Outpatient Surgery

Question 1

Patient, Procedure, & Practitioner Selection

Answer 1

Select cases & patients that create a predictable environment
Predictable, consistent, & directive guidelines
Appropriate surgeon skills & cooperation
Normal # minutes/time per surgery or procedure
Collaboration b/w surgeon, facility, & anesthesia providers
Frequent simulation exercises

Question 2

Safety Supplies

Answer 2

Code cart
MH - Dantrolene or Ryanodex
LAST
Difficult airway \$\$$
- Gold standard = fiberoptic
RNs ACLS & PALS certified

Question 3

Outpatient Surgery Advantages

Answer 3

Financial $ savings ↓medical & life costs
↑hospital bed availability
Reduced time & contact in hospital setting (patients susceptible to infection)
↓risk nosocomial infection
Patient satisfaction
↓delays
Social - less separation anxiety (children), decreased POCD (geriatric patients), less medication & return to familiar environment sooner
Efficient staffing w/ uniform work schedules & more predictable surgical outcomes

Question 4

Outpatient Surgery Disadvantages

Answer 4

Less patient privacy
Multiple visits as compared to hospital 1-stop
Arrange home care
No child life present
Limited time to monitor for adverse effects in PACU
Complication management limited d/t resources available
Emergency → call 911 to transfer to affiliate hospital

Question 5

Patient Seletion

Answer 5

Healthy & optimized

Stable 3mos prior to surgery

Question 6

Inappropriate Patients

Answer 6

Acute substance abuse - acute intoxication

Premature infant < 60wks corrected

Question 7

Seizure Disorder

Answer 7

Schedule early in day to observe 4-8 hours postop

Question 8

Cystic Fibrosis

Answer 8

Protective airway measures

GERD & pulmonary aspiration risk

Question 9

Malignant Hyperthermia

Answer 9

Stocked MH cart
Dantrolene 36 vials stocked & unexpired
Activated charcoal filter
Reduce volatile anesthetic concentration < 5ppm in 2 minutes
1st case Monday to decrease risk

Question 10

Obesity

Answer 10

↑adverse postop outcomes

BMI > 45 kg/m^2

Question 11

Obstructive Sleep Apnea

Answer 11

Bring CPAP

Minimize benzodiazepine & opioid use

Question 12

Preoperative Testing

Answer 12

EKG > 65yo or ASA class III
Routine testing NOT necessary unless history sudden family death, potential blood loss, contrast dye, or potential pregnancy

Question 13

CBC

Answer 13

Patients w/ anemia
Surgeries or procedures w/ anticipated blood loss
Premature infants

Question 14

Coagulation

Answer 14

Personal or family history bleeding disorders
Anticoagulants
Liver disease
Tonsillectomy & neurosurgery (controversial)

Question 15

Liver Function

Answer 15

Cirrhosis

Acute hepatic history

Question 16

Pulmonary Function

Answer 16

Asthma management

Question 17

Urine Analysis

Answer 17

Hardware insertion

Question 18

Type & Screen

Answer 18

Anticipated blood loss >500mL

Rhogam

Question 19

Electrolytes

Answer 19

Recent medication changes that affect potassium or electrolytes

Question 20

Creatinine

Answer 20

Contrast dye study

Question 21

Glucose

Answer 21

DOS

Question 22

When should high risk patients be evaluated for ambulatory surgery?

Answer 22

At least 1 week prior to surgery

Question 23

How long are laboratory tests & diagnostic procedures deemed current IF patient physical condition remains stable?

Answer 23

6 months

Question 24

Most common ambulatory surgery center procedures are _____ & _____

Answer 24

Endoscopy

Opthalmologic

Question 25

How long should higher-risk procedure patients be monitored postop?

Answer 25

24 hour observation

Question 26

Routine procedures performed at ASCs

Answer 26

- Lap chole - Lumbar laminectomy - Cervical laminectomy & fusion - Total joint arthroplasty - Select bariatric surgeries

Question 27

When to cancel a case?

Answer 27

``` Acute illness Untreated or worsening chronic disease state Non-compliance NPO status Pregnancy suspicion URI ```

Question 28

Pulmonary Aspiration | RISK FACTORS

Answer 28

``` Age extremes < 1yo or > 70yo Anxiety Ascites Collagen vascular disease (scleroderma) Depression Esophageal surgery Exogenous medications: - Opioids - Barbiturates - Anticholinergics Failed intubation or difficult airway history Gastroesophageal junction dysfunction (hiatal hernia) Mechanical obstruction (pyloric stenosis, duodenal ulcer) Mechanical disorder - hypothyroid, chronic diabetes, hepatic failure, hyperglycemia, obesity, renal failure, & uremia Neurologic sequelae - developmental delays, head injury, hypotonia, seizures Pain Pregnancy Prematurity w/ respiratory problems Smoking Gastric contents type & composition ```

Question 29

NPO Status

Answer 29

``` Clear liquids = 2 hours Breastmilk = 4 Infant formula = 6 Non-human milk = 6 Light meal = 6 Heavy meal (fried or fatty) = 8 ```

Question 30

Cardiac Disease

Answer 30

Stable cardiac disease NOT unstable angina, labile HTN, severe valvular disease, cardiac dysrhythmias, recent MI < 3mos, drug-eluding stent place w/in 1yr or bare-metal stent w/in 1mos 3+ ischemic heart disease, CHF, insulin-dependent DM, chronic renal insufficiency (creatinine > 2mg/dL), transient ischemic attack, stroke Pacemaker or AICD ?

Question 31

Pulmonary Disease

Answer 31

Perform surgery at hospital when patient symptomatic (wheezing at rest, dyspnea when walking up stairs, pulmonary HTN) Invasive pediatric airway surgery NOT appropriate at ASC

Question 32

Renal Disease

Answer 32

↑creatinine w/ other comorbidities potential impact on surgery outcome AV fistula not appropriate procedure at free-standing outpatient facility Unstable renal failure not appropriate

Question 33

Unstable Patient Conditions

Answer 33

``` ASA III/IV Active substance or alcohol abuse Psychosocial difficulties Poorly controlled seizures Morbid obesity w/ significant comorbid conditions (i.e. angina, asthma, OSA) Ex-preemies < 60wks corrected Uncontrolled diabetes Current sepsis or infectious disease ```

Question 34

Anesthesia Types

Answer 34

``` Avoid opioids & narcotics Multi-modal pain analgesia approach Regional (blocks, epidural, or spinal) + general TIVA > volatile anesthetics PONV prophylaxis ```

Question 35

Who can provide MAC?

Answer 35

Only anesthesia providers

Question 36

Monitored Anesthesia Care | RISKS

Answer 36

``` Able to maintain own airway Always prepare for general anesthesia Over-sedation → apnea Hypoventilation & relative hypoxemia Airway fire risk ```

Question 37

Neuraxial Anesthesia | Advantages

Answer 37

``` ↓anesthesia time ↓turnover Shortened PACU discharge Enhanced postop recovery Pain management ↓PONV ```

Question 38

General Anesthesia | RISKS

Answer 38

``` ↑PONV risk Airway injury Hypothermia Postop cognitive dysfunction Delayed discharge TIVA prevents risks associated w/ volatile anesthetics Avoid ETT intubation Multi-modal anesthesia ↓opioids ```

Question 39

What HbA1c level indicates adequate blood glucose control?

Answer 39

< 7% | Ideal candidates for elective outpatient surgery

Question 40

Insulin Pump

Answer 40

No change day before or DOS | Utilize "sick day" or "sleep" basal rates

Question 41

Long-Acting Insulins

Answer 41

No peak 75-100% morning dose DOS No change day before surgery Reduce nighttime dose

Question 42

Intermediate-Acting Insulins

Answer 42

Day before surgery no change in daytime dose & 75% evening dose 50-75% morning dose DOS

Question 43

Fixed Combination Insulins

Answer 43

No change day before surgery 50-75% morning dose intermediate-acting Lispro-Protamine use NPH instead on DOS

Question 44

Short & Rapid-Acting Insulin

Answer 44

No change day before surgery | Hold morning dose DOS

Question 45

Fast-Tracking

Answer 45

``` Bypass 1st stage PACU & proceed directly to phase 2 - Do not require airway support - Stable cardiopulmonary status - Adequate analgesia ↓cost ```

Question 46

Hypertension

Answer 46

50% ↑risk MI, cardiac arrest, or dysrhythmias 30 days after procedure ACEi → profound hypotension (refractory to drugs) Continue ACEi & ARBs for MAC anesthesia

Question 47

Malignant Hyperthermia | Treatment

Answer 47

Dantrolene or Ryanodex 2.5mg/kg *Minimum 36 vials unexpired Ice packs Foley bladder irrigation

Question 48

Morbid Obesity

Answer 48

↑risk periop events d/t co-morbidities & difficult airway amangement BMI > 35kg/m^2 Anesthesia airway evaluation, cardiac & pulmonary assessment, & endocrine Consider equipment weight capacities

Question 49

OSA

Answer 49

Obstructive sleep apnea → sympathetic neural activation HTN & CV abnormalities Morbidity & sudden death risk during or after periop period ↑risk CVA, MI, bleeding, respiratory failure, difficult intubation, & death Preop screening Sleep study & CPAP therapy prior → improve CV function, ↓HTN, & improve airway management ↑respiratory depression risk → caution w/ opioid admin

Question 50

Ambulatory Surgical Centers vs. | Office-Based Anesthesia

Answer 50

Office-based = dental or plastic surgery Lack appropriate equipment & training for resuscitation & emergencies Risk unqualified surgery/anesthesia providers ASCs = prolonged cases > 2hrs, general anesthesia, & advanced age ↑morbidity Different health code evaluations

Question 51

Multi-Modal Analgesics

Answer 51

``` Gabapentin COX-2 inhibitors Ketamine β blockers Ketorolac Magnesium Dexamethasone Lidocaine ```

Question 52

Pediatric Patients

Answer 52

OSA ↑airway/respiratory events during induction & PACU Risk airway obstruction d/t tissue swelling, laryngospasm, & pulmonary edema Hospital admission - children < 36mos, FTT, craniofacial abnormalities, morbid obesity, cor pulmonale, hypoxemia

Question 53

Rhinorrhea

Answer 53

20-30% | Children < 2yo prone to 5-10 viral respiratory infections annually

Question 54

Rhinorrhea Differential Diagnoses

Answer 54

``` Viral infection Nasopharyngitis Contagious disease Acute bacterial infection Streptococcal tonsillitis Meningitis (delay 2wks; ideal 4-6wks) ```

Question 55

PONV Apfel Score

Answer 55

Useful predictor to prevent PONV in PACU 1st 24hrs | Poor predictor 24-72hrs after discharge

Question 56

Scopolamine Patch

Answer 56

Wash hands after removing | Wear gloves when placing

Question 57

URI | Complications

Answer 57

Upper respiratory infection Present or recent URI ↑risk pulmonary morbidity in periop period Supraglottic edema, stridor, laryngospasm, desaturation, &coughing are associated w/ GA especially when ETT Postpone surgery when current, severe URI (fever, malaise, wheezing, dyspnea) or w/in 4wks severe URI & surgery requires intubation or affects airway

Question 58

Postop Complications

Answer 58

Optimize preop Prevent prolonged cases PONV prophylaxis Monitor outcomes

Question 59

Discharge Criteria

Answer 59

``` Vital signs stable & age-appropriate A&O x4 Appropriate ambulation based on age, baseline, surgery, & medical condition No respiratory distress Protective airway reflexes present Minimal/appropriate bleeding Pain minimal & controlled w/ appropriate analgesia regimen Controlled N/V Responsible caregiver Discharge instructions ``` * PO intake not mandatory * Voiding not mandatory (even after neuraxial analgesia)