Outpatient Anesthesia Flashcards
__ to __% of all procedures in the US performed on outpatient basis. This has increased the need for anesthetists and short acting anesthetics
60-70%
Advantages of outpatient setting
reduced costs, increases number of inpatient beds available, decreaseded exposure to nosocomial infections, minimal interruption in ADLS, more uniform staffing, predictable surgical outcomes
Disadvantages of outpatient setting
decreased privacy, screening may require multiple trips, need for adequate care at home, patient compliance, decreased time for orientation/adaptation, decreased observation post-op
What is the only age limit for outpatient setting
no premature babies
Surgical length is usually less than __ hrs and rarely exceeds __ hrs
2 and 4
Most common surgical procedure is ______ and the second are _______ surgeries
opthalmic / gynecologic
Anticipated surgery should be minimally ________ and have _____ post op problems or pain issues
invasive / insignigicant
If acute substance abuse/intoxication, the case should be ________
cancelled
What is a good anesthetic technique for someone with substance abuse problems or taking suboxone or methadone
regional anesthesia
What is considered a premature infant
37 weeks or earlier gestation
Premature infants are unacceptable, why?
Anemia, underdeveloped gag reflex, immature temperature control, apnea,
Apnea can develop as late as ___ hrs post op in the premature infant
12 hrs
Healthy former premature infants should be greater than ___ to ____ weeks postconceptual age. Each should be evaluated individally.
50 to 60
Infants displaying bronchopulmonary dysplasia should _____ be considered for surgery.
NOT
What puts an infant at increased risk of SIDS?
history of apnea/bradycardic events, siblings with SIDS
Children with prior history of apnea/bradycardia should be free of apnea/bradycardia for ___ months prior to surgery
6
Greater than 37 weeks gestation
full term infant
A healthy full-term infant that is free of any complications can be considered case by case at __ to ___ weeks of age
2 to 4
When considering the geriatric population it is wise to consider ________ age and not just chronologic age
physiologic
Those aged 85 years or greater are at greater risk for what?
Hospital admission and death within the week following surgery
What is important to consider when geriatric having surgery on outpatient basis?
must have adequate home care and transportation
When should someone with a convulsive disorder have a procedure
Very early in the day to provide optimal observation (min of 4-8 hrs postop)
T/F Uncontrolled seizure activity is not acceptable in the outpatient setting?
TRUE
A patient with cystic fibrosis needs to be evaluated very early. ______ function is the primary predictor. Need to consider ability to manage respiratory distress and hydration with these patients.
pulmonary
Malignant hyperthermia suscpetibility criteria
previous MH episode, masseter ridgity with previous anesthesia, 1st degree relative with MH episode or positive muscle biopsy
For someone that is MH susceptible, trigger free anesthesia myst be provided with at least ____ hr post-op observation
4
MH preparedness considerations
adequate monitoring, minimum of 36 vials of dantrolene, schedule early in day, overnight obsercation in the 23hr outpatient has been advocagted
Tell me about Ryanodex
250 mg/vial, reconsititute with 5 ml of sterile water, looks like orange propofol
Ryanodex dose
2.5mg/kg/IV up to 10 mg. Continue with 1 mg/kg Q4-6hrs for at least 24 hrs
If someone is morbidly obese with co-morbidities such as cardiac, endocrine, hepatic, renal or pulmonary….where should surgery take place?
inpatient
T/F Most recent information is BMI of 40 or less is considered acceptable for ambulatory surgery. BMI of 40 to 50 judged on case by case basis.
TRUE
T/F BMI greater than 50 considered very high risk and unacceptable for amublatory surgery center
TRUE
T/F Sickle cell crisis may occur if patient is subject to hypoxia, acidosis or dehydration
TRUE
Sickle cell disease criteria for outpatient
no major organ disease, no sickle crisis for minimum of one year, compliant medical care, schedule early appointment for optimum observation post-op
Unacceptable patient conditions for SDS
ASA III or IV (unstable conditions), active substance abuse, psychosocial problems, uncontrolled seizures, newly diagnosed or untreated OSA, uncontrolled diabetes, isolation necessary, post-op pain not controlled with oral meds
T/F podiatrists are not physicians and can’t write History and Physicals
TRUE
For stable patient, an H/P should be done within ____. For high risk it should be done within ______
30 days / 72 hrs
Lab values are good within _____ days of surgery if patient is stable. Potassium level within ___ days if on a diuretic or dig
60 / 7 days
Review slides
34 and 35
IF coumadin is going to be held how many days prior to surgery should it be held and what should happen morning of surgery?
4-5 days / PT should be drawn
Restart coumadin __ to ___ days post op
1 to 7
New indication is that lisinopril should be continued up until surgery. What can this cause?
May not be responsive to phenylephrine and may have to resort to vasopressin
Want to maintain glucose levels where?
below 180
Rhinorrhea - 20 to 30% of all children have off and on most of the year. Children 2 yrs and younger have __ to ___ viral infections per year.
5 to 10
T/F Recently acquired rhinorrhea 12-24 hrs prior to surgery or chronic condition is not contraindicated in otherwise healthy child.
TRUE
Read slide 41
URTI symptoms
Symptomatic URTI should be scheduled at least _____
4 weeks later
Asymptomatic URTI can be done if what?
Child is older than 1 year, otherwise healthy and surgery is not on thorax or abdomen. AND ETT intubation is not planned
Anesthesia increases respiratory complications __ to ___ fold
2 to 7
What’s going to happen if baby smells like an ashtray
bronchospasm and laryngospasm
Most used anesthetic technique in SDS
General
Why should you use smaller ETT in SDS?
to decrease incidence of post extubation croup, sore throat, and increase ability to resume PO sooner
With neuraxial blockade you want the _____ acting agent capable of providing adequate blockade without prolonging discharge
shortest
Review regional advantages on slide 53
slide 53
Regional anesthesia disadvantage
sympathetic block associated with spinal and epidural may complicate discharge with orthostatic hypotension, inability to empty bladder, PDPH, TNS
Stage I means what
you need PACU nurse watching over you
When can you go to stage II
If you can maintain your airway, not on oxygen, and doesn’t need any IV medications, can sit in chair
In the geriatric patient, greatest risk for postop mortality is __ week
one
A gentle jaw thrust with initial insule is OK, prolonged airway management is a _____ anesthetic
general
MAC monitoring standards
pulse ox, BP, EKG, temp when clinically significant, capnography not required but ventilation assessment by adequate chest rise must be continuous
Is the incidence of brain damage or death higher in MAC or General
MAC
T/F Moderate sedation can be directed by physician performing procedure - depth should not allow loss of protective reflexes
TRUE
Most common cause of hypotension
hypovolemia
PAC and PVC causes
hypomagnesemia, hypokalemia, increased sympathetic tone, myocardial ischemia
Post op laryngospasm
first line treatement is positive pressure. If unresponsive then succinylcholine 0.1 mg/kg IV
Droperidol considerations
avoid in patients with pre-existing ECG abnormalites, recommend 2-3 hrs monitoring and 12-lead ECG following admin
Least effective routes for pain meds
subq and IM
Prominent ambulatory surgeries
D&C hysterospcopy, orthodontic/dental, shoulder arthroscopy, tonsilectomy/adenoidectomy, knee arthroscopy
Pitosin can be given
IU and IV
Methergine can be given ___ only. Also, do not give to HTN patient
IM
D and C positioning
dorsal lithotomy, less than 40 degree abduction recommended
With cervical dilation your patient becomes bradycardic and hypotensive. Why did this occur and what is the treatment?
Vasovagal response. Release of cervix and treat with atropine 0.4 mg IV if needed
Hysteroscopy allows for examination of the _______ cavity
endometrial
Position for hysteroscopy
lithotomy
Intrauterine pressure should be less than ____ mmHg
200
Adequate sensory level for hysteroscopy?
T10
Nerves susceptible to damage with hysteroscopy from lithotomy position
femoral, lateral femoral cutaneous, obturator, saphenous
Does muscle relaxation and GA always improve mouth opening in TMJ patients?
NO
Who needs a GA requiring dental surgery?
mentally retarded, young children, patients with oral sepsis, patients with poorly controlled seizure disorders, patients presenting for TMJ procedures
Tube placement for dental surgeries
nasotracheal
Damage to the lingual nerve during surgical tooth extraction can cause what?
tongue numbness
Damage to the inferior alveolar nerve during surgical tooth extraction can cause what?
lip numbness
Preferred technique for shoulder arthroscopy
regional/GA technique, interscalene block, horner’s syndrome means block is working
Do not premedicate what patients?
OSA or upper airway obstruction
Hypercapnia during emergence can increase _______ which can increase _______
vasodilation / bleeding
Most common complication of knee arthroscopy
hemarthrosis
