is horner’s syndrome and when do you get it?
- Droopy eyelid
- Interscalene block
A mouth gag can cause what?
-ETT kinks and dislodgement
What to check after gag?
- Obstructions
- BBS
- Chest movement
- PIP
Where is ETT secure for T and A?
Midline lower lip
Hypercapnia can cause vasodilation and cause what?
increased bleeding
What is the most common arthroscopic procedure?
Knee
Most common complication of knee arthroscopy?
-Hemarthrosis
Where is knee trocar placed?
-Lateral and medial to patellar
